Explaining change is a central problem for institutional analysis. If institutions are purported to have a kind of staying power, then how can the same institutions explain both stability and change? If institutions limit the scope of action that appears possible to different actors, why can they sometimes escape these constraints? This essay uses the case of national health insurance politics to show how institutions can explain both policy stability and policy change. The key to the analysis is a break with “correlational” thinking. Rather than analyzing policy-making in terms of correlations between policy inputs (such as demands from various social groups or past policy legacies) and policy outputs (such as specific pieces of legislation) the strength of institutional analysis is to show why policy inputs and policy outputs may be linked together in different ways in different political systems.

THE PROBLEM

National health insurance constitutes an excellent case for institutional comparison. Nearly every West European government has considered proposals for national health insurance, that is, compulsory public programs that insure citizens for medical treatment. Although the same health programs have been proposed, however, the policy results differ. Political conflicts over national health insurance have resulted in large differences in the role of government in health care provision. The causes of these different results are not self-evident. Not only have policy-makers deliberated quite similar proposals, but similarly situated interest groups seem to have interpreted their interests in similar ways.