Institutions, Ideas, Interests,
Actors, and the Accidents
of Policy Episodes
Readers of the literature of comparative public policy will recognize the argument of the previous two chapters as a version of "historical institutionalism." This approach emphasizes the importance of decisions taken at crucial points in time, decisions that become crystallized in the formal and informal rules governing behavior, and that establish the context in which subsequent decisions will be made. Historical institutionalism, however, is a house with many mansions: it allows for a variety of emphases regarding the factors that bring about critical moments of decision-making and that shape decisions at those moments.
In this book, I have emphasized the critical importance of the timing of intersections between developments in the health care arena and developments in the broader political arena. In chapters 2 and 3, I argued that episodes of policy change in the health care arena were brought about by the opening of "windows of opportunity" as a result of events in the broader political arena, and that as a result, the timing of those episodes was, from the perspective of the health care arena, virtually "accidental" The resultant policy decisions were then the product of a complex interaction between ideas and constellations of interest then current in the health care arena, and the agenda of the dominant political actors of the day. In this chapter, I relate this argument to a number of other attempts to explain differences in health policy outcomes across nations.