After World War II, the United States and Canada, two countries that were very similar in many ways, struck out on radically divergent paths to public health insurance. Canada developed a universal single-payer system of national health care, while the United States opted for a dual system that combines public health insurance for low-income and senior residents with private, primarily employer-provided health insurance—or no insurance—for everyone else. In National Health Insurance in the United States and Canada, Gerard W. Boychuk probes the historical development of health care in each country, honing in on the most distinctive social and political aspects of each country—the politics of race in the U.S. and territorial politics in Canada, especially the tensions between the national government and the province of Quebec.

In addition to the politics of race and territory, Boychuk sifts through the numerous factors shaping health policy, including national values, political culture and institutions, the power of special interests, and the impact of strategic choices made at critical junctures. Drawing on historical archives, oral histories, and public opinion data, he presents a nuanced and thoughtful analysis of the evolution of the two systems, compares them as they exist today, and reflects on how each is poised to meet the challenges of the future.

Gerard W. Boychuk is director of global governance at the Balsillie School of International Affairs and an associate professor in the Department of Political Science at the University of Waterloo, Ontario, Canada. He is also a research fellow of the Institute for Advanced Policy Research at the University of Calgary.

Contents
List of Illustrations
Preface
Acknowledgments
List of Abbreviations and Acronyms
Part I	Introduction and Context
	Chapter One	Introduction
	Chapter Two	Similar Beginnings, Different Contexts, 1910¿40
Part II	Public Health Insurance in the United States
	
	Chapter Three	Failure of Reform in the Truman Era, 1943¿52
	Chapter Four	The Medicare Package, 1957¿65
	Chapter Five	Race and the Clinton Reforms
Part 3	Public Health Insurance in Canada
Chapter Six	Federal Failure, Provincial Success¿Reform in Canada, 1945¿49
Chapter Seven	National Public Hospital Insurance and Medical Care Insurance in Saskatchewan, 1950¿62
Chapter Eight	Medical Care Insurance in Canada, 1962¿84
Chapter Nine	The Iconic Status of Health Care in Canada, 1984¿2008
Part 4	Conclusions
	Chapter Ten	Contemporary Public Health Insurance in the United States and Canada
	Chapter Eleven	Conclusions and Implications
References
List of Illustrations
Tables
3.1	Support for National Health Insurance (Social Security), United States, by Region, 1945
3.2	Support for National Health Insurance, Various Options, United States, by Region, 1949
3.3	Support for Civil Rights Program, United States, by Region, 1949
3.4	Voluntary Hospital Insurance Coverage, United States, by Region, 1958
4.1	Public Attitudes toward Government Guarantees of Health Care, United States, by Race, 1968
7.1	Voluntary Private Health Insurance Coverage, United States (1950 and 1956) and Canada (1956)
8.1	Provincial Adoption of Medicare-Eligible Physician-Care Insurance, Canada
8.2	Support for Medicare, Canada, by Region, 1968
10.1	Regulation of Individual and Small-Group Insurance, United States, by State, 2003
10.2	Comparable Health Performance Indicators, United States and Canada, 2002
10.3	Out-of-Pocket Health Expenditures, United States and Canada, 2000
10.4	Price Indices for Health Expenditures, United States and Canada, 1991¿2001
Figures
3.1	Public Support for National Health Insurance (Truman Proposals), United States, 1945¿50
4.1	Public Attitude toward Government Intervention in Health Care, United States, 1964¿76
5.1	Perceptions Regarding Attention Paid to Blacks and Other Minorities, United States, 1982¿98
5.2	Support for More/Less Federal Services, United States, 1995
5.3	Perceptions of Minority Usage Intensity and Support for ¿Major Cuts¿ to Specific Programs, United States, 1995
9.1	Federal Cash Transfers to Provinces for Health Care, Canada, 1993¿2007
9.2	Canada Health Transfer, 2004¿14
10.1	Total/Public Health Care Expenditures, U.S. dollars per capita, United States and Canada, 1981¿2001
10.2	Uninsured Children, United States, by State, 2002¿3 (percent)
10.3	Medicaid Coverage, Children Under 18, United States, by State, 2003
10.4	Medicaid Spending per Enrollee, United States, by State, 2000
10.5	Health Plan Enrolment, by Type of Plan, United States, 1988¿2004
10.6	Perceived Quality of Health Services, United States and Canada, 2002¿3
10.7	Perceived Quality of Physician Services, United States and Canada, 2002¿3
10.8	Access Problems Due to Cost, by Income and Insurance Status, United States and Canada, 2001 
Preface
Spending a sabbatical year in Ann Arbor and East Lansing, Michigan, and Durham, North Carolina, in 2005 powerfully reinforced my perceptions of the continuing pervasiveness of issues of race in American politics. I became more and more convinced about an argument that I had been making to my students: if an American were to visit Canada and vice versa and each visitor was then asked to summarize in a single phrase the most distinctive aspect of the political and social system of the country they had just visited, the Canadian observer would likely point to the prevalence of the politics of race in the United States and the American observer would likely point to the territorial politics of language and region in Canada¿especially the issue of Québec¿s place in the Canadian federation. 
