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America’s wars on poverty and the building of the welfare state.

David Torstensson David Torstensson David Torstensson was awarded his doctoral degree in American history from Oxford University in 2009. The title of his dissertation is “The Politics of Failure: Community Action and the Meaning of Great Society Liberalism.”
https://doi.org/10.1093/acrefore/9780199329175.013.276
Published online: 03 March 2016

On January 5, 2014—the fiftieth anniversary of President Lyndon Johnson’s launch of the War on Poverty—the New York Times asked a panel of opinion leaders a simple question: “Does the U.S. Need Another War on Poverty?” While the answers varied, all the invited debaters accepted the martial premise of the question—that a war on poverty had been fought and that eliminating poverty was, without a doubt, a “fight,” or a “battle.”

Yet the debate over the manner—martial or not—by which the federal government and public policy has dealt with the issue of poverty in the United States is still very much an open-ended one.

The evolution and development of the postwar American welfare state is a story not only of a number of “wars,” or individual political initiatives, against poverty, but also about the growth of institutions within and outside government that seek to address, alleviate, and eliminate poverty and its concomitant social ills. It is a complex and at times messy story, interwoven with the wider historical trajectory of this period: civil rights, the rise and fall of a “Cold War consensus,” the emergence of a counterculture, the Vietnam War, the credibility gap, the rise of conservatism, the end of “welfare,” and the emergence of compassionate conservatism. Mirroring the broader organization of the American political system, with a relatively weak center of power and delegated authority and decision-making in fifty states, the welfare model has developed and grown over decades. Policies viewed in one era as unmitigated failures have instead over time evolved and become part of the fabric of the welfare state.

Great Society
War on Poverty
America’s welfare state
President Johnson
Community Action Program

Since President Lyndon B. Johnson left office in 1969 competition between America’s two major political parties has in many ways centered on their relationship to the conflicts of the late 1960s. On most major issues, whether it is how the United States is governed, what role the federal government should play vis-à-vis the states, how minorities—ethnic or sexual—should be treated, or the role of the Supreme Court in interpreting the Constitution, the real and imaginary divisions the 1960s spawned continue to profoundly shape American politics. By and large these divisions have discredited American liberalism, making the 1960s known as the decade of “liberal overreach.” 1 American conservatives have for decades argued that the expansion of government through the Great Society programs was a mistake and often failed to help its intended recipients, the poor and underprivileged. 2 Charles Murray in his mid-1980s social policy blockbuster Losing Ground flatly stated that: “We tried to provide more for the poor and produced more poor instead. We tried to remove the barriers to escape from poverty, and inadvertently built a trap.” 3

While historians and social scientists have generally been more nuanced in their assessment of the Great Society, there is still a distinct sense in the literature that if not outright failures, the Johnson administration’s social programs did not live up to their expectations and were, at the very least, a missed opportunity. 4 Indeed, in one of the leading textbooks on American postwar history William Chafe has argued that the antipoverty effort was fundamentally flawed because policy makers never realized that what was really needed to fight poverty was a massive jobs program and redistribution of income. Other historians have agreed. They have argued that a massive program of employment and/or large-scale income redistribution would have been much more successful and desirable than the War on Poverty. 5

This broadly negative judgment on the Great Society (and in particular the War on Poverty) has become part of the wider narrative on the American welfare state. Ramshackle and largely ineffective, it is often accused of and criticized for not living up to the size and standards set by other developed countries, most notably in Europe. The manner in which the United States fights (or doesn’t fight) poverty is an important example often referred to as illustrating this broader point. Negative pronouncements are made every year in conjunction with the Census Bureau’s publication of the official poverty rates. The perennial questions asked are variations on if America needs a new war on poverty or why decades on (since the original 1964 launch) the war is still being lost. 6 Indeed, critics of varying political colors point to how rates of poverty have barely budged since the mid-1960s and that compared to European countries the United States is far behind and spends ever less on the poor. 7 In the late 1950s and early 1960s the poverty rate stood at over 20 percent. 8 By the early 1970s this had fallen to close to 10 percent and the U.S. Census Bureau’s latest ( 2013 ) estimated rate is 14.5 percent. 9 For example, noted economist and public policy doyen Jeffrey Sachs in 2006 argued in Scientific American that the United States (and other “Anglo Saxon” modeled countries) had fallen behind the high-tax and high-spend Nordic region on most indicators of economic performance. 10 He claimed that “the U.S. spends less than almost all rich countries on social services for the poor and disabled, and it gets what it pays for: the highest poverty rate among the rich countries and an exploding prison population.” 11 Others have argued a similar point. In 2001 a National Bureau of Economic Research paper argued that the United States was indeed much less generous to its poor and did not fight poverty as well as many European countries. 12 The authors argued that this was primarily a result of a political system that by and large was geared against income redistribution and a concomitant lack of broad public support for income redistribution primarily due to racism.

The Great Society and War on Poverty programs offer a fascinating prism for understanding the evolution of the 20th-century American welfare state. Its postwar development is not only a story about a number of “wars” or individual political initiatives against poverty, but also about the growth of institutions within and outside government to address, alleviate, and eliminate poverty and its concomitant social ills. From the New Deal to modern-day reform efforts including the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 , the expansion of Medicare and Medicaid coverage through Medicare Part D and the most recent Patient Protection and Affordable Care Act, one of the key characteristics of the American welfare state is its piecemeal and gradual evolution. While there have been a number of “big bang” reform efforts, overall the story of the postwar period is the incremental development of a welfare state that has evolved and changed as part of other major political and socioeconomic changes and processes. This development has not been driven only by a policy or reform initiative’s perception of success; more intriguingly, policies and reforms considered as grave political errors or failures in a particular era have over time become staples of American social policy. In this respect the Johnson administration’s War on Poverty initiative is instructive. It was largely discredited at the time and since, and few would argue that the Great Society and War on Poverty have an enviable reputation—political or otherwise. Yet the faith of its biggest and most maligned component—the Community Action Program—illustrates how a social policy can fail politically and by reputation, yet survive. Over the long-term the program itself and the ideas underpinning it have become an institutionalized and elemental part of the American welfare state.

“Fighting Man’s Ancient Enemies”: The War on Poverty and Lyndon Johnson’s Great Society

I want to be the President who educated young children to the wonders of their world. I want to be the President who helped feed the hungry and to prepare them to be taxpayers instead of taxeaters. I want to be the President who helped the poor to find their own way and who protected the right of every citizen to vote in every election … This great, rich, restless country can offer opportunity and education and hope to all: black and white, North and South, sharecropper and city dweller. These are the enemies: poverty, ignorance, disease. They are the enemies and not our fellow man, not our neighbor. And these enemies too, poverty, disease, and ignorance, we shall overcome. 13 — Lyndon Johnson, Special Message to the Congress, March 15, 1965 Johnson’s cause—the thing for which he hoped to be remembered—was the Great Society, his effort to outpace the New Deal, outflank group conflict, override class structure, and improve the lot of everybody in America. 14 — Richard Neustadt, in Presidential Power , 1976 edition

When he spoke about poverty, Lyndon Johnson spoke with passion. Whether it be from his childhood growing up in rural Texas, his experience from a year out from college teaching destitute Mexican schoolchildren in Cotulla, south Texas, or in his first major political assignment during the mid to late 1930s managing the Texas National Youth Administration, the 36th president of the United States had a deeply personal relationship with poverty. Throughout his years in public office, in speeches and on the campaign trail, Johnson would frequently—no matter what the topic—revert back to images of the poor and of the basic needs and wants of all peoples, regardless of their color or background. In his public and private remarks the president expressed his belief that most people had the same basic wants and desire for education, medical care, and an opportunity to lift themselves out of poverty. Because this conviction was absolutely central to his presidential program, Johnson never saw the War on Poverty and poverty itself as being discrete policy issues isolated from his overall domestic program. On the contrary, most of the Great Society’s legislative goals and victories—the extension of civil rights, voting rights legislation, setting federal standards and providing funding for elementary and secondary education, funding health care for the elderly and poor through Medicare and Medicaid—were part of the same idea of building on the New Deal to provide and extend equality of opportunity to all. 15

But poverty was never defeated. Instead of leading the fight on poverty, the President’s Office of Economic Opportunity (OEO) and its local staff were accused of playing an active part in the Newark riots of 1967 , funding criminal gangs in Chicago, supporting the staging of racist theater performances in New York City, and embezzling federal money in Mississippi. Such key War on Poverty components as Community Action, the Job Corps, Legal Services, Upward Bound, and even the popular Head Start, were often mentioned in sensational news stories of violence, corruption, and financial mismanagement. Almost as quickly as it had risen to the top of the national policy agenda, the War on Poverty and its programs became one of the topics the president and White House least wanted to discuss. By the end of LBJ’s presidential term when poverty as an issue did present itself, it was in the context of the growing welfare rights movement and the newfound militancy of the poor. Revealingly, for these the president did not have much sympathy. For example, during the summer of 1968 the Poor People’s Campaign—originally a campaign idea by Martin Luther King Jr.—marched and set up a camp in Washington DC. Giving speeches and meeting with administration officials, the campaign demanded that the federal government and Congress do more for minorities and the poor. But the president was not moved. Illustrating just how much the times had changed from four years earlier, when the antipoverty campaign had been launched and Johnson had laid out his Great Society vision, LBJ complained to Agriculture Secretary Freeman: “the very people we are seeking to help in Medicare and education and welfare and Food Stamps are protesting louder and louder and giving no recognition or allowance for what’s been done.” 16 In a remarkable glimpse of the subsequent staple conservative criticism that was to define the Great Society in a post-LBJ world, the president lamented the undesirable social consequences that his programs seemed to have resulted in: “Our efforts seem only to have resulted in anarchy … The women no longer bother to get married, they just keep breeding. The men go their way and the women get relief—why should they work?” 17 If Vietnam became LBJ’s foreign policy albatross, the War on Poverty was viewed by many as his domestic one. Indeed, Time magazine in 1966 wrote that “next to the shooting war in Viet Nam, the spending war against home-front poverty is perhaps the most applauded, criticized, and calumniated issue in the U.S.” 18

Not much has changed since the 1960s. Ronald Reagan’s famous 1987 sound bite—“we had a war on poverty—poverty won” 19 —if not a wholly accepted verdict, still rings true to a lot of subsequent observers and the American public. Indeed, the chief political legacy of the Great Society and War on Poverty programs can best be understood through this prism of chaotic failure. Politically the results have been stark and largely negative for the Democratic Party. Drained by the war in Vietnam and the general perception that although government programs were not directly responsible for urban rioting and student militancy, they were not doing enough to discourage them, the Johnsonian brand of consensus politics that had so dominated the Democratic Party for nearly two decades fell apart. Beginning in 1968 Democrats in a post-Johnson world embraced what many voters deemed social and political radicalism and abandoned the center ground. Indeed, presidential elections since have often been fought on the issues and perception of the issues permeating from the 1960s. In the words of former presidential speech writer to George W. Bush David Frum, Republicans have been “reprising Nixon’s 1972 campaign against McGovern for a third of a century.” 20 The results have been profound: since 1968 virtually no Democratic presidential candidate either running as a self-described liberal or labeled as one by his Republican opponent has won an election. In fact, those who have run as outspoken liberals—George McGovern in 1972 and Walter Mondale in 1984 —lost forty-nine states each and were beaten in some of the biggest landslides in American electoral history.

