History Institutions and Health Insurance The Development of

History, Institutions, and Health Insurance: The Development of Public Health Insurance in the United States & Canada Gerard. W. Boychuk Presented to the Mc. Master/Guelph Public Policy and Administration Program, February 2004

National Stereotypes – Canada and the United States “Canada. . . is a more. . . statist, collectivity-oriented. . . society than the United States. ” S. M. Lipset, Continental Divide l “The differences between the two countries are particularly striking with respect to the role of government in medical care. ” S. M. Lipset, Continental Divide l

Overview l differences in public policy regarding health insurance in the US and Canada l theories of public policy – generating hypotheses l theories of public policy – empirical results l alternative explanations l conclusion

Overview l differences in public policy regarding health insurance in the US and Canada l theories of public policy – generating hypotheses l theories of public policy – empirical results l alternative explanations l conclusion

Differences – Public Policy & Health Insurance in the US & Canada Public health insurance in Canada covers ½ of all health-related expenditures 1. – covers hospital and physician care but not prescription drugs or long-term care (among other things) Universal public health insurance (Medicare) in the US 2. – – for those over 65 (deductibles, premiums and copayments) expenditures on health services for those over 65 covers about ½ of all health-related expenditures in the US

Differences – Public Policy & Health Insurance in the US & Canada Third-party provision of insurance for publicly-insured services is effectively prohibited in Canada. 4. Public expenditures on health insurance in American states are comparable to (and in some cases, higher than) public expenditures in Canadian provinces. 3. – Medicare and Medicaid

Differences – Public Policy & Health Insurance in the US & Canada 5. US health insurance -- coverage and public regulation – state regulation of private insurance – – – l guaranteed issue legislation pre-existing condition legislation community-rating legislation guaranteed renewal legislation mandatory loss ratio varies widely by state

No Regulation Limited Moderate Strong Regulation (1 -3) Regulation (4 -5) Regulation (6 -8) Alabama Arkansas Michigan Pennsylvania Alaska, Arizona Colorado, Delaware Florida, Georgia Kansas, Illinois Indiana, Massachusetts Maryland, Missouri Montana, Nebraska N. Carolina, New Mexico Nevada, Oklahoma Rhode Island S. Dakota California Connecticut Idaho Iowa Louisiana Minnesota Ohio Oregon South Carolina Utah Wyoming Kentucky Maine North Dakota New Jersey New Hampshire New York Vermont Washington

Differences – Public Policy & Health Insurance in the US & Canada 6. Provision of Health Services – both systems based primarily on private, forprofit physician practice – both systems rely primarily on not-for profit (or government-owned) hospitals l varies by state l emergency care/non-compensated care

Differences – Public Policy & Health Insurance in the US & Canada public health insurance is universal in Canada and categorical in the US public health insurance in Canada is compulsory l l – l private provision of insurance for publicly-insured health services is prohibited in Canada but not in the US main differences are in funding (single-publicpayer in Canada, and multiple-payer in the US) not in modes of delivery

Overview l differences in public policy regarding health insurance in the US and Canada l theories of public policy – generating hypotheses l theories of public policy – empirical results l alternative explanations l conclusion

Broad Category of Explanation Society. Centred Explanatory Variable Central Empirical Research Questions

Broad Category of Explanation Explanatory Variable Society. Centred Political Culture Central Empirical Research Questions

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields?

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values?

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes?

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? Interest Groups

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? Interest Groups Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers?

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? Interest Groups Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? Were there significant differences in the extent, structure and organization of private insurance providers?

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? Interest Groups Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? Were there significant differences in the extent, structure and organization of private insurance providers? Did labour interests differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over

Broad Category of Explanation State-Centred – Political Institutions Central Empirical Research Questions

Broad Category of Explanation Central Empirical Research Questions State-Centred – Political Institutions General Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields and, in the absence of major institutional changes over time, across time?

Broad Category of Explanation Central Empirical Research Questions State-Centred – Political Institutions General Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields and, in the absence of major institutional changes over time, across time? Parliamentary vs. Presidential Systems Were sub-national jurisdictions in one country more likely to experiment with public policy? (e. g. prevalence of third party governments)

Broad Category of Explanation Central Empirical Research Questions State-Centred – Political Institutions General Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields and, in the absence of major institutional changes over time, across time? Parliamentary vs. Presidential Systems Were sub-national jurisdictions in one country more likely to experiment with public policy? (e. g. prevalence of third party governments) Federalism Were sub-national jurisdictions more able to experiment with public health insurance? (e. g. institutional differences at the sub-national level, federal equalization)

