Document Type

Contribution to Book



Publication Date



Oxford University Press

Source Publication

The New Politics of the Welfare State

Source ISSN



In this second of three chapters on the distinctive policy dynamics of particular areas of social provision, Susan Giaimo addresses the issue of whether the success of the reformed welfare state in the shape of payers’ and policy makers’ cost‐containment projects have had as their price the sacrifice of equity and solidarity. These questions are explored through the lens of health care reform in Britain, Germany, and the US since the late 1980s: each a country with a distinctive health care system, which undertook major reform initiatives designed to control health care outlays, and addressed the efficiency and equity goals in markedly different ways. Section I provides a broad background to situate the contemporary politics of health care reform, explaining how and why health care systems in Western countries have come under the stress of increasing cost pressures even as governments and employers have become more apprehensive about the possible effects of the welfare state on economic competitiveness. Section 2 develops the argument in greater depth, explaining how existing health care and political systems provide different opportunities or constraints for payers and the state to pursue unilateral cost‐containment strategies, how health care institutions themselves shape policy preferences and strategies of payers, and how some systems require compromise solutions that reconcile equity with efficiency. Section 3 presents each country's case, and the concluding section considers the broader lessons from health care reform for the contemporary politics of welfare state adjustment.


Published version. "Who Pays for Health Care Reform?" in The New Politics of the Welfare State. Ed. Paul Pierson. Oxford: Oxford University Press 2001: 334-367. DOI. © 2001 Oxford University Press. Used with permission.