For the American welfare state the political legacy and poor reputation of the Great Society programs have meant that it has often found itself facing criticism of not doing enough for its intended recipients while maintaining a deep unpopularity with the general public. As sociologist John Myles has put it, there is a general perception that “for middle-aged, middle-income Americans, the welfare state is virtually all cost and no benefit.” 21 Yet while critical in contributing to these negative perceptions of the welfare state, the negative political history and legacy of the Great Society is only half of the story. Paradoxically, many of the most heavily criticized anti-poverty programs are the most misunderstood, as they have had, and continue to have, a long-lasting impact on social and welfare services in the United States.

Maximum Feasible Misunderstanding: The Community Action Program and the Divisions of the 1960s

While more famous programs, such as Project Head Start and Legal Services, have achieved higher levels of visible success and entrenchment within the American social policy framework, it is arguable whether any of the War on Poverty programs have been more influential on American social policy than the Community Action Program (CAP).

When it was launched in the mid-1960s, Community Action was meant to be a way of funneling federal support directly to local communities and involving these communities in the design and implementation of local anti-poverty action programs. It was in many ways intended to bypass conventional interest groups and involve a multitude of stakeholders. Indeed, communities consisting of the poor, local government, and business and labor interests would come together and form not-for-profit Community Action Agencies (CAAs) to coordinate, engage, and devise plans for tackling the problems of local poverty. The CAP designers believed that locally planned and implemented programs would stand a better chance of successfully fighting poverty and coordinating existing federal, state, and local efforts than any program that was centrally designed and managed through existing federal departments. In particular this was a view supported and promulgated by the president’s economic counselors including Walter Heller and Charles Schultze of the Council of Economic Advisors (CEA) and Bureau of the Budget (BOB), respectively. Yet the CAP quickly became one of the Johnson administration’s most heavily criticized and maligned programs. At root was a basic and unresolved disagreement over what Community Action actually meant.

To some the idea of Community Action was simply a management vehicle, a way of coordinating the many disparate and overlapping anti-poverty programs existing within the federal, state, and local bureaucracies. Community Action was in this light viewed as a deliverer and coordinator of services to combat poverty. Certainly, consultation with the poor and participation of the poor were elemental parts of this approach, but this version of Community Action was not about political or social empowerment. It was simply a new way of more efficiently coordinating programs and engaging the poor in an effort to help them help themselves. 22 Bypassing state government and distributing federal funds directly to the CAAs was administratively a relatively new approach, 23 but one based on what the White House and administration viewed as the “traditional and time-tested American methods of organized community effort to help individuals, families and whole communities to help themselves.” 24 This was also the view held by many in Congress. For example, Republican congressman Albert Quie was a staunch supporter of the Community Action concept, if harsh critic of the OEO, arguing that the Community Action concept devolved power locally. 25 Similarly, Carl Perkins, a member of the House Education and Labor Committee to which the poverty bill was referred to in March 1964 , supported the idea of local community involvement and participation of the poor. 26

But to others, Community Action translated into direct political empowerment—a way of forcefully confronting political and economic power structures. It was a way of taking, and giving, power to the poor by means of confrontation. This type of Community Action was closely associated with the thinking of Saul Alinsky, a former Chicago academic and community organizer who ran several independent community organizations around the country and later became associated with some of the more radical OEO-funded programs in Syracuse and Chicago. Crucially, this brand of Community Action became the popularized perception of the program and was extensively covered by major news outlets and in Congress throughout the 1960s. 27

President Johnson’s views on what Community Action would do to shake up social policy and local government appear to be very different and certainly a lot less radical than those of other proponents of Community Action. As he would later reveal in his memoirs: “This plan [community action] had the sound of something brand new and even faintly radical. Actually, it was based on one of the oldest ideas of our democracy, as old as the New England town meeting—self determination at the local level.” 28 The tragedy of Community Action, the OEO, and the War on Poverty is that these efforts never had the type of leadership and clarity of purpose that could have made this vision a political reality and from the beginning effectively sidelined the noisy minority of radicals both within the OEO and on the ground. The anti-poverty director Sargent Shriver was never wholeheartedly committed to the Johnsonian view of the War on Poverty and Community Action. While this does not mean that he was committed to a more radical view of Community Action, Shriver’s political ambitions and willingness to cater to some of his more radical constituents and own staff meant that the fundamental confusion about the purpose of Community Action and the War on Poverty—highlighted in management survey after management survey of the agency—was never resolved. 29 When the anti-poverty director finally attempted to grapple with this fundamental problem in 1967 by amending the anti-poverty legislation to include more representation of local government, the OEO had already reached a political endgame. Once the ghettos started burning and conflict and militancy firmly replaced consensus and peaceful civil rights, neither the OEO director nor the White House were in any position to stem the tide.

When CAP was launched, Shriver expressed the sentiment that it relied “on the traditional and time-tested American methods of organized community effort to help individuals, families and whole communities to help themselves.” 30 While this was certainly the view that the president took, Shriver never consistently or convincingly maintained this position. Norbert Schlei, Department of Justice lawyer and drafter of the original Economic Opportunity Act in 1964 , has argued that relatively early on there was a real shift in the emphasis of the poverty program, a shift that came from the anti-poverty director himself:

I think the whole concept [of maximum feasible participation and Community Action] began to evolve and it got to be much more this matter of putting the target population in charge, putting the local people in charge of the federal money … I really hadn’t understood that that was part of it … I think that even while it was not yet passed [the EOA] there appeared some drift in the whole thinking about community action … Some of it came out of Shriver. I would hear Shriver say things that made me feel that there had been some evolution in thinking since I was directly involved … the idea of putting the target population in a power position and the idea of putting the local government people in a power position seemed to me to be talked about like they were much more integral to the whole idea than I had understood originally. 31

Other OEO insiders have supported this view. For example, Eric Tolmach, who worked on CAP in the OEO, has also described Shriver as sending very mixed messages to those within the agency who supported radical Community Action. Tolmach argued that Shriver felt that by supporting radical CAPs “it separated him from the average bureaucrat in town, and it gained him some credibility on the one hand with large groups of people who were for doing this kind of thing, and with the poor.” 32 This is an important aspect of the history of the War on Poverty as it ties in with the bigger narrative of the changing politics of poverty and the Democratic Party during the mid to late 1960s.

Ambitious Democratic politicians such as Sargent Shriver and Bobby Kennedy—and even some Republicans like New York mayor John Lindsay 33 —saw the radicalization of the political discourse that permeated this period as an opportunity as well as a shift in how future elections and voters would be won. For Shriver, building up and maintaining a natural constituency through the poverty programs was a way of connecting with this new type of politics and its new constituents. Indeed, some have argued that this was in fact Shriver’s raison d’être for staying on as OEO director. In his oral history interview for the Johnson library, Ben Heinemann (chairman of one of the internal White House policy task forces) described Shriver’s and the president’s working relationship as “terrible” and commented that the only reason Shriver stayed on was “ambition” and a desire to “remain in the public view.” 34 The anti-poverty director, Heinemann said, “didn’t have a good alternative [to the War on Poverty] that would still have been in the public eye.” 35 That he was intent on running for office was clear to Heinemann, who described Shriver in 1967 as being “anxious to talk … about the possibilities of his running for Governor in Illinois in ’68.” 36

But Shriver’s constituency and brand of New Politics did not have the kind of national electoral impact for which he had hoped. In 1968 the Democratic presidential coalition fell apart with Richard Nixon and George Wallace combining to shave off almost 20 percentage points off LBJ’s 1964 margin of victory over Goldwater. The New Politics never emerged as a winning electoral force; instead, it created the bedrock for the success of the Republican coalition. In no small measure this was caused by the perceived radicalism of the New Politics constituents: younger voters, Vietnam protesters, and radical civil rights and welfare activists. Many of these groups took their roots in the poverty programs and the type of militancy that became the public image of the OEO. These groups contributed to splitting the Democratic Party by pushing white blue-collar voters into the GOP and shaping subsequent winning Republican presidential coalitions. When Shriver finally ran as George McGovern’s vice presidential candidate in 1972 , Richard Nixon leaned heavily on his opposition to this New Politics coalition and scored a historic victory on par with Johnson’s eight years earlier. Similarly, in 1976 when Shriver was a candidate for the Democratic presidential nomination, he did not win a single primary; his best showing was in Vermont, where he came in second, gaining 28 percent of the vote and losing to the eventual nominee, Jimmy Carter.

