Policy Studies Journal, Vol. 29, No.

I , 2001 (38-55)

The Fate of National Health

Insurance in Canada and the
United States: A Multiple Streams
Explanation
Joe Blankenau
This article uses the multiple streams lens to describe why
Canada eventually adopted national health insurance in the 1960s,
compared with the most recent attempt at adopting national health
insurance in the United States. The analysis strengthens the lens by
paying close attention to the impact of differing institutional
frameworks on the streams. It is found that the lens provides a useful
description of the complexiry of policymaking, pointing out critical
elements in the process that are often overlooked.

The United States is the only modern, industrialized country without

some form of universal health care coverage.’ The failure of the most recent
attempt to introduce universal coverage, Clinton’s Health Security Act (HSA),
spawned much speculation concerning why. Institutions (Marmor & Goldberg,
1995; Rosenau, 1994; Steinmo & Watts, 1995), ideology (Jacobs, 1995; Morone,
1995; Skocpol, 1996), class structure (Navarro, 1989), and interest groups
(Laham, 1996; White, 1995; Wilson. 1996) are among the oft-cited explanations.
However, individually they do not consider the dynamic and holistic nature of the
policy process. For instance, if fragmented political institutions in the United
States thwart attempts toward universal health care coverage, how can the passage
of other sweeping legislation such as the Civil Rights Act of 1964 and the North
American Free Trade Agreement (NAFTA) be explained? Likewise, ideology as
a sole explanation is limited. How can America’s acceptance of significant
government intervention in education and environmental regulation be explained
in light of a general distrust of other forms of massive government intervention,
i.e., national health insurance? Similarly, an interest group or a class explanation
cannot account for why the seemingly omnipotent American Medical Association
(AMA) was unable to block the passage of Medicare, especially since the
beneficiaries were the elderly and poor. Certainly, a more complex description of
the policy process is necessary.
Kingdon’s (1995) multiple streams (MS) provides a theoretical lens to
analyze agenda setting and alternative specification, but it can be readily applied
to the entire policy-formulation process (Zahariadis, 1995, pp. 33-34). MS
assumes that governments are organized anarchies, and that three processes, or
streams, drive the ascension of policy on the agenda and alternative specification.
First, several problems exist within the purview of government, yet only a select
few can be afforded serious consideration at any one time. Which problem makes
it onto the governmental agenda is a function of significant changes in regularly
reported indicators, crises, or focusing events, and policy feedback.
Second, existing juxtaposed to problems are solutions, which are
identified and marketed by policy analysts, politicians, and academic researchers.
Solutions are not necessarily created as a response to an existing problem, but in
fact, are often a progenitor to problems. To be viable, solutions must be

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 Blankemu: The Fate of National Health Insurance

acceptable to the policy community such that they have technical feasibility (are
doable), are affordable, and have value acceptability (are within constraints of
values of the policy system).
The third stream is comprised of political variables including the national
mood, interest group activity, and turnover in government. The national mood
consists of public perception of an issue. Mostly, interest group activity affects
policy through an oppositional role, blocking legislation, not promoting it
(Kingdon, 1995, p. 42). Further, turnover in government, i.e., a new executive
and/or legislative majority, often brings a new policy perspective and a window of
opportunity for action for policy entrepreneurs.
When there is a confluence of streams, a window of opportunity is
opened. Sometimes the opening of one policy window can lead to spillover. For
instance, if a principle of government intervention in health care is established
through protection of certain groups, e.g., the elderly and poor, this might
precipitate even more government involvement in health care.
The MS lens is employed here to examine problems, politics, and policy
solutions as they evolved and interacted leading to the passage of national health
insurance in Canada and the last failure of reform in the United States, 1993-94.
A comparison of these cases is intriguing for several reasons. First, both countries
did not develop national health insurance in the first half of the 20th century, a
period when most industrialized countries had adopted some form of universal
health care. Second, there are many sociopolitical similarities. Relatively
speaking, they have similar political cultures, along with significant ethnic
diversity; equivalent socioeconomic development; relatively weak labor unions;
and comparatively weaker social democratic parties (Lipset, 1990; Maioni, 1997;
Rosenau, 1994; Smith, 1995). On the other hand, there are important differences
in political institutions concerning legislative-executive relations and different
forms of federalism, which weaken these similarities. For instance, while Canada
is generally considered to have weaker social democratic movements, they are
stronger than in the United States, because parliamentary governments are more
amenable to the rise of third parties (Maioni, 1997). This is an important factor in
explaining the eventual passage of national health insurance in Canada.
A major criticism of MS is the inadequate attention to institutions
(Sabatier, 1996; Schalger, 1999). This study refines MS by paying particular
attention to political structure. There are many institutional differences between
Canada and the United States. Regarding legislative-executive relations, the
political structure within the United States is based upon a separation of powers
between the executive and legislative branches, whereas in Canada's
parliamentary system, there is a fusion of these powers. Largely due to the
separation of powers between the executive and legislative branches, political
parties in the United States are comparatively weak, particularly between the
branches of government (Nice & Fredrickson, 1995; Rosenau, 1994). Canada's
parliamentary system, which fuses executive and legislative powers, encourages
stronger party ties (Rosenau, 1994; Taylor, 1990). In the United States the
separation of power creates several veto points, at which government actors can
pressure the blockage of legislation. At these veto points, substantial mobilization
is necessary to circumvent entrenched interests (True, Jones, & Baumgartner,
1999). In the Canadian system, majority governments are generally able to
formulate policy despite legislative opposition, if there is no broad public dissent.
While Canada has a more centralized system of decisionmaking at the
national level, its federal structure is more decentralized. The federal government
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 P o k y Studies Journal, 29:l
is less a breeding ground for national policy as it is a “meeting place for regional
and cultural factions to work out their differences” (Gillroy, 1999, p. 370). Also,
Maioni (1997) argues that Canadian federalism facilitates the election of third
party governments at the provincial level, which as seen here, has an important
role in policy innovation and diffusion. State governments in the United States do
not have the same independence and constitutional authority in certain policy
areas, such as health care, as do Canadian provinces (Maioni, 1997).
Political structure affects MS in several ways. In a federal system of
government problems, politics and solutions at the subnational level may affect
problems and solutions at the national level and vice-versa. Also, a presidential
system is generally less responsive to quick, drastic policy changes because of its
several veto points. A parliamentary system, with a fusion of legislative-
executive relations, is more tenable to quick, significant change, so a shorter
duration for a policy window is sufficient. Therefore, the window of opportunity
needs to be larger and/or longer for a presidential system than for a parliamentary
system. Therefore, a new hypothesis (H:4) for MS is considered along with the
traditional hypotheses in MS. The additional hypothesis accounts for the role of
political structure.
H1: Problems will only make the governmental agenda if there are
widely accepted indicators reporting worsening conditions and/or a crisislfocusing
event.
H:2 In order for solutions to be attached to problems, they must have
technical feasibility and value acceptability.
H:3 In order for the political environment to be conducive to policy
formulation, there must be a supportive national mood, acquiescence from key
interest groups, and entrepreneurship by key governmental actors.
H:4 Political structure affects how long and large a window of
opportunity is necessary for policy change.
H:5 Passage of policy depends upon problems being identified, the
availability of an acceptable solution, and a conducive political environment.
This article contributes both to the development of the MS lens and
subsequently a better understanding of the complexity of major health reform in
the United States and Canada. First, it tests propositions derived from an
emerging theoretical lens (Sabatier, 1999). Mayer (1989, p. 47) notes that
research needs to be “cumulative,” and that the testing of existing theory is
imperative ”for expanding the corpus of what we can say that we know.” Second,
since MS is based upon the assumption that democratic governments are
organized anarchies, it must be employed across democratic political systems and
across time. Third, including a hypothesis of the effect of political structure on
the MS lens provides a necessary refinement of MS if it is to be used
comparatively. Fourth, it shows how the MS lens can be used to incorporate
traditional theories into a more complex understanding of why the United States
does not have national health insurance.
In the following sections, the Canadian experience with national health
insurance is explored first, followed by the United States. In both cases
organization is structured around a discussion of each of the three streams
separately and followed by a consideration of spillover and policy windows. The
conclusion provides a comparison of the streams in both countries and a
placement of these findings within a theoretical context.