	Given this, it is surprising that very few accounts of the development of health care policy in the United States pay adequate attention to the role of racial politics. In providing an overview of existing explanations of the lack of national health insurance in the United States, Jill Quadagno considers an explanation which ¿attributes the failure of national health insurance to the racial politics of the South.¿ (2005, 13) She provides only a single citation (with no page number) to an example of this argument¿Robert Lieberman¿s Shifting the Color Line. Surprisingly to readers following up Quadagno¿s reference, the index to Lieberman¿s book does not include a single reference to health insurance. The passage and citation are very revealing. One would expect¿as Quadagno clearly does¿that there ought to be a number of works attributing the lack of national health insurance in the United States to the politics of race. However, as her own citations reveal, there are none. Similarly, very few accounts of the development of health care policy in Canada pay adequate attention to the role of territorial politics. Even fewer comparative works examining the two countries refer to either of these important factors in explaining the distinct trajectories of development of their health care systems. None point to these differences as providing a central and essential explanation for why the contemporary health care systems in the two countries look so different. 
	At the same time, health care remains a central issue in both countries. In 2005, poll respondents in both the United States and Canada ranked health care as the single most important domestic policy issue. (Ipsos-Reid 2005, 18¿19) Health care was a central fixture in the 2006 Canadian federal election. Health care reform was an important element of President Bush¿s 2006 State of the Union address and is already emerging in the 2008 Democratic presidential primaries. Health care has been at the top of the public policy agenda in both the United States and Canada now for more than a decade and a half. In both countries, this represents only a small segment of health care¿s distinguished pedigree as a long-standing public policy issue. Nearly a full century after national public health insurance was first proposed in the United States by Theodore Roosevelt in 1912 (and a half-decade later in Canada by the Liberal Party under William Lyon Mackenzie King), proposals for health care reform still abound. Health care in both countries comes with a long history and understanding this history is a crucial element in gaining perspective on current reforms. Beginning from very similar starting points prior to World War II, the history of health care took divergent paths in the two countries in the middle of the twentieth century with national public health insurance for hospital and physician services emerging in Canada while, in the United States, a system of public health insurance for seniors and those with low income developed alongside a system of private, primarily employer-provided health insurance. As a result of this pattern of divergent development in these two countries with an otherwise relatively limited set of social, economic, and political differences, our understanding of the historical development of health care in each country is deeply enriched by comparisons of the two.
	Health care is not simply a technical policy issue in either the United States or Canada; rather, public health insurance has been central to perceptions of national identity for both the United States and Canada. For many both inside and outside the United States, its status as the only western industrialized democracy without a system of universal public health insurance is often a central element in claims of American exceptionalism. The Canadian system of public health insurance is even more clearly an explicit element of national identity, which is especially crucial to claims of distinctiveness vis- -vis the United States. Thus, an examination of the historical development of public health insurance in the two countries goes well beyond the type of issues generally perceived to be the province of public policy analysis. Rather, such an examination implicates questions regarding who Americans and Canadians are as peoples, the magnitude and nature of the differences between them, and the underlying sources of those differences.
	This work is intended to develop the argument that the politics of race in the United States and the politics of territorial integration in Canada together provide a powerful explanation of the divergent historical development of public health insurance in the two countries. In doing so, this alternative interpretation is intended as a second opinion offered in contrast to more popular conventional wisdoms in each country. There is a widespread perception that health care in the United States and Canada presents a fairly stark contrast. However, differences in public health care in the United States and Canada as well as the roots of these differences are more subtle and complex than generally recognized both in academic policy analysis as well as in popular debates. These differences, often exaggerated, caricaturized, and simplified, are widely believed to be rooted in fundamental differences in national values or political culture. The American system of targeted public health care and greater reliance on private provision of health care is often seen as evidence of the stronger influence in America of individualism and belief in a more limited role for the state. Canada¿s universal public health care system is often taken as evidence of a greater Canadian predisposition toward collective provision of social well-being and acceptance of a greater role for the state. Alternatively, these differences are sometimes seen as the result of the institutional distinctiveness of the political systems of the two countries¿the fragmentation of power inherent the American ¿separation of powers¿ system in contrast with the relative concentration of power in the Canadian parliamentary system. These institutional differences are in turn usually explained as being historically rooted in divergent perceptions regarding the appropriate role of the state in each country. Finally, differences in public health insurance in the United States and Canada are sometimes explained as the result of path dependent processes¿hinging on earlier differences in the sequence and timing of the development of public health insurance. 
