Reviews/Comptes rendus
Early Modern Concepts for a Late Modern
World: Althusius on Community and
Federalism
by Thomas O. Hueglin. Waterloo, ON: Wilfrid
Laurier University Press, 1999. Pp. ix, 265. $39.95.
Thomas Hueglin, a professor of political science at
Wilfrid Laurier University, claims we have much to
learn from an early seventeenth-century political
theorist whose views on the state were never really
influential and who is now mostly forgotten.
Johannes Althusius (1557–1638) was German and
lived in the dangerous period of religious and political turmoil immediately preceding the rise of the
European territorial state system. Politica, his major work, first published in 1603 and subsequently
revised and expanded, envisaged an alternative to
that system. Now that the European territorial states
are collapsing, and the age of European Union is
upon us, Hueglin maintains that Althusius’ political
theory — which calls for a social contract, popular
sovereignty, and a pact of federated communities
— is relevant today in a way it could never have
been before.
This is a plausible argument, and Hueglin pursues it with admirable energy, but scholars and pragmatic policymakers alike are certain to find
difficulties with it. It is plausible because
Althusius — as Gierke pointed out over a hundred
years ago — was the first complete social contract theorist. The social contract helped early modern theorists
to find room for individual freedom within the state,
without reducing the state to an instrument of individual freedom. But, as Hueglin himself notes, Gierke
failed to emphasize that Althusius’ social contract is
not one among free individuals but among cultural
241
communities, notably cities and provinces. Such a contract, in my view, would not only allow Europeans to
use their cultural communities for individual ends, but
also, over time, force them to choose between cultural
community and individual freedom. It is a recipe for
both anarchy and tyranny, as Hobbes — a far less naive political theorist — would have insisted, had he
known of Althusius’ theory.
The flaw in Hueglin’s argument appears when he
links Althusius with Aristotle’s doctrine that man is
a “political animal.” Aristotle regarded the state as
a natural association: individual freedom could only
go as far as particular states permitted. By contrast,
early modern Europeans saw the state as a voluntary association: individual freedom was prior to the
state. Althusius both affirms and denies this individual freedom: his is an unstable compound of ancient and modern, of community and freedom.
The seventeenth century saw the tension in Europe between cultural community and individual
freedom dissolve into anarchy and the rise of the
absolute state. Hueglin regrets this, but fails to explain why it happened, or why the post-sovereign
Europe of our day will be so different. Europeans
may now be post-modern (or pre-modern) in their
cultural outlook, but in economic life they still possess a robust sense of modern freedom. As long as
they relate to one another and to the European Union primarily through their particular cultural communities they are bound to fall into conflict, more or less
violent, and to demand some new Leviathan. Only then
will they be confident that laws will be generally
obeyed. And Althusius will once again be forgotten.
KENNETH KIERANS, University of King’s College
CANADIAN PUBLIC POLICY – ANALYSE DE P OLITIQUES,
VOL . XXVII, NO . 2 2001
242 Reviews/Comptes rendus
Accidental Logics: The Dynamics of Change in
the Health Care Arena in the United States,
Britain and Canada
by Caroline Hughes Tuohy. Oxford University Press,
1999. Pp. xiii, 312. $88.00.
This book tries to present a way of thinking about
the evolution of the health-care systems of three
nations, culturally similar but very different in the
approaches they took to organizing health care.
Tuohy proposes to look at the various system’s evolution through the lens of punctuated evolution or
path dependence. Her essential argument is that history matters; and that the path a nation followed in
getting to its present position plays a major role in
determining where it will go in the future. Further,
the path that a nation followed can best be understood by looking at how its political circumstances
(the size of electoral majority, for example) interacted with its political institutions and its underlying political philosophy.
The basic idea of the book is sound: it is often
argued, for example, that the American system
reached its present chaotic state as a result of a series of policy interventions, each aimed at dealing
with one specific problem, each designed and implemented with no serious consideration of how they
might interact with earlier interventions, and with
no serious attempt to design a coherent system. That
Tuohy ultimately fails in the attempt to provide a
coherent framework for understanding healthsystem change is probably a matter of the accidents
simply overwhelming any logic that might be
present. Certainly nobody else has been any more
successful in trying to find logic here, accidental or
otherwise.
For each of the three systems, she gives a brief
history of its early stages, passes quickly over its
middle years, then discusses recent changes. This
structure, perhaps dictated by word limits, works
against Tuohy’s objective, since it leaves out so
much of the essential detail of the various paths fol-
CANADIAN PUBLIC POLICY – ANALYSE DE POLITIQUES,
lowed. In her discussion of the UK, for example,
pre-Thatcher reforms are mentioned only in passing, despite the fact that understanding why those
earlier efforts were made, and how they failed, is
essential to understanding that the Thatcher reforms
were not simply free market ideology turned loose.
