Lessons for (and From) America
2003, Vol 93, No. 1 | American Journal of Public Health 61-63
Rudolf Klein, MA
Rudolf Klein is with the
University of Bath, the London School of Economics, and the
London School of Hygiene and Tropical Medicine.
for reprints should be sent to Rudolf Klein, L 12A Laurier
Road, London NW5 1SG, England.
Drawing lessons from international experience for health care
reform in the United States requires striking a
difficult balance between historical determinism
and free will, between cynical pessimism and naïve
optimism. The key to this puzzle may lie in a
paradox: the United States is the most successful exporter
of public health policy ideas and instruments yet has
failed to build an effective health care system.
General ideas (like notions about the role of competition)
and microinstruments (like diagnosis-related
groups) travel better than do health care systems.
Ideas can be adapted to local circumstances, and
instruments may easily fit into preexisting systems.
Importing systems from countries with different histories
and institutions would require a tectonic shift in
the American political landscape.
INTERNATIONAL COMPARISONS hold out one clear lesson for
the United States: the Declaration of Independence
was a blunder. If only the colonists had been
patient, if only they had tolerated British rule
for a few more decades, they would in due course have
received the blessings of a Westminster-type constitution.
Just like Britain herself, and ex-colonies like Canada
and New Zealand, they would have had a system of
majoritarian government that enables the executive
to enact its legislative program. And given such a
system of majoritarian government, it is almost certain
that the United States would long since have enacted some
form or other of comprehensive health care insurance. As it
is, American exceptionalism is reflected both in its
constitutional arrangements—and the generous
opportunities these offer to special interests to
obstruct, delay, or sabotage legislation even if it
has the support of a majority of the population—and the
lack of anything resembling a scheme of comprehensive health
To draw such a lesson may seem absurd. History is not a
film that can be rerun or remade. In any case, the
central contention is highly questionable.
Constitutional arrangements are surely only part of
the explanation for America’s unique failure among
rich countries to adopt national health insurance, since these
did not prevent the introduction of Medicare and Medicaid
despite the opposition of the medical profession and
The point of going back to the Declaration of Independence
is to remind ourselves about a central dilemma in
any lessondrawing exercise. This is how best to
strike a balance between assuming that history is
all—that the past of individual countries determines
the future—and assuming, contrariwise, that policymakers
have a free hand in adopting whatever foreign exemplars take
their fancy. This article elaborates on this theme: historical
determinism versus free will in lesson drawing—and how
best to steer a course between cynical fatalism and naïve
PRISONERS OF THE PAST?
A strong interpretation of historical determinism would
suggest that policymakers are prisoners of the
past. From this perspective, the notion of path
dependency not only explains past history but also
predicts the future. The ideas, institutions, and interests
inherited from the past shape, and constrain, what can
be done in the present. In the case of the United
States, past policies have created powerful
interest groups (notably for-profit insurers and
providers) with the financial and political resources to resist
attempts to reform the system to their disadvantage.
And they operate within a political system that provides
ample scope for wrecking tactics; witness the
opposition to the Clinton plan.
What, then, is the point of seeking to draw
lessons—about, say, the best way of funding a
comprehensive health care system—from countries
whose history has not created similarly powerful interest
groups and whose political systems do not afford similar
opportunities for wrecking strategies? Skepticism
is compounded when we consider other factors, such
as differences in political culture: can policies
reflecting a commitment to the concept of social solidarity
be exported to a country conspicuously lacking any such
The more optimistic free-will approach would argue that
systems do change, and not always in ways that can
be predicted: social scientists are skilled in
rationalizing ex post facto what has happened in
terms of the specific institutional and cultural inheritance
of individual countries, but accurate ex ante facto predictions
based on these same factors are conspicuously rare. Windows
of opportunity, as we know, do open, often unexpectedly.
However, we badly lack convincing window-opening
theories; we are better at explaining continuities
than discontinuities, paths rather than turnings.
And when windows do open, it will be those policy
advocates with well-grounded proposals and persuasive arguments
(for example, evidence that a particular policy works well
elsewhere) who will be best placed to exploit the opportunity.
