Political culture and social security - A comparison of the United States and Germany

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Manufacturers and other businesses cater to consumer demand for products and services that may not optimize health e. Another systemic explanation considered by the panel is whether there is something unique in how decisions are made in the United States, in contrast with other countries, which might produce different policy choices that affect health. Not all of the problems identified in this report are affected by policy decisions—many relate to individual choices or perhaps the inherent nature of life in America—but decisions by government and the private sector may play a role in shaping many of the health determinants discussed throughout this report.

The relevance of public policy to health is perhaps most conspicuous in relation to recognized problems in the U. But the potential causes of the U. People are responsible for their individual behaviors, but individual life-styles are also influenced by the policies adopted by communities, states, and national leaders Brownell et al. Cigarette smoking, second-hand smoke inhalation, and societal norms about smoking are influenced by the price of cigarettes, bans on indoor smoking, and advertising regulations Brownson et al.

The obesogenic environment reflects decisions by the food industry and restaurants about the content and sizes of their offerings; business strategies about where to locate supermarket chains and fast food outlets; ballot decisions on parks, playgrounds, and pedestrian walkways; school board policies on high-calorie cafeteria menus and vending machine contracts; and the marketing of electronic devices to children Brownell and Warner, ; Institute of Medicine, , b , c , c ; Nestle, Public- and private-sector policies affect drinking and driving, binge drinking, prescription and illicit drug abuse, and the use of contaminated needles by injection drug users.

Policies can also influence access to contraceptives and firearms. Both the incidence and lethality of injuries are affected not only by personal choices, but also by decisions made by manufacturers, builders, lawmakers, and regulatory agencies that control product safety, road design, building codes, traffic congestion, law enforcement of safety regulations e. Policies also affect the social and economic conditions in which people live, and the quality of education—from preschool through college and professional schools Bambra et al.

Political and economic institutions, which help drive the economic success of nations, are subject to a range of public policies Acemoglu and Robinson, Tax policy and decisions by employers, business leaders, government, and voters affect job growth, household income, social mobility, savings, and income inequality. They determine the strength of safety net and assistance programs and the quality of the environment, from its physical characteristics e.

The relevance of macroeconomic government policies on health was exhibited in a natural experiment when East and West Germany unified in — after unification, the mortality rates for the elderly in the eastern part of the country declined to those of the western part Scholz and Maier, ; Vaupel et al. Policies that affect public health, education, and the economy are themselves shaped by the institutional arrangements in a society—the governmental and nongovernmental arrangements that organize social relations, rank people into social hierarchies, assign worth, structure employment and the labor market, and address working conditions Bambra and Beckfield, As illustrated in Table , some studies of what has been described as the political economy of health Muntaner et al.

These influences are multilayered and complex. Figure presents a model by Hurrelmann and colleagues , which illustrates the multitude of social and political factors that contribute to population health and, by extension, to cross-national differences in health. A model of structural and political influences on population health. The U. Most European welfare programs came into existence after World War II with the goal of providing more universal access to assistance Bambra and Beckfield, The social democratic model promotes social equality through wage compression, organized through strong collective bargaining by unions, and tax policies that direct resources to the social security system Bambra and Beckfield, As detailed in Part I of the report, the Scandinavian social democratic countries generally have higher health rankings than the United States, along with more favorable measures of social and economic well-being.

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As a group, these social democratic countries report longer life expectancies, lower infant mortality rates, and better self-rated health than do liberal countries, including both the United States and the United Kingdom Bambra, , ; Chung and Muntaner, ; Coburn, ; Eikemo et al. Figure shows that this pattern has existed for decades Conley and Springer, Infant mortality rate for the United States and 30 other countries, classified by welfare regime type.

Infant mortality rates by welfare regime type, — Sociological research is beginning to suggest that the style of governance in a country may exert its own influence on health outcomes, independent of individual-level variables. Another study concluded that the model type predicted approximately 20 percent of the difference in infant mortality rates among countries and 10 percent of the difference in low birth weight Chung and Muntaner, However, the panel notes the limitations of current evidence on this topic, which relies heavily on cross-sectional associations.

