Introduction

None of us, as Rudolf Klein has rightly noted, can escape the “bombardment of information about what is happening in other countries.” Yet, in the field of comparative studies in health care policy, there is an extraordinary imbalance between the magnitude of the information flows and the capacity to learn useful lessons from them. Indeed, I suspect that the speed of communication about developments abroad actually reduces the likelihood of cross-national learning. Why might that be so? What does that speculation suggest about more promising forms of international intellectual learning in the world of health policy? That is the concern of the first part of this chapter. But, even if my hypothesis is fundamentally challenged, the whole point of this part of the discussion is to explore the question of how competent learning from one nation to another can take place in health care policy. The second part begins with the reform stalemate in American federal policymaking that was evident in the death of the Clinton administration's plan in late 1994. It addresses the prospects for reform arising not from the enactment of a single national system of health care, but from local efforts of diverse and separate constituencies in their own jurisdictions— state, county, and business. In the light of cross-national experience, what are the principles to use in appraising those movements for change? And what are the prospects for any of them to animate, over time, national reform?

Part 1: Health Reforms Everywhere on the Public Agenda

There is little doubt about the salience of health policy on the public agenda of each of most industrial democracies. Canada's form of universal health insurance, for example, has been a model of achievement for many observers, the subject of considerable intellectual scrutiny and the destination of many policy travelers in search of illumination. Yet, a majority of its provinces in recent years have felt sufficiently concerned about the condition of Canadian Medicare (and general fiscal pressures) to set up royal commissions to chart adjustments. The United States has been perhaps more obvious about its medical care worries. For most of 1994, only the legal troubles of O. J. Simpson vied with health reform for the dominant attention of the media, with the ubiquitous CNN ensuring that the world would know something about both topics.