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 Blankemu: The Fate of National Health Insurance

Merging Streams: The Canadian Experience

National health insurance found a home in the Liberal party platform of
1919, but fiscal conservatism and provincial autonomy impeded serious attempts
toward national health insurance. In 1947, Saskatchewan adopted a provincial
hospital insurance plan. By 1961, all provinces were participating in the Hospital
Insurance and Diagnostic Services Act (HIDSA), which provided for national
hospital health insurance. In 1962, Saskatchewan led the way again with the
passage of a provincial medical insurance plan, followed in 1966 by the Medical
Care Act, providing for national health insurance. The question, then, is why did
Canada finally adopt national health insurance at this time?
Defining a Problem
Regularly reported indicators, criseslfocusing events, and policy
feedback drive the problem stream. In the early 1960s, all of these factors were
evident in Canada. With respect to indicators, the commissioning of a study on
health played a large role in providing information that would eventually have a
strong impact in the problem stream. Responding to pressure from the popular
Saskatchewan experience with universal insurance and the recommendation of the
Canadian Medical Association (CMA), which was hoping to slow down and
control the debate over health care, the Conservative government appointed a
Royal Commission to study and make recommendations regarding health care
conditions. The findings of the Hall Report were instrumental in propelling health
care onto the agenda. Concerning access, the Royal Commission reported that
over 41.2% of Canadians did not have any type of medical care insurance.’ Of the
less than 60% that did, the adequacy of their insurance was questionable (Royal
Commission on Health Services, 1964, pp. 727-731).
There were other conditions, in the form of policy feedback, shaping the
problem stream. The passage of the HIDSA provided for national hospital
insurance. The HIDSA had the unintended consequence of creating an incentive
for consumers and providers to use more expensive hospital care in order to
ensure payment (Weller & Manga, 1983, p. 229). Further, as discussed below, the
HIDSA led to an important spillover.
Equally, if not more compelling, was a focusing event in Saskatchewan.
After Saskatchewan implemented medical care insurance in 1962, physicians
within the province went on strike in protest. On July 1, physicians in
Saskatchewan refused to provide any services, except emergency care. Such a
risky and provocative strategy by the doctors led to a firestorm of bad press, even
from media organizations that had historically been sympathetic to the concerns of
the physicians (Naylor, 1986, pp. 207-208; Taylor, 1978, pp. 31 1-314). The strike
lasted over 3 weeks, giving the media ample opportunity to discuss the issue
nationwide and for resentment against physicians to increase (Kinch, 1995, pp.
209-210; LeClair, 1975, p. 18). Eventually the strike ended, and the
Saskatchewan medical insurance program survived. The strike, ironically, turned
out to be a focusing event as it directed public attention toward the issue of
national health insurance (Weller & Manga, 1983, p. 230).
An Acceptable Solution
Ideas and proposals in the policy stream rise and fall over the years, and
are molded by competing proposals. For solutions to have credibility, they must
have technical feasibility, be affordable, and have value acceptability. In Canada
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Policy Studies Journal, 29:l

