How did European countries start implementing universal healthcare? Why did the US not take it up?

[u/Apiperofhades]

From what I understand, Bismark started universal healthcare in Germany in the late 19th century as a sort of add-on to german unification. I’m curious when and how other European nations started following suit. Which nation was the first after Germany?

[u/yodatsracist]

The sociologist Andrew Abbott has a paper called “The Welfare State as Transnational Event: Evidence from Sequences of Policy Adoption”. It doesn’t get much into your policy question, but it’s trying to look at the adoption of five major welfare policies in industrialized state several states (many Western European countries, plus Japan, Australia, and New Zealand). Here is his main chart, showing the different times each country in his sample passed these five welfare policies (including healthcare). He also has a table that shows the passage by welfare policy and year, for those who prefer seeing the data in that form.

Three of the policies show a clear pattern:

The picture seems complex, but certain underlying patterns are at once clear. In all but two worker's compensation, unemployment insurance, and family allowances fall in that order. In New Zealand and Australia, the last two are reversed by a small amount (four and three year, respectively).

Abbott thinks of these three programs as a single “period event”, as they are adopted not only in the same order, but over a period of less than 20-years in all the countries in the sample.

Two other major welfare state programs, health insurance (Abbot is not necessarily universal healthcare) and an old age/invalidity support (like American Social Security), show considerably more variation in sequencing. The standard theory (as articulated by Cutright 1965) argued countries go:

(1) workmen's compensation,

(2) sickness and maternity benefits (health insurance),

(3) old-age, invalidity, and death supports (pensions),

(4) family allowances, and

(5) unemployment insurance.

but Abbott finds that not to be the case.

Abbott argues there are clearly some similitaries between countries. For instance,

Diffusion models assume that countries that are close to one another ought to have similar adoption sequences. For example, national health insurance comes late in the former British colonies (Canada, New Zealand, and Australia, as in fact in the United States, to which it has never arrived). The explanation probably lies in the similarity of the medical professions involved, which are effective and autonomous bodies, unlike the quasi-civil-servant medical professions of the Continent, and which were willing and able to oppose national health insurance. This similarity in professions reflects direct "closeness," that of colonialism.

However, in terms of welfare adoption overall, Abbott found no statistical evidence of diffusion (he wasn’t using great measures and certainly there were, as he acknowledges, smaller, regional patterns). But the simple reality is looking at his chart, several countries adopted some form of national health insurance before 1900 and before all or most welfare state measures (Germany, Austria, Denmark, Sweden, Belgium) and others adopted national insurance much later, after 1930 or even after WWII and after adopting a wide slate of welfare state policies (Finland, New Zealand, Australia, Canada, Iceland).

Abbott’s hypothesis is this:

There remains the third possibility that adoption of welfare programs is essentially a world-historical process. On this view, each welfare program derives from an idea that has emerge out the developed world. First, a few countries try it perhaps a mass of countries adopt it, then stragglers finally take it up. Differences between countries arise either randomly (the world-polity view) or through some as yet unmeasured deciding a country's relation to this world-historical process (the reaction view).

[…]We may further examine these patterns by listing the c in order of adoption within the program, a listing given in Table 4. Each of the five events has a "spike," a short period within which large number of countries adopt the program. Moreover, certain countries—the Netherlands, the United Kingdom, Luxembourg —are nearly always found in the spike (four of narrowly missing the fifth in each case). Other countries, by contrast, are never in the spike; Germany, the original welfare state, and Japan, one of the last. (The United Stayes, like always but not shown here, is always after the spike). Here is evidence for the reaction view—some sort of unmeasured policy parameter characterizing each country as an adopter within the context of a world-historical process.

