The American Democratic leadership in the White House and Congress in 2009–10 and the British Conservative/Liberal-Democrat Coalition government in 2010–12 each pursued a strategy of rapidly assembled multiple adjustments to the prevailing policy framework for health care rather than attempting a “big-bang” strategy of sweeping institutional change. Despite their relative modesty, each set of reforms encountered a highly conflictual and tortuous process of legislative passage. Subsequently, the reforms failed to gain broad public acceptance and were variously hobbled (in the United States) and transformed (in the United Kingdom) in the course of implementation. These two cases thus offer some common lessons about the potential and the pitfalls of such complex “mosaic” reforms.

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