Real Reform in Health Systems: An Introduction

Health care reform seems fundamental to the coherence and the future of the welfare state. Health programs occupy a central place in modern systems of social protection, and it is now quite difficult — albeit not impossible, as exemplified by the United States — to conceive of social justice without including health care in the list of goods that should be provided to all as a right of citizenship. Accordingly, questions about the legitimacy and longterm viability of the welfare state usually aim directly at publicly financed health services. The spiraling cost of providing care and the growing demand for services are pinpointed as major factors contributing to the increase in public deficits and related financial instability. Before looking to the future, it is instructive to look to the past. Perhaps we should ask ourselves why access to care historically prevailed over access to education, income security, or even clean water.1 After all, in his master plan for a “comprehensive policy of social progress,” William Beveridge (1942: 6) famously identified five “giants” that needed to be confronted. What he called “disease” was only one priority in a list that also included addressing “want, ignorance, squalor and idleness.” The triumph of health care was not predetermined, and in fact it took decades for the sector to emerge as a central social service, to use Beveridge’s own terminology, with reduced variation from country to country.