the idea of national health insurance was for decades a solution in search of a
window of opportunity. The appointment of the Royal Commission on Health
Services was a watershed event in the policy stream. Emmett Hall chaired the
Commission that was appointed by the Conservative Diefenbaker government.
The composition of the Commission, which heavily represented medical interests,
led many to believe that the Commission’s recommendations would represent the
medical community (Taylor, 1978, p. 342).
The program for national medical insurance that passed in 1966
resembled to a large extent the principles embodied in the Commission’s Final
Report. These recommendations had likewise greatly resembled the HIDSA and
the Saskatchewan medical insurance plan. The main concern for the provinces
was their autonomy. Any plan had to represent this concern. The Hall
Commission’s recommendations provided for a federally financed insurance
scheme, with provincial administration. The provinces were expected to provide
insurance plans that were comprehensive in benefits, with the federal government
supporting 50% of the costs (Royal Commission on Health Services, 1964).
Given that the recommendations from the Final Report were rooted in existing
policy, drafted by members from key interests within the health policy
community, and sensitive to provincial autonomy, the solution reflected the
established values of several, but certainly not all, interests within the policy
system. The ensuing debate centered on the values of government-sponsored
health care versus free enterprise supported by the medical profession and
insurance industry. Indeed, the physician strike in Saskatchewan clearly
demarcated the different values. Technical feasibility was less an issue, since
national hospital insurance had proven workable and universal medical insurance
had been modeled in Saskatchewan.
The Final Report disappointed and dismayed the CMA, which supported
a voluntary scheme providing coverage through government subsidies. The
Commission rejected subsidization for issues of technical feasibility noting that
the number of people who would require subsidy to meet total health
services costs is so large that no government could impose the means
test procedure on so many citizens, or would be justified in establishing
a system requiring so much unnecessary administration. (Taylor, 1978,
p. 346)
Additionally, a subsidized plan was projected to be more expensive than other
alternatives. The CMA interests in the report were also hurt when a potential
advocate, Wallace McCutcheon, an economist who represented business, resigned
from the Commission before the Final Report’s publication (LaMarsh, 1968, p.
120).
The solution of national health insurance had waited for the opportunity
to rise to the top of the policy stream. Yet, it was events in the political and
problem streams, and the opening of a window of opportunity, that allowed for
policy entrepreneurs to push it through the federal government.
Changing Political Conditions
Organized anarchies have fluid participation. Decisionmakers come and
go, and when certain actors are present, change is likely. In the development of
Canadian national health insurance, turnover in party leadership positions and
party composition in Parliament were critical in forging the political stream.

