Gerard. W. Boychuk

History, Institutions, and History, Institutions, and Health Insurance:Health Insurance:The Development of Public Health The Development of Public Health Insurance in the United States & CanadaInsurance in the United States & Canada

Gerard. W. BoychukGerard. W. Boychuk

Presented to the McMaster/Guelph Public Policy and Presented to the McMaster/Guelph Public Policy and Administration Program, February 2004Administration Program, February 2004

National Stereotypes – Canada National Stereotypes – Canada and the United Statesand the United States

““Canada...is a more...statist, collectivity-oriented... Canada...is a more...statist, collectivity-oriented... society than the United States.” society than the United States.”

S.M. Lipset, S.M. Lipset, Continental Continental DivideDivide

““The differences between the two countries are The differences between the two countries are particularly striking with respect to the role of particularly striking with respect to the role of government in medical care.”government in medical care.”

S.M. Lipset, S.M. Lipset, Continental Continental DivideDivide

OverviewOverview

differences in public policy regarding health differences in public policy regarding health insurance in the US and Canadainsurance in the US and Canada

theories of public policy – generating theories of public policy – generating hypotheseshypotheses

theories of public policy – empirical resultstheories of public policy – empirical resultsalternative explanationsalternative explanationsconclusionconclusion

OverviewOverview




Differences – Differences – Public Policy & Health Public Policy & Health Insurance in the US & CanadaInsurance in the US & Canada

1.1. Public health insurance in Canada covers ½ of Public health insurance in Canada covers ½ of all health-related expendituresall health-related expenditures

– covers hospital and physician care but not covers hospital and physician care but not prescription drugs or long-term care (among other prescription drugs or long-term care (among other things)things)

2.2. Universal public health insurance (Medicare) in Universal public health insurance (Medicare) in the US the US

– for those over 65 (deductibles, premiums and co-for those over 65 (deductibles, premiums and co-payments)payments)

– expenditures on health services for those over 65 expenditures on health services for those over 65 covers about ½ of all health-related expenditures in covers about ½ of all health-related expenditures in the USthe US


3.3. Third-party provision of insurance for Third-party provision of insurance for publicly-insured services is effectively publicly-insured services is effectively prohibited in Canada.prohibited in Canada.

4.4. Public expenditures on health insurance in Public expenditures on health insurance in American states are comparable to (and in American states are comparable to (and in some cases, higher than) public some cases, higher than) public expenditures in Canadian provinces.expenditures in Canadian provinces.

– Medicare and MedicaidMedicare and Medicaid

0

500

1000

1500

2000

2500

HEALTH EXPENDITURES, TOTAL PUBLIC, 1996$US per capita (ppp=1.17)

CDA

US


5.5. US health insurance -- coverage and US health insurance -- coverage and public regulationpublic regulation

– state regulation of private insurancestate regulation of private insurance– guaranteed issue legislationguaranteed issue legislation

– pre-existing condition legislationpre-existing condition legislation

– community-rating legislationcommunity-rating legislation

– guaranteed renewal legislationguaranteed renewal legislation

– mandatory loss ratiomandatory loss ratio

varies widely by statevaries widely by state

No RegulationNo Regulation Limited Limited Regulation (1-3)Regulation (1-3)

Moderate Moderate Regulation (4-5)Regulation (4-5)

Strong Strong Regulation (6-8)Regulation (6-8)

AlabamaAlabama

ArkansasArkansas

MichiganMichigan

PennsylvaniaPennsylvania

Alaska, ArizonaAlaska, Arizona

Colorado, Colorado, DelawareDelaware

Florida, GeorgiaFlorida, Georgia

Kansas, IllinoisKansas, Illinois

Indiana, Indiana, MassachusettsMassachusetts

Maryland, MissouriMaryland, Missouri

MontanaMontana, , NebraskaNebraska

N. Carolina,N. Carolina,

New MexicoNew Mexico

Nevada, Nevada, OklahomaOklahoma

Rhode IslandRhode Island

S. DakotaS. Dakota

Tennessee, TexasTennessee, Texas

Virginia, WisconsinVirginia, Wisconsin

West VirginiaWest Virginia

CaliforniaCalifornia

ConnecticutConnecticut

IdahoIdaho

IowaIowa

LouisianaLouisiana

MinnesotaMinnesota

OhioOhio

OregonOregon

South CarolinaSouth Carolina

UtahUtah

WyomingWyoming

KentuckyKentucky

MaineMaine

North DakotaNorth Dakota

New JerseyNew Jersey

New HampshireNew Hampshire

New YorkNew York

VermontVermont

WashingtonWashington


6.6. Provision of Health ServicesProvision of Health Services– both systems based primarily on private, for-both systems based primarily on private, for-

profit physician practiceprofit physician practice– both systems rely primarily on not-for profit both systems rely primarily on not-for profit

