In Medical Doctors in Health Reforms: A Comparative Study of England and Canada, the authors show that the COVID-19 pandemic exposed even more clearly the life-threatening limits of publicly funded health care systems by exacerbating wait times, increasing fiscal burdens, contributing to care workers’ burnout, and further entrenching racial inequalities (183). Yet these challenges have not produced structural reforms to expand access, increase capacity, or reduce racial inequalities. The authors argue that in nations where governments and doctors form a bilateral monopoly over producing and purchasing care, the tensions among doctors’ roles—as experts who can generate policy, as care workers who are expected to cooperate with governments, and as laborers who wish to defend their interest in professional autonomy and universal care—make it difficult to achieve such reforms even after system failure (ix). While doctors may desire a more efficient distribution of services, they are unlikely to draft reforms because that would require them to compromise and to overcome collective action costs. For example, doctors are likely to resist government reforms that attempt to expand access by requiring them to work in underserved areas because that would violate their desire for professional autonomy, and they are unlikely to cooperate with government proposals that impose austerity measures because that would violate their desire for universalism. Therefore, doctors’ preferences often conflict with reform initiatives and incentivize behaviors that impede reform. This insight makes Medical Doctors in Health Reforms especially relevant for understanding how systems might confront, or fail to address, the vulnerabilities revealed during crises.
The authors begin with an argument reminiscent of E. E. Schattschneider's (1935: 288) dictum that “a new policy creates a new politics.” They hypothesize that doctors’ influence on reforms is dependent on preexisting law, with such law acting as a restraint on potential reforms and/or a tool of coercion (171–72). The authors test this prediction using longitudinal case analyses and conclude that doctors in Canada have more influence over reform than their British counterparts. The influence and success of Canadian doctors in health reform, the authors argue, is attributable to two primary factors: (1) Canada's constitution, which requires provincial governments to negotiate with doctors; and (2) statutes (e.g., the Canada Health Act) that prescribe a baseline standard of care (29–30, 91). The different legal contexts in Canada and England have substantial consequences. In 1996, for example, the government of Ontario struggled to cut costs amid a recession because it still needed to maintain the standard of care required under federal law (86–88), whereas the Thatcher government in England was able to impose austerity measures unilaterally because there is no such law in England (104–5).
In addition, governments’ ability to impose budget reforms is dependent on the laws regulating reform. In 2012, for example, the government of Ontario tried to cut doctors’ fees without consultation, but the Ontario Medical Association prevented this reform by suing on the grounds that the constitution requires governments to negotiate with doctors in good faith (78). In contrast, the Thatcher government imposed resource competition between hospitals because there is no legal mechanism requiring the state to negotiate with doctors; England does not have a codified constitution, and the agreement that created the National Health Service (NHS) was never formalized (106). So, although the bilateral monopoly that doctors and governments have over health systems makes cooperation necessary across all legal contexts, Canadian law empowers doctors to shape reform, while British law empowers governments.
Similarly, the authors argue that doctors’ influence during reform debates is dependent on the laws or bylaws structuring how doctors organize. The authors exploit variation in timing across all three cases to illustrate that whether doctors’ unions are legally recognized affects their influence. Ontario recognized a legal bargaining unit much later than Quebec, and this limited the Ontario Medical Association's ability to resist unwanted changes to their billing practices. However, once Ontario recognized a union, that limited the governments’ ability to implement such reforms without negotiating with doctors (68–70). Here, England is a strong counterfactual because the government has yet to recognize a single bargaining unit. Thus, doctors’ organizing power is fragmented across many associations, and governments do not have to consult any of them before imposing reform. Furthermore, doctors’ influence during debates is dependent on professional organizations’ bylaws. The proliferation of professional organizations in England allows the government to exploit their varied internal regulations. Minister Bevan collaborated with royal colleges when designing the NHS because, unlike the British Medical Association, they did not need the approval of their members to negotiate (98). The likelihood of reform and doctors’ influence in shaping said reform, then, is dependent on how doctors organize themselves.
