Lessons for (and From) America

January 2003, Vol 93, No. 1 | American Journal of Public Health 61-63
© 2003

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.

Correspondence: Requests for reprints should be sent to Rudolf Klein, L 12A Laurier Road, London NW5 1SG, England.

ABSTRACT
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.

INTRODUCTION

 
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 care.

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 other interests.

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 optimism.

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 tradition?

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 REFORM

 
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 United States.

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 France).

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 needs.

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.

Footnotes

 
Peer Reviewed

Accepted for publication August 12, 2002.

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