Health and Public Policy

National Health Insurance

The United States is very different from the rest of the developed world in terms of health and public policy. By the end of the 20th century, all but a few developed countries—the United States and South Africa are the two most often cited—had adopted public policies that health care is a right of citizenship and that, therefore, the government accepts a responsibility to pay for the health care of its citizens. In general, the government payment for the health care of its citizens is accomplished through a national health insurance (NHI) plan. However, there are wide variations in the amounts or percentages that NHI pays, from 100% to well under half.

Some countries even go so far as to supplement their NHI with a national health service (NHS) through which the health care of their citizens is in fact provided by health care providers working for the government. The United Kingdom's NHS is an example of this and has been described as one of the greatest social achievements of the 20th century, with its promise to provide free health care for the British people from cradle to grave. But times have changed since that NHS was set up in 1948. Today, the United Kingdom, other countries with an NHS, and most of the countries with NHI are constantly looking for ways to improve the efficiency and effectiveness of their health care services. The perception of longer waiting times to see providers and even copayments in some situations are part of the NHI and NHS in many countries.

The United States does not have NHI. The country operates under a public policy that payment for health care is not the government's responsibility in the main but rather a private responsibility in which health care services are purchased like other goods and services in the economy.

It is of some interest to understand how the United States got to this policy while the rest of the world migrated to a different policy. Historians suggest that Germany was the first country to implement industrialization successfully on a large scale toward the end of the 19th century. Germany's successes with industrialization created another new public policy—the retirement with pensions of able-bodied workers to make room for younger employees. Until that time, the retirement of able-bodied workers with lifelong pension was virtually unheard of as a national policy. During the first half of the 20th century, the United States provided international leadership in counterbalancing the rights of labor with the power of management. The issues of child labor, workplace safety, and wages had dominated labor's agenda during that era. But with the advent of World War II and the U.S. policy of wage and price control, organized labor focused its emphasis on benefits such as health care, an emphasis that far outlived the armistice. Over time, [Page 257]health care insurance became a fringe benefit of labor force participation for both workers and their families.

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