In many ways, the history of Community Action represents a microcosm for the wider War on Poverty and Great Society effort. Maligned at the time, both the very nature of the program and its achievements tell a different story. Now lost in the broader fireworks of the 1960s, the Community Action Program at the time became the prime example of everything that had gone wrong with the anti-poverty effort and a symbol of the Johnson administrations’ and “big government’s” overreach. The most famous and scathing criticism came from former White House and executive branch insider D. P. Moynihan, whose negative assessment of the War on Poverty set the tone for both contemporary understanding and subsequent analysis. 37 In 1968 he went as far as to claim that intended or not, Community Action had contributed to the past summers’ rioting: 38 Although vehemently denied in government press release after press release, this image of the OEO and Community Action Agencies as playing a prominent part in the tearing up of the American social fabric persisted in the popular as well as the political mind.

Yet for all the bad press and brouhaha it is not clear that a majority, or even a large minority, of Community Action Agencies were engaged in the types of activities as depicted in the media. Certainly, there were many instances in which a local agency got into political trouble and hit the front pages of the national newspapers for all the wrong reasons, but these instances are not representative of the policy directions taken by all, or even a majority, of the agencies that had been established by the mid-1960s. By 1967 there were almost 1,100 Community Action Agencies in operation, and only a handful of these can be described as having been marked by the type of radicalism and conflict that has come to define the entire program. And, as accurately noted by historian Alice O’Connor, these grants were primarily from the CAP’s experimental demonstration programs. 39 These facts were noted and understood at the time within the White House. Internal memoranda and research suggests that there was broad support and understanding for the real achievements of Community Action within the War on Poverty. 40 For example, in the recommendations to President Johnson of the 1966 Taskforce on Government Organization it was argued that “community action agencies remain the best available instrument for integrating and focusing government and private social service programs at the local neighborhood and community level” and that “at their best, community action agencies reflect a thoroughly American, solidly conservative approach to social problems: they are locally inspired and controlled, and responsive to the disadvantaged people whom they seek to serve.” 41 Even President Johnson himself lent the program his vocal support in the 1967 State of the Union address, which dealt in some detail with the War on Poverty and, if anything, reaffirmed the president’s commitment to fighting poverty through localized Community Action. 42 Yet, these messages never reached the broader public or, until recently, the scholarship. 43 But for all the negative press, Community Action has lived on and continued to shape American social policy.

While the OEO was finally disbanded by President Gerald Ford in 1976 , Community Action has survived as a federally funded program. Today there are over 1,000 Community Action Agencies. 44 The latest data from the National Association for State Community Services Programs shows that in 2013 Community Action Agencies served close to 16 million individuals (part of 6.7 million families) of which over 70 percent were at or below the federal poverty line. 45

But in contrast to its role set out in the original Economic Opportunity Act of 1964 , the federal government now plays a reduced part in the funding and monitoring of national Community Action. Instead, much of the responsibility has since the 1990s been transferred to the state level.

Created as a new federal agency by Congress in December 1974 , the Community Services Administration (CSA) replaced the disbanded OEO. Never part of the Executive Office of the President, the CSA remained a separate independent agency outside the established federal bureaucracy until its own subsequent closure in 1981 . That year President Ronald Reagan replaced, and Congress approved, the CSA with a small Office of Community Services lodged in the Department of Health and Human Services. This office remains in operation and is today responsible for the government-supported Community Action effort. But under the Omnibus Reconciliation Act of 1981 the federal government’s direct role in funding local CAPs was replaced by Community Service Block Grants (CSBG). No longer do federal grants go directly to local Action Agencies. Instead CSBGs are distributed to the states, which then in turn administer them to organizations that are officially designated Community Action Agencies under the CSBG Act. 46 These block grants are applied for by individual states and approved on an annual basis by the Office of Community Services. Outside of government, Community Action is represented by the National Association of Community Action Agencies, a group formed in 1971 to provide a national voice for Community Action. This association professes to be a “national forum for policy on poverty and to strengthen, promote, represent, and serve its network of member agencies to assure that the issues of the poor are effectively heard and addressed.” 47

It would seem that if longevity is any measure of success, there is a strong argument to be made that Community Action has been anything but a failure. Although the CAAs of today are different from those of the 1960s, the requirement that Community Action boards should be made up of a combination of the poor, local and state government, and the private sector is still there. 48 Outlasting the Office of Economic Opportunity, the continued existence of these CAAs suggests that while the centralized operational arm of President Johnson’s War on Poverty could not survive on its own, the local organization, run for and by local communities, could, and has. This is a powerful testament to the idea that decentralized policymaking in social and welfare policy involving all relevant stakeholders is as an enduring part of American social policy as ever. Remarkably, this belief has since the late 20th century crossed party and ideological lines, becoming a defining characteristic of modern American conservatism.

From Community Action to Compassionate Conservatism

In the mid-1990s compassionate conservatism became part of the mainstream political lexicon. Pioneered by Texas academic Marvin Olasky in his 1992 The Tragedy of American Compassion , compassionate conservatism was embraced by a number of influential Republican thinkers, politicians, and strategists. Indeed, during this time many Republican think tanks and grassroots organizations acutely felt the need for the Republican Party to redefine itself, and move away from the popularized image of the party with a cold heart, dead-set against helping the poor and needy. John Ashcroft, Ralph Reed, Bob Dole, Bill Bennett, Jack Kemp, Dan Coats, and Jim Talent all became part of this burgeoning compassion movement. Loudest of the voices calling for a new direction was freshly appointed Speaker of the House, Newt Gingrich, who pleaded for more compassion in the GOP. During his first session as Speaker he repeatedly made reference to Olasky’s work when outlining the need for Republicans to adopt a new conservative agenda. 49

But it was not only in Washington that Republicans were talking about compassion. While George W. Bush had shown an interest in the founding ideas of compassionate conservatism as early as 1993 —even meeting with Professor Olasky—and had during his first term as governor made it easier under Texas state law for private and religious charities to operate, Bush would not become compassionate conservatism’s national face until his 1998 gubernatorial re-election. On victory night of his landslide win he declared that he had big plans for the future, wanting to give the Republican Party a new look, that of compassionate conservatism. 50

During the following primary campaign for the Republican 2000 presidential nomination, Governor Bush set out his vision and philosophy for what compassionate conservatism meant to him and a future Bush administration. In a defining speech summing up the work of a task force of policy analysts and academics he had appointed in February, Bush in July 1999 outlined what compassionate conservatism meant and what as president he could do for America’s poor. Central to this speech, and the governor’s conception of compassionate conservatism, was the idea that anti-poverty initiatives should be local and as far as possible designed and run by third-sector agencies. He argued that local communities, religious organizations, and other nongovernmental groups should together with local, state, and the federal government fight poverty and provide opportunity for the poor, homeless, and needy:

We will make a determined attack on need, by promoting the compassionate acts of others. We will rally the armies of compassion in our communities to fight a very different war against poverty and hopelessness, a daily battle waged house to house and heart by heart. This will not be the failed compassion of towering bureaucracies. On the contrary, it will be government that serves those who are serving their neighbors. It will be government that directs help to the inspired and the effective. It will be government that both knows its limits and shows its heart. And it will be government truly by the people and for the people. 51

To Governor Bush, such a plan to fight poverty stood in stark contrast to the efforts of the War on Poverty and the Great Society, which he accused of being too bureaucratic, government-centered, and lacking in true compassion:

In the past, presidents have declared wars on poverty and promised to create a great society. But these grand gestures and honorable aims were frustrated. They have become a warning, not an example. We found that government can spend money, but it can’t put hope in our hearts or a sense of purpose in our lives. 52

The ideas of fighting poverty through local charities and religious organizations became a defining feature of Bush’s successful presidential campaign. Compassionate conservatism and the belief that faith-based organizations could revolutionize the way in which the federal government delivered its social welfare programs became one of the campaign’s core selling points on domestic policy. Indeed, as early as June 1999 political correspondent Adam Nagourney of the New York Times was writing about compassionate conservatism as being Governor’s Bush’s defining political slogan. 53 Once he took office, the president’s Faith-Based Initiative was at the center of his compassionate agenda. While the actual legislation put forward for the initiative was primarily about the federal government not discriminating against religious groups when providing funding for local anti-poverty and social welfare services, at its heart the initiative was as much about local action being the best remedy for social problems like poverty, drug addiction, and single parenthood. 54 Yet what Governor and then President Bush failed to at least publicly acknowledge was that the influence of the War on Poverty and Community Action had already extended and heavily influenced the manner in which America’s welfare state actually provides and delivers its public services. The Great Society’s, War on Poverty’s, and Community Action’s most important social policy legacy is perhaps the contribution it made toward the outsourcing of service provision to the third sector and nonprofits.

Community Action and Modern American Social Policy

Local, decentralized, usually not-for-profit and nongovernmental—in all but a few instances, these are the defining characteristics of the providers of many of the public services Americans receive today. Since the 1960s and the launch of the Great Society programs, the growth in the provision of governmental services through the third sector has been astonishing. Although in sheer numbers the Social Security program is still the number one social welfare program today, many public services are not provided through or by the American government. Instead, government services are now largely provided by nongovernment entities and nonprofits in particular. This is especially pronounced with regard to social services and human services, where nonprofit organizations actually deliver a larger share of the services government finances than do government agencies themselves. 55 Through some of the biggest federal welfare and human services programs such as Medicare, Medicaid, student aid, and food stamps, the American state at all levels—federal, state, and local—serves mainly as the ultimate payer and regulator, but not provider of public services.

