When policy change is considered, what determines its success or failure? Why do plans for broad reforms often fall short, and why do certain types of change become more difficult over time? This article addresses these questions by examining health policy development in Canada, Australia, and the United Kingdom — specifically, why Canada alone failed to adopt nationwide, public pharmaceutical insurance. It demonstrates that the pace of change has significant implications for the scope of policy development. It provides new mechanisms to explain why incremental reforms stall based on the reciprocal relationship between elite ideas and public expectations and suggests that similar factors can explain how barriers to policy change develop and the conditions under which those barriers may be overcome.