June 21, 2005
Parting At The Crossroads
My apologies for stepping in Matt Holt's territory, but I was preparing this quick post before Ezra's intervention (which makes it even more relevant), so I'd thought I'd go ahead anyway. I wanted to strongly recommend Antonia Maioni's superb book Parting at the Crossroads, which is a comparative study of the emergence of different health care policies in the United States and Canada. To put it in Brad Plumer's terms, Maioni (like Brad) emphasizes the importance of structural factors, with some additional explanations based on Canadian federalism and party politics.
The Canadian case is particularly illuminating because it allows us to control for factors that are not controlled for in comparisons to Europe. Maioni's study makes it clear that three of the factors adduced by Plumer have been overrated in their importance. The strength of organized labor cannot explain the difference because at the time Canada developed its single-payer system organized labor was significantly weaker in Canada than in the U.S. The opposition of interest groups also doesn't give you much leverage, since the Canadian Medical Association was just as steadfastly opposed to single-payer at the time as the AMA. Finally, while path dependence explains why single-payer has endured, it cannot explain why Canada created a different system, since they started from a similar point. The key factor, then, is the political institutions. Canada's centralized Parliamentary system allowed for major changes that the veto-point laden Madisonian institutions of the United States have not. I haven't read Jill Quadagno's book, but as Plumer describes it a comparative analysis makes clear that she left out the most important factor. As Sven Steinmo titled his article about the failure of Clinton's attempted reform, "it's the institutions, stupid."
As a final note, another interesting aspect of Maioni's book is that the Parliamentary system causes federalism to have somewhat different effects than in the U.S. Federalism can mitigate major reform, in that lots of policies are left with a large number of subgovernments , but it can also facilitate innovation. In the Canadian system, where it's far easier for the federal government to pass major legislation, these innovations have a greater chance of becoming national policy than in the U.S. And this is what happened in Canada. Socialized medicine was first created in Saskatchewan by the government of Tommy Douglas (whose party was the CCF, the forerunner of the modern moderately socialist NDP.) The CCF/NDP used its regional base to get enough seats to exert some influence on national government, as the Liberals wanted to co-opt them. Once the Liberals decided they wanted to do it, the relative autonomy of the Canadian state allowed them to do it despite interest group opposition. Unfortunately, this can't really be replicated in the United States. Until a rare opportunity like 1937 or 1965 comes along, I'm not sure any strategy can make major health care reform viable.
TrackBack URL for this entry:
Listed below are links to weblogs that reference Parting At The Crossroads:
Ah, many thanks! One minor point that maybe I wasn't clear enough on: As far as labor goes, it seems that the problem wasn't really that unions in the United States were weak. When labor did decide to organize and push for reform -- as it did with disability insurance and later Medicare -- it got what it wanted. The problem is that too often labor wasn't even pushing for health care reform. Some of that was accidental, some of it was due to the personalities involved, and some of it was due to that dreaded "path-dependence" (for instance, George Meany thought labor would be better served by negotiating better benefits with companies directly rather than by lobbying Congress for national health care.)
Anyway, sounds like an interesting book!
Posted by: Brad Plumer | Jun 21, 2005 8:35:44 PM
Brad--I think the error was mine, not yours; I was speaking of labor as a factor more broadly than the more nuanced point you were making. (Certainly, the particular strategy of organized labor may help explain why some form of socialized medicine didn't emerge during the Johnson administration.)
Speaking of good books by Canadian-based scholars, I've been meaning to discuss your post about Ran Hirschl's book for a while--maybe later this week...
Posted by: Scott Lemieux | Jun 21, 2005 9:18:46 PM
In 1937 we were still grappling with the Great Depression. Why was Medicare able to get through in 1965?
Posted by: Abby | Jun 21, 2005 10:05:29 PM
Abby--just an unusual confluence, when there was a very progressive President with huge majorities in both houses of Congress (and exceptional abilities to leverage Congress) and the momentum of the civil rights struggle, which blunted the influence of Southern Senators.
Posted by: Scott Lemieux | Jun 21, 2005 10:14:02 PM
Great comment Scott. And of course we need a parliament and a King here too...ho ho. Interesting to see that even Churchill when he was prime minister in the 1950s in the UK would not allow the Conservatives to try to overturn the "socialist's experiment" which of course included the National Health Service. The answer is that the US needs either an overwhelming electoral victory (1964) or a national crisis (1932) to get anything done. The issue is (as I'll expound later in the week) that we might get there.
Posted by: Matthew Holt | Jun 21, 2005 11:22:37 PM
Posted by: peter.w | Sep 16, 2007 9:41:48 PM
The comments to this entry are closed.