(or government-owned) hospitals(or government-owned) hospitals varies by statevaries by state emergency care/non-compensated careemergency care/non-compensated care

HOSPITAL, BY TYPE OF CONTROL, 1997

0%

20%

40%

60%

80%

100%

FL TN TX LA SC AL UT AZ CA WV WV GA AR KY MS VA OK NH NM CO MO NC IN DC WY ID MA KA OR IL AK OH HI NY WA MD PA CT ME ND NE MI MT IO NJ WI MN SD DE RI VT

Profit

NFP

State and Local


public health insurance is universal in Canada public health insurance is universal in Canada and categorical in the USand categorical in the US

public health insurance in Canada is compulsory public health insurance in Canada is compulsory – private provision of insurance for publicly-insured private provision of insurance for publicly-insured

health services is prohibited in Canada but not in the health services is prohibited in Canada but not in the USUS

main differences are in funding (single-public-main differences are in funding (single-public-payer in Canada, and multiple-payer in the US) payer in Canada, and multiple-payer in the US) not in modes of deliverynot in modes of delivery

OverviewOverview




Broad Broad Category Category of Explanationof Explanation

Explanatory Explanatory VariableVariable

Central Empirical Research QuestionsCentral Empirical Research Questions

Society-Society-CentredCentred





Political Political CultureCulture






Are differences within a particular policy field (e.g. Are differences within a particular policy field (e.g. public health insurance) representative of broader public health insurance) representative of broader differences across policy fields?differences across policy fields?







Is public opinion sufficiently distinct to suggest that it Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values?is based on fundamentally divergent sets of values?








Do the tenor and language of public debates differ Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual debate to a degree that seems likely to effect actual policy outcomes?policy outcomes?









Interest Interest GroupsGroups










Did central interest groups (i.e. AMA and CMA) differ Did central interest groups (i.e. AMA and CMA) differ significantly in their support for/opposition to public significantly in their support for/opposition to public health insurance and did they differ in their structural health insurance and did they differ in their structural ability to wield influence over policymakers?ability to wield influence over policymakers?











Were there significant differences in the extent, Were there significant differences in the extent, structure and organization of private insurance structure and organization of private insurance providers?providers?












Did labour interests differ significantly in their support Did labour interests differ significantly in their support for/opposition to public health insurance and did they for/opposition to public health insurance and did they differ in their structural ability to wield influence over differ in their structural ability to wield influence over policymakers?policymakers?

Broad Category Broad Category of Explanationof Explanation


State-Centred –State-Centred –Political Political InstitutionsInstitutions




GeneralGeneral Are differences within a particular policy field (e.g. Are differences within a particular policy field (e.g. public health insurance) representative of broader public health insurance) representative of broader differences across policy fields and, in the absence differences across policy fields and, in the absence of major institutional changes over time, across of major institutional changes over time, across time?time?





Parliamentary Parliamentary vs. Presidential vs. Presidential SystemsSystems

Were sub-national jurisdictions in one country more Were sub-national jurisdictions in one country more likely to experiment with public policy? (e.g. likely to experiment with public policy? (e.g. prevalence of third party governments)prevalence of third party governments)






Were sub-national jurisdictions in one country more Were sub-national jurisdictions in one country more likely to experiment with public policy? (e.g. likely to experiment with public policy? (e.g. prevalence of third party governments)prevalence of third party governments)

FederalismFederalism Were sub-national jurisdictions more able to Were sub-national jurisdictions more able to experiment with public health insurance? (e.g. experiment with public health insurance? (e.g. institutional differences at the sub-national level, institutional differences at the sub-national level, federal equalization)federal equalization)



State-Centred –State-Centred –Historical Historical InstitutionalismInstitutionalism




Historical Historical ContingencyContingency





Are there historical points at which outcomes Are there historical points at which outcomes appeared to be open and contingent? [Are there appeared to be open and contingent? [Are there points in time where answers to the questions above points in time where answers to the questions above do not provide a compelling explanation for do not provide a compelling explanation for divergent policy developments?]divergent policy developments?]