Broad Category of Explanation State-Centred – Historical Institutionalism Central Empirical Research Questions

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency Are there historical points at which outcomes appeared to be open and contingent? [Are there points in time where answers to the questions above do not provide a compelling explanation for divergent policy developments? ]

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency Are there historical points at which outcomes appeared to be open and contingent? [Are there points in time where answers to the questions above do not provide a compelling explanation for divergent policy developments? ] Path Dependence What are the specific processes over time which either reinforce or transform the development of policy? [What is the degree to which answers to the questions above were shaped by a process of interaction with earlier policy decisions? ]

Overview l differences in public policy regarding health insurance in the US and Canada l theories of public policy – generating hypotheses l theories of public policy – empirical results l alternative explanations l conclusion

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields?

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? • New Deal – pensions and social assistance

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values?

Date Pollster Question 199 4 From what you know, if you had to choose between the American and Canadian health care systems, which would you prefer? Louis Harris & Co. Response

Date Pollster Question Response 199 4 From what you know, if you had to choose between the American and Canadian health care systems, which would you prefer? American – 50. 4% Canadian – 30. 6% Not sure – 19. 0% Louis Harris & Co.

Date Pollster Question Response 199 4 Louis Harris & Co. From what you know, if you had to choose between the American and Canadian health care systems, which would you prefer? American – 50. 4% Canadian – 30. 6% Not sure – 19. 0% 199 6 CBC Based on your own impressions, which county do you think has the better healthcare system – Canada or the United States? American – 49% Canada – 32% Don’t Know/No Answer – 19%

Date Pollster Question Response 199 4 Louis Harris & Co. From what you know, if you had to choose between the American and Canadian health care systems, which would you prefer? American – 50. 4% Canadian – 30. 6% Not sure – 19. 0% 199 6 CBC Based on your own impressions, which county do you think has the better healthcare system – Canada or the United States? American – 49% Canada – 32% Don’t Know/No Answer – 19% 199 8 Zogby Internati onal Please tell me if you support or oppose…a government-run health care plan that covers everyone in the same way, like the system used in Canada. It would be paid for through taxes and cover all necessary medical costs. Support – 51% Oppose— 38% Not Sure – 11%

Date Pollster Question 1988 Louis In Canada, they have a system of Harris & national health insurance, under which Co. the government pays most of the cost of health care for everyone out of taxes, and the government sets all fees charged by doctors and hospitals. Under the Canadian system, people can choose their own doctors and hospitals. On balance, would you prefer the Canadian system or the system we have here? Response

Date Pollster Question 1988 Louis In Canada, they have a system of Harris & national health insurance, under which Co. the government pays most of the cost of health care for everyone out of taxes, and the government sets all fees charged by doctors and hospitals. Under the Canadian system, people can choose their own doctors and hospitals. On balance, would you prefer the Canadian system or the system we have here? Response Prefer Canadian System – 61. 0% Prefer the “system we have here” – 36. 80% Not sure – 2. 20%

Date Pollster Question Response 1988 Louis In Canada, they have a system of Harris & national health insurance, under which Co. the government pays most of the cost of health care for everyone out of taxes, and the government sets all fees charged by doctors and hospitals. Under the Canadian system, people can choose their own doctors and hospitals. On balance, would you prefer the Canadian system or the system we have here? Prefer Canadian System – 61. 0% Prefer the “system we have here” – 36. 80% Not sure – 2. 20% 1991 Louis As above Harris & Co. Prefer Canadian System – 67. 60% Prefer the system “we have here” – 29. 10% Not sure – 3. 40%

Date Pollster Question Response 1988 Louis In Canada, they have a system of Harris & national health insurance, under which Co. the government pays most of the cost of health care for everyone out of taxes, and the government sets all fees charged by doctors and hospitals. Under the Canadian system, people can choose their own doctors and hospitals. On balance, would you prefer the Canadian system or the system we have here? Prefer Canadian System – 61. 0% Prefer the “system we have here” – 36. 80% Not sure – 2. 20% 1991 Louis As above Harris & Co. Prefer Canadian System – 67. 60% Prefer the system “we have here” – 29. 10% Not sure – 3. 40% 1995 Wirthlin Group Prefer Canadian System – 48% Prefer the system As above.

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes?

