History of the welfare state
Résumé
For a long time, sociological comparative studies strived to explain national characteristics of welfare states with a few model-like types. By contrast recent historical research papers emphasize the plurality of welfare systems.
This diversity is shown, on one hand, by international comparison of welfare states. In addition to contrasting approaches an approach focusing on transfer history is also possible. The importance of transfers lived significant changes throughout welfare state history. The trade union movement and international expert panels carried out 19th-century sociopolitical transfers. In the 20th century they were partly completed and replaced by international and intergovernmental organizations such as the International Labour Organization and the International Social Security Association.
On the other hand, the diversity of welfare states is also apparent within individual welfare state systems. This inner heterogeneity is based on varying linkage and interdependence structures of public and private actors, as exemplified for instance by the history of health insurance. In this matter the role of public actors is better researched than that of private actors and the role of the labor movement and philanthropy better than that of commercial actors, which remain unexplored for many welfare states.
The functional heterogeneity and organizational fragmentation of modern welfare states require a new comprehension of Statism. A more fruitful analytical approach consists in pluralizing the term of modern Statism by thinking of a multitude of “styles of Statism.”
Introduction
1. The Social Sciences’ welfare state research from a historiographical perspective1
Throughout the 1980s and 1990s research on the history of the modern welfare states was conducted primarily by the Social Sciences. Comparative and typological studies were especially influential, in particular the works of Danish sociologist and political scientist Gøsta Esping-Andersen. In his groundbreaking work “Three Worlds of Welfare Capitalism” Esping-Andersen distinguishes three types of western capitalist welfare states.2 First the liberal Anglo-Saxon model, in which social benefits cover basic necessities, and, social security, is left to the private sector. Esping-Andersen included the United States in this model. His second model describes the conservative-corporatist welfare state. It includes Germany as well as other continental European countries. In this model social benefits depend on amount and duration of paid social security contributions. For this reason the conservative-corporatist welfare model tends to reproduce income gaps and class structure of a given society. As third type Esping-Andersen defined the social democratic welfare state as manifest in Scandinavia (Nordic model). It is directed towards the redistribution of income and wealth, and creating an egalitarian social structure. This is ensured through extensive wage-replacement benefits as well as vast state funded social benefits for certain populations such as families or the unemployed. The appeal of Esping-Andersen’s typology was his proposal of a seemingly coherent model to explain the diversity of welfare systems. His implicit evaluation of types of welfare states formulates a teleological compass for social policy. If welfare states wanted to better themselves, then the Scandinavian model set the course.
But the historical sciences had difficulty with typological models such as the one developed by Esping-Andersen. The variety of historical welfare systems and especially their evolution through the ages could not be forced into the rigid and ultimately ahistorical typology corset. During the 1990s it became clear to researchers that many of the western welfare states—including most outer European states—did not fit into any of his three categories. Australia and New Zealand were somewhere between the liberal and the social democratic welfare type. The southern European welfare states possessed conservative and corporatist elements but also social democratic traits. Yet their character was so distinctly different that researchers soon began to speak of a fourth type.3 And the history of the Swiss welfare state appeared to unite approaches of all three models in a syncretistic manner (History of social security).4 In addition, ideational transfers and genealogic relationship links, which are formative phenomena in the history of welfare states, cannot be registered by a comparative typology.
Thus, over the last years, historical approaches focusing on complexity and interdependence have proven to be more fruitful regarding welfare state research than older typological approaches. This can further be illustrated with the striking example of health insurance. The organization of health insurance and the healthcare system differs widely in Europe. It ranges from nationalized systems, as it is the case in Great Britain, to corporatist, as in Germany or France, to comparatively liberal models, as in Switzerland. These divergences are the result of long-term development processes, whose origins are rooted in similar contexts. The earliest providers of social health insurance, funds or health insurance companies, arose in the 19th century as associations or cooperatives and often continued early modern traditions of guilds and occupation-specific relief funds.5 Industrial health insurance, such as the British Friendly Societies, emerged in the 1820s. Towards the middle of the century it reached France and Switzerland with Mutualisme, and, in form of local, auxiliary or relief funds, also Germany.6 Although during these early stages health insurance completed local and governmental instruments of poor relief, it also competed with them in certain cases.7 By 1880 the „European relief fund movement“, as one might call these insurance institutions in a nutshell, was structured similarly in all industrialized countries. It consisted of a patchwork of particularistic small organizations, which ranged from syndicalist to corporatist, and from charitable civil funds to para-governmental funds. Modern health insurance funds grew out of this heterogenic movement after 1880. They eventually became integrated into the national social insurance program in all afore-mentioned states. This integration however occurred in fundamentally different forms and sometimes only after heated arguments between public and private actors, and in particular between organized medical profession and local and public healthcare facilities. The outcome of these altercations was of utmost importance for the development of the respective health care system.