Similarly, and while conceptually different, the expansion of the use of grants-in-aid programs since the 1960s has also significantly bolstered the use of nonprofits and nongovernmental entities in the provision of public services. Through grants-in-aid the federal government provides block grants to state and local governments with relatively few programmatic requirements on how services should be provided. These grants are then used and distributed by state and local governments, which contract out the provision of services to nonprofits and the private sector. 56

In 2011 it was estimated that over 30 percent of the federal government’s budget went to the direct purchasing of public services or grants to provide such services. 57 For nonprofits in particular the growth has been significant both for direct purchases and grants, growing by an estimated 195 percent for the former between 1977 and 1997 and over 330 percent for the latter in the two decades between 1982 and 2002 . 58

While the seeds of the use of nonprofits and nongovernmental entities existed prior to the 1960s, the Johnson administration’s anti-poverty and welfare programs greatly expanded and institutionalized the use of the third sector in the provision of public services, primarily through the War on Poverty programs and the use of Community Action. Indeed, political scientist and noted historian of the third sector Peter Hall saw the War on Poverty as central to the growth of the postwar nonprofit sector:

if the political right supplied the rhetoric for efforts to down-size government, liberals and progressives could take credit for actually implementing large-scale privatization, first through local nonprofit organizations—many of them faith-based—subsidized by Lyndon Johnson’s War on Poverty, and later through deinstitutionalization of the mentally disabled and the subsequent creation of a vast system of community-based treatment and care provided by nonprofits operating under contract with state and local government. 59

Conclusion: America’s Wars on Poverty and Welfare State

In his classic 1990 dissection of the welfare state, Danish sociologist Gøsta Esping-Andersen outlined three welfare state regimes: liberal, corporatist, and social democratic. 60 With its traditional reliance on the power of the market, strict entitlement rules and means-testing, low social welfare benefits, and a culture of individualism the United States was described as the archetypical liberal regime standing in stark contrast to most European nations. 61 While Esping-Andersen’s work has been much criticized since—and revised by the author—the idea that the American welfare state is fundamentally different (indeed even exceptional) in size, purpose, and function from other developed Organisation for Economic Co-operation and Development (OECD) economies lives on both inside and outside academia. But what does the evidence actually show?

Traditionally, measures of welfare states and social protection look at the availability of social insurance (e.g., unemployment and health insurance) and availability of welfare and assistance programs, as well as labor market policies. 62 More often than not these are measures of total public and government expenditure. Using these traditional measures of social spending as an initial gauge of the size of the welfare state it is clear that the United States has historically spent less than other developed countries on social and welfare services. For instance, OECD data from 2014 show public social expenditure in the United States totaled just over 19 percent of GDP. 63 This is in comparison to an average of between 28 and 32 percent in France, Finland, Belgium, Italy, Sweden, and others. Clearly the United States is behind these countries. And for this year the United States was also below the OECD average of 21.62 percent but ahead of both Canada and Australia. But levels of public spending do not necessarily tell the whole picture.

Less attention has been paid to private or third-sector spending and activities and indirect variables such as the impact of tax laws. Regarding the latter, instead of authorizing direct social spending, American lawmakers have long used the federal tax code as a social policy tool. The most notable example in which the tax code works as a government subsidy by tax exempting certain types of benefits is the employer-based health insurance benefit, which is exempt from income and payroll taxation. While this benefit has been in place since the 1940s it was formalized into law in the 1954 Revenue Act. 64 The growth and development of this benefit has profoundly shaped the American welfare state and while nominally in the nonpublic sphere of spending it is nevertheless a significant de facto concession of tax revenue for the federal government. In 2013 this was estimated to amount to a loss of revenue to the federal government of $250 billion or roughly 7 percent of the total 2013 federal budget. 65 Moreover, if one looks beyond levels of public social expenditure and also include spending outside of government the U.S. position changes dramatically. Looking at the latest total public and private spending estimates by the OECD the United States actually has one of the highest rates of social expenditure—and biggest welfare states—in the world at close to 29 percent of GDP in 2011 , behind only France. 66 Table 1 shows this data for the United States and other OECD countries.

Table 1 Net total social expenditure (public and private), % of GDP, OECD countries 2011. 67

By comparison the country and welfare model the American welfare state is most often contrasted with, Sweden, is quite far behind with a rate of 24.6 percent of GDP net social expenditure in 2011 . Furthermore, if one looks at the trajectory of public social expenditure over a longer time-frame it is not at all clear that the American postwar experience is any different from that of other developed countries or the EU. OECD data going back to 1960 suggest that while always lagging behind average public spending levels in the EU (which is explained by the higher levels of nonpublic spending) U.S. government expenditure has since the 1960s followed an almost identical trajectory. Table 2 shows public social expenditure from 1960 to 2014 comparing levels in the United States, Japan, EU21, and OECD.

Table 2 Public social expenditure, % of GDP, United States, Japan, EU-21, and OECD, 1960–2014. 68

As Table 2 shows, the spending patterns and trajectory are very similar across all countries and regions. Interestingly, the data in the table also suggest that social spending has over the long term, by and large been immune to changes in government and political affiliation. For example, except for the Reagan years, social expenditure in the United States grew quite markedly during periods of Republican administrations particularly in the 1970s and 2000s under presidents Richard Nixon and George W. Bush. Indeed, the period in which the biggest difference between levels of social expenditure between the EU 21 and the United States can be seen is between the mid-1970s and early 1980s. During this time social spending continued to grow in the EU21 while in the United States it actually decreased under President Jimmy Carter.

The above statistics and data from the OECD show that measured as a share of economic output the United States invests a similar amount to other developed countries in social spending. They also show how since the 1960s and throughout most of the postwar period the trajectory of American public social expenditure has not been markedly different from other developed economies. Instead, the difference between the United States and other countries has been the presence of nonpublic entities. One of the key findings by political scientist Jacob Hacker in his 2002 The Divided Welfare State was that in the United States a large portion of social spending and the make-up of the American welfare state is nonpublic. 69 Looking at the history of the American welfare state, there was no Beveridge report or equivalent starting point for a complete overhaul and introduction of a welfare model. The closest the United States came to this was during the New Deal era and World War II. Some have indeed argued that U.S. policy planners during the latter stages of the New Deal (and particularly during the course of WWII) were intent on moving America toward a Beveridge-style full-employment welfare state. 70

The War on Poverty and the Great Society illustrate the development of the postwar American welfare state. The Community Action Program specifically offers an instructive historical example of the ways in which the modern American welfare state—the provision of public services through nonprofits—gradually and paradoxically developed over decades out of what was and has been widely regarded as a prime example of a failed social policy. Mirroring the broader organization of the American political system, with a relatively weak center of power and delegated authority and decision-making in fifty states, the welfare model has developed and grown over decades. Policies such as Community Action viewed in one era as unmitigated failures have instead over time evolved and become part of the fabric of the welfare state.

Discussion of the Literature

There is no distinct unitary historiography of all themes covered in this article, that is, Great Society liberalism, President Johnson, the War on Poverty, Community Action, and the American welfare state. Instead, broadly speaking, scholars have focused on various aspects within these topics, which, while although often overlapping, are often best viewed and understood as coming from discrete research silos. For example, studying the American welfare state has often been the purview of social scientists. Perspectives have ranged from the quantitative to sociological to political institutional to a more traditional history narrative. 71 Looking at the Great Society, the Johnson administration, and the War on Poverty programs, this literature can roughly be divided into two categories: that which looks specifically at, say, the War on Poverty (or specific programs or components of the War on Poverty including Community Action, Legal Services, etc.), and that which looks at either of these within the context of bigger themes like the 1960s, Great Society liberalism, the Johnson presidency, or the evolution of the American welfare state. Since the 1970s more has been published on the latter than the former; consequently, books on these broader themes make up the larger and more well-established literature. They include textbook accounts and more traditional sweeping narratives, including biographies. Because Community Action and the War on Poverty never lived up to their political or policy expectations—neither vanquished poverty or revolutionized the way federal, state, and local anti-poverty efforts were coordinated—much of the general historiography about the two tends to emphasize failure—failure to fight poverty, failure to adequately plan programs, failure to foresee the conflict that the War on Poverty programs (in particular Community Action) are viewed as invariably leading to. There is also a strong tendency to view Community Action and the War on Poverty as targeting black poverty. These ideas are as common in specialist studies as in general surveys of American history and the 1960s. Examples where one or more of these perceptions are prominent include William Chafe’s The Unfinished Journey , Walter Trattner’s From Poor Law to Welfare State , Irving Bernstein’s Guns or Butter , and Judith Russell’s Economics, Bureaucracy, and Race: How Keynesians Misguided the War on Poverty . There are a few exceptions to this negativism, including Robert F. Clark’s 2002 The War on Poverty: History, Selected Programs and Ongoing Impact , Michael Katz’s The Undeserving Poor: From the War on Poverty to the War on Welfare , and John E. Schwarz’s America’s Hidden Success: A Reassessment of Public Policy from Kennedy to Reagan . However, these have had a relatively limited influence on public or academic perceptions of the poverty programs.

Recently, a new generation of scholars have been examining the War on Poverty and local programs, often from a grass-roots perspective. Examples of these include Kent B. Germany’s 2007 New Orleans after the Promises , Robert Bauman’s 2007 Journal of Urban History article “The Black Power and Chicano Movements in the Poverty Wars in Los Angeles,” Noel Cazenave’s 2007 Impossible Democracy: The Unlikely Success of the War on Poverty Community Action Programs , Susan Youngblood Ashmore’s 2008 Carry It On: The War on Poverty and the Civil Rights Movement in Alabama , and Guian McKee’s 2008 The Problem of Jobs: Liberalism, Race, and Deindustrialization in Philadelphia . 72 These studies are all of real importance, as they form part of a new historiography that in many respects challenges established perceptions about the War on Poverty. They provide an often detailed and rich account of a particular local anti-poverty effort and real insight into the local politics of a program. While many of these studies still focus on urban areas, there has also emerged a new sub-field in the study of anti-poverty programs that examines its rural component. 73 Just as with their urban counterparts these studies are adding nuance and much needed detail to the War on Poverty scholarship. They are showing how rural anti-poverty efforts functioned and were part of wider historical processes that were changing the complexion of American society, in particular the advance of civil rights in the South and Southwest.

Primary Sources

The National Archives, College Park, Maryland, and Lyndon Johnson presidential library in Austin, Texas, house the most important primary sources with regard to the federal and presidential aspects of the War on Poverty, Johnson administration, and Community Action Program. For the Community Action Program the most relevant archival records and record groups are: National Archives, College Park, Maryland, Records of the Community Services Administration, Record Group 381, Headquarters Records of the Office of Economic Opportunity 1963–1981 . For the War on Poverty and administration of the OEO the most relevant files in the Johnson library archives are organized around the President’s key staffers. 74 The Johnson Library also houses a number of important oral history interviews of the key figures in the War on Poverty. The Miller Center of Public Affairs, University of Virginia, Scripps Library and Multimedia Archive, houses a significant collection of oral history interviews and tape recordings from a number of postwar presidencies including the Johnson administration. 75 Significantly, these collections are digital and housed in an online library accessible to all anywhere in the world.