Are there historical points at which outcomes Are there historical points at which outcomes appeared to be open and contingent? [Are there appeared to be open and contingent? [Are there points in time where answers to the questions above points in time where answers to the questions above do not provide a compelling explanation for do not provide a compelling explanation for divergent policy developments?]divergent policy developments?]

Path Path DependenceDependence

What are the specific processes over time which What are the specific processes over time which either reinforce or transform the development of either reinforce or transform the development of policy? [What is the degree to which answers to the policy? [What is the degree to which answers to the questions above were shaped by a process of questions above were shaped by a process of interaction with earlier policy decisions?]interaction with earlier policy decisions?]

OverviewOverview















Are differences within a particular policy field (e.g. Are differences within a particular policy field (e.g. public health insurance) representative of broader public health insurance) representative of broader differences across policy fields?differences across policy fields?•New Deal – pensions and social assistanceNew Deal – pensions and social assistance








DatDatee

PollsterPollster QuestionQuestion ResponseResponse

19919944

Louis Louis Harris & Harris & Co.Co.

From what you know, if you had to choose From what you know, if you had to choose between the American and Canadian health between the American and Canadian health care systems, which would you prefer?care systems, which would you prefer?

DatDatee


19919944



American – American – 50.4%50.4%Canadian – Canadian – 30.6%30.6%Not sure – Not sure – 19.0%19.0%

DatDatee


19919944




19919966

CBCCBC Based on your own impressions, which Based on your own impressions, which county do you think has the better healthcare county do you think has the better healthcare system – Canada or the United States?system – Canada or the United States?

American – American – 49%49%Canada – 32%Canada – 32%Don’t Don’t Know/No Know/No Answer – 19%Answer – 19%

DatDatee


19919944




19919966

CBCCBC Based on your own impressions, which Based on your own impressions, which county do you think has the better healthcare county do you think has the better healthcare system – Canada or the United States?system – Canada or the United States?

American – American – 49%49%Canada – 32%Canada – 32%Don’t Don’t Know/No Know/No Answer – 19%Answer – 19%

19919988

Zogby Zogby InternatiInternationalonal

Please tell me if you support or oppose…a Please tell me if you support or oppose…a government-run health care plan that covers government-run health care plan that covers everyone in the same way, like the system everyone in the same way, like the system used in Canada. It would be paid for through used in Canada. It would be paid for through taxes and cover all necessary medical costs.taxes and cover all necessary medical costs.

Support – Support – 51%51%Oppose—38%Oppose—38%Not Sure – Not Sure – 11%11%

DateDate PollsterPollster QuestionQuestion ResponseResponse

19881988 Louis Louis Harris & Harris & Co.Co.

In Canada, they have a system of In Canada, they have a system of national health insurance, under which national health insurance, under which the government pays most of the cost the government pays most of the cost of health care for everyone out of taxes, of health care for everyone out of taxes, and the government sets all fees and the government sets all fees charged by doctors and hospitals. charged by doctors and hospitals. Under the Canadian system, people can Under the Canadian system, people can choose their own doctors and choose their own doctors and hospitals. On balance, would you hospitals. On balance, would you prefer the Canadian system or the prefer the Canadian system or the system we have here?system we have here?




Prefer Canadian Prefer Canadian System – 61.0%System – 61.0%Prefer the “system Prefer the “system we have here” – we have here” – 36.80%36.80%Not sure – 2.20%Not sure – 2.20%






As aboveAs above Prefer Canadian Prefer Canadian System – 67.60%System – 67.60%Prefer the system Prefer the system “we have here” – “we have here” – 29.10%29.10%Not sure – 3.40%Not sure – 3.40%






As aboveAs above Prefer Canadian Prefer Canadian System – 67.60%System – 67.60%Prefer the system Prefer the system “we have here” – “we have here” – 29.10%29.10%Not sure – 3.40%Not sure – 3.40%

19951995 Wirthlin Wirthlin GroupGroup

As above.As above. Prefer Canadian Prefer Canadian System – 48%System – 48%Prefer the system Prefer the system we have here – 45%we have here – 45%Not sure – 7%Not sure – 7%

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Pe

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nt

Universal Universal (limits onchoice of doctor)

Universal (with waitinglists)

SUPPORT FOR UNIVERSAL PUBLIC HEALTH INSURANCE COVERAGE, United States, 2003

















•attempted health insurance reforms in the US historicallyattempted health insurance reforms in the US historically









•attempted health insurance reforms in the US historicallyattempted health insurance reforms in the US historically•elite opinion on public health insurance in the US and Cdaelite opinion on public health insurance in the US and Cda

““I don’t see anything socialistic about that I don’t see anything socialistic about that [compulsory health insurance.] It’s absolutely [compulsory health insurance.] It’s absolutely necessary, and I’m going to fight for it until I necessary, and I’m going to fight for it until I die.”die.”