The affinity between welfare states goes back to similar origins as has been illustrated with the example of the history of health insurance. In addition, transfer processes between different welfare states have also left their trace. In the 19th century the labor movement, expert committees surrounding world exhibitions, and international academic conventions, had an important role when it came to knowledge transfer between different welfare states.8 In the 20th century these actors were completed and partly replaced by international and intergovernmental organizations such as the International Labour Organization (History of the ILO) and the International Social Security Association (History of the ISSA and Cédric Guinand). The Organization for Economic Co-operation and Development (OECD) too set itself the task of encouraging the development of welfare states throughout Europe and around the world (Social Expenditure Database).
The experts of said groups and organizations had to acquire knowledge and know-how regarding welfare states in order to share it. For this purpose they defined sociopolitical models mostly based on the example of certain European welfare states. During the first half of the 20th century the German social insurance introduced by Otto von Bismarck was thought of as being exemplary around the world. From the inter-war period on Nordic welfare states were increasingly seen as being model-like. After 1945 other models were also seen as exemplary, such as the British universal social security programs (Report on Social Insurance and Allied Services, The Post War Consensus and the Welfare State) and since the 1970s the mixed economy Anglo-Saxon and the Swiss welfare states (Social Security History, Geschichte der sozialen Sicherheit).
2. Historical reasons for the inner diversity of welfare states
Recent historical welfare state research has pointed out the inner diversity and fragmentation of modern welfare systems. Non-governmental institutions such as non-profit associations, private enterprises or public corporations exercise central functions in most European social security systems, especially in health insurance and old-age insurance. In the early 1990s Peter Baldwin already observed the influence of social classes and interest groups on the shaping of social security funds in European model welfare states (Germany, Great Britain, France, Sweden and Denmark). Baldwin thus radically criticized the thesis of a linear teleological development towards a universalistic, social democratic welfare state type as most prominently supported by Esping-Andersen.9 As Baldwin showed, even ideal universalistic social states historically rely on coalitions of individual interests—in Denmark and Sweden for instance between landowners, self-employed and workers—and are therefore not as homogenous as often assumed.10 Gender historical research on the issue of the development of welfare states has indicated that social security systems were often organized according to the model of the male breadwinner, contrary to their universalistic claim, and therefore structurally discriminated women.11
These innovative approaches have been further pursued and radicalized over the last years. Recent Anglo-Saxon welfare state research in particular has closely examined the role of non-governmental actors and non-insurance instruments in the genesis and development of social security in the U. S. A. In the process hitherto little known institutional tension and potentials for conflict among social welfare actors were revealed. For instance, it was shown, that in the U.S. private insurance industry significantly interfered with the development of governmental welfare instruments in the health insurance and old age assurance segments, in some cases impeding development entirely.12 In the U.S. extensive tax incentives indirectly generate financial benefits covered by social security in other countries, especially regarding family and health policy. In this context the role of the U.S.-fiscal policy as hidden welfare state has also further been emphasized by recent studies.13
Among the aspects that stand for an inner diversity of welfare states, the sociopolitical role of private insurance industry remains relatively little studied.14 During the second half of the 19th century the insurance sector in western industrialized countries tapped into new markets such as insurances against accidents at work or life insurance. The insurance industry thus managed to meet the needs of wage-earning populations. In France the insurance against accidents at work was de facto delegated to private, commercial and non-commercial insurance companies until 1946. After World War One the insurance industry consolidated its role within the social insurance system in many European states. One of its new occupations was health care. It allowed insurance companies to operate their own health insurance funds or offer reinsurance to associated companies. Another field