In an effort to prevent such financial entropy, the government established a decentralized, three-tier system of administration for the Italian health care structure. At the top, the national government enjoys the ability of regulation by instituting minimum service levels for each region – approved by Parliament - and specifies the conditions under which the private sector can provide service to individuals. The National Health Council, a convoluted organization composed of officials from each region, central administration, industry professionals and social unions, advises Parliament as to creation of such standards. The duties of implementation, planning, financing and monitoring of the health care system fall upon the 21 regions of the Italian state. On average, each region contains about 320 local health units, called Unitarie Sanitarie Locali (USL), which act as the chief health care providers in each district (Gardini 704). A small percentage (10) of hospitals are private and provide some care but used primarily for teaching (Gardini 703; Del Favero 167). This three-tier system of administration, although convenient in theory, fails to alleviate the financial burden placed on the health care system but gives patients more localized care.
The Italian health care system lacks efficient central authority and organization leading to great dissatisfaction among Italians. Although health statistics in Italy often exceed other OECD member nations, many Italians voice discontent with the SSN, citing high taxes, rampant tax evasion, corruption, massive national debts and inefficiency (Ferrera 231). The reforms of 1992, including privatization and deficit reduction, have not succeeded in quelling Italian anxiety (Ferrera 242). To illustrate this general discontent, Italians, ironically, feel not as healthy as other OECD member citizens; only 55.6% of Italians between the ages of 15-65 in 1999 reported that they considered their health “good,” while people in France and United Kingdom report 83.2% and 75.1%, respectively (OECD 67). Even though they are not, Italians feel less healthy than their OECD counterparts, indicating a degree of distrust for the SSN; furthermore, they grow weary of the continual bureaucracy plaguing the health care system, despite legislation to curb those frustrations.
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III. The Elusive Dream: An Understanding of American Health Care
The American system is simple in that it virtually does not exist. No central, national health care system can be found in America and only limited assistance programs are offered to the most underprivileged and health care-starved members of society. The federal government offers two types of federal insurance plans to help this special sector of the population. Medicare subsidizes treatment for people 65 years and older, while Medicaid aids the fringes of the socio-economic spectrum like low-income populations, blind and disabled people, low-income people 65 years and older, and children of low-income families (Babour 8). The government funds 44.8% (1998) of the cost of these programs, while the OECD average stands at 75.2 percent (OECD 85). In 1998, health care expenditures in America amounted for 12.9% of its GDP, compared to the OECD average of 8.2%. When juxtaposed, these figures illustrate the government’s inability to deliver health care services and its reliance on the private sector for health care provision. Some exceptions, however, do exist. For example, the United States funds, administers and operates the Indian Health Service (Barbour 4). Both state and federal governments, however, oversee federal expenditures in health care by establishing budgets within jurisdictions, setting re-imbursement rates and administering their distribution (Barbour 4). In the United States, the government plays no significant role in health care and its populace feels the burden.
Many Americans face great risk in the case of disease since their economic realities prevent them from purchasing health care insurance. Approximately 45 million Americans (17% of the total population) do not have health insurance (Barbour 5). Of this group, many, but not all, refuse to pay for private, preventative care and rely on free health clinics or hospital emergency rooms in case of serious health problems (Barbour 5). To illustrate some Americans’ inability to receive health attention, the number of consultations with doctors per capita in 1996 in America was 5.8, compared to the OECD average 6.8 (OECD 56). This figure is undoubtedly inflated in the United States because most wealthy Americans probably consult physicians more frequently than the majority of citizens in other OECD-member nations, so this heightens concern about the lack of medical attention received by the one-fifth of Americans who lack health care insurance. The near-complete privatization of health care in the United States leaves a substantial of Americans population at great health risk.
