Why Do Anglo-Saxons like Single Payer?
There will be short posts today and tomorrow, as I finish up a work project.
Peter Hall and David Soskice distinguish three different types of welfare states: a Liberal model, a Universalistic model, and a Christian Democratic model. These typologies will all coexist within countries, but they capture important tendencies. In the liberal model, the poor are given vouchers so that they can choose which goods to purchase in the private sector, such as food stamps or housing vouchers. America, Canada, Australia, and the UK are all inclined to structure programs in this manner. In the universalist model, the government provides a service to free of charge to everyone in the population regardless of income. This generous model is sometimes associated with the Nordic countries, but all developed world, have public education systems based on this principle.
Finally, the Christian Democratic model involves an element of moralism in program eligibility. Rather than citizens having a right to a Liberal voucher or Universalistic service, the welfare state is reconceived more as a two-way moral compact than as an entitlement. Think of programs to house the homeless that demand sobriety or work requirements for cash assistance. This model is variously criticized for relying on faulty notions of a “deserving poor,” creating administrative burdens that keep the needy out, or being too paternalistic in their prescriptions. On behalf of this model, conservatives argue these restrictions engender behaviors and cultures that are in poor’s longterm interest.
Generally, the Anglosphere countries prefer the Liberal model, with America opting for a healthy dose of the Christian Democratic model as well. That makes it so striking that the non-American Anglo nations have by far the most statist healthcare systems. The UK is basically alone in having the government own all the hospitals and leave a minuscule role for private insurers outside the NHS. Canada has fairly skimpy single-payer system (which does not even cover prescription drugs!). New Zealand had an almost entirely government system until the 80’s, when the market was granted a secondary role in the insurance market. This Anglo-Saxon single payer fixation contrasts to generally more activist European governments that merely regulate prices than become the main insurer themselves.
My very rough theory is that European governments have a grater culture of the public and private sectors collaborating. This tradition leaves government better equipped to competently monitor and advise something as complicated as private health insurance markets and hospital price setting. For example, in setting up German vocational training the government works hand and glove with large employers to determine needed skills. That sort of cozy relationship looks like corruption to those with more liberal inclinations. Meanwhile, the private sector actors have a greater sense that they are semi-public in their mission, rather than just seeking profits. Here is a speculative example: perhaps they don’t need as many costly regulations banning price discrimination, because they would not engage in the highly exclusionary pricing American insurers did before Obamacare. Both sides are more nimble and so can pull off a system of public oversight and private sector restraint.
Meanwhile, the liberal economies have a sharp sense of public and private. The public sectors here has a reflexively adversarial stance to private entities, rather than seeing it as their job to work alongside companies to make the industry more effective overall. (For evidence, just look to the NRC or FDA). Meanwhile, our private sector has more of a “Greed is Good” mentality that can lead to disaster in healthcare.
In a sense we end up with such a statist system, because of our comparative inexperience in doing a lighter touch mixed approach in other sectors.