of activity was old-age insurance: private insurers offered group insurance for smaller workforces. The division of labor between commercial insurance companies and auxiliary funds within welfare states varied depending on national context. In Germany private insurers tapped into the growing market of private and supplementary insurances while subsidiary funds were left in charge of compulsory health insurance. In Great Britain both auxiliary funds and commercial insurance companies provided public health care services. In the old-age assurance sector insurance companies often offered their own policies sometimes prior to the implementation of a public pension system, as in the case of Switzerland, and sometimes as supplementary insurance in addition to state pensions as was the case in Great Britain, France and Germany.15
3. Welfare states from the point of view of an extended concept of state
Which are the operating logics, by which governmental and non-governmental elements are combined in social security systems? Is it about functional differentiation or rather about institutional delegation of the state to private actors? Is the link between public and private actors of synergetic or conflictive nature? Does the combination of the two signify a fragmentation or hybridization of the system? The international and inner diversity of modern welfare states require a new concept of statehood. To this end Peter Baldwin demanded to rethink and qualitatively extend the concept of state in a programmatic article published a few years ago.16 Conventional analytical categories such as liberal versus interventionist, federalist versus centralist, or oppositions such as welfare versus insurance models, are unlikely to be helpful for the further analysis of heterogeneous or hybrid social state establishments. According to Baldwin a more qualitative-based concept of state, which can be grasped with the help of “styles of statism”, is needed: „A two-dimensional axis of social policy endeavour between active and residual welfare states is now, after two decades of empirical comparative work, inadequate. (…) We need, as a starting point, a typology, or at least a grasp of the possibility, of various kinds of states“.17 The extended concept of state is aimed toward the inner linkage between private and public elements of individual social security systems, to create a sort of combination of the different types of welfare state models with the varieties of capitalism.18 To this end a qualitative-extended concept of state would focus less on the normative ideal type and more on the empirical diversity of welfare state insurance models thus surpassing the thesis of „worlds“ or models of welfare states.
1 The following statements are partly based on: Lengwiler, Martin: Competing globalizations. Controversies between private and social insurance at international organisations (1900-1960), in: Pearson, Robin (Hg.): The Development of International Insurance, London 2010, S. S. 167–186.; and, Lengwiler, Martin: Competing Appeals. The rise of mixed welfare economies in Europe, 1850-1945, in: Clark, Geoffrey (Hg.): Appeals of Insurance, Toronto 2010, S. S. 173–200.
2 Esping-Andersen, Gøsta: The Three Worlds of Welfare Capitalism, Cambridge 1990.
3 Ferrera, Maurizio: The "Southern Model" of Welfare in Social Europe, in: Journal of European Social Policy 6 (1), 02.01.1996, S. 17–37. Online: esp.sagepub.com, <www.dx.doi.org/10.1177/095892879600600102>, Stand: 09.12.2015.
4 Studer, Brigitte: Soziale Sicherheit für alle? Das Projekt Sozialstaat, in: Studer, Brigitte: Etappen des Bundesstaates. Staats- und Nationsbildung in der Schweiz, Zürich 1998, S. 159–186, S. 180f.
5 Ritter, Gerhard: Der Sozialstaat : Entstehung und Entwicklung im internationalen Vergleich, München 1991, S. 62f.
6 See Dreyfus, Michel: Mutualités de tous les pays : «un passé riche d’avenir», Paris 1995.
7 See contributions in: Grell, Ole Peter; Cunnigham, Andrew (Hg.): Health Care and Poor Relief in 18th and 19th Century Northern Europe, Aldershot 2002.
8 For the world exhibition see Meller, Helen: Philanthropy and Public Enterprise: International Exhibitions and the Modern Town Planning Movement, 1889–1913, in: Planning Perspectives 10 (3), 01.07.1995, S. 295–310; for early international organizations see Herren, Madeleine: Sozialpolitik und die Historisierung des Transnationalen, in: Geschichte und Gesellschaft 32, 2006, S. 542–559.
9 Baldwin, Peter: The Politics of Social Solidarity. Class Bases of the European Welfare State 1875-1975. Cambridge 1990.
10 Baldwin, Peter: The Politics of Social Solidarity. Class Bases of the European Welfare State 1875-1975. Cambridge 1990, S. 62f.
11 See Kulawik, Teresa: Wohlfahrtsstaat und Mutterschaft. Schweden und Deutschland 1870-1912, Frankfurt 1999.; Wecker, Regina; Studer, Brigitte; Sutter, Gaby: Die «schutzbedürftige Frau». Zur Konstruktion von Geschlecht durch Mutterschaftsversicherung, Nachtarbeitsverbot und Sonderschutzgesetzgebung, Zürich 2001.