The authors also argue that governments are the primary initiators of reform and are more likely than doctors to generate proposals. As the unequal distribution of medical care across Quebec became increasingly apparent in 2002, the provincial government proposed legislation to coerce doctors into serving in understaffed areas (58). Doctors did not counter by drafting a new proposal; instead they attempted to negotiate with the terms outlined in the government's bill (59). Generally, such a reactive disposition correlates with less influence during reform debates, but this tendency varies across cases with the status of unions (2). Unions are doctors’ primary tool for organizing and developing strategies to address system inadequacies and counter government proposals, so without a single legally recognized union, doctors are less likely to overcome collective action problems that inhibit their ability to set the agenda by generating policy proposals. In contrast, governments are predisposed to be generative because in publicly funded systems, they are especially responsible for ensuring that voters’ tax dollars are being used efficiently (166). In such cases, doctors can only be reactive because once governments set the agenda, they must focus their remaining organizational power on resisting provisions that may weaken their status and compromise their working conditions (141, 166). When unions are legally recognized, however, doctors have more opportunities to be generative and influential. As an example, the authors point out that Quebec recognized a union earlier than Ontario and England, which created a more influential workforce in Quebec and incentivized the government to cocreate policy with doctors. Although Quebec's doctors chose not to write an entirely new proposal to address the unequal distribution of care, the government was incentivized to create a revised policy with them because they had a single legally recognized bargaining unit. Although this process of mutual policy creation has impeded reform as much as it has facilitated it (57), collaboration was not a venture where the union simply refused to acknowledge system failures in reckless pursuit of protecting the status quo. During this process, doctors demonstrated a desire and an ability to alter policy by advocating for the use of positive reinforcement to encourage practicing in underserved areas (167, 56–59). So, while doctors are generally reactive, the Quebec case demonstrates that this approach is dependent on their ability to organize and that a generative disposition does not necessarily ensure successful reform (181).
The arguments that doctors’ influence is dependent on legal context, organizational practices, and whether they are reactive makes Medical Doctors in Health Reforms useful for understanding why attempts to address system vulnerabilities might succeed or fail, but not necessarily in the way that Denis et al. expected. Although the authors suggest that their research has implications for predicting reform, recent events challenge this claim. In the epilogue, they reflect on their findings and express optimism about future reforms on the grounds that the COVID-19 pandemic demonstrated an underlying cooperative demeanor among doctors and governments (183). For this reason, they end on a valuable reminder that the challenge of medical politics is not in creating a commitment to cooperation but in carrying that commitment to the negotiating space. This reminder has merit, but hindsight reveals that COVID-19 did not lead to the transformative restructuring of publicly funded systems. The discrepancy between the authors’ predictions and the pandemic's consequences is perhaps due to the extraordinary demands that the crisis put on doctors and governments to provide care. These circumstances have not continued through to the present, and they no longer bind doctors and governments to cooperation. This would suggest that their behaviors during the pandemic are not generalizable outside the COVID-19 political context.
Additionally, the authors may have overestimated the consequences of COVID-19 because the nature of their analysis requires them to select on observables. They cannot account for conflicts between doctors and governments that take place off the record because they focus on documents meant for public consumption (24–25). It is possible, for example, that governments only present legislation when there is reasonable certainty that doctors can be coerced into negotiating or ignored entirely. In this case, cooperation would not be the norm at all, but rather an illusion constructed by strategic behavior. This, of course, is a notable limitation of the authors’ methodology and raises the possibility that doctors and governments are less cooperative than the analysis suggests.
Nevertheless, the strength of Medical Doctors in Health Reforms is that its arguments account for both failure and success. The authors’ emphasis on law is not only a welcome application of legal political economy to health politics, but also a strategy that effectively highlights the contingencies that inhibit reform. While the pandemic was a large exogenous shock with the potential to spur change, Denis et al. caution that law can impede reform by limiting doctors’ organizing power. The authors’ argument complements existing literature demonstrating that reform does not occur because crises shift actors’ perspectives. Instead, doctors’ organizational strategies are just as important as their individual preferences (Immergut 1990; Perera 2021). Further, Denis et al. explicitly state that legal contexts limiting doctors’ organizational power also impede their ability to generate policy proposals during reform debates, which incentivizes a reactive strategy and lends itself to incomplete reforms as doctors attempt to pursue their own autonomy at the expense of presenting comprehensive solutions. Even though Medical Doctors in Health Reforms concludes on an unfulfilled prediction about the consequences of COVID-19, Denis et al. have produced a thorough analysis that withstands its own limitations.