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 Blankemu: The Fate of National Health Insurance
In 1957 the Liberal party lost control of Parliament to the Conservatives.
In response to losing control of parliament, new Liberal leadership was elected.
Lester Pearson and progressive forces seized control of the Liberal party. In 1963,
Pearson led the Liberal party back into control of the Parliament, albeit in a
minority government.
Key appointments in the Pearson Cabinet led to policy entrepreneurship.
Pearson appointed Judy LaMarsh as Minister of Health and Welfare. LaMarsh
was particularly committed to national health insurance, because she had seen, in
the illnesses of her mother and grandmother, the devastating financial toll of long-
term illnesses (LaMarsh, 1968, p. 121). On the night Pearson requested that she
be Minister of Health and Welfare, he remarked that she would have to “fight the
Minister of Finance” for money for the pension and national health insurance
programs. She reflected, “It flashed through my mind at the time that considering
the extent of Walter Gordon’s (the new Minister of Finance) commitment to these
programs...that fight wouldn’t be too tough” (LaMarsh, 1968, p. 47). In previous
Liberal governments, Ministers of Health and Welfare who were committed to
national health insurance had to tangle with Ministers of Finance unsupportive of
national health insurance (Taylor, 1990, p. 142). LaMarsh and Gordon’s
entrepreneurship was instrumental in crafting the national health insurance bill
and providing the political momentum for it in 1966. Interestingly, Gordon’s
replacement at Finance, Mitchell Sharp, an opponent of the bill, was able to delay
the actual implementation a full year, with Pearson’s approval, because of the
government’s worsening financial situation (Pearson, 1975, p. 227). Had Sharp
been Minister of Finance in 1963, there might not have been a national health
insurance bill in 1966.
The New Democratic Party (NDP) party, which evolved from the union
of Cooperative Commonwealth Federation (CCF) and labor, was gaining power at
the federal level. The NDP, a social democratic third party, was a champion of
national health insurance. It was a CCF government in Saskatchewan that
originally brought compulsory medical insurance into Canada. After the 1963
election, the NDP represented the “balance of power” in the Parliament for the
shaky Liberal minority government (Maioni, 1997, p. 417).
Also in the political stream, the CMA was strongly against any plan that
would affect the traditional fee-for-service financing scheme. However, the
public relations disaster in the Saskatchewan strike hurt the CMA’s attempt to
extinguish the spark for national health insurance. In one of the more infamous
stories concerning the strike, the New York Times reported that a 9-month-old
baby died on the first day of the strike, purportedly because his parents had to
drive to a variety of locations looking for physician services (Badgley & Wolfe,
1967, p. 61). While events in the political and problem streams provided the
immediate impetus for the opening of a window of opportunity, the foundation for
change evolved slowly through time as the result of spillover.
Spillover and Opening a Policy Window
Spillover is the process by which change through the opening of one
policy window sets a precedent facilitating change for the opening of another
window. In this case, spillover consisted of a gradual acceptance by provincial
governments of national financing of health care. While health care was
historically the domain of provincial governments, the principle of provincial
autonomy in health care began to erode after the Depression. As a result of the
federal-provincial conference immediately after WWII, a principle was set when
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the provinces accepted a cost-sharing plan from the government for the planning
and construction of hospitals (Vayda, Evans, & Mindell, 1979, p. 219; Weller &
Manga, 1983, pp. 226-227). The adoption of HIDSA significantly strengthened
this principle (Crust, 1997, p. 21) and was central to the process of spillover and
therefore merits attention here.
Government-sponsored hospital insurance began at the provincial level.
Saskatchewan was the first province to adopt compulsory hospital insurance.
Therefore, it is important to show that the MS lens describes how compulsory
hospital insurance evolved in Saskatchewan, and then how the principle of
government-sponsored hospital insurance in Saskatchewan led to spillover at the
national level with the passage of the HIDSA.
With respect to problems, Saskatchewan had been particularly hard hit
by the Great Depression. A sole reliance on a grain economy led to a boom-bust
cycle, with mostly bust during the Depression. The Depression had reduced the
ability of traditional funders of hospital care, e.g., municipal government,
religious groups, and private contributions, to keep up with the increasing cost of
hospital care (Vayda & Deber, 1992, p. 127).
The political stream was also driven by the devastating impact of the
Depression. Badgley and Wolfe (1967, p. 4) argue that the populace, devastated
by the misery of the Depression, developed a sense of entitlement for social
services (without means testing). Turnover in the political machinery also
occurred. The CCF captured the Saskatchewan government in 1944. The CCF
had a clear goal toward complete socialized medical services (LeClair, 1975).
Opposition from the medical profession was limited, because many physicians felt
that such a plan would help them receive payment for services and generally did
not affect their position (Badgley & Wolfe, 1967).
Concerning solutions, the Saskatchewan plan for compulsory hospital
insurance “was probably the most dramatic health policy innovation in North
America to date” (Weller & Manga, 1983, p. 227). It could be argued that it was
merely a natural extension of health plans already in place within rural
communities. Some rural municipalities were already paying for the services of
doctors via general taxation and funding hospital construction.
Once the Depression hit, falling tax revenues eviscerated such plans.
Consequently, the Depression served as the window of opportunity for the CCF
government. The ubiquitous economic impact of the Depression, an increasing
acceptance of government intervention in health care, and a weak opposition from
potential opposition, all led to the passage of provincial hospital insurance in
1947. Soon after, three other provinces set up similar schemes.
The hospital insurance plans were quite popular. As such, most
provinces began to actually pressure the federal government to adopt the national
hospital insurance plan as a way to help financing (Vayda et al., 1979). Provinces
were in the position of having to convince the national government to pass a
national hospital plan. In 1948, Louis St. Laurent was elected prime minister.
While his Liberal party had always supported the idea of national hospital
insurance, St. Laurent, a former corporate lawyer with a strong predilection
toward market-oriented solutions to social problems, was not enthused about a
national hospital plan.
At the 1955 federal-provincial conference in April of 1955, provincial
premiers pressured a politically weakened St. Laurent to put the issue of national
hospital insurance on the agenda of the conference. Further, Health and Welfare
Minister Paul Martin, a supporter of national hospital insurance, threatened to
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 Blankenau: The Fate of National Health Insurance
resign if St. Laurent remained opposed to its consideration. At the
commencement of the conference, St. Laurent appointed a study committee
comprised of representatives from his cabinet and provincial governments to
consider the costs and benefits of hospital insurance. As the problem stream and
policy streams were moving toward passage, the political stream merged in 1957
when the HIDSA was passed unanimously. There was strong opposition from
expected sources (industry and commerce), but the CMA was not stridently
opposed, even though it did not support the final legislation (Taylor, 1990, pp. 82-
95).
The abatement of the barrier of provincial omnipotence in health care,
first with hospital construction grants and later with the HIDSA, was critical in
establishing an acceptance of federal intervention in providing medical insurance.
With this principle established, the streams were able to merge for the passage of
medical insurance in 1966. However, when the plan was implemented in 1968,
only two provinces were on board. By 1972 all provinces were on board. Largely
their acquiescence was due to pressure to pass a popular plan. In Quebec, for
instance, the Toronto Daily Star editorialized that thousands of “Canadians may
suffer preventable, and untreatable disease.. .because of the Quebec government’s
insistence on maintaining its precious autonomy” (Schwartz, 1974, p. 304). In the
end, after almost 50 years from first being adopted as a platform of the Liberal
party, national health insurance had come to Canada. South of the border,
different currents in the three streams were shaping the fate of national health
insurance.
Parallel Streams: The United States and National
Health Insurance
The United States flirted with national health insurance several times in
the first half of the century. Passage of Medicare and Medicaid significantly
increased government provision of health insurance in the 1960s to the elderly and
the indigent. During the Bush administration and the 1992 presidential campaign,
national health insurance once again received serious consideration. Why did
national health insurance fail at this time?
A Divided Problem Stream
In the late 1980s and early 1990s, evidence was building that health care
conditions in the United States were worsening, particularly with respect to cost
and access to insurance. A 1992 report on the status of health care in the United
States noted “almost unanimous sentiment that the U.S. health-care financing
system is unsatisfactory, and there are disturbing trends that it may be
unsustainable” (Organization for Economic Cooperation and Development, 1992,
p. 41). In the 1980s, medical-specific inflation increased at an annual rate of
2.7%. Most other modern industrialized countries experienced medical-specific
inflation at a much lower rate (Organization for Economic Cooperation and
Development, 1993, p .24). A 1992 Kaiser/Commonwealth Insurance survey
reflected growing concern with cost, as Americans listed cost as their number one
health concern (Walden, 1995, p. 160).
Higher costs were pinching many groups. Large companies thal
provided health insurance to employees were frustrated at the increasinglj
expensive benefit of health insurance. From 1970 to 1990, health care costs foi
businesses increased from 3% to 7% of total compensation (Organization foi
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Economic Cooperation and Development, 1992, p S6). Labor was concerned that
higher health care costs being absorbed by employers were leading to higher-cost
sharing for workers and lower wages. Policy feedback was also shaping the
problems streams, because state governments were feeling the effect of higher
costs on their Medicaid budgets. The federal government also found Medicare
costs rapidly increasing (Hacker, 1997; Rovner, 1995).
Devoting a significantly higher percentage of its gross domestic product
(GDP) to health care did not in itself cause alarm. As a whole, higher costs were
not translating into better access and quality of care. It was estimated that roughly
14% of the U.S. population (31-36 million) was without health insurance
(Schieber, Poullier, & Greenwald, 1991, p. 12). Roughly 20 million Americans
were underinsured, bringing the total of underhninsured to over 54 million people
(Pepper Commission, 1990, p. 23). There were also concerns about the quality of
health care in the United States. The United States had the highest infant
mortality of the 24 Organization for Economic Cooperation and Development
(OECD) nations except for Portugal, Greece, and Turkey.
Despite these indicators, it was a special election for a vacated Senate
seat in Pennsylvania that propelled the issue on the national agenda (Hacker,
1997; Laham, 1996; Skocpol, 1996). In 1991, Democrat Harris Wofford was
appointed to temporarily fill the Senate seat left open by the untimely death of
Republican Senator John Heinz. Many considered that the special election would
go to Republican Richard Thornburgh. In a surprising turn of events, Wofford
won the election. Through polling, Wofford’s campaign team had stumbled
across a deep concern for health care among voters in Pennsylvania.
Consequently, they pushed the issue hard during the campaign. Since the election
in Pennsylvania came during an off year and 1 year before the next presidential
election, it received considerable attention and became a focusing event.
There was a sense that the health care system had many problems and
perhaps was in a state of crisis, but the problem stream was divided. First, while
health care indicators emphasized problems in access to health insurance for 14%
of the population, 86% of the population had health insurance. Consequently,
access problems in the United States were for a much smaller percentage of the
population. Heclo (1996, p. 26) argues that those without health insurance “posed
the classic problem of collective action by a poorly organized, non-affluent body
of people.” ‘Poor quality of health was found primarily in lower income and
minority groups. Infant mortality rates were 230% higher for Blacks than Whites
(Weiss, 1997, p. 16). Second, events in the problem stream are shaped by
budgetary constraints (Kingdon, 1995). In the early 1990s, the most salient issue
facing government was the increasing federal debt.
An Unacceptable Solution
Finding sustained consensus in the policy stream proved unattaimble for
Clinton. The legacy of past defeats of national health insurance lingered and
precluded value acceptability. During previous battles, its opponents had
effectively attached the label of “socialized medicine” to national health
insurance. Given this environment, any form of national health insurance had to
elude such negative perceptions. This proved impossible for Clinton, as
America’s underlying antistatist ideology provided a deep well for opposition in
raising concerns about increasing the role of big government in health care
(Skocpol, 1996, pp. 133-172).