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? • attempted health insurance reforms in the US historically

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? • attempted health insurance reforms in the US historically • elite opinion on public health insurance in the US and Cda

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

l “I don’t see anything socialistic about that [compulsory health insurance. ] It’s absolutely necessary, and I’m going to fight for it until I die. ” Harry S. Truman, 1959

l “I don’t see anything socialistic about that [compulsory health insurance. ] It’s absolutely necessary, and I’m going to fight for it until I die. ” Harry S. Truman, 1959 l “You know, Mr. Frost doesn’t like hospital insurance either. ” Prime Minister Louis St. Laurent 1957

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? • attempted health insurance reforms in the US historically • elite opinion on public health insurance in the US and Cda • rhetoric surrounding public health insurance debates

l “Health insurance will constitute the next great step in social legislation. ” l “The concept of universal medical coverage is not new and the approach by government to seek support is just the same as it was when first enunciated by Karl Marx in his Communistic Theories of the last century. . . ”

l “Health insurance will constitute the next great step in social legislation. ” Dr. R. Blue Presidential Address, 1916 American Medical Association l “The concept of universal medical coverage is not new and the approach by government to seek support is just the same as it was when first enunciated by Karl Marx in his Communistic Theories of the last century. . . ” Compulsory Medical Care Needed? Public Relations Kit, 1960 Saskatchewan Medical Association

Broad Category of Explanation Explanatory Variable Central Empirical Research Questions Society. Centred Political Culture Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields? Is public opinion sufficiently distinct to suggest that it is based on fundamentally divergent sets of values? Do the tenor and language of public debates differ sufficiently to suggest differences in the broad public consensus constituting boundaries on the terms of the debate to a degree that seems likely to effect actual policy outcomes? • attempted health insurance reforms in the US historically • elite opinion on public health insurance in the US and Cda • rhetoric surrounding public health insurance debates

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? Interest Groups

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? • complex patterns of support and opposition • both initially supportive [to 1920 in US] • period of divergence – support in Canada (with exceptions) and opposed in US [1920 -1945] • both opposed [after 1950] Interest Groups

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? • complex patterns of support and opposition • both initially supportive [to 1920 in US] • period of divergence – support in Canada (with exceptions) and opposed in US [1920 -1945] • both opposed [after 1950] • power of AMA overstated in US case Interest Groups

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? • complex patterns of support and opposition • both initially supportive [to 1920 in US] • period of divergence – support in Canada (with exceptions) and opposed in US [1920 -1945] • both opposed [after 1950] • power of AMA overstated in US case • “He [FDR] was clearly looking forward to doing battle with those fellows in Chicago. ” FDR Advisor Interest Groups

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? • complex patterns of support and opposition • both initially supportive [to 1920 in US] • period of divergence – support in Canada (with exceptions) and opposed in US [1920 -1945] • both opposed [after 1950] • power of AMA overstated in US case • “He [FDR] was clearly looking forward to doing battle with those fellows in Chicago. ” FDR Advisor • structural power of Canadian physicians • e. g. Saskatchewan vs. California • physician opposition more muscular in Canada than in US • Saskatchewan doctors’ strike (1962) • Quebec specialist strike (1968) Interest Groups

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? Interest Groups Were there significant differences in the extent, structure and organization of private insurance providers?

Voluntary Private Insurance Coverage, US & CDA, 1950 -56 United States Canada 1956 Coverage (% of population) 1956 70. 1% 44. 7%

Voluntary Private Insurance Coverage, US & CDA, 1950 -56 United States Canada 1950 Coverage (% of population) 1956 50. 5% 70. 1% 44. 7%

Voluntary Private Insurance Coverage, US & CDA, 1950 -56 United States Canada 1950 Coverage (% of population) 1956 Unadjuste Adjusted d 50. 5% 70. 1% 44. 7% 54. 3%

Voluntary Private Insurance Coverage, US & CDA, 1950 -56 United States Canada Ontario 1950 Coverage (% of population) 1956 Unadjuste Adjusted d 50. 5% 70. 1% 44. 7% 54. 3% 74. 4%

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? Interest Groups Were there significant differences in the extent, structure and organization of private insurance providers? • voluntary coverage was not more widespread in the US (when reform failed) than in Canada (when reform succeeded) • private insurance provision more concentrated in Canada

Broad Explanatory Category Variable of Explanation Central Empirical Research Questions Society. Centred Did central interest groups (i. e. AMA and CMA) differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers? Interest Groups Were there significant differences in the extent, structure and organization of private insurance providers? Did labour interests differ significantly in their support for/opposition to public health insurance and did they differ in their structural ability to wield influence over policymakers?

Broad Category of Explanation State-Centred – Political Institutions Central Empirical Research Questions

Broad Category of Explanation Central Empirical Research Questions State-Centred – Political Institutions General Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields and, in the absence of major institutional changes over time, across time?