Harry S. Truman, 1959Harry S. Truman, 1959


Harry S. Truman, 1959Harry S. Truman, 1959““You know, Mr. Frost doesn’t like hospital You know, Mr. Frost doesn’t like hospital

insurance either.” insurance either.” Prime Minister Louis St. Prime Minister Louis St.

Laurent Laurent 19571957









•attempted health insurance reforms in the US historicallyattempted health insurance reforms in the US historically•elite opinion on public health insurance in the US and Cdaelite opinion on public health insurance in the US and Cda•rhetoric surrounding public health insurance debatesrhetoric surrounding public health insurance debates

““Health insurance will constitute the next great step Health insurance will constitute the next great step in social legislation.”in social legislation.”

““The concept of universal medical coverage is not The concept of universal medical coverage is not new and the approach by government to seek new and the approach by government to seek support is just the same as it was when first support is just the same as it was when first enunciated by Karl Marx in his Communistic enunciated by Karl Marx in his Communistic Theories of the last century...”Theories of the last century...”

““Health insurance will constitute the next great step Health insurance will constitute the next great step in social legislation.”in social legislation.”

Dr. R. BlueDr. R. BluePresidential Address, 1916Presidential Address, 1916American Medical AssociationAmerican Medical Association

““The concept of universal medical coverage is not The concept of universal medical coverage is not new and the approach by government to seek new and the approach by government to seek support is just the same as it was when first support is just the same as it was when first enunciated by Karl Marx in his Communistic enunciated by Karl Marx in his Communistic Theories of the last century...”Theories of the last century...”

Compulsory Medical Care Needed?Compulsory Medical Care Needed?Public Relations Kit, 1960Public Relations Kit, 1960Saskatchewan Medical AssociationSaskatchewan Medical Association









•attempted health insurance reforms in the US historicallyattempted health insurance reforms in the US historically•elite opinion on public health insurance in the US and Cdaelite opinion on public health insurance in the US and Cda•rhetoric surrounding public health insurance debatesrhetoric surrounding public health insurance debates






Did central interest groups (i.e. AMA and CMA) differ Did central interest groups (i.e. AMA and CMA) differ significantly in their support for/opposition to public significantly in their support for/opposition to public health insurance and did they differ in their health insurance and did they differ in their structural ability to wield influence over structural ability to wield influence over policymakers?policymakers?






Did central interest groups (i.e. AMA and CMA) differ Did central interest groups (i.e. AMA and CMA) differ significantly in their support for/opposition to public significantly in their support for/opposition to public health insurance and did they differ in their health insurance and did they differ in their structural ability to wield influence over structural ability to wield influence over policymakers?policymakers?•complex patterns of support and oppositioncomplex patterns of support and opposition

•both initially supportive [to 1920 in US]both initially supportive [to 1920 in US]•period of divergence – support in Canada (with period of divergence – support in Canada (with exceptions) and opposed in US [1920-1945]exceptions) and opposed in US [1920-1945]•both opposed [after 1950]both opposed [after 1950]








•power of AMA overstated in US casepower of AMA overstated in US case








•power of AMA overstated in US casepower of AMA overstated in US case•““He [FDR] was clearly looking forward to doing He [FDR] was clearly looking forward to doing battle with those fellows in Chicago.” FDR Advisorbattle with those fellows in Chicago.” FDR Advisor








•power of AMA overstated in US casepower of AMA overstated in US case•““He [FDR] was clearly looking forward to doing He [FDR] was clearly looking forward to doing battle with those fellows in Chicago.” FDR Advisorbattle with those fellows in Chicago.” FDR Advisor

•structural power of Canadian physicians structural power of Canadian physicians •e.g. Saskatchewan vs. Californiae.g. Saskatchewan vs. California•physician opposition more muscular in Canada than physician opposition more muscular in Canada than in USin US

•Saskatchewan doctors’ strike (1962)Saskatchewan doctors’ strike (1962)•Quebec specialist strike (1968)Quebec specialist strike (1968)•Ontario doctors’ strike (1986)Ontario doctors’ strike (1986)








United StatesUnited States CanadaCanada

19561956 19561956

Coverage Coverage (% of (% of population)population)

70.1%70.1% 44.7%44.7%

Voluntary Private Insurance Coverage, US & CDA, 1950-56Voluntary Private Insurance Coverage, US & CDA, 1950-56