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 Blankenau: The Fate of National Health Insurance
It could also be argued that Clinton’s plan lacked technical feasibility.
By attempting to reform the entire system, Clinton was in essence trying to
restructure one-seventh of the economy. Such a monumental change is wrought
with technical problems, such as what would be the role of private insurance
companies. Also, Clinton’s plan did not meet the test of being budget neutral.
According to the Congressional Budget Office, savings from cost controls would
have been consumed by extending coverage, and as a matter of fact, additional
funds would have been required (Aaron, 1996).3
Eventually, managed competition within a budget became the foundation
of Clinton’s HSA. Hacker (1997) and Davidson (1995) argue that Clinton’s
solution was flawed in that it represented Clinton’s reliance on policy analysis in
an attempt to achieve political compromise, which was a poor strategy with a plan
lacking value and technical feasibility. The process of alternative specification
became the focus of the Clinton administration with little regard for strategy in the
decisionmaking process.
A Shallow Political Stream
Wofford’s victory over Thornburgh and the election of Democrat Bill
Clinton indicated that the political stream might be responsive to coupling.
Winning only 43% of the popular vote, Clinton’s victory appeared more a
repudiation of Bush. Furthermore, Clinton’s victory was not paralleled with
significant electoral success for the Democrats in Congress.
In considering Canada, certain policy entrepreneurs were critical in
shaping national health insurance and expediting its passage (e.g., LaMarsh and
Gordon) in the Pearson government in Canada. Clinton, on the other hand,
suffered a tremendous setback when a key actor, House Ways and Means
Chairman Dan Rostenkowski, was forced to step down because of charges of
misuse of congressional and campaign funds. Once Rostenkowski stepped down,
Clinton had no powerful champion in the House, and reform consensus was
severely hindered.
The landscape of interest group politics had changed significantly since
the last time national health insurance had been debated. By 1990, the AMA was
no longer omnipotent in health policy. In the newly emerging policy network,
new actors, such as congressional staff, academic researchers, and nonprofit
health providers, have a much larger influence on health policy (Peterson, 1994).
Indeed the AMA participated in the development of strategies for national health
insurance coming up with its own plan, Health Access America. The AMA was
not the only interest group that initially rallied behind the idea of national health
insurance. The American Hospital Association, the Pharmaceutical
Manufacturers Association, the Health Insurance Association of American
(HIAA), and large businesses (represented by the Business Roundtable, the
National Association of Manufacturers, and the U.S. Chamber of Commerce) all
originally worked to shape a national health insurance plan that they felt was
inevitable.
Nevertheless, there was stiff opposition to reform from other interests.
For instance, the National Federation of Independent Businesses (NFIB) proved to
be a worthy opponent of any employer mandate to finance national health
insurance. They sought out “gettable” legislators. For instance, powerful
proponent John Dingell, Chairman of the Energy and Commerce Committee, was
unable to get national health insurance out of his committee. Swing votes on his
committee, such as Kansas Democrat Jim Slattery, were heavily lobbied, both in
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Policy Studies Journal, 29:l