Controlled trials to produce more definitive evidence would be untenable, and all studies on this subject must cope with a variety of methodological challenges, such as the potential endogeneity of the political and social environments, as well as issues relating to aggregate efficiency, intertemporal dynamics, and macroeconomic effects.


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Typologies for regimes, such as welfare states, can be blunt measures that require further refinement to properly differentiate policy nuances across and within countries and to track changes that affect countries over time. For example, social democratic countries like Sweden had low infant mortality rates early in the 20th century Regidor et al. There is little question that the European welfare model is effective in redistributing income and reducing poverty.

More universal and generous welfare systems achieve greater income equality than other systems through more generous income transfers through taxes and services Esping-Andersen and Myles, These entitlement benefits may buffer the health effects of material deprivation and thereby improve health outcomes but they may have other consequences that are not economically or politically viable in the United States.

Related characteristics of Scandinavian society, such as greater gender equality Stanistreet et al. Political empowerment of minority groups and women appears especially important to health Beckfield and Krieger, As noted in Chapter 7 , citizen engagement in the United States, such as voting in elections, is lower than in most other OECD countries e , and the United States has one of the lowest rates of female participation in the national legislature Congress Armingeon et al. Scandinavian society is also known for having less income inequality than in the United States see Chapter 6 , a likely product of the welfare state.

The Luxembourg Income Study provides evidence that social democratic policies have, over time, substantially reduced income inequality Alderson and Nielsen, The Scandinavian welfare programs universalism, generous wage replacement rates, extensive welfare services may also narrow income inequalities and provide low-income individuals with greater access to services Coburn, However, as discussed in Chapter 6 , it remains unclear whether income inequality itself, or the policies that affect income inequality, bear more on the U.

There is some evidence to suggest that aggregate spending on social programs is associated with better health. One study examined spending on health care and social services in 30 OECD countries and found that U. More importantly, the study found a significant association between social spending and life expectancy, infant mortality, and potential years of life lost Bradley et al.

In a commentary about the U. Authors of another study also noted that the United States ranks poorly on measures of full-time employment, public child care, union representation, and parental leave Pettit and Hook, see Table Many of these may be less acceptable in the United States because of related tax burdens and other implications. In seeking a systemic cause for the U.

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A subjective comparison of Germany and the United States

We have suggested a potentially promising line of inquiry based upon differences in social policy contexts. However, the challenge is obviously to identify the particular social and labor policies that have a causal impact on health and that may contribute to cross-national health differences. For example, do the more generous parental leave policies in Europe contribute to their comparative health advantage? Have employment protection policies contributed to the better health of European workers compared with their U.

The great variation in policy reform during the last 50 years across Europe and the United States provides us with a potentially fruitful set of natural experiments to consider. Broadening the scope of our inquiry to include the social and policy context of nations might help to solve the puzzle of the U. Even the reduction in income inequality achieved by this form of capitalism probably results from the interaction and combination of multiple policies e.

Nor is the social democratic model a panacea for public health. Compared with Scandinavian countries, health gradients tend to be lower in Bismarkian countries e. As discussed in Box , a variety of explanations for the paradox have been proposed Bambra, ; Dahl et al.

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Explanations for the Scandinavian Welfare Paradox. One proposed explanation for the paradox of greater health inequalities in many Scandinavian welfare states is that lower social strata may have a higher relative concentration of individuals at increased more The United States can take little comfort in debates about why some European countries do better than others in reducing health gradients, because it is still the case that the United States and the United Kingdom generally fare worse than all of them—on both aggregate health status and the steepness of the health gradient Avendano et al.

What Do Europeans Really Think About Americans?

