Course Article

Topics: Health economics, Universal health care, Health care Pages: 36 (8955 words) Published: March 31, 2014
Parting at the Crossroads: The Development of Health Insurance in Canada and the United States, 1940-1965
Author(s): Antonia Maioni
Source: Comparative Politics, Vol. 29, No. 4 (Jul., 1997), pp. 411-431 Published by: Ph.D. Program in Political Science of the City University of New York Stable URL: http://www.jstor.org/stable/422012 .

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Parting at the Crossroads
The Development of Health Insurance in Canada and the
United States, 1940-1965
AntoniaMaioni
Frequentlyraised in recent discussions abouthealth care reformin the United States has been the model of the Canadianhealth insurancesystem.' While debates about health insurance often turn into polemical battles over which country offers the "best" health care for its citizens, the issues at stake raise a fundamentalquestion. Why did these two neighbors develop different forms of health insurance, a health care in Canada and a dual-tiered

universal system of government-financed
of Medicare and Medicaid targeted at the elderly and poor in the United system
States? The contrast is even more significant when we consider that these two countries, generally classified as "liberal"welfare states,2 share many common economic, political, and social attributesand resemble one anotherin many of the features that influence welfare state expansion.3Why, then, did Canada and the United States embarkupon two very differentpathsto healthreform,one of the most importantpillars of the welfare state?

The extensive literature the developmentof the welfare state provides us with on
at least threeclues as to the types of factorsthatcan explain divergentpathsto health reform in Canadaand the United States: the influence of social forces, the role of state actors, and the impact of state structuresand political institutions. Social explanations concentrate on the role and influence of organized groups by examiningthe power of professionalgroupsand business interestsin shaping social reform.4 Neo-Marxist explanations focus on how social policy reflects the class the

struggleand demonstrate correlationbetween higher social expendituresand the of the working class mobilized into a social democraticparty.'The political strength
state-centeredapproachemphasizes the role of individual state actors, influential and
bureaucrats, political leadersin settingthe policy agendaand shapinglegislation and the state's administrativecapacity to implement social reform.6The recent application of neoinstitutionalismto the study of the welfare state has further enhancedour understanding the interactionbetween social forces and the state in of

the developmentof social policy. This approachbuilds on the idea that the "rulesof the game" of a political system impose certain constraints and opportunities conditioning legislative outcomes. These rules are derived from the constitutional settings that shape political institutions.7

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ComparativePolitics July 1997
This article contributesto the theoreticaldebate by looking at how demand...
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