Washington and in their district by the NFIB. Similarly, the HIAA, which
originally supported national health insurance, became an opponent when the
Clinton plan called for a regulation of insurance rates. Its infamous “Harry and
Louise” television ads depicted a middle-class couple lamenting over the
complexity and restrictiveness of the Clinton plan. The ad quickly became the
centerpiece of media coverage of the debate (Scarlett, 1994). The NFIB and
HIAA showed that because of the many veto points in American politics, a strong
and willful interest could have a profound impact (Headden, 1994; Johnson &
Broder, 1996).
Limited Spillover and a Closed Window?
In Canada, spillover was an important piece of the puzzle. Was spillover
evident in the case of the United States? The answer is somewhat complicated.
The passage of Medicare and Medicaid established the principle of national
involvement in the financing of health care, albeit for only two target groups, the
elderly and indigent, and not a cross section of Americans
Another important spillover occurred in Canada when certain provinces
established universal hospital insurance, which was then the impetus for a
subsequent federal plan. The same process occurred with respect to medical
insurance. In the 1980s and early 1990s, state governments in the United States
were facing essentially the same conditions driving the problem stream at the
federal level. In several states the political streams were moving toward universal
health coverage for their residents. In the policy stream an eclectic assortment of
solutions was considered and implemented. Hawaii, in fact, had passed near-
universal health insurance roughly two decades earlier. In 1993 Washington State
passed a health reform package far more reaching than any other state and
resembling the Clinton plan, but the plan was repealed a few years later. Oregon
further pushed the frontiers of innovation with its plan to increase the number of
people eligible for Medicaid using rationing as a tool for keeping costs in check.
Several other states also enacted plans in the early 1990s intended to broaden the
number of people under the umbrella of state-sponsored health insurance.
Why did state innovations in the United States not also lead to spillover
at the federal level, as was the case in Canada? The answer largely lies within the
differing frameworks of federalism. In Canada, the decentralized structure,
coupled with the strong tradition of provincial autonomy in health care, allowed
provinces to create policy unencumbered by federal restrictions, and then
provinces could pressure the federal government for fiscal support. In the
centralized structure in the United States, the sharing of responsibility for health
care frustrated reforms at both levels. Major reform at the federal level was
complicated by the state purview over insurance regulation and licensing of health
care providers. On the other hand, federal obstacles limited states. The Employer
Retirement Income and Security Act (ERISA) preempted states from regulating or
taxing employer health funds. According to Rodgers (1999, all states seeking
health reform had problems dealing with the limitations of ERISA. Further,
Medicare, which represents around 40% of health spending, is not controllable by
states. This restricted state flexibility in drafting health reform.
Conclusion: Comparing the Streams
An analysis of the cases along the MS framework is compared
systematically in Table 1. A measurement of variables in the three streams

48
 Blankenau: The Fate of National Health Insurance
illuminates key differences that help describe the varying fates of national health
insurance during the two time periods. Nevertheless, such an analysis is clearly
limited by the nature of the MS framework. First, since the MS framework is
designed for description over prediction, it is inclusive of several variables for
which concrete measurement is difficult. Second, it is based on the premise that
policymaking is often the fate of random, unpredictable events. Its application is
prone to problems of ex post facto analysis, which can lead to a skewing of data to
fit the framework. Within these conditions of the MS framework, it is still
possible to provide measures that are replicable and refutable. Nevertheless,
subjectivity is undeniably inherent in the operationalization, measurement, and
interpretation of the variables.

Table1
Comparison of Problem, Policy, and Political Streams

Streams United States Canada

Problem
Indicators Medium Medium
Focusing event Strong Strong
Policy feedback Medium Medium
Policy
Technical feasibility Weak Strong
cost Weak Medium
Value acceptability Weak Medium
Political
National mood Medium Medium
Interest group activity Weak Medium
TurnoverPolicy entrepreneurship Medium Strong

In the following section each variable is operationalized and interpreted

(based upon the case studies) with summary results provided in Table 1. The
summarization of each variable within the three streams is based upon a crudely
specified scale: Strong = clear and strong evidence that this variable supports the
opening of a window of opportunity; Medium = some evidence that this variable
supports, or at least does not inhibit, the opening of a window of opportunity;
Weak = little to no evidence that this variable supports the opening of a window
of opportunity.
The operationalization of each of the nine variables closely mirrors
Kingdon (1993, with some slight modifications. Indicators, focusing events, and
policy feedback measure the problem stream. Most indicators within health care
are embedded within one of three critical areas; cost, access, or quality.
According to Kingdon, routine monitoring or special studies of indicators are
important for assessing how a condition is changing, but whether or not conditions
become a problem is left up to interpretation. Through analysis based on
interpretations of politicians, the media, policy analysts, and key interest groups, it
is generally clear whether or not a condition will be considered a problem. In the