So even if foreign exemplars offer options that may seem
totally unrealistic in today’s circumstances,
there is no way of telling when they might become
relevant and appealing. Indeed, optimists might
even argue that acting on the assumption of policy
free will could actually bring it about by stretching the
imaginations and challenging the assumptions of decisionmakers
and the wider public, while historical determinism can
all too easily become self-fulfilling by creating a
corrosive pessimism about the possibilities of
change. In which case, distilling lessons for
America from the experience of other countries becomes a
useful, if contingent, exercise.
The best way of addressing these contrasting views is
perhaps by disaggregating the notion of lesson
drawing by distinguishing between different kinds
of policies and arenas. The politics of systems
reform will be different from the politics of introducing
change within the framework of an existing system. And,
in turn, the politics of within-system change may
vary from issue to issue, bringing different actors
and different interests into play. Some may rouse
ideological passions: the introduction in the 1990s
of mimic markets in Britain’s National Health Service
(NHS) is a case in point.
These changes did not affect the principles or
funding mechanisms of the NHS, but they caused much
outrage—all the more so because they were seen as an
example of lesson drawing from the United States, of all countries
(a warning that the perceived provenance of lessons may
be an important factor in determining their reception). Other
changes may be more technical in character and therefore involve
much smaller but concentrated constituencies, such as the
medical profession, with a passionate self-interest in the
issues at stake.
THE POLITICS OF SYSTEMS
Starting with systems reform, there is indeed one overriding
lesson that emerges from the contributions in this
issue: there is no one lesson or formula for
creating, and funding, the kind of comprehensive,
universal health care system that other advanced countries
take for granted but that the United States has found so
elusive. Germany and France have insurance-based systems;
Britain has a tax-based system. Both models offer a
complex mixture of strengths and weaknesses. The
insurance-based systems appear to be more
successful in creating high-standard services, offering
choice to the consumer. But the method of finance inflates
labor costs, has higher administrative costs than a
tax-based system, and is also less progressive.
Conversely, Britain’s tax-based, progressively
financed system has been conspicuously successful
in containing costs but much less so in terms of standards
of service, let alone consumer choice.
The case of Britain is worth pondering on further as a
warning of the pitfalls of lesson drawing. Lessons
drawn tend to vary over time as perceptions shift.
So, for many decades, Britain was held out as the
supreme exemplar of successful cost containment—as indeed
it was. However, at the turn of the millennium, the Labour
Government decided that the political costs of
successful cost containment were too great. The
medical profession and others who had argued that
the NHS had been seriously underfunded appeared to
be vindicated as the government announced extra billions for
the NHS to cut waiting lists, improve services, and introduce
(eventually) patient choice.
So what conclusion is to be drawn from this turnabout, from
virtue suddenly turning into vice? If tax funding meant
that the NHS was indeed underfunded for the first
50 years of its existence—a dubious, if widely
held, assumption—does this mean that the model is
fundamentally flawed? Or is the appropriate lesson
to draw that the model, despite its flaws, can
still be salvaged? Different answers are likely to be given
to these questions, depending on the relative weight put
on cost containment versus service standards.
If the first lesson to be drawn from the country
contributions is that there are different paths
toward achieving much the same objectives, the
second lesson is therefore that all paths pose
problems for the traveler. Dissatisfaction with existing systems
appears to be the rule. All the countries covered in this
survey are tinkering, to varying degrees, with their systems.
As the country reports show, policymakers are
continuously striving to repair, improve, and
experiment, even in countries that appear to be
doing rather well—particularly when compared with the
If Britain is embarking on radical reform yet again—with
the Labour Government reinventing the mimic market
(market-like mechanisms designed to increase
competition among public-sector providers), so
loudly denounced when originally introduced by Mrs
Thatcher’s administration—this is perhaps no surprise,
given a national consensus that the system has failed to
deliver. But France has been reengineering aspects of its
system, despite placing first in the World Health
Organization’s notorious ranking exercise. In
Germany there is a vigorous political debate about
how to reform the system, while Canada is awash with
commissions and committees investigating options for the future.
