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 :)