United StatesUnited States CanadaCanada

19501950 19561956 19561956


50.5%50.5% 70.1%70.1% 44.7%44.7%


United StatesUnited States CanadaCanada CanadaCanada

19501950 19561956 19561956UnadjusteUnadjustedd

19561956AdjusteAdjustedd


50.5%50.5% 70.1%70.1% 44.7%44.7% 54.3%54.3%


United StatesUnited States CanadaCanada CanadaCanada OntarioOntario

19501950 19561956 19561956UnadjusteUnadjustedd

19561956AdjusteAdjustedd

19561956


50.5%50.5% 70.1%70.1% 44.7%44.7% 54.3%54.3% 74.4%74.4%









•voluntary coverage was not more widespread in the voluntary coverage was not more widespread in the US (when reform failed) than in Canada (when US (when reform failed) than in Canada (when reform succeeded)reform succeeded)•private insurance provision more concentrated in private insurance provision more concentrated in CanadaCanada








Did labour interests differ significantly in their Did labour interests differ significantly in their support for/opposition to public health insurance support for/opposition to public health insurance and did they differ in their structural ability to wield and did they differ in their structural ability to wield influence over policymakers?influence over policymakers?

UNIONIZATION RATES, US & CDA, 1920-1995

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1920 1930 1940 1950 1960 1970 1980 1995

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1920 1930 1940 1950 1960 1970 1980 1995

Pe

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1920 1930 1940 1950 1960 1970 1980 1995

Pe

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nt

(%)

CDA

US













Were sub-national jurisdictions in one country more Were sub-national jurisdictions in one country more predisposed to experiment with public policy? (e.g. predisposed to experiment with public policy? (e.g. prevalence of third party governments)prevalence of third party governments)






Were sub-national jurisdictions in one country more Were sub-national jurisdictions in one country more predisposed to experiment with public policy? (e.g. predisposed to experiment with public policy? (e.g. prevalence of third party governments)prevalence of third party governments)

FederalismFederalism Were sub-national jurisdictions more able to Were sub-national jurisdictions more able to experiment with public health insurance? experiment with public health insurance?

•federal equalizationfederal equalization•sub-national institutional differencessub-national institutional differences








Are there historical points at which outcomes Are there historical points at which outcomes appeared to be open and contingent? appeared to be open and contingent?






•prior to 1945 in the USprior to 1945 in the US•to 1965 in Canadato 1965 in Canada







What are the specific processes over time which What are the specific processes over time which either reinforce or transform the development of either reinforce or transform the development of policy? policy?








•effects of categorical coverage in USeffects of categorical coverage in US•political marginalization of the uninsuredpolitical marginalization of the uninsured•displacement effect of private voluntary coverage in the USdisplacement effect of private voluntary coverage in the US

““How worried are you that if you become seriously How worried are you that if you become seriously ill, you will not be able to get the medical care you ill, you will not be able to get the medical care you need because you cannot afford it?”need because you cannot afford it?”

0

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30

40

50

60

Very Somewhat Not Too

USCanada

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30

40

50

60

Pe

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nt

Very Satisfied SomewhatSatisfied

SomewatDisatisfied

Very Disatisfied

SATISFACTION WITH QUALITY OF HEALTH CARE RECEIVED United States, 2003

General Population

Insured

Uninsured








•effects of categorical coverage in USeffects of categorical coverage in US•political marginalization of the uninsuredpolitical marginalization of the uninsured•displacement effect of private voluntary coverage in the USdisplacement effect of private voluntary coverage in the US

•there was nothing automatic or necessary about there was nothing automatic or necessary about these outcomesthese outcomes

•Medicare considerably more expensive than it needed to beMedicare considerably more expensive than it needed to be•voluntary private insurance could create demand for public voluntary private insurance could create demand for public insurance (as it did in Canada)insurance (as it did in Canada)

OverviewOverview




““While it is tempting to view the existence of blacks in the While it is tempting to view the existence of blacks in the United States as a minor issue at most, race is the ghost United States as a minor issue at most, race is the ghost with a permanent seat at the table of American life, the with a permanent seat at the table of American life, the spirit whose existence gives definition to all others.”spirit whose existence gives definition to all others.”