If countries are not worrying about spending too little (like
Britain), they are worrying about spending too much (like
There are, of course, good reasons for this. On the one
hand, there are exogenous pressures on health care
systems. Some, like the changing demographic
structure of the population, are general. Others
are specific to Europe: the European Union’s common
currency rules about budget deficits constrain governments
already fiscally stressed as a result of dipping rates
of economic growth. Hence the
preoccupation—Britain always excepted—with cost
containment, an issue that inevitably creeps up the political
agenda when economic indicators slide down. Other
pressures are endogenous to health care systems.
Crossnationally, the configuration of services is
changing and new patterns of practice are
developing. Thus a common theme across European systems is
how to strike a new balance between curative and preventive
interventions, between hospital and primary care.
In short, to add to the traditional criteria for evaluating
health care systems such as comprehensiveness, value for
money, and equity, a new one is now emerging: the
ability of health care systems to adapt and
change—by exploiting, for example, the
opportunities offered by the combination of information technology
and evidence-based medicine. Moving from systems or
macropolicymaking to the next level of technical or
micropolicymaking, where should we be looking for
lessons about how to promote flexibility,
innovation, and experimentation?
EXPORTING AMERICAN IDEAS
Ironically, the answer to that question appears to be the
United States. In this respect, if in no other, it
is the rest of the world that looks for lessons to
the United States, not the other way around. The
United States is, without doubt, a net exporter of
ideas and exemplars. It is worth pondering this curious
phenomenon for what it tells us about the flow of
lessons from country to country. The US health care
system (if indeed it can be called that) is, by
common consent, a conspicuous failure: too much money
is spent protecting too few people. The point does not need
belaboring: critical self-examination and continuous debate
about reform is part of the American health care scene.
And yet American ideas—notably notions of
competition—have been influential in a range of
European countries. And American policy tools—for
example, diagnosisrelated groups–based systems of
remuneration—have been widely adopted.
Why? Consider, first, the diffusion of American notions
about systems design. One plausible explanation for
this is that, since the 1970s, economic theory has
played an increasingly important part in shaping
social policy while economic reality has been
increasingly important in forcing countries to reassess their
policy trajectory. Health care is no exception.
And it so happens that American economists—by
sheer weight of numbers, quite apart from any
intellectual distinction—tend to dominate the
international debate, as a count of journal articles
would no doubt confirm. To varying degrees, American ideas
and rhetoric about the benefits of competition and the importance
of incentives have therefore become naturalized in other
countries—a sort of intellectual convergence based on
the role of economic ideas in the policy process. Exogenous
ideas have been absorbed to the extent that they speak
to endogenous concerns: most specifically, how best
to adapt paternalistic, solidaristic health care
systems to a consumer society where individual
choice is sovereign (as is the case in Britain and, to
a lesser extent, Sweden and the Netherlands).
The widespread adoption of American policy tools is perhaps
less surprising. One way of characterizing health care
in the United States is that it represents a heroic
but doomed endeavor to bring order to chaos, a
never-ending battle to overcome the perversities of
a system that might have been designed to fail.
It is this that spurs the participants in the system to
ever-greater feats of ingenuity and inventiveness.
It is this that promotes managerial, as well as
technological, innovation on a scale that no other
country can even begin to match. For the outside world,
the US health care scene is therefore a kind of supermarket
where they can shop selectively. But having shopped,
they also adapt; once again, the crucial element is
the local environment and context—and the extent
to which imports fit, or can be made to fit, local
So here the argument comes full circle. The United States
will draw lessons from other countries to the
extent that these are most consistent with local
circumstances. In health care, there is no such
thing as "the best buy" system. And lessons are
learned not because of the intrinsic merits of some
foreign system but because of the compatibility of
its features with the institutions and ideology of
the importing country. For the United States, the
lessons learned are therefore likely to depend on whether
increasing inequality, linked to increasing economic
turbulence, produces a tectonic shift in the
country’s political scenery.
Accepted for publication August 12, 2002.
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