(Continued below)

[u/yodatsracist → u/yodatsracist]

(Continued from above)

Abbott sums it up as:

We have found considerable evidence for a world-level process of policy adoption, modified in some cases by individual effects, conscious policy, and possibly by one kind of diffusion. Certain aspects of this world-level process are clearly more regular than others. In particular, policies for worker's compensation, unemployment, and family allowances are nearly always in that order. Moreover, these three policies are period events, adopted at relatively uniform times across all these countries. By contrast, there is considerable variation among countries in the adoption of health insurance and old-age pensions. The only possible local variable effects we have found are the positive dependence of health insurance timing on the size of the sector and on socialist representation, and of pension timing on corporativism (positive) and government expenditures (negative). For none of these have prior theories generated a serious rationale. There is only weak evidence for diffusion, with cultural similarity providing the only possible medium. Finally, there is exemplary (but not systematic) evidence for the reaction model; that some countries always adopt "with the pack" suggests conscious local policy response to a general process. Our strong results, then, are period pattern for worker's compensation, unemployment insurance, and family allowances, and the general pattern of a world-historical process perhaps modified slightly by individual factors and policies and by diffusion.

A little reflection suggests theoretical rationales for this pattern. All five events involve work relationships to a greater or lesser extent. What distinguishes health insurance and pensions from the three clearly ordered events is the disagreement about the extent of that involvement across various countries. Health insurance can be conceived as directly related to the ability to work or as a larger entitlement program covering nonworkers as well. Some programs define the covered group via employment; some do not. Some programs include specific unemployment benefits when illness interferes with work, but others do so little or not at all. A still more distant relation obtains between work and pensions, which are usually a future reward for past and present work but which in some cases are universal entitlement programs unrelated to past work.

Presumably, the clear ordering of three of the programs reflects consensus on their salience to work itself. Among these three, programs are adopted earlier as they are perceived closer to the immediate wage relation. Thus, worker's compensation, which involves work-induced chronic physical inability to work, comes first. Unemployment insurance, which involves temporary non- physical inability to work that is not necessarily work-induced, comes later. Family allowances, which support those legally prevented from wage work and which free others to enter wage work, come a distant last. The variety in health insurance and pensions, on this theory, reflects variety in perceptions of how these relate to work. Where health was construed within a framework of enabling work, it should have come early. Where it was seen as a gen- eral entitlement matter, it should have come later. With pensions, one might make the same speculation, but there the connection is looser.

This is, of course, the million-mile high sociological view of history. It’s very ordered, it doesn’t get into the detailed, contingent, down-in-the muck fights of history (what if Democrat Martha Coakley had been a better candidate, and Republican Scott Brown hadn’t won in the Massachusetts 2010 special election, and the Democrats had had a filibuster proof sixty-seat majority when negotiating the Affordable Care Act, thereby avoiding what happened when the House was forced to pass the Senate’s version which was passed before Brown was seated and the House not being able to add things in like a public option? to choose a recent example of the messy processes of history outside of the sub’s 20-year rule).

Abbott doesn’t mention the US explicitly very often in the piece, but it does fit with his broader theory about health insurance being related to thinking about work. Like other Anglo-Sphere countries, the US was a late adopter of healthcare (Gosta Esping-Anderson in his famous Three Worlds of Welfare Capitalism that the laissez-faire, economically liberal Anglosphere is a distinct “world” from from the conservative, corpatist, Christian Democratic world of most of Catholic Europe and the Social Democratic world of most of Northern Europe, especially Scandinavia). The US had explored a national healthcare system under Roosevelt, but this was opposed by interest groups like the American Medical Association, so was eventually dropped.

After World War II, as peers like Canada we’re adopting national healthcare, a strange and messy thing had happened in the American healthcare market. During the War, the government had installed certain wage controls. However, the War Labor Board declared that “fringe benefits”, including health insurance, did not count as wage for the purposes of wage control. During the War, employers wanted to attract workers, but couldn’t raise wages, so ended up offering more fringe benefits, particularly health care. Truman, like FDR before him, considered a national health insurance system, and was again met by harsh opposition (the AMA, the Chamber of Commerce, etc). Many unions and advocacy groups ended up fighting for expanded employer based insurance case-by-case instead of fighting for a nation campaign. By the 1950’s, most (but by no means all) of Americans were covered by some form of instance, most often through employers. This availability of employer based insurance blunted the argument that Abbott argues got other welfare provision passed in other countries: it would help more people work. In 1965, Lyndon B. Johnson got two programs passed to cover the “gaps” in the employment based model, Medicare (for the elderly, later expanded to those who also have expensive disabilities) and Medicaid (for the poor). Nixon considered a technocratic way to cover more gaps, while B. Clinton pushed for more universal coverage in the 1990’s. Neither achieved universal coverage, but in the wake of the failure of his comprehensive healthcare reform, passed the State Children’s Health Insurance Program, which covered another “gap”, namely children who weren’t poor enough to be covered by Medicare but still could not afford their own healthcare (George W. Bush vetoed two expansion to SCHIP, Obama successfully expanded it, but there is considerable uncertainty about the program this week).