Broad Category of Explanation Central Empirical Research Questions State-Centred – Political Institutions General Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields and, in the absence of major institutional changes over time, across time? Parliamentary vs. Presidential Systems Were sub-national jurisdictions in one country more predisposed to experiment with public policy? (e. g. prevalence of third party governments)

Broad Category of Explanation Central Empirical Research Questions State-Centred – Political Institutions General Are differences within a particular policy field (e. g. public health insurance) representative of broader differences across policy fields and, in the absence of major institutional changes over time, across time? Parliamentary vs. Presidential Systems Were sub-national jurisdictions in one country more predisposed to experiment with public policy? (e. g. prevalence of third party governments) Federalism Were sub-national jurisdictions more able to experiment with public health insurance? • federal equalization • sub-national institutional differences

Broad Category of Explanation State-Centred – Historical Institutionalism Central Empirical Research Questions

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency Are there historical points at which outcomes appeared to be open and contingent?

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency Are there historical points at which outcomes appeared to be open and contingent? • prior to 1945 in the US • to 1965 in Canada

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency Are there historical points at which outcomes appeared to be open and contingent? Path Dependence What are the specific processes over time which either reinforce or transform the development of policy?

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency Are there historical points at which outcomes appeared to be open and contingent? Path Dependence What are the specific processes over time which either reinforce or transform the development of policy? • effects of categorical coverage in US • political marginalization of the uninsured • displacement effect of private voluntary coverage in the US

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

Broad Category of Explanation Central Empirical Research Questions State-Centred – Historical Institutionalism Historical Contingency Are there historical points at which outcomes appeared to be open and contingent? Path Dependence What are the specific processes over time which either reinforce or transform the development of policy? • effects of categorical coverage in US • political marginalization of the uninsured • displacement effect of private voluntary coverage in the US • there was nothing automatic or necessary about these outcomes • Medicare considerably more expensive than it needed to be • voluntary private insurance could create demand for public insurance (as it did in Canada)

Overview l differences in public policy regarding health insurance in the US and Canada l theories of public policy – generating hypotheses l theories of public policy – empirical results l alternative explanations l conclusion

“While it is tempting to view the existence of blacks in the United States as a minor issue at most, race is the ghost with a permanent seat at the table of American life, the spirit whose existence gives definition to all others. ” Richard Iton, Solidarity Blues, 236 l “In countries that are deeply divided along regional lines. . . the territorial role of the welfare state is highly salient. . . [. . . ] Canada is a rich case study in the subtle interplay between territorial politics and the welfare state. [. . . ] National social programs developed in the postwar years quickly emerged as important instruments of legitimation for a federal system facing serious regional challenges, and some of the most bitter battles in subsequent decades were fought over which level of government would control these levers of cultural definition. ” Keith G. Banting, “The Welfare State as Statecraft. ” l

The Politics of Race and Public Health Insurance in the US l New Deal and health insurance (1935 -40) – proposed permissive federal-state public health insurance reforms – failure circa 1940 l partially due to state recalcitrance l Truman comprehensive national health insurance reforms (1945 -50) – President’s Committee on Civil Rights (1947) l endorsed in President’s special message to Congress on civil rights (1948)

l President’s Committee on Civil Rights (1947): – S. V. 1. In general: The elimination of segregation, based on race, color, creed, or national origin, from American life. The conditioning by 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 discrimination and segregation based on race, color, creed, or national origin. ” – S. V. 5. For health services: The enactment by the states of fair health practice statutes forbidding discrimination and segregation based on race, creed, color, or national origin, in the operation of public or private health facilities. ” – S. V. 6. For public services: The enactment by Congress of a law stating that discrimination and segregation, based on race, color, creed, or national origin, in the rendering of all public services by the national 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 unit in the federal Bureau of the Budget to review the execution of all government programs, and the expenditures of all government funds, for compliance with the policy of nondiscrimination…

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 and hospital care that people might need in the future? (% supporting) 1943. The South All Regions Total 64% 66% +500, 000 70% -- 100, 000 -499, 999 59% 64% 10, 000 -99, 9999 68% 72% 2, 500 -9, 999 64% 65% Under 2, 500 59% 63% Farm 59% 68% Source: Schiltz, 1970: 138.