Richard Iton, Richard Iton, Solidarity BluesSolidarity Blues, , 236236

““In countries that are deeply divided along regional In countries that are deeply divided along regional lines...the territorial role of the welfare state is highly lines...the territorial role of the welfare state is highly salient...[...] Canada is a rich case study in the subtle salient...[...] Canada is a rich case study in the subtle interplay between territorial politics and the welfare state. interplay between territorial politics and the welfare state. [...] National social programs developed in the postwar [...] National social programs developed in the postwar years quickly emerged as important instruments of years quickly emerged as important instruments of legitimation for a federal system facing serious regional legitimation for a federal system facing serious regional challenges, and some of the most bitter battles in challenges, and some of the most bitter battles in subsequent decades were fought over which level of subsequent decades were fought over which level of government would control these levers of cultural government would control these levers of cultural definition.”definition.” Keith G. Banting, Keith G. Banting,

“The Welfare State as Statecraft.”“The Welfare State as Statecraft.”

The Politics of Race and Public The Politics of Race and Public Health Insurance in the USHealth Insurance in the USNew Deal and health insurance (1935-40)New Deal and health insurance (1935-40)

– proposed permissive federal-state public health proposed permissive federal-state public health insurance reformsinsurance reforms

– failure circa 1940failure circa 1940 partially due to state recalcitrancepartially due to state recalcitrance

Truman comprehensive national health Truman comprehensive national health insurance reforms (1945-50)insurance reforms (1945-50)– President’s Committee on Civil Rights (1947)President’s Committee on Civil Rights (1947)

endorsed in President’s special message to Congress on endorsed in President’s special message to Congress on civil rights (1948)civil rights (1948)

President’s Committee on Civil Rights (1947):President’s Committee on Civil Rights (1947):– S.V.1. In general: The elimination of segregation, based on race, color, S.V.1. In general: The elimination of segregation, based on race, color,

creed, or national origin, from American life. The conditioning by creed, or national origin, from American life. The conditioning by Congress of all federal grants-in-aid and other forms of federal assistance Congress of all federal grants-in-aid and other forms of federal assistance to public or private agencies for any purpose on the absence of to public or private agencies for any purpose on the absence of discrimination and segregation based on race, color, creed, or national discrimination and segregation based on race, color, creed, or national origin.”origin.”

– S.V.5. For health services: The enactment by the states of fair health S.V.5. For health services: The enactment by the states of fair health practice statutes forbidding discrimination and segregation based on practice statutes forbidding discrimination and segregation based on race, creed, color, or national origin, in the operation of public or private race, creed, color, or national origin, in the operation of public or private health facilities.”health facilities.”

– S.V.6. For public services: The enactment by Congress of a law stating S.V.6. For public services: The enactment by Congress of a law stating that discrimination and segregation, based on race, color, creed, or that discrimination and segregation, based on race, color, creed, or national origin, in the rendering of all public services by the national national origin, in the rendering of all public services by the national government is contrary to public policy; the enactment by the states of government is contrary to public policy; the enactment by the states of similar laws; the establishment by act of Congress or executive order of a similar laws; the establishment by act of Congress or executive order of a unit in the federal Bureau of the Budget to review the execution of all unit in the federal Bureau of the Budget to review the execution of all government programs, and the expenditures of all government funds, for government programs, and the expenditures of all government funds, for compliance with the policy of nondiscrimination… compliance with the policy of nondiscrimination…

Question: Do you think it would be a good idea or a bad idea Question: Do you think it would be a good idea or a bad idea if the Social Security law also provided paying for the doctor if the Social Security law also provided paying for the doctor and hospital care that people might need in the future? (% and hospital care that people might need in the future? (% supporting) 1943.supporting) 1943.

All RegionsAll RegionsThe SouthThe South

TotalTotal 64%64% 66%66%

+500,000+500,000 70%70% ----

100,000-499,999100,000-499,999 59%59% 64%64%

10,000-99,999910,000-99,9999 68%68% 72%72%

2,500-9,9992,500-9,999 64%64% 65%65%

Under 2,500Under 2,500 59%59% 63%63%

FarmFarm 59%59% 68%68%

Source: Schiltz, 1970: 138.

Question: Which of these two plans [for health insurance] would you, yourself, Question: Which of these two plans [for health insurance] would you, yourself, prefer: the proposed plan of the Truman administration which would...provide all prefer: the proposed plan of the Truman administration which would...provide all employed persons and their families with insurance for medical, dental, and hospital employed persons and their families with insurance for medical, dental, and hospital expenses; or the proposed plan of the American Medical Association which would expenses; or the proposed plan of the American Medical Association which would encourage more people to take out medical and hospital insurance with organizations encourage more people to take out medical and hospital insurance with organizations like the Blue Cross or private insurance companies, with the Government providing like the Blue Cross or private insurance companies, with the Government providing money to states and local communities to take of poor and unemployed people who money to states and local communities to take of poor and unemployed people who can’t afford proper medical attention? 1949.can’t afford proper medical attention? 1949.