Obvious irritation towards the health care system brews in America as well. Since the rise of welfare state politics in America, marked by FDR’s administration and the New Deal, improvements to health care echo among other American social demands. In 1937, 80% of Americans supported an increased governmental role in health care delivery, and, by 1992, a resilient 75% of Americans continued to support this measure with little fluctuation during the period (Steinmo 332). Multiple presidential elections, including Truman vs. Taft and Bush vs. Clinton, focused on the legislation of sweeping health care reform (Steimon 341, 362). Despite their good health, from FDR to Clinton, Americans grow increasingly weary of their health care system, and the lack luster results of the 1992 initiatives only serve to heighten this malcontent.
Americans continue to wait for a viable health care system. Almost one-fifth of all Americans lack any method of health care. Most all Americans altruistically support massive health care reform, including a national health care service. Americans do enjoy relative health but feel their advanced nation ought boast a better, more universal health care system.
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- Unhealthy Health: Discontent in Italy and America Despite Relative Health
Despite this frustration with the respective systems, both Italians and Americans take pleasure in higher relative health when compared to other OECD member countries. The following tables illustrate OECD averages and Italian and American performance for the first year on OECD record and the most recent complete year on key health issues:
Table 1
Life Expectancy (in years)
All averages weighted by OECD
Table 2
Infant Mortality (deaths per 1,000)
* OECD Avg. inflated due to Turkey’s disproportionate rates of 189.5 (1960) and 37.5 (1997)
The above tables show the relative health of both Italians and Americans, whom enjoy both greater life expectancies and lower infant mortality rates than most OECD member nations. These statistics illustrate the success of both health care systems, particularly in the case of Italy. The Italian state founded the SSN in 1978, and results were immediate. OECD reports that in 1970 the Italian infant mortality rate was 29.6 and by 1980, only two years after the implementation of the health care system, the rate dropped to an astonishing 14.6 (OECD 70). Granted the advances in medicine and pre-natal care affected this statistic, but some of the drop must be attributed to the SSN. Comparatively, between 1970 and 1980 the infant mortality rate in the United States reduced from 20.0 to 12.6, a percent change of 37.0. Italy’s much more impressive 50.7 percent change in infant mortality between 1970 and 1980, in addition to America’s superior health technology (thus, disproportionately reducing American infant mortality rates), further illustrates the SSN’s remarkable initial success. Conversely, the United States showed no significant increases in life expectancies, which the 1992 Medicaid and Medicare reform targeted, before the initiative in 1990 and after its implementation 1996. Regardless of the success of the American program, Americans remain among the healthiest people in the world, as do the Italians, yet resent towards the respective health care systems linger in both these nations.
In spite of of their high statistical performance regarding national health, both Americans and Italians desperately seek reforms. The American health care system’s virtual inexistence and the Italian establishment’s unbelievable bureaucratic clutter incite great frustration and dissatisfaction in their respective citizens. The problems of both health care systems arose from both countries fear of powerful central governments. Their Constitutions outlay serious checks on the kind of government necessary to implement and coordinate a viable and efficient national health care system by strictly limiting the powers of their respective national governments.
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IV. A Pear Tree Doesn’t Yield Apples: Constitutions that Limit Health Care
Both the Italian and American Constitutions share a common trepidation of authoritative government, which yield weak governments lacking the political resources needed to organize national health care systems. The American Constitution of 1787, for example, arose from an apprehension of authoritative governments due to the perceived tyrannical rule of English King George III (Countryman 175). “The history of the present King of Great Britain,” reads Thomas Jefferson’s Declaration of Independence, “is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States.” (Declaration of Independence) This anti-authoritative intellectual climate catalyzed the creation of a Constitution featuring an array of checks and balances, including federalism, to curb possible usurpation by future American governments. States’ rights promoted weak and limited federal initiatives, barring against extensive and expensive legislations such as national health care. For the first time, the processes of legislation, implementation and administration were divided into separate and independent government institutions. Furthermore, the American forefathers established an autonomous judiciary to ensure no government action impeded or underscored “the Supreme Law of the Land.” The American Constitution was deliberately designed to be inefficient and discourage any massive state endeavors in order to prevent another authoritative ruler such as King George III.
