ABSTRACT
This article analyses the evolution over the last twenty years of two important interrelated policy changes involving a major restructuring of Spanish political institutions: regional decentralization and health care reform. Focusing on (1) the political decentralization of health care policy; (2) the formulation and implementation in Spain of the British NHS model; and (3) the ‘reform of the reform’ undertaken in the Spanish health care system in the 1990s, the main conclusions are that major policy reforms are especially difficult when they involve substantial transfers of powers to subnational governments or private agents. The successful completion of such ambitious reform seems to require a combination of political elites’ intense preferences and citizens’ extensive preferences for the reform model. Generally, the historical coincidence of intense and extensive political preferences depends on the existence of a common cultural heritage concerning the ways in which different institutions work.