As noted in Chapter 6 , at least one study has reported that the health gradient by education is steeper in the United States than in Western European countries Avendano et al. These cross-national comparisons certainly shed light on the U. Social, economic, and public health policies are often an expression of societal values, set against the backdrop of other exigencies e. Social rights were extended at minimal cost to the entire population in a social contract that sought to eliminate status privilege Bambra and Beckfield, On issues that pertain directly to the U. The United States ranks poorly on a number of factors that could explain its health disadvantages.

As detailed in Chapters 4 — 7 :. These conditions reflect multiple factors, including history, governance models, societal values, and priorities that cannot be ignored in trying to understand the U. For example, as discussed in Chapter 4 , the lack of universal health insurance coverage sets the United States apart from most high-income nations, but there are reasons this situation has existed for generations.

Dalton, Politics in Germany -- Chapter 10

At the same time that countries in Europe were establishing universal access to health services, attempts to do so in the United States, beginning with the Truman administration in the s, met with political resistance, as it still does today Altman and Shachtman, ; Starr, The resistance has been shaped not only by interest groups, such as medical organizations and health insurance companies, but also by societal beliefs about the proper role of government and the private sector in health care Freeman and Marmor, Similarly, to make sense of why Americans are more likely to engage in certain unhealthy behaviors or injurious practices see Chapter 5 , the role of societal values in enacting or resisting countermeasures cannot be ignored.

Yet there is little empirical evidence to prove that values in the United States differ substantially from those in other high-income countries. The internal and external validity of the indicators and sampling techniques used in such surveys is less than ideal.

However, the panel believes that the individual behaviors and policies of Americans in relation to public health and socioeconomic issues are, to at least some extent, influenced by prevailing values and priorities Goldberg, For example, five iconic American beliefs seem especially relevant: individual freedom, free enterprise, self-reliance, the role of religion, and federalism. Individual Freedom Strong beliefs in individual freedom, as expressed in the Declaration of Independence and Bill of Rights, remain powerful drivers in modern America Fairchild et al.

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Some personal freedoms carry special significance in the United States, such as the right to bear arms, a constitutional protection that does not exist in most other countries Glantz and Annas, Free Enterprise American society is committed to free-market capitalism and generally eschews restrictions on industries, especially when they impede economic activity or involve an expansion of governmental regulatory authorities.

Many aspects of the political process, including the campaign finance system in the United States, give large donors and special interests a degree of influence over the formulation of policy than may exist in other countries Mann and Ornstein, Whether regulations are meant to protect public health, assist vulnerable populations, or meet other needs, a popular refrain in the United States is that effective solutions for social and economic problems are best achieved through the free market and more directly by families and their communities see discussion on self-reliance, below.

It is also true that a vibrant and growing economy is good for public health and for the health of the population, that anything that impedes economic growth and flexibility can have detrimental population health effects, and that strategies to boost employment and raise levels of income and wealth can yield important health benefits. Thus, raising taxes for state-financed social or health programs is often unpopular with a large proportion of American voters. In contrast, there is a consensus in many other high-income countries around shared responsibility, solidarity, and the principle that a certain standard of living is a right of citizenship Bambra and Beckfield, ; Esping-Andersen, ; this consensus that may not be as pervasive in the United States.

Role of Religion Although the separation of church and state is a core principle in the United States, the United States is less secular than most other high-income countries Taylor, ; World Values Survey Association, , and religious beliefs are often raised in public discourse. Sensitive public health policies, such as those related to contraception or adolescent sexuality, may not be as contentious in other countries Darroch et al. Federalism The United States originated with a revolution against an overbearing government, and Americans continue to seek limits on the size and budget of government, including agencies responsible for social services, safety, and even health itself.

Although this decentralized model is an ingenious strategy for separation of powers and is of growing appeal in other countries Charbit, , the resulting fragmentation complicates attempts to set national policy priorities that many smaller countries with more centralized governments can pursue more easily. It also creates an uneven distribution of resources that might not exist in countries with more centralized models and that often affect the neediest.