David Owen discovered, on becoming British minister of health, that the geographical distribution of
hospitals in his day was unchanged from that of the
Victorian era, despite the shifts that had occurred in
the geographic distribution of the population. Private Victorian philanthropists had done a better job
than the state system of putting the hospitals where
the people were. Similarly, Tuohy’s discussion of
the American experience of the 1960s neglects the
impact of Vietnam. Lyndon Johnson was much more
committed to social programs than Jack Kennedy
had ever been, but his hands were tied by the need
to continue to pay for Kennedy’s (then still popular) war.
Perhaps the biggest weakness of this work, however, is its failure to give enough weight to the possibility that some ideas are good and some are bad.
Consider the Clinton reform effort, for example. Tuohy
quotes Bill Clinton on how the plan was caricatured
by its opponents as an example of a massive, intrusive
government program intended to control every aspect
of health care and remove all individual freedom of
choice. In fact the Clinton plan did not need to be caricatured: it was a caricature, all thousand odd pages of
it. It failed not because of clever advertising by the
insurance industry: in one Newsweek poll, 62 percent
of respondents called the “Harry and Louise” ads dishonest. It failed because it was a bad plan. The Clinton
plan was a typical Ira Magaziner plan, grand, interventionist, and basically everything its Republican
opponents said it was. It was not one of the better
Magaziner-type plans, and it did immense damage to
hope for serious reform of American health care. Similarly, perhaps the reason the changes Tony Blair has
made to the post-Thatcher National Health Service are
more cosmetic than real is because the Thatcher reforms actually did not do too badly.
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Ultimately, Tuohy fails to fit health-system reform
into a consistent theoretical framework, and one of the
most valuable features of the book is that she is quite
explicit about where her framework fails. Nevertheless, this is a very useful book. In the process of attempting what may be the impossible, she has given
243
as good a summary as one is likely to find of the facts
of recent policy changes in the three systems. As a
reference source alone, this is a book worth owning.
BRIAN FERGUSON , Department of Economics, University of Guelph
CANADIAN PUBLIC POLICY – ANALYSE DE P OLITIQUES,
VOL . XXVII, NO . 2 2001
244 Reviews/Comptes rendus
Precarious Values: Organizations, Politics and
Labour Market Policy in Ontario
by Thomas R. Klassen. Montreal and Kingston:
McGill-Queen’s University Press for the School of
Policy Studies, Queen’s University and the Institute
of Public Administration of Canada, 2000. Pp. xx,
200. $24.95.
Values are precarious, according to Thomas Klassen,
when “they are not widely shared or strongly held
by the groups with political, social, and economic
power” (p. 3). Values regarding labour market policy
have certainly been precarious in Canada over the
past 25 years. This lack of common values has resulted in a steady succession of contentious strategies, programs, and agencies at both the federal and
provincial levels, and significant dissatisfaction with
their performance. This holds true even for issues
such as training, where there is widespread agreement that training and the development of a training culture is a good thing. Values are still precarious
because there is disagreement about the type of training that should be provided, who should provide it,
who should receive it, and who should pay for it.
Given the precarious values, any organization
responsible for labour market policy will face considerable difficulties. This is the basic premise of
Thomas Klassen’s book. He describes the creation
and demise of two such organizations in Ontario:
the Ministry of Skills Development and the Ontario
Training and Adjustment Board.
The Ministry of Skills Development was announced in 1985 and its original mandate was to
rationalize the existing labour programs and their
federal-provincial responsibilities, ensure that youth
initiatives are linked to training and employment,
and develop a comprehensive skills development
policy. Over time, the ministry was also given responsibility for more social policy type goals such
as literacy, and training for persons with special
needs and in targeted groups. After a promising start,
the ministry floundered and it was dismantled in
stages. By 1990, over half of its programs were
CANADIAN PUBLIC POLICY – ANALYSE DE POLITIQUES,
transferred to other ministries and the remaining
programs were slated to be transferred to the proposed Ontario training board.
In 1993, after a long and difficult development
period, the Ontario Training and Adjustment Board
took over the remaining programs of the Ministry
of Skills Development. The board was an ambitious
attempt at corporatism; made up of representatives
from business, labour, education, and social action
groups. Unfortunately, the combination of precarious values and a structure that made it difficult for
members to act independently meant that the parties could not find much common ground. There was
little agreement on policy or administration and the
board was subsequently dissolved in 1996.