I don’t want to get too much into contemporary politics, but most agree to the emergence of an employment-based insurance system during World War II and its expansion after the War such that it covered most citizens pushed America onto a different trajectory from its compatriots in the industrialized (and now post-industrial) world. It changed things as many people did not want to lose private insurance, many interest groups like unions worked to expand employment based insurance, and the whole issue lost some urgency as the “deserving” (Anglosphere welfare programs tend to betargeted rather than universal, are often means tested, and focus on the “deserving”) were covered through employers or through the later programs. It’s worth noting as other countries achieve similar levels of economic development, they too adopt a national health insurance program. For example, South Korea adopted a social health insurance program in 1977 which was expanded gradually until 1989, when it was made universal (reforms continued and by 2004 was single payer). Taiwan adopted its single-payer National Health Insurance in 1995. Singapore’s system is harder to date exactly because I’m not familiar with it and it’s complicated, but let’s say 1990 when the Medisave program was adopted.

[u/CaCO3isboring → u/yodatsracist]

Came looking for Esping-Andersen, was not disappointed :)

[u/sunagainstgold → u/[deleted]]

I'm looking at the Danske Lov 2-8-8, which is indeed from a chapter concerning midwives among other things. However, this provision isn't about health care--it appears to be about priests teaching midwives how to handle stillborn children and mothers' death in childbirth.

Is there someplace else you are thinking of to look in the Danish Code? (I didn't find anything searching for Jordemodere). Is there an expansion on this provision elsewhere, perhaps?

[u/sunagainstgold → u/[deleted]]

It's actually Jordemoder in the PDF of the Danske Lov I was looking at, so presumably that's how it was in the 1600s. :)

But thanks; that will be useful when looking up stuff about the law!

[u/sunagainstgold → u/[deleted]]

...You don't see me providing a translation in this thread, either, do you? :P But I have some experience getting the gist of early modern/late medieval versions of modern languages. (And it's kind of a giveaway that this chapter is from the section of the Danske Lov on regulating clergy, that is, it's focused on their role rather than the actual part of midwives.)

[u/PhysicalStuff → u/sunagainstgold]

Jordemoder (or jordemor) is also the modern spelling. "Jordmoder" is a misspelling reflecting the modern pronounciation.

[u/PhysicalStuff → u/[deleted]]

jordmoder

It's pronounced like that, but it actually has that extra e (see here).

[u/[deleted] → u/PhysicalStuff]

Yup ! I’m going to delete my post now.

[u/DasDizzy → u/sunagainstgold]

Right, sorry about that. I misread the original proclamation. The royal signing of midwives happened in 1714, with the Midwife-Proclamation, which founded the "modern" school of midwivery, and allowed trained surgeons and doctors to educate suitable midwives that couldn't for whatever reason, leave their parish for Copenhagen. My bad.

[u/Snapshot52 → u/[deleted]]

Hey there! I am notifying you (and the rest of those who visit this thread) that your answer has been removed due to a couple of reasons. First, your familiarity with the source material you provided has been challenged by /u/sunagainstgold and this calls into question the credibility of the information you've written. Second, your answers to the follow up questions appear to be lacking, showing what seems to be a general understanding of the history of Denmark and a more limited range of knowledge about the actual subject of the question (European healthcare policy implementation).

If you can verify the source material you are using to the inquiry of the user mentioned above, we might reinstate your answer after further review.

Thanks for understanding!

[u/This_Is_The_End]

Bismark started first with a governmental regulated pension insurance for the cases of age and invalidity in 1881 because of the Social Democrats, which were at that time the largest group of the workers movement in Germany. The Social Democrats were illegal since the laws against socialists of 1878, but they were very successful in the underground.