49
Policy Studies Journal, 29:l

case of Canada, the highly respected study by the Hall Commission provided
ample evidence that there were problems both with quality of health care and
especially with access to medical insurance across a large percentage of the
population. Further, cost was a problem, because the HIDSA encouraged people
without medical insurance to seek costly hospital care. In the United States, the
case analysis showed a growing consensus that indicators concerning cost and
access were suggestive of an impending crisis. However, concerns about cost and
access were not complimentary, because not all politicians and interest groups
were equally concerned with each. Corporate and medical industry interests were
most concerned with cost, not access, whereas certain citizen groups and some
more liberal-minded politicians were more concerned with access. Different
interests demanding different interpretations of the problems within health care
divided the problem stream.
Operationalization of a focusing event entails analyzing whether or not
there was a crisis or event that galvanized the attention of the political system, the
media, and the public around the issue. In both cases, it is clear that there were
focusing events. In the case of Canada the physician’s strike in Saskatchewan
after the passage of medical insurance was an event that propelled the issue onto
the national agenda. In the United States, the Wofford Senate election victory
also acted as a focusing event, thrusting national health insurance onto the 1992
election agenda.
Policy feedback is also evident in both cases. In Canada, the HIDSA was
a popular policy, thus increasing support for expansion of government-provided
health financing. On the other hand, there was also negative feedback, because
Canadians without medical insurance reportedly used expensive hospital
insurance for health care. In the United States, policy feedback was largely
negative, in that cost shifting was leading to a greater reliance on Medicare and
Medicaid, greatly increasing the costs of these programs. Such expenditures were
particularly onerous in times of federal and state budget deficits.
In the policy stream, Kingdon refers to many factors that affect the ability
of a solution to be seriously considered. These factors can be collapsed into three
variables: technical feasibility, affordability (cost), and value acceptability.
Technical feasibility can be measured by whether or not the solution is capable of
being administered and if its cost is not prohibitive. In Canada, the passage of
national hospital insurance illustrated that a universal health insurance system
could be administered. In other words, a how-to model already existed, which
enhanced technical feasibility. Any program of the magnitude of national health
insurance raises concerns of affordability, which is a function of the cost in
relation to the health of government budgets and the overall strength of the
economy. In Canada at the time of passage, budget deficits were causing alarm,
and the economy was facing rising inflation. Such concerns delayed the
implementation of national health insurance and forced cutbacks in other health
programs (Taylor, 1978, pp. 376-377). The technical feasibility of Clinton’s
amorphous plan was attacked from several perspectives. Frustrating its feasibility
was the fact that the more compromises there were to fix criticisms, the more
problems there were for implementation (Weissert & Weissert, 1996, pp. 302-
303). Regarding costs, increasing budget woes made any plan highly susceptible
to attacks concerning affordability.
As applied here, value acceptability contains two components; how well
a solution fits the values of policymakers and the public. In Canada the values of
the policymakers were divided. The CMA supported a subsidization policy that
50
 Blankenau: The Fate of National Health Insurance

would retain physician control over the distribution of medical services. On the
other hand, the Liberal party, and to a much greater degree the NDP, was
committed to the concept of national health insurance. Most importantly,
subsidization was rejected by the Royal Commission in place of national health
insurance, and the Commission’s plan became the working foundation of reform
consideration. In the United States, there were clear divisions about the type of
government intervention that would be acceptable to reform the financing of
health care. While early on in the debate there seemed to be a growing consensus
for some type of national health insurance among policy specialists, this cohesion
quickly dissipated over matters such as financing mechanisms, eligibility, price
controls, etc.
Concerning the value acceptability of the people, antistatist American
ideology makes significant attempts to increase government intervention difficult,
particularly within the area of health care (Kingdon, 1995). Canadian political
ideology is generally more accepting of government intervention (Lipset, 1990;
Weller & Manga, 1983). Further, the success of the HIDSA laid the groundwork
for value acceptability for medical insurance.
Political variables include national mood, interest group activity, and
turnover in government. National mood is a vague concept measured not only by
surveys of the general public, but also by the perceptions of policymakers as
garnered from contacts with interest groups, activists, and political elites
(Kingdon, 1995, p. 156). In Canada the national mood seemed to be supportive of
more government intervention in health care (Taylor, 1978; Vayda et al., 1979;
Weller & Manga, 1983). Likewise, the physician strike in Saskatchewan affected
the public’s perception of the medical profession.
However, national mood is fickle and ephemeral. For instance, the
Liberals were handed a stunning defeat shortly after the assent of the HIDSA, and
the CCFfNDP lost the,next election to the Liberal party after passing medical
insurance in Saskatchewan. Also, even though the HIDSA was proven to be
popular, and medical insurance in Saskatchewan although controversial was
eventually embraced, there was still not strong electoral or polling support for the
Liberal government. Making medical insurance a part of the 1965 election did not
help the Liberals out of a minority government, as they only won two more seats,
and a public opinion poll did not show strong support for making medical
insurance compulsory (Taylor, 1990, p. 148). Overall, Canadians seemed to be
supportive of existing plans of government intervention and for reform, but
ambivalent about how medical care insurance should be implemented.
In the United States, there was strong sentiment, as indicated by several
polls, that the national mood was supportive of reform. This was probably more
reflective of malaise caused by the recession in 1991, which began to dissipate
even before Clinton assumed office. Following the issue-attention cycle, the
public’s attention was not sustained for long through the complicated discussion
over the seemingly intractable problems of health reform. As the economy turned
around, attention turned elsewhere to other concerns such as crime and deficit
reduction (Weissert & Weissert, 1996). More evidence that the national mood
was not strongly for reform lies in the defeat of the Democrats in the 1994
elections, where the Republicans gained control of Congress for the first time in
decades.
Interest group activity shapes the political stream as significant
opposition to proposed legislation and comparatively weaker or divided support
decreases the likelihood that the political stream will converge with the other
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Policy Studies Journal, 29:l