Klassen was a policy advisor in the Ontario government from 1986 to 1996 so, in addition to published government documents and interviews, his
sources include participant observation and an insider’s access to personalities and confidential materials. While references to confidential documents
and interviews raise some questions about attributions and whose point of view is being presented,
confidentiality is a prerequisite for this sort of work
and Klassen certainly appears to be even-handed in
his treatment.
Klassen does not discuss labour market policy
directly, except in so far as it affects the organizations. Klassen’s focus is solely on the organizations
and his treatment is detailed and insightful. The clear
writing, rich detail and descriptions of the players
makes the book quite compelling at times. The author helps the reader master the large amounts of
detail by including an index, chronology, list of dramatis personae, and a list of acronyms.
As for the analysis, the author examines internal
factors (such as the mandate, structure, and leadership of the organization) and external factors (such
as the prevailing political and economic conditions,
and the organization’s position and status in the
bureaucracy) that affected the rise and fall of the
VOL. XXVII , NO . 2 2001
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245
organizations. The central thesis is that the organizations’ failures were due to precarious values, specifically; fundamental disagreements about what the
organizations should be doing, how it should be
done, the organizations’ position and power within
the governments’ bureaucracy, and the historical
animosity between the stakeholders. The conclusions include lessons to be learned from the events
and a recommendation for an organizational model
that may coordinate labour market policy effectively.
discussion of the actual labour market policies and
the problems of federal-provincial relations would
have been useful, the book offers valuable insights
about why labour market policies and agencies fail.
For anyone interested in public administration, organization theory or the politics of the labour market, the book provides two excellent case studies
which are interesting in their own right and could
be used for class projects at either the graduate or
undergraduate level.
Klassen’s book covers a lot of ground in a short
space and it is certainly worth reading. While more
F ELICE M ARTINELLO , Department of Economics,
Brock University
CANADIAN PUBLIC POLICY – ANALYSE DE P OLITIQUES,
VOL . XXVII, NO . 2 2001
246 Reviews/Comptes rendus
The Making and Meaning of Hospital Policy in
the United States and Canada
by Terry Boychuk. Ann Arbor, MI: The University
of Michigan Press, 1999. Pp. xix, 178. $42.50.
Canadians, puzzled as to why the United States, a
world leader in so much, has never been able to find
a way to have public health insurance, need wonder
no longer. Boychuk, in this remarkable book, traces
the difficulty back to the Elizabethan Poor Laws.
Developments since colonial times produced a twotier system: public hospital care for the poor and
private, voluntary hospital care for those with means.
The author contrasts and compares this with the way
hospital insurance came about in Canada.
From earliest times, the Elizabethan Poor Laws
made local government responsible for charity. Later,
when Christian denominations began to build hospitals, they were financed from the beginning on fees.
Charity cases were the responsibility of the municipal
authorities, which, as times went by, built public hospitals in the larger centres. In Canada, this segregation
was never a problem since the law specified that all
hospitals receiving public aid would be public institutions accepting any sick person who came to the door.
The preface to the book explains what each chapter is about. The first one is a general introduction,
in which he compares and contrasts the two national
systems. Chapter two is devoted to the development
of hospital policy in Canada. Chapters 3 to 5 trace
developments in the US from colonial times to the
present. The final chapter summarizes his thesis and
presents his conclusions.
In Boychuk’s view, the American Hospital Association (AHA) can take full credit for the failure to
develop a comprehensive public health plan for hospital care. He documents how at every juncture,
when something began developing that might end
up in a rational approach to the problem, the AHA
would be there, adamantly in opposition, flanked
most often by the American Medical Association. It
is instructive to learn that in Canada, too, it was the
CANADIAN PUBLIC POLICY – ANALYSE DE POLITIQUES,
intransigence of organized medicine that stood in
the way of employing a single-pay health insurance
system. According to Boychuk, the only way that
the health reformers in Canada could advance was
to drop any idea of a comprehensive plan, and concentrate on finding a way to fund hospital care,
something that the doctors reluctantly supported.
In the US, President Truman favoured a publicly
financed and administered health insurance system,
but southern Democrats and Republicans opposed
it. “Beyond Congress, proposals for national health
insurance faced the implacable hostility of the medical profession, voluntary hospitals, commercial and
non-profit insurance carriers and assorted business
lobbies” (p. 135).