Truman PlanTruman Plan AMA PlanAMA Plan Neither Neither No OpinionNo Opinion

TOTALTOTAL 33%33% 47%47% 7%7% 13%13%

New New England/Mid England/Mid AtlanticAtlantic

38%38% 40%40% 7%7% 15%15%

East CentralEast Central 31%31% 52%52% 6%6% 11%11%

West CentralWest Central 27%27% 52%52% 4%4% 17%17%

SouthSouth 22%22% 52%52% 11%11% 15%15%

Far WestFar West 37%37% 47%47% 5%5% 11%11%

Source: Mildred Strunk, “The Quarter’s Polls,” Public Opinion Quarterly 13, 2 (Summer 1949): 358. [AIPO – April 6th, 1949]

PUBLIC SUPPORT, GOV'T INTERVENTION IN HEALTH CARE, US, 1937-1965

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1937 1942 1956 1960 1965

Schiltz

Steinmo/Watts

PUBLIC SUPPORT, GOV'T INTERVENTION IN HEALTH CARE, US, 1937-1965

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1937 1942 1956 1960 1965

Schiltz

Steinmo/Watts


– failedfailed

Truman comprehensive national health Truman comprehensive national health insurance reforms (1945-50)insurance reforms (1945-50)– failedfailed

Medicare/Medicaid (1958-1965)Medicare/Medicaid (1958-1965)


– failedfailedTruman comprehensive national health Truman comprehensive national health

insurance reforms (1945-50)insurance reforms (1945-50)– failedfailed

Medicare/Medicaid (1958-1965)Medicare/Medicaid (1958-1965)– Medicare and Medicaid – both replicated Medicare and Medicaid – both replicated

compromises inherent in Social Security Act, 1935compromises inherent in Social Security Act, 1935– enforcement of non-discrimination requirementenforcement of non-discrimination requirement


– failedfailed


Medicare/Medicaid (1958-1965)Medicare/Medicaid (1958-1965)post-1965post-1965

– declining support for Great Society programsdeclining support for Great Society programs

PUBLIC ATTITUDES, GOV'T INTERVENTION IN HEALTH CARE, US, 1964-1976

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1964 1968 1972 1976

Gov't Intervene

Gov't stay out


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Gov't Intervene

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1964 1968 1972 1976

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– failedfailed


Medicare/Medicaid (1958-1965)Medicare/Medicaid (1958-1965)post-1965post-1965

– declining support for Great Society programsdeclining support for Great Society programs

Territorial Politics and Canadian Territorial Politics and Canadian Health CareHealth Care Conference on Reconstruction, 1945Conference on Reconstruction, 1945

– Heagerty Report – a federally financed and Heagerty Report – a federally financed and administered plan for public health insurance was never administered plan for public health insurance was never an option in Canadaan option in Canada

– Green Book proposals droppedGreen Book proposals dropped– failure of Conference on Reconstructionfailure of Conference on Reconstruction

federal cost-sharing for medical, hospital, dental, federal cost-sharing for medical, hospital, dental, pharmaceutical and nursing benefitspharmaceutical and nursing benefits

– reversal of CMA supportreversal of CMA support– Saskatchewan public hospital insurance (1947)Saskatchewan public hospital insurance (1947)

Territorial Politics and Canadian Territorial Politics and Canadian Health CareHealth CareHospital Insurance (1957)Hospital Insurance (1957)

– the ‘accidental reform’– federal provincial the ‘accidental reform’– federal provincial brinkmanshipbrinkmanship

Ontario – key but not keenOntario – key but not keen

– effect – windfall cash for Saskatchewan effect – windfall cash for Saskatchewan enabling the advent of provincial medical (e.g. enabling the advent of provincial medical (e.g. physician care) insurance plan 1962physician care) insurance plan 1962

Territorial Politics and Canadian Territorial Politics and Canadian Health CareHealth Care Medicare (1965)Medicare (1965)

– Saskatchewan 1962Saskatchewan 1962 reinforced opposition of CMAreinforced opposition of CMA spurred adoption of alternative health plans in other provinces spurred adoption of alternative health plans in other provinces

(e.g. voluntary private insurance)(e.g. voluntary private insurance)– Alberta, BC, Ontario, QuebecAlberta, BC, Ontario, Quebec

– public opinion poll (1965)public opinion poll (1965)– 52% preferring voluntary approach, 41% preferring a 52% preferring voluntary approach, 41% preferring a

compulsory plan [Toronto Star]compulsory plan [Toronto Star]

– the advent of universal physician care insurance looked the advent of universal physician care insurance looked tenuous!tenuous!