Italians, too, when drafting their Constitution in 1947 feared over ambitious national governments with few constraints on the scope and domain of their power. Although beloved at first, Mussolini’s totalitarian regime ultimately ruined Italy, both physically and mentally. Mussolini’s decision to enter World War II led to the eventual scorn of Italian cities and countryside. The campaign divided Italy as the Allied-controlled South fought the Nazi-controlled Northerners. Pinned against one and other, the Italian psyche suffered tremendously from the later stages of the World War II campaign. After Liberation, the authors of the Constitution, composed primarily of Resistance leaders, drew up a document echoing these sentiments against totalitarian regimes and divisive wars, which Article 11 best exemplifies. It reads:
Italy rejects war as an instrument of aggression against the freedoms of others peoples and as a means for settling international controversies; it agrees, on conditions of equality with other states, to the limitations of sovereignty necessary for an order that ensures peace and justice among Nations; it promotes and encourages international organisations having such ends in view. (Italian Constitution, Article 11)
Clearly, post-World War II Italian fears yielded a document that prevented too much political power to rest in one person’s hands, resulting in a government with a strong, yet large, Parliament with two executive offices, President and Prime Minister, that are, essentially, subject to Parliament (Di Scala 284). Like America, the Italians retained regional autonomy, assuring both the uniqueness of cultural institutions and the prevention of Roman political domination. For both the Americans and the Italians, fears of authoritative governments stemming from distinct histories led to Constitutions preventing large, centralized national governments with concentrated power to enact rapid and extensive legislation.
Both Constitutions established large, representative bodies as the chief legislative force in national politics. Both the Italian Parliament and The American Congress enjoy a broad scope and domain of powers, like budgetary control and complete legislative authority, but these two institutions, in accordance with the political fears underlying their Constitutions, dilute political power into an immense number of individuals (Italian Constitution Art. 70-82; American Constitution Art. I Sec. 1-10). In creating such a weak state, Italian and American constitutional framers probably prevented future authoritarian rule in their respective states but, consequently, developed a system that, by its very nature, is incapable of legislating complex initiatives, such as national institutionalized health care.
The nature of national health care systems require an exuberant amount of coordination, not just in the administrative process, but also, and maybe more so, in the development phase. Ensuring that the 275 million Americans and the 58 million Italians receive, not only care, but also quality and efficient treatment requires thorough and diligent planning (OECD 59). Furthermore, the countless number of interested parties, including but not limited to physicians, insurance companies, politicians and ordinary citizens, creates a innumerable assortment of opinions as to the proper direction of health care systems, often times disproportionately beneficent to certain groups (Freeman 42). Discontent towards the Italian system illustrates that the mere implementation of a hap hazardously organized national health care system will not, in the long run, satisfy a populace’s need for quality health care (Gardini 706). Furthermore, the Italian model shows that improperly planned national health care systems, once put into practice, may create institutions nearly impossible to reform. To illustrate, the habits formed by the initial health care initiatives, such as pharmaceutical black markets and massive financial deficits, continue to plague the SSN despite the 1992 reforms directly targeting these unwanted structures (Ferrera 233, 240). The need for clearly defined standards, an organized central authority, and fiscal efficiency required by any effective national health care system involves straight-forward, yet meticulous planning, which Congressional-based governments like the United States and Italy cannot provide.
The nature of both the Italian and American states require extensive compromising for the ratification of legislation. Bills must pass in two separate Houses in the respective legislative bodies then subject to presidential review. As a consequence, most all the players in this extensive legislative process demand provisions in legislative initiatives, the majority of which must be compromised (sometimes quite suddenly), often confounding and muddling health care reform proposals, thus yielding inefficient and cluttered “solutions.” The 1965 American Medicare proposal illustrates the adverse affect of this “compromise factor” on health reform initiatives. Realizing the inevitability of change Rep. Mill asked to combine the Democratic initiative with a Republican stipulation to pay physician fees through a voluntary insurance program, and proposed that poor Americans not covered by Medicare also receive benefits. The provision, when approved, curbed future health reforms in the United States for obvious economic reasons: further expansion meant more expenses (Steinmo 348). Had Mill not inserted such last-ditch provisions, more efficient and tested health care reform may have been introduced, but the need to compromise in this Congressional system yielded economically irresponsible reform, which discouraged further initiatives, and created yet another inefficient, difficult-to-reform health care institution. The nature of governments with powerful congressional institutions, like Italy and the United States, yields a system continually in dire straits to compromise in order to ratify any legislation, producing convoluted and inefficient programs, which later plague health care reform initiatives.
