Universal Health Care: From the States to the Nation?

When I first heard of the Massachusetts state legislation, two things came to mind. One of them was a piece of Canadian history little known to Americans: universal care in that country began with the Canadian provinces, gradually spreading to its federal government. Is that kind of development possible in the United States? The other was the famous 1932 phrase of Supreme Court Justice Louis Brandeis that the states are the "laboratories of democracy." Could the Massachusetts law serve as a laboratory for national universal health care?

While the two questions are related, they raise different issues. The Canadian example bears on the direction and trajectory of health care reform, not on its content. Brandeis's phrase encompasses the nature of the reforms. The Massachusetts law is encouraging on both counts, but there are reasons to be hesitant in one's hopes.

The Canadian movement toward universal care began in 1947 in Saskatchewan. Tommy Douglas, then premier of that province, introduced universal hospital insurance, overturning decades of resistance. Nor was it all that popular with the province's physicians, who staged a famous but unsuccessful strike against it in 1962. As time went on, Alberta adopted similar policies and, most important, Canadian physicians—led by some socially prominent and influential doctors, sometimes called "red tories"—came to see the advantages of national universal care. In1984 the last of a number of gradual steps led to the Canada Health Act, the cornerstone of present policy. That policy is a mixture of publicly funded and privately delivered health care, and it rests on five principles: universality, accessibility, comprehensiveness, portability, and public administration.

That history is interesting, but its instructional—and inspirational—value for the United States is limited. Up until the 1950s or so, Canadian and American health care both consisted primarily of fee-for-service medicine, limited health insurance, and strong physician resistance to government-dominated health care. The paths of the two countries diverged partly because of cultural differences: Canada is a far more communitarian, less individualist country than the United States, with a strong welfare system, greater friendliness toward government, and a powerful commitment to the value of solidarity. Additionally, its parliamentary system allows for a more decisive pursuit of social goals than does ours.

But while Canadian-U.S. historical and cultural differences are important, the idea of the states as "laboratories" is attractive. To serve effectively in that role, their example must be noted and well publicized, their innovative policies reasonably successful, and they must have policy ingredients that can be used in a national plan. Those elements were in place in the 1930s, when Justice Brandeis used the "laboratory" metaphor. Much of President Roosevelt's New Deal agenda came out of successful state programs. And, I would add, the times must be ripe to expand suggestive policies from the state to the national level, and to gain traction they must first spread among the states.

The times may be ripening now. Once again talk of a health care "crisis" is in the air, and there is state movement beyond the Massachusetts example. Public opinion surveys show considerable discontent with American health care, the business community is increasingly distressed in trying to cope with ever-rising costs, and a long-awaited stimulus for serious reform may be at hand: middle-class alarm at a deteriorating situation for those previously well covered by insurance. The fact that a majority of personal bankruptcies in this country are occasioned by individual and family health care debts is a sobering figure. If the 46 million uninsured do not catch the congressional eye, maybe the steady increase of the uninsured and the rise in bankruptcies will.

Yet some combination of hope and hesitation is in order before thinking that movement among the states may finally do the trick. The hope comes from the fact that over a dozen states are actively working in their legislatures to fashion universal care plans. The Massachusetts plan shows how a resourceful governor can manage to bring together a number of diverse interests and constituencies.

The hesitation is appropriate because the plan...