11 Needs and Risks in the Welfare State

Jan Zutavern is a team leader at the University of Luxembourg.

Martin Kohli is Emeritus Professor of Sociology at the European University Institute in Florence.

Published: 02 September 2010
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This article describes what empirical-analytical research can learn from normative scholarship for the explanation of welfare state responses to needs and risks. It illustrates how welfare state theories have treated needs and risks, and makes some suggestions as to how they can do so more systematically. The article then turns to the empirical literature to portray the major challenges facing welfare states today. The policy challenge confronting post-industrial societies arises from the coexistence of new social needs and risk profiles with those enduring ‘Fordist’ needs that continue to lend strong support to traditional welfare state institutions. The governance of post-industrial welfare states will require a higher sensitivity to unvoiced but experienced needs if it is to retain its legitimacy and effectiveness in addressing social problems.

Introduction

Welfare states exist to meet the needs of their citizens. While this is only one of the welfare state's many raisons d'être, it would seem odd to defend a welfare state that did not at least also do that: satisfy needs. Evoking needs is an essential way of staking claims to the welfare state, and responding to them a key justification of its existence. This applies equally to risks. Compulsory protection from typical risks is one of the major means through which welfare states have addressed needs. Throughout this chapter we will refer to risks as the likelihood that a need does or does not arise, where that likelihood can be calculated and influenced by human action (Zinn 2008 ). It should be kept in mind, however, that, particularly with regard to individual control, the notions of need and risk may have different, even opposing meanings.

To the welfare state scholar, the relation between needs and the welfare state raises two questions: first, which needs must welfare states attend to in order to preserve their legitimacy and, second, which needs do welfare states effectively address, and how well do they do it? Explicit and systematic usage of the concept of needs in the literature has been largely confined to the former, normative perspective. Different conceptions of needs and the question of their appropriateness in establishing legitimate grounds for social policy intervention have been at the centre of normative debates ever since the modern welfare state was born. Empirical welfare state research, on the other hand, has generally not considered concepts of needs to be of much analytical use. Although the notion is regularly evoked in empirical inquiries, it remains conceptually underdeveloped and often unconnected to theories and empirical findings.

Our first objective in this chapter, therefore, is to sound out what empirical‐analytical research can learn from normative scholarship for the explanation of welfare state responses to needs and risks. As we will see, normative conceptual distinctions are relevant also for positive theories. But do needs and risks still matter empirically? Hasn't the expansion of the welfare state in the West (here our discussion is limited to the OECD countries) mothballed needs along with the fragmented social policies of the pre‐modern Poor Law era? And hasn't the transition to a post‐Fordist society multiplied and individualized risk to the point at which social insurance has lost its effectiveness? Answering these questions is our second objective. Taking note of the recent literature, the answer is a clear no. On the one hand, old labour market and life‐course related needs and risks are far from disappearing. On the other, the very maturation of the welfare state has propelled a number of new needs and risks onto the policy agenda. What they are and how they vary between welfare states is the third issue we address.

Conceptualizing Needs and Risks

In common parlance, needs are ubiquitous. Plants need water, firms need capital, governments need support, and sometimes all we need is love. The needs that fall within the purview of the welfare state are the needs of individual citizens. Since their resources are limited, welfare states have to be selective in the needs that they provide for. According to a widely held view, welfare states respond to the needs of those individuals who, owing to their organizational strength and political resources, prevail in the struggle for influence over governments. But how, then, did welfare states ever come to attend to the destitute and socially marginalized, who lack such political clout? Somehow, needs seem to make demands on the welfare state that are in part independent of the individual who claims the need. What you want the welfare state to do for you, e.g. if you are about to lose your job, is entirely your matter. What you need it to do in that situation is not. Assessing a particular condition in the metric of needs—and the same applies to risks—withdraws that evaluation from the sphere of the subject. This implies that welfare state responses to needs are not entirely contingent upon preferences and the conflicts that ensue from them. Rather, they are always also the result of a (more or less) public—and (more or less) rational—evaluation of what people ‘really’ need, and of the risks they effectively face. Such a partial liberation of justifications and causes for social policy from subjective fiat does not, however, by itself direct us to an unambiguous normative or positive standard, on the basis of which we could evaluate different needs and their consequences for policy. It is the diversity of such standards that has been the bread and butter of normative debates (see Chapter 2 ). The most fundamental opposition is between proponents of absolute and of relative conceptions of needs.

Advocates of absolute concepts argue that there exists a set of ‘basic’ needs that are so fundamental that their satisfaction becomes a pre‐condition for anything else human beings may want to achieve (e.g. Goodin 1985 ; Alkire 2002 ). This essential nature of basic needs confronts the welfare state with a strong moral obligation to provide whatever it takes to satisfy them where other social institutions fail to do so. Ultimately, proponents of such absolute conceptions of needs have to prove that there exists a list charting basic needs that finds sufficiently widespread approval to represent an ‘overlapping consensus’ (Nussbaum 2000 ), but remains specific enough to serve as practical policy guidance. Doyal and Gough ( 1991 ) have addressed this problem by proposing a hierarchical model of universal goals (avoidance of serious harm, participation in a chosen form of life), basic needs (health, autonomy) and those universal characteristics of satisfiers required to meet basic needs (e.g. adequate nutrition, security). Their model is an attempt systematically to link basic needs to specific, variable, and practically relevant forms of satisfaction. Ultimately, the model stands or falls with the acceptability of universal standards for assessing the adequacy of specific satisfiers for basic needs. Scholars have expressed strong doubts whether Doyal and Gough's bid is successful (Soper 1993 ). And it is indeed questionable whether standards for the evaluation of needs can ever be ‘fundamental’, in the sense that they unambiguously and completely rank all possible, culturally specific interpretations of needs (Sen 2000 ; Fraser 1989 a ). Despite the theoretical hurdles that absolute conceptions of needs face, they have found important applications in the form of practical standards for policy intervention such as the Human Development Index or the official poverty lines of the United States. No matter how incomplete such absolute standards are, their normative weight makes them a powerful foundation of social policy and thus a crucial object of research.

Whereas absolute concepts focus on what is ‘essential’ about human needs, relative notions of needs draw attention to the variety of ways in which any basic need can be satisfied. Proponents of relative concepts put their finger on the practical manifestations of basic needs and the conditions of their satisfaction. While concepts of absolute needs motion us towards those needs that any society has to satisfy in one way or another, relative needs explicate the dimensions in which forms of satisfaction vary. Rather than being mutually exclusive, the two concepts thus allow us to build a bridge between the—necessarily open—normative conceptions of needs and the empirical question of how societies, and welfare states in particular, meet needs. A first source of variation in needs satisfaction is spatial and temporal differences in the physical, economic, and cultural constraints and resources for satisfying basic needs. One way of evaluating the constraints and opportunities that determine what exactly individuals need is to assess empirically how basic needs are ‘normally’ satisfied inside a given reference group. Where members of that group lack such ‘normal’ means, the satisfaction of basic needs is likely to be curtailed. This interpretation of group‐specific social standards underlies several statistical measures such as ‘normal’ baskets of goods or relative poverty thresholds. In contrast to absolute measures, which define a priori or normatively what constitutes ‘adequate’ satisfaction of basic needs, such relative indicators rely on an empirical determination of ‘typical’ levels of satisfaction to which they may add a relative threshold, e.g. 50 per cent of median income (Boarini and Mira d'Ercole 2006 ).

But reference groups are not only an indication for potentially successful needs satisfaction. They also define what is required in order to be accepted as a full member of a given community (Sen 1983 ; Goodin 1990 b ). Cultural practices and standards constitute the things, beings, and doings that members of a community are generally able and expected to achieve. By implication, this kind of relativity only applies to those basic needs for which inter‐individual comparisons are a constitutive element. These are generally all participatory basic needs, such as the need for social recognition or the need for a cultural identity. This conception finds important practical application in measures of inequality (Atkinson and Bourguignon 2000 ; Förster and Mira d'Ercole 2005 ), relative deprivation (Townsend 1979 ; Boarini and Mira d'Ercole 2006 ), or social exclusion (Atkinson and Davoudi 2000 ; Hills et al. 2002 ). The reverse of the need for identification and participation is the need for distinction. Differentiation is needed to assure communities of their identity and individuals of their personal achievements. Satisfaction of the need for distinction is inversely related to other individuals' achievements or group specific status endowments; in other words, satisfiers for distinction are ‘positional goods’. By implication, participatory and differentiation needs conflict where they demand the same satisfiers. Measures aimed at extending participation through e.g. progressive taxation or equal opportunity policies thus withdraw from individuals some of the means for ascertaining their distinctiveness. Welfare states vary considerably with respect to the relative weights they attach to the two needs and the characteristics—occupation, employment status, gender, age—that they select as the basis for legitimate distinction.

In sum, different conceptions of needs draw attention to different types of analytical problems. First, the values on which notions of basic needs rest point to the potential breadth of needs that welfare states may be confronted with. Even the most parsimonious concepts add to the ‘classical’ domains of welfare state provisioning a series of needs and related risks—e.g. health, education, emotional care, physical security, or salutary environments—in the satisfaction of which the state is already involved, but which are rarely considered in conjunction by policy‐makers and researchers alike. Secondly, a perspective on the different environmental conditions under which basic needs are satisfied reminds us of the relative importance of and interaction between global, national, and local contexts, and of the specific constraints they impose on needs satisfaction. Thirdly, concepts of relative needs grounded in inter‐individual comparisons stress the trade‐offs and potential conflicts involved in the satisfaction of needs, both between different social groups and for the individual as a member of various reference groups. Stated as political claims, needs call for different forms of social policy at various levels of intervention. Where they underlie specific policy instruments such as poverty thresholds, means tests, or insurance principles, they act as powerful filters for the way welfare states respond to changes in their socio‐economic environments. The confrontation of needs claims with policy instruments, finally, draws attention to the critical question of who has authority to define needs or risks and adequate satisfaction or protection. In the next section, we show how welfare state theories have treated needs and risks, and make some suggestions as to how they can do so more systematically.