12 See Hacker, Jacob S.: The Divided Welfare State: The Battle Over Public and Private Social Benefits in the United States, Cambridge 2002.
13 See Howard, Christopher: The Hidden Welfare State. Tax Expenditures and Social Policy in the United States, Princeton 1999.
14 For Switzerland see Lengwiler, Martin: Risikopolitik im Sozialstaat. Die schweizerische Unfallversicherung (1870-1970), Köln 2006.; Leimgruber, Matthieu: Solidarity Without the State? Business and the Shaping of the Swiss Welfare State, 1890-2000, Cambridge 2008.
15 See: Internationaler Kongress für Versicherungswissenschaft, Bd. 4, Rom 1934, S. 92-105, S. 109-127; Internationaler Kongress für Versicherungswissenschaft, Bd. 2, Paris 1937, S. 151-170 (United Kingdom), S. 171-187 (Germany), S. 189-206, 379-385 (Switzerland), Internationaler Kongress für Versicherungswissenschaft, Bd. 5, Paris 1937, S. 230-236 ; for Germany also see Conrad, Christoph: Vom Greis zum Rentner . Der Strukturwandel des Alters in Deutschland zwischen 1830 und 1930, Göttingen 1994 ; for Great Britain see Pearson, Robin: Who pays for pensions? Das Problem der Alterssicherung in Großbritannien im zwanzigsten Jahrhundert, in: Zeitschrift für Unternehmensgeschichte / Journal of Business History, 2003, S. 48–57; for Switzerland see Leimgruber, Matthieu: Solidarity Without the State? Business and the Shaping of the Swiss Welfare State, 1890-2000, Cambridge 2008; Lengwiler, Martin: Competing Appeals. The rise of mixed welfare economies in Europe, 1850-1945, in: Clark, Geoffrey (Hg.): Appeals of Insurance, Toronto 2010, S. S. 173–200.
16 Baldwin, Peter: Beyond Weak and Strong. Rethinking the State in Comparative Policy History, in: The Journal of Policy History 17 (1), 2005, S. 12–33. Online: <http://www.sscnet.ucla.edu/history/baldwin/Beyond_Weak_and_Strong.pdf>, Stand: 09.12.2015.
17 Baldwin, Peter: Beyond Weak and Strong. Rethinking the State in Comparative Policy History, in: The Journal of Policy History 17 (1), 2005, S. 19. Online: <http://www.sscnet.ucla.edu/history/baldwin/Beyond_Weak_and_Strong.pdf>, Stand: 09.12.2015.
18 See Hall, Peter A.; Soskice (Hg.): Varieties of Capitalism: The Institutional Foundations of Comparative Advantage, Oxford 2001.
Webpages
In die Zukunft gedacht (2015)
Bundesministerium für Arbeit und Soziales:
In die Zukunft gedacht, 2015.
Germany’s social history
With the Future in Mind is a website that allows to time travel throughout the history of poor relief and welfare state in Germany since the Middle Ages. In addition to texts about periods subjects, and terms, the site also offers images, videos and teaching material. The site is based on an exhibition of the same name, which can for instance be seen at the Federal Ministry of Labour and Social Affairs in Berlin. The Ministry is also the publisher of this website.
The principal branches of the German welfare state were funded in the 1880s, when the Otto von Bismarck government established accident, health, old-age, and disability insurance for male and female workers. Previously existing worker’s funds or company insurances were integrated into the new social insurance schemes. Ever since the German State has been characterized by an occupationalStatism and a structural continuity.
Website is offline since 2018. Partialy available through the internet archive wayback machine.
Social Security History
The United States Social Security Administration:
Social Security History.
History of National Social Security in the U.S.A.
The website was published on the occasion of the 80th anniversary of the 1935 Social Security Act, which constitutes the starting point of the American welfare state. It documents the history of the American welfare state with a focus on the beginning and development of the Social Security Administration, which is also the website’s publisher. The milestones and influential characters of Social legislation and social state agency are also further elaborated. Even though the website also includes a general history of social security since the 19th century, it’s presentation gains significance only with the Social Security Act of 1935.
