Health care reform or health care rationing? A comparative study (Canada, the U.S. and the U.K.).

While the impact of the neo-conservative drift in Western states in the final decades of the twentieth century has been varied, yet everywhere it has provoked examination of the `allocation of scarce resources' in social policy fields. Health care policy is one of the most important of these areas, and the 1990s has been marked by reforms in this area of public policy. Changes have been driven by two broadly shared concerns: the total cost of care in relation to national economies, and whether the existing systems can be managed more efficiently (Jerome-Forget, et al. 1995). Hence the language of reform has many cross-national similarities, although specific outcomes are quite dissimilar. This paper examines reform efforts in the United States, the United Kingdom and Canada, focusing particularly on state-specific proposals and outcomes. The three countries provide an interesting comparative study: although they have much shared historical experience and considerable evidence of exchanges of ideas concerning health policy, their approaches to the provision of health care and to health policy reform are quite distinct. It is of interest also to note that while each is focusing on the need for extensive reform, the percentage of gross domestic policy (GDP) devoted to health care is markedly different in the three nations (See Table 1). Already the United Kingdom has contained costs more successfully than almost any other Western nation, and the United States has had the least success. Canadian spending falls between the two.

The paper first examines different theoretical approaches to the allocation of limited health care resources (rationing) and then discusses the importance of particular political and societal institutions that affect policy determination. A third section then traces health policy in the three countries and relates it to the rationing/institutional discussion. It will be argued in the conclusion that policy choice and policy result are constrained by state-specific historical experience.

I. APPROACHES TO RATIONING

Health insurance programs are a symbol of the great divide between liberalism and socialism (Immergut, 1992), and as redistributive social programs they are inescapably linked to class divisions in society (Lowi, 1964); hence they are subjected to endless political and societal discord. As Section III will show, the United Kingdom, the United States and Canada have faced similar conflicts and pressures over the direction of health policy, yet they have resolved their problems in different ways. Despite many commonalties, shared experiences and convergent tendencies, their approaches to the provision of health care to their citizens and the allocation of resources to their health care sectors have diverged (see Tables 1, 2, & 3). Health care costs are frequently described in apocalyptic terms,

Table 1. Total expenditure on health care in GDP, 1960-1992 Percent of GDP 1960 1970 1975 1980 1985 1990 1992 United States 5.3 7.4 8.4 9.2 10.5 12.4 14.0 Japan 3.0 4.6 5.6 6.6 6.5 6.6 6.9 Germany 4.8 5.9 8.1 8.4 8.7 8.3 8.7 France 4.2 5.8 7.0 7.6 8.5 8.9 9.4 Italy 3.6 5.2 6.1 6.9 7.0 8.1 8.5 United Kingdom 3.9 4.5 5.5 5.8 6.0 6.2 7.1 Canada 5.5 7.1 7.2 7.4 8.5 9.4 10.2 Average of above countries 4.3 5.8 6.8 7.4 8.0 8.5 9.3 Table 2. Public share in total spending on health, 1960-1992 Percent 1960 1970 1975 1980 1985 1990 1992 United States 24.5 37.2 41.5 42.0 41.4 42.2 45.7 Japan 60.4 69.8 72.0 70.8 72.7 70.8 71.2 Germany 66.1 69.6 77.2 75.0 73.6 71.8 71.5 France 57.8 74.7 77.2 78.8 76.9 74.5 74.7 Italy 83.1 86.4 86.1 81.1 77.1 77.8 75.2 United Kingdom 85.2 87.0 91.1 89.6 86.3 84.4 84.4 Canada 42.7 70.2 76.4 74.7 74.7 73.1 72.2 [Part 1 of 5] Table 3. Health-related administrative costs, 1970-1992 Total Total expenditure on health Total expenditure on health expenditure on administration as % of total administration as % of total health expenditure on health expenditure on health administration as % of total expenditure on health 1970 1980 United States 3.7 4.9 Japan .. .. Germany .. 5.9 France 1.3 1.4 Italy .. .. United Kingdom .. .. Canada 1.6 1.4 [Part 2 of 5] Table 3. Health-related administrative costs, 1970-1992 Total expenditure on health administration as % of total expenditure on health Public expenditure on health administration as % of public expenditure on health 1985 1992 or 1970 last year United States 6.0 5.8 3.9 Japan ...

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