Needs, Risks, and Theories of the Welfare State

Most historiographies of post‐war welfare state theorizing distinguish between functionalist, political, and institutionalist families of explanations (Myles and Quadagno 2002 ; C. Pierson 1991 ). All three implicitly use the notion of needs. Nonetheless, we argue that there is room for a more systematic conceptualization of needs in all of them. For functionalists, social policies are the unmediated response to social and economic pressures. Potentially intervening forces such as the political organization of social demands or governmental institutions are assumed to be either neutral towards or fully determined by socio‐economic change. Welfare states do what they need to do in the face of socio‐economic challenges. Their response is triggered whenever transformations of socio‐economic conditions for economic production and social reproduction cross a threshold beyond which existing forms of needs satisfaction lose their effectiveness. Functionalist explanations, then, stand or fall with their specification of the needs they assume to be the responsibility of the welfare state. Wilensky's classical argument that industrialization and demographic change caused welfare state expansion by creating new needs, especially among the elderly, may serve as a case in point (Wilensky 1975 ). By failing to distinguish between an expansionary pull, that is due to slackening economic constraints on the satisfaction of basic material needs of the elderly, and an expansionary push, resulting from political demands for and a policy commitment to reducing age‐related inequalities by enabling the retired to participate more fully in social life or maintain their achieved status, Wilensky misses the far‐reaching practical consequences of these different needs conceptions for policy design. No matter what one thinks about the persuasiveness of functionalist explanations as such, functionalists need to be specific about needs if they are to accommodate empirical variations in welfare provision.

Once we raise the question of which needs welfare states are committed to, we also want to know what causes variations in need satisfaction. One way of addressing this question is to examine variations in the social and economic changes that give rise to needs and risks. To the extent that processes such as (de‐)industrialization and demographic change not only have advanced to different degrees in different countries, but also have distinct national manifestations, they could be an effective source of variations. However, the consequences of social and economic transformations for human needing must be articulated as problems for the welfare state if they are to trigger policy changes. As long as these political sources of variation are not taken into account, the explanatory force of even the most sophisticated accounts of socio‐economic change will remain limited.

Thus, political and institutional approaches to welfare state theory have argued that ‘politics matters’ by showing how variations in organizational capacities, institutionalized procedures for decision making and administrative practices selectively channel and process social demands and grievances. First of all, such a perspective vigorously veers to political preferences based on wants and desires. Social policy outcomes become the result of institutionally mediated power struggles between organized interests (‘power resource’ approach, e.g. Korpi 1983 ; Huber and Stephens 2001 a ). But for determining the interests that actors are presumed to pursue, power‐based accounts tend to rely in part on the notion of needs. If we assume actors to be rational in setting their (political) goals, it is rather implausible that they would want something which they do not also need. Since we can assess needs without having to rely exclusively on the subjects that bear them, they allow us to formulate preference‐based hypotheses independent of the aims expressed by political actors. Awareness of the different normative conceptions of needs should help us to appreciate the potential tensions that actors face when trying to satisfy conflicting needs. Normative theories also remind us that there is no principle that would allow the researcher to unambiguously rank the potential needs of any given actor. Acknowledging this inherent ambiguity of needs, several authors have made a case for abandoning objective assessments of needs altogether. They argue that we should instead focus entirely on the actual political contestations through which needs are defined as real and legitimate (Stone 2002 ; Fraser 1989 b ; Robertson 1998 ).

One powerful player in such contestations is the welfare state itself. Most social policy instruments are founded upon or entail a specific conception of recipients' needs or risks. As rules for policy implementation, they influence the chance of any need or risk finding public recognition. At the level of policy design, such rule‐based legacies of needs satisfaction and risk protection are often fiercely guarded by current beneficiaries to the disadvantage of new, insufficiently articulated and poorly organized needs and risks (P. Pierson 2006 ). At the level of implementation, they circumscribe the discretion of street‐level bureaucrats in defining the range of needs and risks to which they will respond. By posing the question of which needs and risks benefit from discretion or rules respectively, the recent trend towards the decentralization and individualization of social benefits and services has opened up a research agenda of increasing importance.

Finally, different conceptions of needs are part and parcel of basic welfare regime variations, e.g. as conceived prominently by Esping‐Andersen ( 1990 ). It is, however, not only liberal welfare states that are ‘needs‐based’, as Esping‐Andersen's narrow notion of needs leads him to argue. Liberal welfare states do, indeed, target much of their social policy towards individuals who face constraints in satisfying their basic (non‐comparative) needs, which allow for autonomy of agency and avoid interventions that might curtail the fruits of individual achievement. Scandinavian welfare states, on the other hand, have gone furthest in meeting needs of participation in the national community and, thus, in inequality reduction across various social groups, whereas welfare states on the European continent have traditionally placed more emphasis on distinctions based on seniority and occupational membership.

In other words, social policy variations are due to an important extent to the institutionalization of different forms of need satisfaction and risk protection. Such variations may persist even where the socio‐economic conditions responsible for the emergence of needs and risk profiles have been transformed and new needs or risks are competing for political attention. It is precisely this question of the relation between new and old needs or risks that has gained prominence in recent welfare state scholarship. In the next section, we turn to the empirical literature to portray the major challenges facing welfare states today.

Socio‐Economic Challenges, Needs, Risks, and Welfare States

Although welfare states are inherently political achievements, the impetus for their development often lies in the disruptive force that large, macro‐historical transformations have levelled against extant social orders. National variations notwithstanding, it was the watermark of first‐generation welfare states to have institutionalized a model of social provisioning closely articulated with the functional exigencies of industrializing societies. The model relied on a gendered division of work based on male full‐time and continuous employment and female care work inside the family, sustained by economic growth and high labour demand. The welfare state's key contribution was the mobilization of solidarity in those ‘legitimate’ circumstances in the life of a worker in which the successful commodification of his labour power could no longer be expected. It thereby helped to institutionalize a ‘Fordist’ life course consisting of three main stages—education, employment, retirement (Kohli 2007 ; Mayer 2001 )—providing financial support for its first and especially last phase and protecting its middle phase against unforeseen or short‐term vulnerabilities (sickness, accidents, disability, short‐term unemployment).

Today, this model is showing clear signs of wear. The social and economic conditions that sustained its performance have receded. New needs and risks are joining old ones, as a result of structural and cultural changes and of welfare state institutions protected by their old constituencies. The key developments to which the literature has attributed the emergence of new needs and risks are the tertiarization, feminization, and flexibilization of the labour force, increasingly unstable families, and declining fertility rates that combine with higher longevity to tilt the age structure of societies upwards. As the data for selected OECD countries in Table 11.1 illustrates, the onset and speed at which these processes have advanced differ considerably. Critical for welfare state responses has been a society's progression prior to the tightening of economic conditions at around the time of the first oil crisis. By then, in countries such as the United States and the Netherlands, less than a quarter of the working‐age population was still employed in the primary and secondary sectors. Accordingly, further losses have been rather low and more than compensated for by a vigorous expansion of the service sector. Other countries such as Germany, Italy, and Japan have only recently reached comparable levels, and thus have had to cope with the bulk of pressure for adaptation under conditions of low economic growth and austerity.

While it would seem that the loss of employment in the primary and secondary sectors has been (over‐)compensated for by the growth of the tertiary sector—the German and United Kingdom service sectors are the only ones that, in aggregate terms, have been unable to absorb all employment made redundant in agriculture and manufacturing—the picture changes when we consider rising female labour force participation during this period. The Netherlands and Spain have witnessed the largest expansion of female employment since the early 1980s, followed by Australia and Germany. With respect to tertiarization, the service‐heavy economies of the United States and the Netherlands have been joined by Australia, the United Kingdom, Sweden, and Denmark, in part as a correlate to high levels of female labour force participation concentrated in both public and private services. The Netherlands, France, and the United Kingdom stand out for their landslide flexibilization of family relations—a change that had already largely occurred in the Nordic countries as well as the United States as early as the 1970s. Japan combines a substantial increase in family disruptions with extremely low levels of children born out of wedlock. Tradition has persisted most strongly in Italy, for which the main challenge in this respect still lies ahead. In comparison to the World War II birth cohort, when only Germany was clearly below the replacement level, the fertility of women born around the time of the first oil crisis has decreased everywhere, 1 with the highest relative declines recorded in Australia, Italy, Japan, and Spain—countries in which life expectancy at birth is now among the highest in the world.

The data reported here largely confirm the welfare regime variations of socio‐economic change described in the literature (e.g. Goodin et al. 1999 ), with the Nordic and English‐speaking societies leading the shift to post‐industrialism, while Japan, continental, and especially Southern Europe are trailing. Nonetheless, the diachronic perspective reveals significant country differences within regimes (compare e.g. the high rate of change in Spain with the low rate in Italy), as well as within‐country contrasts between labour market and family‐related change.

Notes : Data on employment are percentages. We report 5‐year averages (Ø) except where data is not available. Δ is the sum of yearly changes through the indicated time period.

Sources and definitions : Sectoral employment = civilian employment in percent of the working age population (15–64); female labor force participation rate is in percent of the female working age population (15–64), missing: Denmark: 1982, UK: 1982–3; see OECD 2009 e . Total divorce rates = sum of the divorce rates by duration of marriage for the respective year; OECD 2002 a : Tab. GE5.1. Births out of wedlock are as a percentage of all births; OECD 2007 b : Tab. 2.2. Total fertility rates for the cohort born 1941–45 are completed, for the cohort born 1971–5 projected; D'Addio and Mira D'Ercole 2005: Tab.2. Life expectancy at birth in years is from OECD 2008 f ; data for Italy and the UK refer to 1971, data for Spain refer to 1970.