	The central conclusion of this study is that the emergence of different systems of public health insurance in the United States and Canada was not predetermined by political culture, institutional configuration, or path dependence. Historical differences between the two countries in public health care provision, which are at once both profound and subtle, are not easily explicable simply by reference either to broad national-level cultural or institutional differences. Each was important; however, the key development of public health insurance in each country took place in a radically different social and political context¿heavily shaped in one case by the politics of race and the politics of territory and language in the other. The divergent outcomes in the two countries were strongly shaped by the intersection of the process of development of public health insurance with other broad-scale social processes occurring at the same time¿most notably, the extension of civil rights in the United States and the process of territorial integration in Canada.
	In developing this argument, this work does not claim to present a definitive history of the development of public health insurance in either country and is, rather, an interpretation of that history. As such, the historical rendering here is far from comprehensive and selected events and developments are emphasized to highlight particular patterns and illustrate specific themes¿patterns and themes which contribute to arguments which, I hope, readers will find both provocative and compelling. 
Acknowledgments
I would like to thank all the people who provided helpful comments on the manuscript or various parts of it including, among others, Keith Banting, Colleen Grogan, Antonia Maioni, and Ted Marmor. My colleagues at the University of Waterloo and Wilfrid Laurier University, Sandra Burt, Colin Farrelly, and Debora VanNijnatten, were kind enough to read the manuscript in its early, unvarnished versions. Julie Simmons, Mark Sproule-Jones, and Debora VanNijnatten each afforded me the opportunity to lead graduate seminars on the manuscript material which was invaluable in helping me organize and sharpen my arguments. Kevin Wipf, Andrew Banfield, Brad Ullner, and Matt Walcoff provided invaluable research assistance.
	I would like to thank Tom Kent, former principal secretary to Prime Minister Lester B. Pearson, who kindly agreed to a personal interview that, as evident in the text, was extremely helpful. Monte Poen also kindly engaged in a long email exchange that helped clarify a number of questions I had regarding the development of national health insurance proposals in the United States during the Truman era.
	Parts of the manuscript were written while holding the Fulbright¿Michigan State University Chair in Canadian Studies. For this, I would like to thank the Canada¿U.S. Fulbright Program and its executive director, Michael Hawes. For welcoming me to MSU, I would like to thank Phil Handrick, Mike Unsworth, Alane Enyart, David Katz and Catherine Yansa. In 2005, Duke University kindly hosted me as a visiting research professor at the Center for Canadian Studies. For their kindness during my stay, I would like to thank Janice Engelhardt, Gilbert Merks, and John Herd Thompson.
	I would like to also thank everyone at Georgetown University Press. Barry Rabe encouraged me to write this book and agreed to remain as editor emeritus through its final stages; I greatly appreciate this commitment. As many contributors to this series are well aware, Barry represents the gold standard for series editors. Gail Grella at Georgetown University Press was extremely patient and helpful in moving this manuscript along. Her consummate professionalism is greatly appreciated. Gail is simply the best acquisitions editor one could hope to have. I would like to thank two anonymous referees for their helpful and incisive comments that certainly contributed to strengthening the manuscript. I would especially like to thanks James Morone for his invaluable comments which were thoughtful, enthusiastic and constructive. Although we have never met in person, in some important senses, he rescued the soul of the manuscript. 
	Finally, I would like to thank Debora VanNijnatten for her loving support of this and all my endeavors.
	Of course, as always, any errors in fact or interpretation remain mine.
Abbreviations and Acronyms
ADC		Aid to Dependent Children
AFDC		Aid to Families with Dependent Children
AHA		American Hospital Association
AMA		American Medical Association
BCMA		British Columbia Medical Association
BNA Act	British North America Act, 1867
BQ		Bloc Québécois
CCF		Cooperative Commonwealth Federation
CES 		Committee on Economic Security
CHA		Canada Health Act, 1984
CHIA		Canadian Health Insurance Association
CHT		Canada Health Transfer
CHST		Canada Health and Social Transfer
CIHI		Canada Institutes for Health Information
CLIA		Canadian Life Insurance Association
CMA		Canadian Medical Association
CMAJ		Canadian Medical Association Journal
CPP		Canada Pension Plan
DHEW		Department of Health, Education and Welfare
EPF		Established Programs Financing
ERISA		Employee Retirement Income Security Act
FLQ		Front de Libération du Québec
FSA		Federal Security Administration
HIPAA	Health Insurance Portability and Accountability Act 
HMO		health maintenance organizations
IPA		Individual Practice Association
JAMA		Journal of the American Medical Association
JNMA		Journal of the National Medical Association
MP		member of Parliament 
NAACP	National Association for the Advancement of Colored People
NDP		New Democratic Party
NMA		National Medical Association
NPC		National Physicians Committee
OMA		Ontario Medical Association
PCCR		President¿s Committee on Civil Rights
POS		point of service plans
PPO		preferred provider organization
PQ		Parti Québécois
QPP		Québec Pension Plan
SCHIP		State Children¿s Health Insurance Program
SSA		Social Security Administration
UFA		United Farmers of Alberta