Alongside the “compromise factor,” both Italy and America often fall victim to the tyranny of the minority, whom find safety in the institution of the congressional committee. The existence of committees in both systems often increases productivity and specialization through the division of labor. The drawback of the committee organizational scheme, however, is committees often times insert their own provisions into legislation, which can normally be tolerated but not with health care. In 1949, for example, Rep. Robert L. Doughton (R - NC), who opposed National Health Insurance (NHI) despite resounding popular support for the measure, successfully blocked the initiative because he chaired the House Ways and Means Committee and, therefore, exerted great influence over it. Since the Constitution provides that all legislation necessitating the raising of revenue initiate in the House, and since the House-established rules delegate budgetary control to its Ways and Means Committee, the future of American health care lay in Doughton’s hands. Despite a Democratic control of both the presidency and the House and broad popular support, one individual dismantled the majority of a nation’s hopes by never bringing the legislation to the floor for vote (Steinmo 343). Ironically, the authors of the Constitution sought to dilute power across a vast number of citizens, yet the committee system allowed one individual to crush a widely supported initiative. In legislative systems riddled with committees and highly specific procedural rules, small minorities terrorize health care legislation, by inserting inefficient provisions or simply not bringing the issue to a vote.
Congressional systems also increase the role and influence of political parties, creating a conflicting dichotomy between party solidarity and individual political ambition. Theoretically, the party system ought create more thought out and comprehensive health care proposals with an increased incidence of passage and devoid of fatal compromises, attributable to solidarity. In America, however, the reality remains that parties shadow the individual politician, which in systems featuring frequent, institutionalized elections, such as Italy and the United States, pose a threat to politicians reelection bids. Steinmo and Watts illustrate how the “political entrepreneur,” like Mill and Doughton, champions particular issues, most often in opposition of massive government overhauls, such as health care reform, and utilizing propaganda, like limited government, to rally support (Steinmon 345). Often times, these “political entrepreneurs” employ institutional “loop-holes,” like closed-rules and committees, combined with mass-media, which began to reach national levels during FDR’s term, to achieve their goals thus foiling often popular and worthwhile reform and also augmenting apathy towards government and, as a consequence, hindering future reform. Furthermore, a prisoner’s dilemma arises as those politicians loyal to the party seeking effective reform are forced to defect and become “political entrepreneurs” for fear losing their jobs, thus minimizing the likelihood of quality reform even more so. The American party system creates a vicious cycle of ambitious politicians jockeying for name recognition, which furthers public distrust of government and makes meaningful reform more difficult.
The Italian party system creates a similar problem due to its institution of pure proportional representation. Aside from demanding more compromise for legislation, the multi-party system also creates “political party entrepreneurs,” although much individual jockeying for position also occurs but holds a less adverse affect on the ratification of legislation. Since Italy lacks the famed Five Percent Clause that German proportional representation electorate system boasts, which bars parties receiving less than 5% of the vote out of government, Italian parties stand to step into the national limelight with a mere one percent of the vote (Di Scala 285). So small parties on the political fringes can quickly gain popularity, and as a consequence, power, if they utilize the public spotlight properly. For example, the proto-fascist party, in recent years, gained enough support to ascend to government, with 1.7% of the vote in 1963, and utilized the national media to appeal to disenfranchised Italian, thus gaining gradual popularity, capturing 8.7% of the national vote in 1972. This institutional system encourages minority parties to oppose mainstream legislation, like health care reform, on ideological grounds. Thus, Italy faces the exact problem the United States does with the “political entrepreneur:” the decrease in likelihood of effective reform, increased incidence of the tyranny of the minority and rising apathy towards government due to its inability to legislate reform.