What is the significance of these social and economic transformations for the welfare state? Insofar as they do, indeed, mark a departure from the conditions that sustained the ‘old’ Fordist model of provisioning, they not only give rise to new social needs and risks, but also undermine the viability and effectiveness of existing welfare arrangements (Esping‐Andersen 1999 ; Taylor‐Gooby 2004 ; Bonoli 2005 ). The unwinding of agricultural and industrial employment entails a devaluation of sector‐specific skills (Iversen and Cusack 2000 ) and thus the risk of frictional and structural unemployment. In contrast to this transitional phenomenon, the growth of the service sector has brought with it a number of risks that are likely to persist. Unstable employment and wages that are no longer poverty‐proof can be attributed to the polarization of skill requirements and wages in tertiary employment. The consequences are working poverty and rising inequality. Welfare states and social partners that intervene with protective labour regulations to stabilize employment biographies and wages pay the price of lower employment levels and higher and longer unemployment (Iversen and Wren 1998 ; Kenworthy 2003 ).

As women are entering the labour market under conditions that are still likely to be more adverse than those of their male colleagues, they also face a dilemma at home. A largely undiminished desire for children (OECD 2007 b ) and a preference for ‘intimacy at a small distance’ between parents and adult children make it difficult for women to dissociate themselves from care work inside the family, which still falls predominantly on their, rather than on their male partners', shoulders. Women's choice, then, is between the stress of balancing employment aspirations with care for children or the elderly and the stress of having to forego one or the other (Hakim 2000 ; Lewis and Huerta 2008 ). Divorce significantly increases the risk of material and social deprivation. But while a more fragile solidarity between partners may have indeed diminished the ability of families to stabilize unsteady employment biographies and provide effective poverty safeguards, supporting ties across family generations remain strong (Kohli et al. 2010 ). Through a net flow of transfers from parents to their adult children, the fruits of the industrial welfare state are partly handed down to post‐industrial generations (Albertini et al. 2006 ).

Country‐specific risk profiles (see Tables 11.2 and 11.3 ) again largely conform to regime variations, but exhibit some significant nuances. Sweden stands out for its low labour market related risk scores and the virtual absence of any child penalty for female employment. Denmark registers comparable or slightly higher risk levels, but is conspicuous for its low levels of part‐time work among mothers with two or more children. Employment‐related risk levels are relatively low also in the United States, 2 with the unsurprising exception of low‐wage work—almost a quarter of full‐time dependent workers in the United States bring home less than two‐thirds of full‐time median earnings. While the United Kingdom diverges from the liberal pattern with a relatively high average incidence of long‐term unemployment (which has, however, decreased significantly since its peak in the mid‐1990s), Australians are more likely than Anglo‐Saxons in the Northern hemisphere to work in temporary or low‐skill jobs, and Australian mothers are more likely to withdraw from the labour market, on a par with the Mediterranean countries.

On the European continent, the risk profiles of the Netherlands, France, and Germany largely resemble each other. Beyond similarities, labour market risks in the Netherlands are marked by the well‐known prevalence of part‐time employment. Four out of five Dutch mothers with two and more children work part‐time. The German labour market, on the other hand, is characterized by a significant child penalty for working mothers. It also has a below‐average employment ratio of low‐skilled people, reflecting, in part, the relatively high level of education of the young adult population. In Italy, by contrast, a quarter of the population between 15 and 64 were low‐skilled employees in 2003; this figure is topped only in Spain, which registers the same high proportion of young adults not completing a higher education (40 per cent of the 25–34 age group). The two Southern European countries also have had the highest proportion of long‐term unemployment. Employers in Spain, moreover, make particularly heavy use of temporary contracts.

With respect to family transformation, a contrast between the data from Tables 11.1 and 11.3 shows that the high rates of divorce and out‐of‐wedlock births in the Nordic and liberal welfare states do, indeed, translate into higher shares of children growing up with single mothers. In Southern Europe, on the other hand, single parent families continue to be a marginal phenomenon. Whereas their level in Italy has fluctuated within a narrow band, it is growing in Spain. Demographic change has been most pronounced in Italy and Japan. The ageing process has been slower in the United States, the United Kingdom, France, and Scandinavia, but different levels in the early 1970s have led to significant risk variations also here. While material provision for the elderly in Northern Europe has limited their poverty risks, Italy and above all Japan face, together with Australia and the US, the highest levels of relative poverty in old age. The largest numbers of children growing up in income‐poor households live in the United Kingdom and the United States.

The bigger picture, then, is one of an increasing incidence of risky life circumstances that either have become problematic or more prevalent in post‐industrial societies. They thus present new challenges to the industrial model of social provisioning. While ‘old’ industrial needs and risks have not disappeared (Scarbrough 2000 )—and their successful coverage may indeed foster provision also against new risks, e.g. through intergenerational transfers—welfare states face potential pressures for adaptation. These pressures, however, are of a political nature. Without the articulation of new needs, either by those who bear them or by their advocates in the policy arena, social and economic transformations and the corresponding risk profiles will not effectuate policy change.

Besides considerable cross‐regime and cross‐country variations in the onset and progression of such transformations (Bonoli 2007 ), scholars have looked to the specific constellations of risk groups and their organizational capacities, and to the existing policy schemes that determine how welfare states have responded to these risks (Armingeon and Bonoli 2006 ). Their conclusions tend to be pessimistic. The population affected by new social risks—children and young people, single mothers, low‐skilled and low‐wage service workers, long‐term unemployed—is less likely to be politically active, and to be present in political organizations. Even where new needs find political recognition, they face well‐organized opposing interests in zero‐sum games that leave little room for political exchange. This lack of political clout has caused some scholars to caution against too much optimism about those strategies of policy ‘recalibration’ on which welfare states have already embarked. Policies for the ‘activation’ of benefit recipients and the ‘de‐familialization’ of working‐age women in particular are bound to walk a tightrope between meeting the multiple needs of affected individuals and the political demands of those whose solidarity is called upon (Dean 2003 ; Taylor‐Gooby 2006 ; Leitner and Lessenich 2007 ).

Notes : a 1984; b 1999; c 2003: see Table 11.1 .

Sources and definitions : Total unemployment = unemployment as a percentage of the labour force; long‐term unemployment = unemployment spells >1 year as a percentage of total unemployment; part‐time employment = civilian employees usually working under 30h per week as a percentage of total civilian employment; OECD 2009 e . Fixed‐term employment as a percentage of total employment is from Kalleberg 2006: Table 5.2. Low wage employment = percentage of full‐time workers earning less than two‐thirds of full‐time median earnings; OECD 2009 f . Low‐skill employment = percentage of the working age population (25–64) in employment that has not completed an upper secondary education or higher (data not entirely comparable over time); own calculations based on data from OECD 1994 b , 2005 c .

Notes : a 2002; b 1980; c 1971; d 1995: see Table 11.1 .

Sources and definitions : Working mothers = employment rate of women with 2 or more children <15 and shares working part‐time (see Table 11.2 ); OECD 2002 b : Tables 2.4 and 2.5. Lack of higher skills = percentage of the population aged 25–34 that has not completed an upper secondary education or higher; OECD 2005 c : Table A1.2a. Children in single mother households = percentage of all children <18 living in a single mother household; Luxembourg Income Study Inequality and Poverty Key Figures. Old age dependency ratio = population 65+ as a percentage of population 15–64; OECD 2009 e . Dependent poor = share of children (<17) and the elderly (66+), respectively, with an equivalized disposable income below 50 per cent of the median for the entire population, as a percentage of total population; own calculation based on data from Förster and Mira D'Ercole 2005 : Annex Table A6, A7.

In short, the policy challenge confronting post‐industrial societies arises from the coexistence of new social needs and risk profiles with those enduring ‘Fordist’ needs that continue to lend strong support to traditional welfare state institutions. Rather than ushering in a wholesale restructuring of the welfare state, this growing heterogeneity pressures existing policy arrangements to adapt to a larger variety of risk situations. Tight financial limits and increasingly fragile political resources for the legitimation of state interventions imply that such a differentiation of policies will have to draw on increasingly diverse forms of private social provision. However, grievances voiced outside established policy arenas are unlikely to reach policymakers through institutionalized channels for the aggregation of class‐ or milieu‐specific interests. The governance of post‐industrial welfare states will thus require a higher sensitivity to unvoiced but experienced needs if it is to retain its legitimacy and effectiveness in addressing social problems. For welfare state scholarship, the agenda comprises both a careful analysis of the socio‐economic developments that cause new needs and risk profiles and an assessment of how the latter will be voiced and mobilized. The precondition for both tasks is a theoretically grounded, nuanced conceptualization of needs and risks.

The cohort perspective given here yields higher values than the current period Total Fertility Rate (TFR) but is close to the current period TFR adjusted for tempo effects (as calculated by the Vienna Institute of Demography, see www.populationeurope.org ).

It should be noted, however, that a low share of fixed‐term employment can also indicate a low degree of employment protection, in other words, an easy pattern of ‘hire and fire’.

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Research article
Open access
Published: 27 December 2013

Understanding the role of welfare state characteristics for health and inequalities – an analytical review

Kersti Bergqvist 1 ,
Monica Åberg Yngwe 1 &
Olle Lundberg 1 , 2

BMC Public Health volume 13 , Article number: 1234 ( 2013 ) Cite this article

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The past decade has witnessed a growing body of research on welfare state characteristics and health inequalities but the picture is, despite this, inconsistent. We aim to review this research by focusing on theoretical and methodological differences between studies that at least in part may lead to these mixed findings.

Three reviews and relevant bibliographies were manually explored in order to find studies for the review. Related articles were searched for in PubMed, Web of Science and Google Scholar. Database searches were done in PubMed and Web of Science. The search period was restricted to 2005-01-01 to 2013-02-28. Fifty-four studies met the inclusion criteria.

