The Development of National Medical Care Programs in the United Kingdom and Canada: Applicability to Current Conditions in the United States

Abstract

After a hiatus in the early to mid-1980s, a growing number of policy leaders, policy organizations, and citizen groups are advocating programs that ensure basic medical care for all. Although a large literature examines the applicability to the U.S. of national medical care programs that have been established in other countries from the perspective of operations and effectiveness, little attention has been given to the applicability of the experience of other nations in securing these programs. This paper examines the development of national programs in the U.K. and Canada and addresses two questions. First, what factors were critical to the establishment of the British National Health Service and the Canadian hospital and physician insurance programs? Second, how applicable are those factors to current conditions in the U.S.? The paper reviews the roles played by dislocations in society, by established models of state-sponsored medical care programs, by political institutions and leaders, and by the major medical sectors. It shows that the U.S., while differing in many particulars, presents several parallels to the U.K. and Canada. The paper argues that the current environment in the U.S. offers the nation the opportunity to develop at state or local levels government-sponsored programs that guarantee basic medical benefits to all. A new and powerful coalition, moreover, may in the coming years advance the cause of broader, more substantive change at the national level.

Back to the Future? Health Benefits, Organized Labor, and Universal Health Care

“…By tying citizens closer to the paternalistic state, Bismarck aimed to weaken the attraction of the rival Social Democrats (Rimlinger 1971: 112 -113). In the case of Great Britain, it is also hard to discern much of a part for business in the establishment of the National Insurance Act of 1911 and the subsequent creation of the National Health Service shortly after World War II (Fox 1986;Hollingsworth 1986: 124;Navarro 1994: 143 -144;Sakala 1990). While there is no ironclad consensus on why national health insurance took root in Canada, by most accounts business played only a negligible role.…”

The Making of National Health Insurance in Britain and Canada: Institutional Analysis and its Limits

“…The second logical pitfall derives from studies that overemphasize the impact of national constitutions and the formal decision-making rules of government. For example, Sakala (1990) and Steinmo and Watts (1995) argue that parliamentary regimes have an inevitable legislative advantage over American style governments that are limited by the separation of powers. Even more frequently, scholars assert that a Arguing that a decentralized political system hinders the development of national policies while ignoring the way in which decentralization can be a prod used to force national action federal form of government inhibits the enactment of national programs.…”

“…He contends that states in competition for business investments are reluctant to introduce legislation that will increase the cost of doing business within their borders. Similarly, analysts strongly agree that the enactment of Canadian health policy was held hostage to resolution of jurisdictional disputes between the provinces and a weak federal government (see Taylor 1978;Orloff 1993;Sakala 1990;Weller and Manga 1983; see discussion below). Without negating the importance of these factors, I contend that these institutional structures were less stable than these arguments would suggest.…”

“…In contrast to studies privileging class conflict or macroeconomic structures, scholars working within this framework emphasize the preeminent role of formal state structures, political parties, and administrative capacities in explaining the evolution of social policies across societies. Recently this approach has been used to explain the development of varying health insurance systems in western industrialized societies facing many of the same economic and social problems (see Steinmo and Watts 1995;Maloni 1995;Immergut 1992;Orloff 1993;Sakala 1990). Although these scholars focus on different cases and reflect varying points of view, their work is undergirded by the assumption that national traditions, embodied in formal political structures, are the decisive factors explaining health policy outcomes.…”

Financing Universal Health Insurance: Taxes, Premiums, and the Lessons of Social Insurance

“…Unlike the German sickness funds, the approved societies only handled cash disability benefits whereas medical benefits were administered by insurance committees at the county level (Falk 1936). Over time, the commercial insurers surpassed the friendly societies in importance (Sakala 1990). The complexity of these multiple administrative bodies led Beveridge (1942) to call for unified public administration of social insurance in Britain, with elimination of the approved societies and their high administrative costs.…”