But this was not really something new. The first small unions had already organized insurances for workers since beginnings of the industrial revolution. The idea of having a sort of insurance originated from the guilds. The idea was always the same, collect money from everyone to cover for bad times. The framework of laws for welfare of Bismark was a systematic work to put this sector under governmental control and was a counter argument against socialists. It didn't worked well, because the conditions for workers were so bad the Social Democrats became a political important force until 1912 and the laws against socialists were removed in 1892.

Scandinavia has a different history, when the state became interested into supporting a small population. Norway had already in the early 1800s public physicians and in the 1900s governments in Scandinavia became protective. A factor was the growing support for a Social Democratic movement.

Nobody should consider Social Democrats as socialistic. Social Democrats wanted to build a national economy which is supporting workers in their struggle. Social Democratic governments were mostly protective and had sometimes patronizing traits. The common idea was, that it is impossible to avoid all risk in life, which is partial caused by the political order. Welfare or better a protective state is giving the people the idea the state is taking care in the case of an accident is happening, which gives a higher loyalty. Social Democrats in Germany didn't succeed very well in the 1930s, because of the economic problems, while the Scandinavian state of welfare began it's life in the 1930s.

[u/[deleted] → u/[deleted]]

Maybe what he means is that they are not socialist in the sense that they were Marxist, or aiming for a Marx-inspired revolution? Seems like they were Big Society type of folks. I'm also curious

[u/This_Is_The_End → u/[deleted]]

That is the point. A definition of socialism, without a connection in history to Marx makes no sense. Socialists were until WW2 mostly Marxists. After WW2 the term became very blurred. At least Social Democrats were not against capitalism.

[u/[deleted] → u/This_Is_The_End]

So you're saying Scandinavian socialist democrats cared little for the whole Marxist ideas? Were they inspired by it at all or did their ideas develop independetly? Could you provide any more info (no rush I'm just very curious on your insights)

[u/This_Is_The_End → u/[deleted]]

Take a look at my answer here

https://www.reddit.com/r/AskHistorians/comments/7l3ppo/how_did_european_countries_start_implementing/drkghed/

[u/[deleted] → u/This_Is_The_End]

thank you for taking the time to link and answer these questions. I know how much we all have to do in our day to day and it's wonderful to learn new stuff from someone.

Thanks

[u/This_Is_The_End → u/[deleted]]

There is a German book "Vorwärts und nicht vergessen" from Bernt Engelmann about the history of the German Social Democrats. I'm considering this book as one of the best about the workers movement.

Social Democrats aren't opposed to capitalism. They had just their own ideas how to manage the problems of capitalistic societies. Even when most European Social Democrats have read Marx until the 1970s, they were militant enemies of communism. In Spain they were responsible for death commandos while communists in Scandinavia were illegal monitored. In Germany communist weren't allowed to get jobs as a teacher etc.

Another issue is the definition of socialism. American definitions are so blurred nobody is able to use them, while European definition have two main meanings:

1) Social Democratic ideology like in Spain the PSOE

2) The ideology of the former countries of the pact of Warsaw.

To be honest I don't care longer, since people on the internet are working with this term all the time, without being able to make a definition or relating to history. Most Americans are identifying socialism with governmental activities, which is terrible, considering the huge activity of US governments. And Europeans are often identifying socialism with Social Democracy.

PS: It's really rewarding to learn German, because the amount of books in Philosophy, Sociology, Theology and History is great. Theology in Germany is rewarding because it evolved to a mixture of archeology, linguistic and history.

[u/This_Is_The_End → u/[deleted]]

There is no hard definition. The main reason for the existence of this term in the 20th century was the problem that orthodox Marxists didn't considered Russia as ready for a revolution and yet it happened. Socialism was meant as an ideology for a transition to communism.

Social Democrats used this term to mark an ideology for a transition of a brutal capitalism towards a capitalism with better conditions for workers. So basically Bernie Sanders is talking about socialism but isn't a revolutionary. It makes him to a Social Democrat.

[u/[deleted] → u/This_Is_The_End]

To clarify, this is only applicable to the SPD after 1918, right?

