Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada

With the extraordinary opportunities that modern medicine bring us, and knowing that we cannot afford all we want, how do we choose who will get what and how much? Are these choices rational given the interplay of power centers in a democracy? Can we describe the social and political processes that lead to such fundamental choices, such as how much government direction should be applied to health care in contrast to a market-based system?

In Accidental Logics, Carolyn Hughes Tuohy, a political scientist, tries to explain how such policies develop, grow, and change in three English-speaking countries—the United States, Britain, and Canada. Each system has made some major choices in connection with these key questions, such as universal access, compensation of physicians, and who will bear the cost of care.

As the title of the book implies, the author believes that health care choices are "accidental" in the sense that they occur in a place and at a time in which there is a unique window of opportunity shaped by ideas and agendas within a broader social and political system.

The book is rather densely written, even for this policy-oriented reviewer, but in the complexities elucidated, some interesting insights emerge. The author distinguishes between a hierarchical system, in which the exercise of authority comes vertically from the top down, and an exchange or mixed system, in which the deployment of wealth is more market-driven, horizontal, and in private hands.

Tuohy also understands clearly the power of professionals in what she calls the "collegial" system, in which the exercise and monopoly of skill creates a third, and significant, power center in the decisions that are made. In addition, the information system revolution has given consumers a much larger knowledge base from which to make critical choices about their own or their family members' health care; this, too, changes the dynamics of the health care system in unpredictable ways.

The failure of the Clinton health reform efforts in 1993 and 1994 is better understood within the parameters presented in this book. It was a policy that was extraordinarily complex in trying to simultaneously expand access within a system characterized by a large number of entrenched stakeholders and a basic distrust of regulation and systems of care. If the authors of the Clinton proposal had understood the dynamics of change in the health care arena, they might have opted for a much more straightforward and simple approach.

Contrasting the British, U.S., and Canadian systems is a very useful exercise for policy makers and clinicians. While opportunities for treatment, remuneration, and physician power differ among the three health care systems, trade-offs between economics and clinical risks are common to all. As long as a zone of clinical uncertainty exists in which we are dealing with statistics and risks, there will be opportunities for either governmental or market-driven rationing, depending on the choices society might make.

This book has obvious implications for mental health policy; the health care policy of a given country has a profound effect on access to, quality of, and cost of mental health care. Advocates for mental health will benefit strategically from an understanding of the "accidental logics" of health care.