«ضد آمریکایی» و یا غیر ضروری؟ رد امریکا از بیمه سلامتی دولت اجباری در دوران اصلاح طلبی

Between 1915 and 1920, 18 U.S. states considered the introduction of compulsory health insurance. Progressive reformers expected state health insurance to be welfare enhancing for American wage-workers since it would result in lower cost insurance and an extension of coverage to more of the population. The evidence presented in this paper indicates that the absence of broad political support for health insurance legislation in this early period reflects that compulsory insurance would not have improved on what was available and affordable through voluntary arrangements and had the potential to reduce the welfare of wage-earners.

Progressive reformers in the U.S. interpreted state provided health insurance as the necessary and inevitable response to the moral and economic inadequacies of voluntary insurance and self-help arrangements in protecting households against the consequences of sickness.1 Given the developments in Europe and the introduction of Worker’s Compensation in many states before World War I, the reformers believed that government health insurance was the next step in social progress for the U.S.2 At the impetus of the American Association for Labor Legislation (AALL), between 1915 and 1920, as many as 18 U.S. states investigated but rejected compulsory-state health insurance (CHI). The AALL reformers and many scholars today consider this outcome to be a policy failure and significant for explaining why the U.S. does not have, and is unlikely to have in future, national health insurance.3 If CHI was efficiency enhancing and stood to have made some or all wage-workers better off as the AALL reformers argued, then why were legislators and political “brokers” unable to evoke the necessary political action for its introduction? Anderson (1968, 1987) argues that the indifference of Americans towards compulsory health insurance in this early period left organized groups, such as doctors and life insurers, with political clout and vested interests in the defeat of CHI to determine the outcome. Social reformers such as the members of the AALL interpreted public indifference to CHI as evidence that wage-workers were either ignorant of their true needs for economic security, and/or ideologically driven to reject social insurance as “un-American” despite their dire needs for the programs. In contrast, business organizations, employers associations and insurance companies argued that the indifference of American wage-earners to CHI reflected that they did not need it due to their earning power. Americans had a capacity to save and to purchase insurance coverage through voluntary arrangements. For government action on CHI to have been politically profitable for legislators and political brokers, significant failures in private markets must have existed for CHI to be a welfare enhancing institutional alternative to the market. To assess this condition for the political viability of CHI in the U.S., I quantify the frequency and duration of work-related disability and I use these estimates to value the expected insurance costs and benefits of the proposed AALL CHI legislation and available voluntary arrangements. This comparison shows that despite the AALL reformers’ concerns for the lower earning wage workers, their proposed CHI contract did not offer any advantages to this target group over what was available through voluntary arrangements. The analysis provides empirical support for Costa’s (1995) suggestion that CHI was, at best, an expensive duplication of insurance available through voluntary avenues. Rodgers (1998, p. 243) describes how some proponents of compulsory health insurance in the United States viewed social insurance like CHI as nothing more than a complicated scheme for compulsory savings. The main purpose of CHI would have been to compel wage-workers to purchase higher levels of insurance coverage. Even though CHI was expensive, it could still have been welfare enhancing for wage-workers if households lacked the necessary surplus in their budgets to purchase the voluntary-insurance contracts. My estimates of household budget surpluses from data from the 1888–90 U.S. Commissioner of Labor Cost of Living study and the 1917–19 BLS Cost-of-Living Survey show that, contrary to the claims and evidence of the AALL reformers, American wage-workers could insure against sickness without CHI. Further, the capacity to self-insure, or purchase insurance coverage, increased over the life-cycle, and for wage-workers under age 40, it increased between the late nineteenth century and 1920. CHI would have locked Americans into saving for a single purpose for the length of their working lives even though the need for this insurance coverage was primarily at younger ages. The commitment of so much of household income to the insurance of a single risk was not necessarily desirable. Unlike CHI, the household’s savings could be used for covering any losses of income due to illness, or unemployment. The evidence in this paper supports that the suggestions of Costa, 1995, Emery and Emery, 1999, Beito, 2000 and Emery, 2006 and Murray (2007) that CHI would not have been welfare improving for American wage-earners which in turn can explain the lack of political support for the legislation in the Progressive Era. Emery and Emery, 1999, Beito, 2000 and Emery, 2006 and Murray (2007) provide evidence that voluntary insurance funds of fraternal orders, unions and work-placed based groups were competently managed and provided meaningful assistance to the members of these organizations as late as the Depression of the 1930s. These studies provide necessary, but not sufficient, evidence to refute the progressive reformers’ views that voluntary sickness insurance was an inadequate alternative to CHI. Progressive reformers acknowledged that voluntary funds worked well for the better paid of the wage-earning classes but they believed that CHI was necessary to extend coverage to the lower wage earners who would never be covered in the voluntary arrangements. As such, showing the competence of these organizations and the self-insurance capabilities of the better paid wage earners who belonged to them cannot refute the reformers’ claims about the societal need for social insurance. Evidence that voluntary-insurance contracts were affordable for lower wage-earners provides direct evidence to address the reformers’ case.

The AALL reformers believed that their draft act defining a CHI program would have improved the welfare of wage earning Americans by providing affordable insurance coverage that existing voluntary arrangements had failed to provide. In addition, the reformers expected that through compulsion and subsidization, CHI would extend coverage to the lower wage earners. The evidence in this paper shows that CHI was not necessarily any less expensive than the coverage provided through voluntary arrangements and it would primarily have generated advantages for higher earning wage-workers. Estimates of savings rates show that American wage earners had the necessary budget surplus to meet expected sickness costs or to purchase voluntary insurance coverage, and counter to the claims of the reformers, savings capacities improved over time. In this early period, the costs of sickness were frequent but manageable for most wage-earners through voluntary insurance contracts and self-insurance. In all likelihood, CHI would have been welfare reducing for Americans as it added nothing over what was available through voluntary arrangements, and its cost would have taken all of a household’s surplus income to meet the costs of a single income risk. The rejection of CHI before 1930 should not be considered a policy failure. As Weaver (1983, pp. 295 and 300) argues, the need for social insurance in the U.S. must not have been strong and this is a logical explanation for the lack of political action towards the enactment of social insurance legislation. Continuing to perpetuate the view of institutional and ideological American exceptionalism limits our understanding of American social policy development. Rodgers (1998, p. 255) argues that social insurance was only one of many competing social policies that was being proposed in the north Atlantic economy by 1914 so concluding that the U.S. was a social policy failure because of its lack of compulsory-state-social insurance overlooks the abundance of social policy initiatives. Engel (2002) suggests that in the 1930s, while Americans did not seem particularly enthusiastic about compulsory health insurance, Americans were supportive of subsidies for medical care for poor Americans. As Thomasson (2002) and Beland and Hacker (2004) observe, the U.S. has used tax incentives to encourage the expansion private health insurance provided through the workplace and then to reserve public insurance coverage for the poor and the aged. This work also suggests that should the extent of health-insurance coverage fall in the U.S., or if the cost of voluntary coverage increases, Americans could support a move to national-health insurance.