Why some countries have national health insurance, others have national health services, and the U.S. has neither

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This article presents a discussion of why some capitalist developed countries have national health insurance schemes, others have national health services, and the U.S. has neither. The first section provides a critical analysis of some of the major answers given to these questions by authors belonging to the schools of thought defined as 'public choice', 'power group pluralism' and 'post-industrial convergence'. The second section puts forward an alternative explanation rooted in an historical analysis of the correlation of class forces in each country. The different forms of funding and organization of health services, structured according to the corporate model or to the liberal-welfare market capitalism model, have appeared historically in societies with different correlations of class forces. In all these societies the major social force behind the establishment of a national health program has been the labor movement (and its political instruments-the socialist parties) in its pursuit of the welfare state. In the final section the developments in the health sector after World War II are explained. It is postulated that the growth of public expenditures in the health sector and the growth of universalism and coverage of health benefits that have occured during this period are related to the strength of the labor movement in these countries.

Original languageEnglish (US)
Pages (from-to)887-898
Number of pages12
JournalSocial Science and Medicine
Issue number9
Publication statusPublished - 1989



  • comparative health policy
  • labor movement
  • national health insurance
  • national health service

ASJC Scopus subject areas

  • Economics and Econometrics
  • Public Health, Environmental and Occupational Health
  • Social Psychology
  • Development
  • Health(social science)

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