As a result of the focus on administrative and organizational history the essence of the liberal U.S.-welfare model is pushed into the background. Compared with European states the financial involvement of the United States regarding social security funds is relatively minimal. Instead, the country relies on private insurances to a large degree.
Geschichte der Sozialen Sicherheit (2013)
Bundesamt für Sozialversicherungen BSV:
Geschichte der Sozialen Sicherheit, 2013.
The website „The History of Social Security in Switzerland“ was created on the occasion of the 100th anniversary of the Swiss Federal Social Insurance Office. Several Swiss universities participated in the project. The website offers a chronological overview of the development of the Swiss social state since the 19th century. But it also highlights individual aspects from the topic areas risks, actors, institutions and figures.
Unlike in other northern and western European welfare states non-governmental actors are strongly represented in the Swiss social security scheme. Also, the financial participation of the insured is relatively high. Switzerland stands for a functional heterogeneous organizationally fragmented and institutionally hybrid modern type of welfare state.
Social Security in Japan (2014)
Ministry of Foreign Affairs of Japan:
Social Security in Japan, 2014.
The Ministry of Foreign Affairs of Japan’s website „Social Security in Japan“ is one of the few historically reflected Internet resource on a non-western welfare state. It addresses the poor relief law of 1874 (Jyukkyu Kisoku) and the health insurance of 1922, which constitute the origins of the Japanese welfare state. Similar to European welfare states Japanese social services were largely extended after World War Two. In addition the website offers an overview of today’s Japanese social security schemes.
History of the ILO
International Labour Organization:
History of the ILO.
The websites run by the International Labour Organization (ILO) include a summary of the organization’s history, an interactive timeline, a short film and a bibliography. The ILO emerged in 1919 as part of the League of Nations. Following the international trade union tradition the ILO aimed to improve labor legislation in individual countries by introducing international standards in order to curb international competition for minimal social costs. In addition, the organization plays a significant role in the knowledge and know-how transfer between individual welfare states.
History of the International Social Security Association (ISSA)
International Social Security Association:
History of the International Social Security Association (ISSA).
The International Social Security Association (ISSA) offers a brief overview of its history in form of a timeline. An expert organization, the ISSA has worked closely with the International Labour Organization (ILO) ever since it was first created. The ISSA serves as umbrella organization for public and private providers of social insurance schemes. It includes member organizations from more than 150 nations. Since 1927 the ISSA has distinguished itself as forum for questions about social security, specifically in the fields of work safety and health protection.
Online Publications
Beyond Weak and Strong (2005)
Peter Baldwin:
Beyond Weak and Strong: Rethinking the State in Comparative Policy History, 2005.
In the early 1990s Peter Baldwin observed an influence of class and group interests on the shaping of social security funds in European model welfare states (Germany, Great Britain, France, Sweden and Denmark). In his study „The Politics of Social Solidarity: Class Bases of the European Welfare State“ Baldwin radically criticized the thesis of a linear teleological development towards a universalistic, social democratic welfare state type. As Baldwin showed, even ideal types of universalistic social states historically rely on coalitions of individual interests—in Denmark and Sweden for instance between landowners, self-employed and workers—and are therefore not as homogenous as often assumed. In the present text Baldwin develops a new approach of dealing with welfare states based on his concept of “styles of Statism”.
International Organizations (2011)
Sandrine Kott:
International Organizations – A Field of Research for a Global History, 2011.
With their anthology „Globalizing Social Rights: The International Labour Organization and Beyond“ Sandrine Kott and Joëlle Droux published a pioneering work on the history and impact of International Labour Organization (ILO). In a different text, published online, they give an overview on the research field of international organizations. It explains how this field contributed to incite increasing interest for global history and the research of globalization processes.
Zur Entstehung von IVSS und IAO (2008)
Cédric Guinand:
Zur Entstehung von IVSS und IAO, 2008.
Der Artikel von Cédric Guinand rekonstruiert die Gründungsgeschichte der Internationalen Vereinigung für Soziale Sicherheit und zeigt die vielschichtigen Beziehungen zur Internationalen Arbeitsorganisation (ILO) auf.
The creation of the ISSA and the ILO (2008)
Cédric Guinand:
The creation of the ISSA and the ILO, 2008
Cédric Guinand’s article reconstructs the founding history of the International Social Security Association and shows its complex relations with the International Labour Organization (ILO).
