Studies in American Political Development

The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy 9

a1 Yale University


Government-sponsored health insurance is a central pillar of the modern welfare state. In advanced industrial democracies, public spending on medical care accounts for an average of 6 percent of gross domestic product (GDP), making it the largest category of social spending after public pensions. 1 Despite the popularity and resilience of established health programs, however, the introduction of government-sponsored health coverage has been highly controversial everywhere. Few social programs involve the state so directly in the workings of the economy and the practice of a powerful profession. Few entangle the interests of so many diverse and resourceful groups. And few cast in such stark relief the ideological principles at stake. Although the participants in conflicts over health policy have differed from nation to nation, no country has acquired national health insurance without a fierce and bitter political fight.


9 For helpful comments on the manuscript, I thank Peter Hall, John Kingdon, David M ayhew, Theodore Marmor, Theda Skocpol, and especially Paul Pierson. Oona Hathaway supported my efforts with her usual congenial mix of love, advice, and patience. I am also grateful for the thoughtful and detailed responses of two anonymous reviewers and for the assistance of the journal editors. An earlier draft of this essay was delivered at the 1997 annual meeting of the American Political Science Association, where it was commented on by Eric Einhorn and Sven Steinmo.

1 Computed from Organization for Economic Cooperation and Development, The Reform of Health Care Systems: A Review of Seventeen OECD Countries (Paris: Organization for Economic Cooperation and Development, 1994), 38. The comparison with pensions is made by Karl Hinrichs, “The Impact of German Health Insurance Reforms on Redistribution and the Culture of Solidarity,” Journal of Health Politics, Policy and Law 20 (1996): 653–87.