^1. Flora, Peter, ed., The Western European Welfare States Since World War II (Berlin and New York, 1986), 1: xii.Google Scholar

^2. There are considerable archival sources, but few secondary sources, in point. I am preparing an article that examines the early history of the British National Health Service in the context of the administration of the Marshall Plan. Documents in the Public Record Office and the Truman Library reveal that, despite occasional tension and complaints from a few members of Congress, American executive branch officials accepted higher social and health spending (and hence less investment in the production of goods and commercial services) from European governments than was tolerable in the United States. In 1948, for example, Thomas K. Finletter, chief of the Economic Cooperation Administration Mission in the United Kingdom, defended the British welfare state in testimony to a Senate committee meeting in executive session. He described the need for more hospital services, physicians, and nurses in the U.K., justifying their cost by an offsetting increase in worker productivity. Then he noted that the transfer payments of public insurance programs are not “resources diverted from other purposes.” The committee accepted his reasoning at a time when other Senate committees, operating to full publicity, rejected its application to domestic policy by some officials of the Truman administration. (U.S. Congress, Senate, Committee on Foreign Relation, 80th Cong., 2d sess. Foreign Relief Assistance Act of 1948. Hearings held in Executive Session, February–April 1948, p. 171.)

^3. Kunz, Diane B., Butter and Guns: America's Cold War Economic Diplomacy (New York, 1997), 118Google Scholar. Kunz (102) makes the useful point that according to the “American postwar bargain … the middle and lower classes would not demand the cradle-to-grave economic security that democratic socialist governments had installed in Europe…. Instead they would accept lower taxes and upward mobility, they could rely on the most unfettered capitalist system in the world to provide them with lives far better than their parents had enjoyed.”

^4. Eichengreen, Barry, “Institutions and Economic Growth: Europe After World War II,” in Crafts, Nicholas and Toniolo, Gianni, eds., Economic Growth in Europe Since 1945 (Cambridge, 1996), 65.Google Scholar

^5. There is a vast literature on these points. A good introduction is Ashford, Douglas E., “The Historical and Political Foundations of the Welfare State: A Lost Opportunity for the Left?” Journal of Policy History 5:3 (1993): 311–34Google Scholar. A witty summary is “The Changing Face of the Welfare State,” The Economist, 16 August 1995, 41–42. For a more traditional view, see Levine, Daniel, Poverty and Society: The Growth of the American Welfare State in International Comparison (New Brunswick, N.J., 1988)Google Scholar. A solid comparative study skeptical of polemical interpretations is Baldwin, Peter, The Politics of Social Solidarity: Class Bases of the European Welfare State, 1875–1975 (Cambridge, 1990)Google Scholar. Another study attempting ideological neutrality is Ferlie, Ewan, Ashburner, Lynn, Fitzgerald, Louise, and Pettigrew, Andrew, The New Public Management in Action (Oxford, 1996).Google Scholar

^6. Ashford, Douglas, The Emergence of the Welfare States (Oxford, 1986), 27.Google Scholar

^7. Ringen, Stein, The Possibility of Politics: A Study in the Political Economy of the Welfare State (Oxford, 1987), 207.Google Scholar

^8. Klein, Rudolf, “O'Goffe's Tale, Or, What Can We Learn from the Success of the Capitalist Welfare State?” in Day, Patricia, ed., Only Dissect: Rudolf Klein on Politics and Society (Oxford, 1996), 310.Google Scholar

^9. Edmund S. Phelps, “On the Damaging Side Effects of the Welfare System: How, Why, and What to Do?” and Malinvaud, Edmond, “Is the European Welfare State Unsustainable?” in Baldassari, Mario, Paganetto, Luigi, and Phelps, Edmund S., eds., Equity, Efficiency, and Growth: The Future of the Welfare State (New York, 1996).Google Scholar

^10. Mancur Olson, “The Varieties of Eurosclerosis: The Rise and Decline of Nations Since 1982,” in Economic Growth in Europe Since 1945 (above, note 4). Most claims about welfare-state history are contentious, hence Keman, contrary to Olson, found no “conclusive evidence for the contention that the size and organization of the public sector is indeed hazardous to economic develoment [though] the way the public sector is organized does matter with respect to labor market performance”: Hans Keman, “Proliferation of the Welfare State: Comparative Profiles of Public Sector Management, 1965–1990,” in Eliassen, Kjell A. and Kooiman, Jan, eds., Managing Public Organizations: Lessons from Contemporary European Experience, 2d ed. (London, 1993), 33.Google Scholar

^11. Esping-Anderson, Gosta, The Three Worlds of Welfare Capitalism (Oxford, 1990), 9, 33.Google Scholar

^12. Steinmo, Sven, Taxation and Democracy: Swedish, British, and American Approaches to Financing the Modern State (New Haven, 1993), 173, 196.Google Scholar

^13. Immergut, Ellen M., Health Politics: Interests and Institutions in Western Europe (Cambridge and New York, 1992), 11Google Scholar. Similarly, Ruggie, Mary, Realignments in the Welfare State: Health Policy in the United States, Britain, and Canada (New York, 1996)Google Scholar, insists that health policy does not differ from other social policies (260–66) but addresses mainly financing and organization, with the exception of a brief discussion of rationing.

