Understanding the Welfare State: The Case of Health Care
| Author | Michael Moran |
| Published date | 01 June 2000 |
| Date | 01 June 2000 |
| DOI | 10.1111/1467-856X.00031 |
| Subject Matter | Article |
British Journal of Politics and International Relations,
Vol. 2, No. 2, June 2000, pp. 135–160
Understanding the welfare state:
the case of health care1
MICHAEL MORAN
Abstract
This article redresses an imbalance in the study of the welfare state: the comparative neglect
of health-care programmes as sources of evidence about the changing politics of the welfare
state. It explains why health care should be central to our understanding of the welfare state;
summarises the present debates about the pressures on welfare states; explains how to think
about health-care governance in this connection; develops a typology of ‘health-care states’;
and shows how the experience of health care reflects, and how it departs from, the wider
experience of welfare states.
Understanding the welfare state
Debates about health-care policy should be central to our understanding
of the contemporary welfare state, for some obvious reasons. In the bundle
of goods and services commonly packaged up in the welfare state health
care is a major component—whether we measure by resources consumed,
numbers employed in creating and delivering health-care goods and ser-
vices, historical importance in the statecraft that built welfare states, or the
subjective attachment of citizens to the services of health-care institutions.
Yet oddly, the literature on health-care policy is often semi-detached from
the wider literature on the welfare state, being immersed instead in its own
specialist controversies; conversely, writings on the welfare state often
seem to marginalise health-care policy. Though any observer of the welfare
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state acknowledges that health care is a big component of welfare pro-
vision, it is striking that many of the major contributions that have in
recent years shaped debates about the welfare state (Esping-Andersen
1990 is a good example) have had health policy at the corner of their eye
rather than in the centre of their vision. The purpose of this article is to
redress this semi-detached condition.
Welfare states in trouble
A decade or so ago the comparative literature on the welfare state was
consumed by the language of crisis—the exact meaning being that a revo-
lutionary transformation of the condition of the welfare state was to be
expected; for ‘critical’, if it is not simply used for rhetorical effect, must mean
a turning point after which the circumstances of the ‘patient’ are trans-
formed (see Moran 1988). In fact,we now know that the welfare state in
the 1980s was not poised on the brink of critical transformation. On the
contrary, the dominant experience was what Pierson calls ‘stickiness’: the
structures of policy making, coupled with the powerful interests them-
selves created by previous episodes of welfare expansion, made flexible
policy adaptation immensely difficult (Pierson 1998, 552ff.). The policy-
making structures of welfare states proved incapable of anything like
critical transformation; policy change there has been, but constrained or
enabled by highly contingent circumstances of particular programmes and
their clients.
It is precisely this disjunction between institutional arrangements and
changing social and economic structures that leads, in Rhodes’ phrase, to
the conclusion that ‘welfare states are in trouble’ (Rhodes 1996, 307).
Four kinds of change are important: transformed demography; trans-
formed labour markets; a shift to a more global economy; and the growth
of Europeanisation. Each are here examined in turn.
Demography has been transformed since the 1950s, the era when wel-
fare state-making as an exercise in statecraft was at its height. The decline
(in some instances collapse) of birth rates, coupled with increasing lon-
gevity, is producing increasingly old populations. The most suggestive
general conceptualisation of this change is offered by Alber (1995). The
established research on the welfare state concentrated heavily on transfer
payments because these were a critical mechanism for addressing problems
arising from class inequalities created by the workings of labour markets.
Alber argues that these issues arising from labour-market location are
being supplanted—or at least joined—by a range of social problems tied to
Michael Moran
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