Territorial Politics and Canadian Territorial Politics and Canadian Health CareHealth CareMedicare (1965)Medicare (1965)

– Quebec and territorial politicsQuebec and territorial politics political crisis in Quebec (1960s)political crisis in Quebec (1960s) Quebec federalism victories (university grants, QPP, Quebec federalism victories (university grants, QPP,

opting out)opting out) Quebec beginning to move on health insuranceQuebec beginning to move on health insurance strong public support in Quebec for Medicarestrong public support in Quebec for Medicare

Support for Medicare, January 1968Support for Medicare, January 1968

CDACDA QBQB ONON West West

Federal gov’t should bring in Medicare as Federal gov’t should bring in Medicare as promisedpromised

55%55% 64%64% 49%49% 55%55%

Medicare should be postponedMedicare should be postponed 19%19% 20%20% 19%19% 19%19%

Medicare should be droppedMedicare should be dropped 19%19% 12%12% 23%23% 19%19%

Can’t sayCan’t say 7%7% 4%4% 9%9% 7%7%

Source: Taylor, 1987: 391.

Territorial Politics and Canadian Territorial Politics and Canadian Health CareHealth Care Medicare (1965)Medicare (1965)

– Quebec and territorial politicsQuebec and territorial politics political crisis in Quebecpolitical crisis in Quebec Quebec federalism victories (university grants, QPP, opting Quebec federalism victories (university grants, QPP, opting

out)out) Quebec beginning to move on health insuranceQuebec beginning to move on health insurance Quebec public support for MedicareQuebec public support for Medicare

– the federal strategythe federal strategy social development tax (“health insurance tax”)social development tax (“health insurance tax”)

Territorial Politics and Canadian Territorial Politics and Canadian Health CareHealth CareCanada Health Act, 1984Canada Health Act, 1984

– problem of extra-billingproblem of extra-billing federal loss of power under EPFfederal loss of power under EPF

– extra-billing banned...extra-billing banned... BC and QuebecBC and Quebec important ramifications for territorial politicsimportant ramifications for territorial politics

Territorial Politics and Canadian Territorial Politics and Canadian Health Care Health Care the politics of fiscal unsustainability (1990-2004)the politics of fiscal unsustainability (1990-2004)

– tension in federal-provincial relationstension in federal-provincial relations fiscal arrangements (EPF, CHST) combined with CHAfiscal arrangements (EPF, CHST) combined with CHA

– ““...our current system is not sustainable, the principles of ...our current system is not sustainable, the principles of the Canada Health Act are at risk and health care as we the Canada Health Act are at risk and health care as we know it will not survive the end of the decade.”know it will not survive the end of the decade.”

Premier Pat Binns (PEI)Premier Pat Binns (PEI)Communique, Council of the Communique, Council of the

FederationFederation February 25February 25thth, 2004, 2004– declining public confidence in the Canadian health care declining public confidence in the Canadian health care

systemsystem

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In a state of crisis Basically in goodshape

dk/na/refuse

VIEW OF HEALTH CARE SYSTEM, US & CDA, 2002

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Conclusions...Conclusions... comparison between the two countries provides critical comparison between the two countries provides critical

leverage in understanding development of public health leverage in understanding development of public health insurance within each countryinsurance within each country– simple differences between US & CDA (e.g. political culture, broad simple differences between US & CDA (e.g. political culture, broad

institutional differences) are not sufficient to explain the complexity of institutional differences) are not sufficient to explain the complexity of the divergent development of public health insurance in each countrythe divergent development of public health insurance in each country

history and context mattershistory and context matters– history mattershistory matters

sequencing is importantsequencing is important but also historical contextbut also historical context

– institutions are important but they operate within a given historical institutions are important but they operate within a given historical contextcontext

much historical institutional policy analysis is much historical institutional policy analysis is unduly institutionalistunduly institutionalist and and insufficiently historicalinsufficiently historical in orientation in orientation

– be wary of arguments positing historical contingency and path be wary of arguments positing historical contingency and path dependencedependence

these are patterns that must be empirically establishedthese are patterns that must be empirically established

Documents

Gerard. W. Boychuk