Another key institutional feature plaguing both Italian and American health care reform stems from their commitment to decentralized rule. Both countries wrote such provisions into their Constitutions for the same reason they developed strong congressional/parliamentary systems: fear of concentrating power. With 50 sovereign States in America and 21 autonomous regions, these nation-states clearly enjoy a greater safeguard against authoritative rule and oppression through local laws, relative legal and economic independence, as well as, the ability to preserve local culture. The latter benefit is particularly important to both Italians and Americans who take great pride in their particular regional cultural affiliation. This institution of decentralization, like other provisions protecting against tyrannical rule, further hinder welfare state development in the two nations.
Massive logistical problems arise from the possible implementation of reform initiatives in regions or states with distinct local laws and social institutions. Each locality features unique cultures and traditions, revealing unique social institutions in need of consideration when devising a reform program. In Sicily, for example, Mafia corruptly extorts the pharmaceutical retrieval process and any reform would likely disturb the Mafia, creating a serious problem. Likewise, Californian law requires citizens to pay State, as well as Federal, income tax so possible financing of reform through State taxation may meet fierce resistance in California but maybe not in Nevada, per say. Like the difficulties of reforming hap hazardous health care systems, regionalism heightens the complicatedness of reform because of the vast number of unique local institutions and laws.
Also, regionalism magnifies the adverse affect of the “compromise factor” because, not only must reform address a variety of political concerns, health care reform in decentralized states like Italy and the United States need also meet regional concerns and expectations, stemming from a variety of cultures. In 1949, southern Democrats occupying influential positions in committees, like the Ways and Means Committee, blocked widely popular health care reform because it failed to satisfy their particular southern ideologies (Steinmo 345). In a sense, both Italy and America must deal with an additional constraint: “regional political entrepreneurs.” Regional divisions create feelings of nationalism towards that area, increasing political stubbornness thus adding to the list of inefficient reform forced upon legislation by the need to compromise.
Furthermore, both nations face serious problems reforming their health care systems because of the difficulty of destroying established institutions. Path dependency theory states that institutions, once created by law or society, may impede future change as interested parties wish to continue such institutions; thus, as John Myles and Paul Pierson argue, “choices made in the past systematically constraint the choices of the future.” (Pierson 306) So, for example, the health insurance companies in the United States would strongly oppose health care reform in the United State for fear of decreasing stock value. The American lobby tradition inflates the influence of path dependency as interested parties exert a strong financial influence over voting representatives. Social institutions arise as well that make reform difficult. In Italy, for example, the complex system of dual-payment of pharmaceuticals spurred corruption, particularly in the South where mafia prevails, so changing the system would surely meet staunch resistance. Both Italy and America face uphill battles in reforming their health care systems because the current systems created sticky institutions, which impede reform due to the increased number of interested parties.
In conclusion, the Italian and American Constitutions created provisions limiting authoritative and centralized rule but, also, hindering massive national welfare programs like health care. The nature of limited government makes implementing large welfare overhauls difficult because representative governments open the doors to a variety of different interest groups. Furthermore, the legislative process in such governments creates systems prone to inefficient compromises. Large welfare programs such as national health care are marked by their need to be well organized and planned out, and such compromises too often impede such meticulous arrangements. Other political institutions further cramp the legislative process, like the party systems, lobbying, and regionalism. Simply stated, the nature of health care butts heads with the nature of weak, decentralized governments found in Italy and the United States. Despite their countless historical and cultural differences, Italy and America fall victim to a common enemy when it comes to significant health care reform: themselves. Without changing their institutions that impede comprehensive national welfare program legislation and implementation, meaningful advances to both their health care systems is doomed.
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