Question: Which of these two plans [for health insurance] would you, yourself, prefer: the proposed plan of the Truman administration which would. . . provide all employed persons and their families with insurance for medical, dental, and hospital expenses; or the proposed plan of the American Medical Association which would encourage more people to take out medical and hospital insurance with organizations 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 can’t afford proper medical attention? 1949. Truman Plan AMA Plan Neither No Opinion TOTAL 33% 47% 7% 13% New England/Mid Atlantic 38% 40% 7% 15% East Central 31% 52% 6% 11% West Central 27% 52% 4% 17% South 22% 52% 11% 15% Far West 37% 47% 5% 11% Source: Mildred Strunk, “The Quarter’s Polls, ” Public Opinion Quarterly 13, 2 (Summer 1949): 358. [AIPO – April 6 th, 1949]

The Politics of Race and Public Health Insurance in the US l New Deal and health insurance (1935 -40) – failed l Truman comprehensive national health insurance reforms (1945 -50) – failed l Medicare/Medicaid (1958 -1965)

The Politics of Race and Public Health Insurance in the US l New Deal and health insurance (1935 -40) – failed l Truman comprehensive national health insurance reforms (1945 -50) – failed l Medicare/Medicaid (1958 -1965) – Medicare and Medicaid – both replicated compromises inherent in Social Security Act, 1935 – enforcement of non-discrimination requirement

The Politics of Race and Public Health Insurance in the US l New Deal and health insurance (1935 -40) – failed l Truman comprehensive national health insurance reforms (1945 -50) – failed l Medicare/Medicaid (1958 -1965) l post-1965 – declining support for Great Society programs

The Politics of Race and Public Health Insurance in the US l New Deal and health insurance (1935 -40) – failed l Truman comprehensive national health insurance reforms (1945 -50) – failed l Medicare/Medicaid (1958 -1965) l post-1965 – declining support for Great Society programs

Territorial Politics and Canadian Health Care l Conference on Reconstruction, 1945 – Heagerty Report – a federally financed and administered plan for public health insurance was never an option in Canada – Green Book proposals dropped – failure of Conference on Reconstruction l federal cost-sharing for medical, hospital, dental, pharmaceutical and nursing benefits – reversal of CMA support – Saskatchewan public hospital insurance (1947)

Territorial Politics and Canadian Health Care l Hospital Insurance (1957) – the ‘accidental reform’– federal provincial brinkmanship l Ontario – key but not keen – effect – windfall cash for Saskatchewan enabling the advent of provincial medical (e. g. physician care) insurance plan 1962

Territorial Politics and Canadian Health Care l Medicare (1965) – Saskatchewan 1962 l l reinforced opposition of CMA spurred adoption of alternative health plans in other provinces (e. g. voluntary private insurance) – Alberta, BC, Ontario, Quebec – public opinion poll (1965) – 52% preferring voluntary approach, 41% preferring a compulsory plan [Toronto Star] – the advent of universal physician care insurance looked tenuous!

Territorial Politics and Canadian Health Care l Medicare (1965) – Quebec and territorial politics political crisis in Quebec (1960 s) l Quebec federalism victories (university grants, QPP, opting out) l Quebec beginning to move on health insurance l strong public support in Quebec for Medicare l

Support for Medicare, January 1968 CDA QB ON West Federal gov’t should bring in Medicare as promised 55% 64% 49% 55% Medicare should be postponed 19% 20% 19% Medicare should be dropped 19% 12% 23% 19% Can’t say 7% 4% 9% 7% Source: Taylor, 1987: 391.

Territorial Politics and Canadian Health Care l Medicare (1965) – Quebec and territorial politics l l political crisis in Quebec federalism victories (university grants, QPP, opting out) Quebec beginning to move on health insurance Quebec public support for Medicare – the federal strategy l social development tax (“health insurance tax”)

Territorial Politics and Canadian Health Care l Canada Health Act, 1984 – problem of extra-billing l federal loss of power under EPF – extra-billing banned. . . BC and Quebec l important ramifications for territorial politics l

Territorial Politics and Canadian Health Care l the politics of fiscal unsustainability (1990 -2004) – tension in federal-provincial relations l fiscal arrangements (EPF, CHST) combined with CHA – “. . . our current system is not sustainable, the principles of the Canada Health Act are at risk and health care as we know it will not survive the end of the decade. ” Premier Pat Binns (PEI) Communique, Council of the Federation February 25 th, 2004 – declining public confidence in the Canadian health care system

Conclusions. . . l comparison between the two countries provides critical leverage in understanding development of public health insurance within each country – simple differences between US & CDA (e. g. political culture, broad institutional differences) are not sufficient to explain the complexity of the divergent development of public health insurance in each country l history and context matters – history matters l sequencing is important l but also historical context – institutions are important but they operate within a given historical context l much historical institutional policy analysis is unduly institutionalist and insufficiently historical in orientation – be wary of arguments positing historical contingency and path dependence l these are patterns that must be empirically established