^14. Barr, Nicholas, “Economic Theory and the Welfare State: A Survey and Interpretation,” Journal of Economic Literature 30 (June 1992): 742, 745.Google Scholar

^15. Rudolf Klein is a partial exception to this generalization. He prefers to generalize about welfare states and to see similarities among policies within and across national boundaries. Over many years of conversation with the author, he has sometimes conceded that health policy has what he calls a “technological imperative.”

^16. Fox, Daniel M., Health Policies, Health Politics: The British and American Experience, 1911–1965 (Princeton, 1986), 3–36Google Scholar, documents this point for these countries. There is considerable evidence that the same generalizations hold for Canada and the countries of Western Europe.

^17. Ibid., chaps. 2–4.

^18. Fox, Daniel M., Power and Illness: The Failure and Future of American Health Policy (Berkeley and Los Angeles, 1995), 32–36.Google Scholar

^19. Organization for Economic Cooperation and Development (OECD), New Directions in Health Policy, Health Policy Studies No. 7 (Paris, 1995), 13Google ScholarPubMed. See also Howard Oxley and Maitland MacFarlan, “Health Care Reform: Controlling Spending and Increasing Efficiency,” OECD Economic Development Working Papers, No. 149, 1994, idem, “Health Care Reform: Controlling Spending and Increasing Efficiency,” OECD Economic Studies, No. 24, 1995, 1.7–52.

^20. Abel-Smith, Brian, “The Escalation of Health Care Costs: How Did We Get There?” in Organization for Economic Cooperation and Development (OECD), Health Care Reform: The Will to Change, Health Policy Studies No. 8 (Paris, OECD, 1996)Google Scholar. For the history of health-care cost containment, see Abel-Smith, Brian, “Cost Containment and New Priorities in the European Community,” The Milbank Quarterly 70:3 (1992): 393–416Google Scholar. For the history of the budget crisis of welfare states, see Pen, Jan, “Expanding Budgets in a Stagnating Economy: The Experience to the 1970s,” in Maier, Charles S., ed., Changing Boundaries of the Political: Essays on the Evolving Balance Between the State and Society, Public and Private, in Europe (Cambridge, 1987), 321–61.Google Scholar

^21. Abel-Smith, note 20 above. See also Morone, James A. and Goggin, Janice M., eds., “European Health Policies: Welfare States in a Market Era,” Journal of Health Politics, Policy and Law 20 (1995): 557–785.CrossRefGoogle Scholar

^22. As in other comments in this article about contemporary health policy, I rely on voluminous published and unpublished sources to which I have access because my principal employment brings me into daily contact with decision makers in health policy in the public and private sectors of the United States and, to a lesser extent, other countries. Much of what I know from primary sources is privileged, not because the information cannot be made public but because I learned it under conditions in which I did not request permission to use information in publications. Readers seeking more information from published sources about any of the issues raised here can seek them through any of the health or medical databases readily available on the Internet. Readers curious about methods of translating information received as a participant in policymaking into scholarly publications might see Fox, Daniel M., “From Piety to Platitudes to Pork: The Changing Politics of Health Workforce Policy,” Journal of Health Politics, Policy and Law 21 (Winter 1996): 825–44.CrossRefGoogle ScholarPubMed

^23. I have addressed European issues in more detail in Daniel M. Fox, “Chronic Disease and Policy in the Twentieth Century,” Proceedings of the First World Congress of Medicine and Philosophy, Bulletin of the European Society for the Philosophy of Medicine and Health Care (1995), 3: Special Issue (compact disk); a Dutch version is in Gezondheit 3 (1995): 136–44.Google Scholar

^24. Pierson, Paul, Dismantling the Welfare State: Reagan, Thatcher, and the Politics of Retrenchment (Cambridge and New York, 1994), 181.Google Scholar

Ruggie, Realignment in the Welfare State, 264. Similarly, Steffen, Monika, The Fight Against AIDS: An International Public Policy Comparison Between Four European Countries–France, Great Britain, Germany, Italy (Grenoble, France, 1996)Google Scholar, regards the response to AIDS as a triumph of the welfare state. I interpret the same data as evidence about the ability of industrial countries to mobilize for emergencies, and note that in the late 1990s, when AIDS is no longer conceptualized as a plague, policy for treating persons with AIDS/HIV infection has the same strengths and weakness in each country as policy for treating persons with other chronic diseases. Another approach, argued by the director of the School of Management Studies at Oxford, holds that the “great paradox of the market revolution … is that an emphasis on market forces and individual rights has led to an increase in State spending on social support…. We have transferred many of the costs of … insecurity from corporations to individuals and hence to the state.” Kay, John, “Taxation: The Issue That Mattters Too Much to Be Talked About, Times Literary Supplement, 25 April 1997, 15.Google Scholar

^25. “The Withering Away of the State,” The Economist, 6 April 1996, 82. On the other hand, an article that has received little notice argues, on the basis of statistical analysis, that “in 1990, not only were suicide rates higher in [American] states that spent less for public welfare than in states that spent more, but states' spending for public welfare was the only variable that accounted for the widening of differences in states' suicide rates:” Shirley L. Zimmerman, “Psychache [sic] in Context: States' Spending for Public Welfare and Their Suicide Rates,” Journal of Nervous and Mental Disease 183:7, 425–34. Professor Zimmerman was unable to refer me to other research making a similar point.