streams. In Canada, powerful and entrenched interests, including the CMA and
the Canadian Health Insurance Association, heavily attacked the recommendation
of the Royal Commission. Opponents within the medical profession and the
insurance industry framed the issue of national health insurance in terms of
capitalism and choice versus socialized medicine (Taylor, 1978), but the physician
strike in Saskatchewan affected the opposition’s political maneuverability and
public perception. On the other hand, consumer-interest groups, such as the
Canadian Labour Congress and the Canadian Federation of Agriculture, criticized
the medical profession and the insurance industry for their opposition to the
Commission’s recommendations. These groups had strong support bases and
were important in countering the medical and insurance industries (Taylor, 1978).
In the United States, while former oppositional interest groups such as
the AMA were actually calling for some type of reform, several groups, e.g., the
NFIB and the HIAA, became fierce opponents as the Clinton plan materialized.
Overall more than 1,000 interest groups became involved, and the Center for
Responsive Politics declared that lobbying effort, with respect to money and the
number of people involved, was the biggest ever (Weissert & Weissert, 1996, p.
100). Strong opposition to reform, coupled with endless demands by various
interests, and several veto points within the system, made the interest group
composition inimical to reform.
A change in administration is one of the most powerful effects on
turnover. This is quite clear in Canada as a new progressive Liberal leadership,
support of the NDP, and appointments of supportive cabinet ministers led to an
opening of a window of opportunity and eventual passage of national health
insurance. Some of these new members of the administration acted as key policy
entrepreneurs in the passage of both the HIDSA (i.e., Martin) and national
medical insurance (i.e., LaMarsh and Gordon). In both cases these entrepreneurs
skillfully worked legislation through windows of opportunity. In the United
States the 1992 election of Clinton did not lead to a strong showing of Democrats
in Congress. Clinton clearly did not have the numbers and key policy
entrepreneurs in Congress to push his proposal.
There were two other important variables that stand out in the case
analysis-spillover and the role of political structure. In Canada, the acceptance
of a federal role in health care was instrumental in the passage of national health
care. Provinces in Canada have more power in Canada’s federal system than
states do in the United States. They were able to develop provincial plans without
federal intervention and later lobby the national government for help financing the
popular programs. In the United States, there was some spillover in moving
toward an acceptance of a stronger federal role, but the spillover was complicated
by an enmeshment of the federal government in health care through Medicare,
Medicaid, and ERISA.
The different legislative-executive relations also influenced the streams.
In Canada, because of centralized executive control within the legislature, once
the streams merged, passage was expedited. Also, Canada’s parliamentary system
of government allows for a greater role for third parties, which can, as seen here,
be a critical component in the opening of a window of opportunity. In the United
States, the split between the executive and legislative branches makes it necessary
for windows of opportunity to be strong, so that through political maneuvering
policy entrepreneurs can forge important coalitions necessary to circumvent
institutional veto points.

52
 Blankenau: The Fate of National Health Insurance
While MS informs these two cases, how does the analysis here affect the
larger development of the MS lens? First, the replication of the MS lens over time
and political structure illuminates its dynamic nature and provides important
support for its validity. In Canada the idea of national health insurance had been
around for decades before the problem and political streams finally provided a
window of opportunity, but all of this was incumbent upon the role of spillover.
Second, if the MS lens is going to be applicable in a comparative context, it must
take into consideration the impact of political structure. As seen here, the degree
of centralization in legislative/executive relations and federalism were important
in shaping the flow of the streams. In the United States, the centripetal forces of
federalism mitigated the impact of spillover. In Canada, the centrifugal forces
deepened the impact of spillover. Third, the MS lens is able to absorb several
competing theories of the policy process. In this application the lens illuminated
the importance of power differentials among interest groups. The variables of
national mood and value acceptability of solutions arguably reflect the concept of
ideology. As seen here, an institutional analysis can also be incorporated into MS.
Examination of the streams illuminates the importance of class structure.
Problems in the United States were largely confined to the lower class strata, a
group that is not well supported in the political system. This affected how the
problem was defined and also the solution. The business and medical industries
couched the definition in terms of rising costs and wanted reform built around
controlling costs. Others wanted to consider not only problems of cost but also of
access. In the policy stream the debate centered around whether reform should
focus on cutting costs and consequently increasing access, or should access be the
most important priority with costs being reduced by increased access. Class
politics was also evident in Canada, where there was a very intense ideological
war along class lines pitting the medical and insurance industries against social
democratic policy.
In conclusion, the MS lens describes the complex and largely
unpredictable forces within the policy process that are generally necessary for the
passage of controversial policy. There are other underlying factors such as
institutions, interest groups, ideology, and class structure that drive the policy
process and cannot be ignored. However, focusing on the underlying forces
misses the importance of critical elements shaping the policy process.
***
Joe Blankenau is a graduate of the University of Nebraska-Lincoln and
is currently assistant professor in political science at Wayne State College in
Wayne, Nebraska. His research focuses on health care policy and politics.
Notes
The author wishes to thank Monica Snowden, June Davidson, and the anonymous reviewers
for their assistance with this article.
'Universal health coverage can come in various forms, such as a national health service,
e.g., the United Kingdom, where coverage comes from general taxation and government planning is
strong in all areas of the health system. National health insurance is another form and is also eclectic
in design; however, it is distinguished as consisting of government-mandated health insurance and
strong government intervention in the financing of personal medical care but a more limited role for
government planning in other areas of the health care system. For a complete discussion of the
typology of health systems, see Roemer (1991).
2Medicalcare is separate from hospital care.

53
Policy Studies Journal, 29:1
3Clinton’s team provided a different perspective on the numbers, showing his plan to
reduce the budget deficit by $72 billion from 1996 to 2000 (White House Domestic Policy Council,
1993, p. 283).

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