Hospitals have traditionally found it hard to make
ends meet. In Canada, public money from provincial
and municipal governments helped. In the US, public money could be used for poor relief, but not for
hospitals. Public hospitals, built on a Poor Laws
foundation, eventually appeared, in larger centres,
for charity cases. The private, voluntary hospitals
which popped up everywhere, depended on funds
from fees and donations in order to get by. In the
post-World War II period in Canada hospital insurance came to the rescue. In the US, charity cases
outside the larger centres were a problem for the
social conscience. US voluntary hospitals, always
on the verge of bankruptcy found a most useful ally
in the development of the Blue Cross system. The
latter made it possible for those employed of moderate means to pre-pay hospital charges, bringing
in much needed revenue. The AHA fully supported
this, but subsequently in the 1960s did an aboutface, and instead of taking their customary stance
of opposing public funds for hospital support, actually lobbied for the legislation in Congress in the
1960s which brought in Medicaid and Medicare.
These Acts put federal money at the disposal of the
private, voluntary hospitals in smaller as well as
larger centres, with no strings attached, to pay for
the unemployed and the elderly. The AHA thereby
found a way to help keep their hospitals solvent,
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and at the same time head off any drive to rationalize the system, through the use of a single payer.
Much more lies in store for the readers of this
tightly written and informative book. It might have
been improved by an explanation of what were the
reasons for the opposition of the AHA, and the
AMA. Was there an economic argument that could
have been advanced? Or was it purely ideological?
Still, it is an excellent addition to the literature.
247
This book is a must for students of health policy,
and should be read also by politicians, health administrators, and the general public. As a result,
public debate would be much richer.
J.A. BOAN, Professor Emeritus, University of Regina
CANADIAN PUBLIC POLICY – ANALYSE DE P OLITIQUES,
VOL . XXVII, NO . 2 2001
248 Reviews/Comptes rendus
The Nonprofit Sector in Canada: Roles and
Relationships
edited by Keith G. Banting. Montreal and Kingston:
McGill-Queen’s University Press and School of Policy
Studies, Queen’s University, 1999. Pp. x, 268. $22.95.
Virtually all writings on the nonprofit sector in
Canada begin with two observations: that the
nonprofit sector is of growing importance and that
we know very little about it. The preface to this book
is no exception to this rule. Arising from a series of
research projects sponsored by the School of Policy
Studies at Queen’s University and funded by the
Kahanoff Foundation’s Non-profit Sector Research
Initiative, the book presents a collection of diverse
articles designed to inform us on a variety of subjects related to this sector.
At first glance, the table of contents gives the
reader an uneasy feeling that the thread linking these
papers together is rather thin: just because research
was funded by the same organization does not provide adequate justification for lumping them together in one volume. However, I have to admit that
as I read through the diverse papers — on homecare,
on religious nonprofit organizations, on accountability and collaboration, on ethnocultural associations
— I began to see that the real thread that binds these
papers together is one that illuminates their differences rather than forcing conformity among the diverse members of this sector. These papers paint in
fine detail several trees in what has hitherto been
depicted as a mass of green forest: by examining
these few trees, the reader gains an appreciation of
the complexity of the issues surrounding the
nonprofit sector.
The book begins with a well-written review by
Michael Hall and Keith Banting of what we know
in general about the nonprofit sector (the forest),
providing a nice backdrop for the papers that follow. Four of the papers rely on a small number of
CANADIAN PUBLIC POLICY – ANALYSE DE POLITIQUES,
case studies to illustrate a particular facet of
nonprofit provision. Jenson and Phillips, for instance, look at a couple of cases reflecting two models of community-care provision. Phillips and
Graham’s discussion on accountability and collaboration relies on a few case studies. Dart and
Zimmerman zero in on two charitable organizations
in Ontario in order to say something about the effects of engaging in revenue-generating activities
in order to fund charitable endeavours. Finally,
Kobayashi focuses on the role played by the Canadian Ethnocultural Council to look at ethnocultural
group participation in Canadian public policy.
Two papers conduct their own surveys of special
subgroups within the Canadian nonprofit sector.
Handy and Cnaan look at social service provision
by religious organizations in Ontario, interviewing
members from some 46 organizations in Kingston,
London, and Toronto. While Brown, Troutt and
Boame cast light on the nonprofit sector in Manitoba by surveying a small subsample of this sector,
uncovering several interesting areas for future study.
There are a number of reasons why people interested in the nonprofit sector might want to read this
book. First, it presents several in-depth analyses of
important facets of this sector, leading the reader to
a broader understanding of the intricacies that define this sector. Second, the papers are written by
researchers working in a variety of disciplines —
economics, political science, public administration,
and geography, to name a few — and hence provide
a nice introduction to the various lenses through
which this important sector may be viewed. And,
finally, the papers are well-written and researched,
and represent a useful entree into this small but
growing area of research.
R OSE A NNE D EVLIN , Department of Economics,
University of Ottawa
VOL. XXVII , NO . 2 2001