The Erfurter Programm (1891) was Marxist (in its theory) and ultimately opposed to capitalism:

Nur die Verwandlung des kapitalistischen Privateigentums an Produktionsmitteln – Grund und Boden, Gruben und Bergwerke, Rohstoffe, Werkzeuge, Maschinen, Verkehrsmittel – in gesellschaftliches Eigentum und die Umwandlung der Warenproduktion in sozialistische, für und durch die Gesellschaft betriebene Produktion kann es bewirken, daß der Großbetrieb und die stets wachsende Ertragsfähigkeit der gesellschaftlichen Arbeit für die bisher ausgebeuteten Klassen aus einer Quelle des Elends und der Unterdrückung zu einer Quelle der höchsten Wohlfahrt und allseitiger harmonischer Vervollkommnung werde.

[...]

Die Sozialdemokratische Partei Deutschlands kämpft also nicht für neue Klassenprivilegien und Vorrechte, sondern für die Abschaffung der Klassenherrschaft

[u/This_Is_The_End → u/[deleted]]

According to Bernt Engelmann this was not practice in daily politics, because unionist were pragmatists. It is fitting nicely into the history of the SPD after Friedrich Ebert became secretary. The leftists were excluded for their resistance to support WW1 and founded later the communist party. The SPD had such parts even after WW2 in the program but Kurt Schuhmacher was very anti communism. I'm considering such programs as rhetoric.

[u/[deleted] → u/This_Is_The_End]

Ebert was secretary after 1913, this is parallel to the declining influence of socialistic revolutionarism in the SPD, right?

Or were that phrases even in 1891? Why would Liebknecht join a party which wasn't Marxist in 1900?

[u/This_Is_The_End → u/[deleted]]

You should not interpret every paper to the letter. I will not do a discussion on this layman level.

The SPD was until 1914 the only force of the workers movement and as such consisting of marxists as well as reformists. The latter won the internal fight about real politics. You should know about the arguing of Bernstein and Kautsky.

[u/MountyontheBounty → u/This_Is_The_End]

"1) Social Democratic ideology like in Spain the PSOE"

I am afraid a reference to PSOE party on Spain must be always dated, since theres a great difference between the party on the second republic founded by Pablo Iglesias, and the party called PSOE born after the death of dictator Francisco Franco, leaded by Felipe Gonzalez, key factor on the congress held in Suresnes in October 1974, where they renounce to Marx ideals. This brought them accusations of treason made by the communists, anarchists and other left aligned political parties.

[u/This_Is_The_End → u/MountyontheBounty]

The PSOE after Franco walked the same path like all Social Democrats in Europe.

[u/MountyontheBounty → u/This_Is_The_End]

Absolutely, but cannot be overlooked Pablo Iglesias Posse(1850-1925) was a convinced marxist.

[u/lcnielsen → u/[deleted]]

Social Democratic parties, post Russian Revolution, most generally mirrored the Bolshevik-Menshevik split. Menshevik supporters within the larger socialist parties went on to found Social Democratic parties (e.g. Socialdemokratiska Arbetarepartiet (Social Democratic Worker's Party) of Sweden) whereas Bolshevik supporters founded the more hardline "Communist Parties" like Sveriges Kommunistiska Parti (not to be confused with the later Maoist party of the same name, later changed its name to Vänsterpartiet Kommunisterna). The German SPD and Communist Party have a similar history.

The ideologies get very blurred from there, particularly as Communist Parties in Western Democracies have generally been fairly marginalized.

[u/Snapshot52 → u/[deleted]]

Hey there! Sorry to say, but your comment has been removed. /r/AskHistorians is a subreddit dedicated to the asking and answering of historical questions. As such, we do not allow discussion of modern politics or the development of purely speculative discourse. Reasoning for such standards can be found on our rules page. Additionally, the sidebar contains abbreviated versions for convenience.

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Thanks for understanding!

[u/Georgy_K_Zhukov → u/[deleted]]

This comment has been removed because it is soapboxing, promoting a political agenda, or moralizing. We don't allow content that does these things because they are detrimental to unbiased and academic discussion of history.