Category Archives: policy

Origins of the Modern Welfare State

This, from Ta-Nehisi Coates,  on the origins of the welfare state in Western Europe:

I am coming at this as a total amateur and a total American whose exposure to the post-war narrative was something like—”The Germans learned their lesson and everyone (in the West, because no one talks about the East) resumed their status as upstanding white people.” Somewhere in there I knew something about the Marshall Plan. But whereas the narratives which nations tell themselves so often have a moral component, Judt is giving us something less flattering and more atheistic. Even Europe’s great achievement—a broad strong social safety net—seems inseparable from the barbarism from which it had just been plunged. A safety net (often means-tested) existed in Europe before the War, but there was not the same sense that a state should be a comprehensive guarantor of the health and happiness of its people:

It was the war that changed all this. Just as World War One had precipitated legislation and social provisions in its wake—if only to deal with the widows, orphans, invalids and unemployed of the immediate post-war years—so the Second World War transformed both the role of the modern state and the expectations placed upon it.

The change was most marked in Britain, where Maynard Keynes correctly anticipated a post-war ‘craving for social and personal security’. But everywhere (in the words of the historian Michael Howard) ‘war and welfare went hand in hand’. In some countries nutrition and medical provision actually improved during the war: mobilizing men and women for total war meant finding out more about their condition and doing whatever was necessary to keep them productive…

(He’s quoting from Postwar, by Judt)

This reminds me greatly of Atul Gawande’s piece in the New Yorker about the origins of the healthcare systems in Europe. Like Judt, he finds that much of the system grew out of World War 2.

On Britain:

The program proved successful and lasting, historians say, precisely because it was not the result of an ideologue’s master plan. Instead, the N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War. The single most important moment that determined what Britain’s health-care system would look like was not any policymaker’s meeting in 1945 but the country’s declaration of war on Germany, on September 3, 1939.

As tensions between the two countries mounted, Britain’s ministers realized that they would have to prepare not only for land and sea combat but also for air attacks on cities on an unprecedented scale. And so, in the days before war was declared, the British government oversaw an immense evacuation; three and a half million people moved out of the cities and into the countryside. The government had to arrange transport and lodging for those in need, along with supervision, food, and schooling for hundreds of thousands of children whose parents had stayed behind to join in the war effort. It also had to insure that medical services were in place—both in the receiving regions, whose populations had exploded, and in the cities, where up to two million war-injured civilians and returning servicemen were anticipated.

As a matter of wartime necessity, the government began a national Emergency Medical Service to supplement the local services. Within a period of months, sometimes weeks, it built or expanded hundreds of hospitals. It conducted a survey of the existing hospitals and discovered that essential services were either missing or severely inadequate—laboratories, X-ray facilities, ambulances, care for fractures and burns and head injuries. The Ministry of Health was forced to upgrade and, ultimately, to operate these services itself.

On France:

n France, in the winter of 1945, President de Gaulle was likewise weighing how to insure that his nation’s population had decent health care after the devastation of war. But the system that he inherited upon liberation had no significant public insurance or hospital sector. Seventy-five per cent of the population paid cash for private medical care, and many people had become too destitute to afford heat, let alone medications or hospital visits.

Long before the war, large manufacturers and unions had organized collective insurance funds for their employees, financed through a self-imposed payroll tax, rather than a set premium. This was virtually the only insurance system in place, and it became the scaffolding for French health care. With an almost impossible range of crises on its hands—food shortages, destroyed power plants, a quarter of the population living as refugees—the de Gaulle government had neither the time nor the capacity to create an entirely new health-care system. So it built on what it had, expanding the existing payroll-tax-funded, private insurance system to cover all wage earners, their families, and retirees. The self-employed were added in the nineteen-sixties. And the remainder of uninsured residents were finally included in 2000.

In Britain, it seems that the NHS was born as a result of the government running a healthcare system for wartime, and in France, the sheer volume of problems the post war government was facing lead to it expanding what was available to a majority of its population.

America hasn’t faced those kind of pressures, and so it seems we don’t have the sense that government should provide. Seems like that accounts for much of the libertarian streak here.

As Coates points out, we probably can change to have an outlook that mirrors that of Western Europe by going through something similar.

Are there other states that haven’t faced much (any?) conflict on the home front in the 20th century? I’d be interested in the outlook on welfare those states have.