For All These Rights (2010)
Jennifer Klein:
For All These Rights. Business, Labor, and the Shaping of America’s Public-Private Welfare State, 2010.
Jennifer Klein’s study is a central work in recent American welfare state historiography. She examines the relation between governmental, union and commercial or labor-friendly organizations and interests in American social state history. To this end she studies the example of the New Deal’s social legislation with a special focus on old age and health insurance. She gives an exemplary insight into U.S.-mixed welfare economics and the traditionally strong position of private actors within the American social state.
The Nordic model (2013)
Mary Hilson:
The Nordic model: Scandinavia since 1945, 2013.
Mary Hilson’s book offers a broad introduction to the so-called „Nordic model“, of which the Scandinavian social state models form part. According to Hilson Scandinavian states share a common regional history reinforced by comparable modernization processes in these countries. Traditional liberal values, high standards of living, and a comparably high level of social security that comes with a high fiscal burden characterize all Scandinavian nations.
Databases
Social Expenditure Database (2015)
Organisation for Economic Co-operation and Development OECD:
Social Expenditure Database (SOCX), 2015.
The OECD Social Expenditure Database (SOCX) includes statistical information on public and private social expenditure of 34 member states since 1980. As of 2014, France, Finland, Belgium and Denmark rank first in international comparison. Germany ranks ninth, Switzerland and the U.S.A. are in lower middle score range and Korea, Chile and Mexico finish last. The OECD publishes evaluations of social expenditure on its website on regular basis (see Social Expenditure Update). It’s 2014 evaluation shows a slight decrease of social expenditure in some OECD-member states. However, if the numbers are compared to the mid-term development since 1960, social expenditure is still on a historical high.
Eurostat Sozialschutz
Europäische Kommission:
Eurostat Sozialschutz (ESSOSS).
ESSPROS, the integrated system of social protection statistics, provides a coherent comparison between European countries of social benefits to households and their financing. The data includes social benefits supplied to households and their financing since 1990. Social benefits are transfers to households, in cash or in kind intended to relieve them from the financial burden of a number of risks or needs.
The functions covered by social benefits are disability, sickness/health care, old age, survivors, family/children, unemployment, housing and social exclusion. In addition to quantitative data regarding social security systems’ revenue and spending, qualitative metadata of individual systems is also recorded.
NATLEX
International Labour Organization:
NATLEX . Database of national labour, social security and related human rights legislation.
The ILO maintains several databases on the issue of work and social security. NATLEX, database of national labour, social security and related human rights legislation includes over 88,000 records covering 196 countries and over 160 territories and subdivisions. Newer information system NORMLEX brings together information on International Labor Standards (such as ratification data, reporting requirements, comments of the ILO's supervisory bodies, etc.) as well as national labor and social security laws.
Documents: Video, Sound, Pictures etc.
Post War Consensus and the welfare state (2013)
Keith Laybourn:
1945-64 - Post War Consensus and the welfare state, 2013.
The English Historical Association’s website includes a podcast in which Professor Keith Laybourn of the University of Huddersfield looks at the period 1945-64. Laybourn examines the post war consensus and the British welfare state with a special focus on social security funds, state housing policy, educational system and the role of political parties. What were the key forces that led to the welfare state and the ‘post war consensus? To what extent did this consensus transform the lives of British people?
Like other European countries, Great Britain experienced an important social reform following World War Two. A core element of British reforms was the introduction of the National Health Service in 1948. That same year France created the integrated Sécurité sociale with various insurance sectors. Switzerland introduced its AHV, the federal old-age and survivors’ insurance, in 1947.
Beveridge Report. Social Insurance and Allied Services (1942)
William Beveridge:
Beveridge Report. Social Insurance and Allied Services, 26.11.1942.
The Beveridge-report significantly influenced social reforms launched in many European countries following World War Two. Written by economist and social state expert Lord William Beveridge. and published by the British government during the war in 1942, the „Report on Social Insurance and Allied Services“ advocated the creation of state-subsidized social security systems. The intention was to protect citizens „from the cradle to the grave“ from want, disease, ignorance, squalor and idleness. After the deprivations of war the Beveridge-report quickly grew to become the British government’s most important point of orientation during economic recovery. It led to the introduction of the National Health Service and heavily influenced several other western states forced to deal with the same issues.