Three main approaches to comparative welfare state research are identified; the Regime approach, the Institutional approach, and the Expenditure approach. The Regime approach is the most common and regardless of the empirical regime theory employed and the amendments made to these, results are diverse and contradictory. When stratifying studies according to other features, not much added clarity is achieved. The Institutional approach shows more consistent results; generous policies and benefits seem to be associated with health in a positive way for all people in a population, not only those who are directly affected or targeted. The Expenditure approach finds that social and health spending is associated with increased levels of health and smaller health inequalities in one way or another but the studies are few in numbers making it somewhat difficult to get coherent results.

Conclusions

Based on earlier reviews and our results we suggest that future research should focus less on welfare regimes and health inequalities and more on a multitude of different types of studies, including larger analyses of social spending and social rights in various policy areas and how these are linked to health in different social strata. But, we also need more detailed evaluation of specific programmes or interventions, as well as more qualitative analyses of the experiences of different types of policies among the people and families that need to draw on the collective resources.

Peer Review reports

In the area of health inequality research, as well as in the wider fields of social and public health sciences, there is an on-going and ever developing discussion on macro versus micro level explanations. The terminology used varies, but the core issue remains the same; what are the most important factors behind poor health and health inequalities, the upstream or downstream, distal or proximal, structural or individual ones? From an etiological or causal point of view, this duality can at least in part be resolved by building more complex models, where different levels of mechanisms are nested and organised sequentially. From a policy point of view, this sort of understanding is also important, but there is still the issue of where to find the best policy entry points.

Here the recent years’ work on social determinants have constituted an attempt to draw the attention of policy makers to the causes of the causes , in other words to the wider social circumstances in which people live their lives and that more or less indirectly affect their chances to be healthy and live long. The renewed interest in public health for more general conditions of life such as childhood and conditions of upbringing, education and training, work and economic resources has also led to a larger focus on the wider policy context. If we think that the causes of the causes are embedded in conditions of life more generally, then we also need to look for policy options wore widely. More concretely, this means that a broad range of policies and programmes dealing with and affecting education, work and incomes of people becomes of great interest also from a public health perspective.

These sets of policies are in turn often not combined randomly. On the contrary, a long and rich research tradition has studied how different welfare states vary systematically in the principles that have guided the design and execution of policies for poverty alleviation, to take but one example. In this tradition of ‘Welfare State Research' , one prominent question has been the driving force behind the growth of modern welfare states, while another key issue has been the consequences of different types of welfare state solutions in terms of e.g. poverty or fertility rates. With a growing interest in public health research for the wider policy context, it is quite natural that the past decade has witnessed a growing body of research on welfare states characteristics and health inequalities. The logic behind this is undisputable – if it can be argued that some types of welfare states are more successful in combating poverty and deliver a decent life to a larger share of the population there is reason to believe that improvements in the level and distribution of the ‘causes of the causes’ will also lead to better health and smaller inequalities.

However, while early comparative studies suggested that countries like Sweden had smaller inequalities than countries like Great Britain [ 1 ], larger and more systematic comparative studies have not been able to demonstrate clear differences in health inequalities that match traditional welfare state clusters [ 2 ]. In addition, some recent reviews of the field have found clearly mixed results [ 3 , 4 ].

The mixed findings provide a challenge for welfare state research and public health research alike, and even more so for policy making. If social determinants and ‘causes of the causes’ can be demonstrated to be important, why is it so hard to get consistent results when analysing welfare states and health inequalities? One possible answer to this important question may be that there are substantial theoretical and methodological differences between studies that at least in part lead to different findings. A fundamental issue is that there are several ways of analysing welfare states and health inequalities in comparative health research.

Dahl and van der Wel [ 5 ] describe three common approaches to characterise the welfare state; as regime types, as welfare institutions or as social spending. Comparative health research has been dominated by the ‘ Regime approach' , in which classifications of countries based on various political elements are used. Those who support this approach have argued that certain countries cluster together in ‘welfare state regimes’ based on similar ideologies and policies or political traditions. One cluster of countries may, for example, support universal access to different services while another operates on the individual’s private responsibility to take care of and handle one’s own welfare, and that only the most poor qualify for social support. The general idea is that by specifying ideal types it is possible to assess the underlying commonalities and principles of social structures and welfare institutions [ 5 ]. In addition, the Regime approach comes in a variety of versions that differ both in terms of theoretical and empirical foundations and the countries included. By design, these ideal types will not fit the complex reality perfectly and might therefore give a rather crude result. Hence, this approach might be less useful in capturing mechanisms that generate inequalities in health. To complement the picture it may be important to also look at characteristics of social, health and labour market policy [ 5 ].

Another common approach is the ‘ Institutional approach ' , which focuses more on how welfare institutions and specific social policies and programmes are designed and how these translate into population health. The Institutional approach addresses the characteristics of policy programmes for, for example, pensions, sickness pay, unemployment benefit, family policies and work accidents. These characteristics may for example be qualifying criteria, replacement rates, duration and coverage [ 6 ]. Several international comparative databases (e.g. the Social Citizenship Indicator Programme, SCIP) provide historical information on such characteristics including policy programmes. In order to construct relevant programme features the databases apply a number of assumptions regarding for example, age and family situation of a ‘standard worker’ [ 6 ]. This could be problematic if there are important groups that fall outside the living situations captured by these type cases.

A third approach is the ‘ Expenditure approach ' , which focuses on welfare state effort and generosity by concentrating on public spending on social protection and services. The spending on social protection and services is often expressed in terms of percentage of the Gross domestic product (GDP). The rationale for this is that ‘the government should be transferring relatively the same level of social expenditure as other nations in order to be considered as providing an equivalent degree of generosity and protection’ [ 7 ]. The spending approach has been criticised for its inability to differentiate between effort and need – a large spending on unemployment benefits and programmes may simply reflect a larger share of unemployed and not a higher ambition in terms of coverage or replacement rates [ 8 ]. Recent studies have tried to overcome this problem by weighting procedures [ 5 ], and their analyses also suggest that different choices regarding the spending variable (gross/net, absolute/relative) have little impact on the results.

We are not the first to point out that there are complications with these approaches (e.g. [ 5 ]), but we believe there to be a need to clarify and describe why results are as diverse as research suggests. To our knowledge, we are the first to stratify these studies according to how they are classified in each approach, for example by welfare regime typology, something that will complement existing research.

If we look at the existing literature with a more analytical view, taking into account methodological and theoretical differences, we might be able to sort out substantial findings from ‘noise’ caused by methodological and other shortcomings. Therefore, we aim to review the literature on welfare state, health and health inequalities, taking earlier reviews as our starting point. Our analytical approach is to further classify these later studies, published 2005 and later, according to their principal way to characterise the welfare state; as regime types, as welfare institutions or as social spending. Since the regime type approach is dominating, we also attempt at further distinctions within this category in order to find patterns that might explain the inconsistent results. Based on this analytical framework, we discuss the general findings in the literature, comment on the different investigative approaches, and point to where substantial conclusions about welfare state policies and health inequalities can be made.

Search strategy

This review adopted several search strategies to detect relevant studies [see Figure 1 ]. The first step was to manually explore three large reviews related to the subject; by Beckfield and Krieger [ 9 ], Muntaner et al. [ 4 ] and Brennenstuhl et al. [ 3 ]. The NEWS report [ 10 ] was also explored since it includes studies relevant to the Institutional approach. Studies related to any of the three core approaches were selected, studies with themes such as globalisation or democracy were excluded. After reading the abstracts of the related studies, six studies were selected from Beckfield and Krieger [ 9 ], 17 from Muntaner et al. [ 4 ], 21 from Brennenstuhl et al. [ 3 ] and three relevant studies were selected from the NEWS report. This strategy yielded 31 exclusive studies. The selected articles were thoroughly read in order to make sure they were placed in the correct “pile of approaches”.

Summary of search strategy. Summary of the search strategy used; the different identification methods and study selections.

The second step was to search for ‘related articles’ to the three reviews in PubMed, Web of Science and Google Scholar. In order to get the most recent publications the strategy was to find articles that have cited any of the three reviews. Brennenstuhl et al. [ 3 ] (published in 2012) had not been cited any time in Web of Science, once in PubMed and five times in Google Scholar (2 articles selected). Muntaner et al. [ 4 ] (published in 2011) was cited eight times in Web of Science, twice in PubMed and 18 times in Google Scholar (1 article was selected). Finally, Beckfield and Krieger [ 9 ] (published in 2009) was cited 31 times in Web of Science (4 articles selected), seven times in PubMed (1 article selected) and 53 times in Google Scholar (4 articles selected). This strategy yielded six related exclusive studies [ 5 , 11 – 15 ].

The third step was to search for key words in Web of Science and PubMed. The searches were limited to the period 20100101–20130228 and was based on the fact that the reviews were published in 2009 [ 9 ], 2011 [ 4 ] and 2012 [ 3 ] and would therefore hopefully exhaust the number of articles prior to 2010 in this field of research. Searches were based on search terms related to the approaches mentioned above leading to three sets of search strings each combining the related terms with the health terms. Attention was put on health inequalities. An initial screening was done by looking at the titles, and thereafter the abstracts of relevant articles were read.

The first search string combined welfare regime related terms and health inequalities ((welfare state* or welfare typ* or welfare regime*) AND (health inequalit* or health inequit* or health disparit*) AND (Humans[Mesh])) and resulted in 182 citations in Web of Science and 622 citations in PubMed. Seven relevant “new” studies were found.

The second search string combined policy-related terms and health inequalities ((social polic* or health polic* or family polic* or pension polic*) AND (health inequalit* or health inequit* or health disparit)* AND (Humans[Mesh])) and resulted in 2230 citations in Web of Science and 654 citations in PubMed. Two relevant “new” studies were found.

The third search string combined expenditure-related terms and health inequalities ((spending or expenditure or welfare state generosity) AND (health inequalit* or health inequit* or health disparit*) AND (Humans[Mesh])) and resulted in 466 citations in Web of Science and 625 citations in PubMed. Seven relevant “new” studies were found.

The fourth, and final, step was to manually explore the reference lists of the selected articles. This resulted in one study [ 16 ], relevant to the ‘Institutional approach’.

Inclusion criteria

Articles selected for this review had to be an empirical peer-reviewed study published in English in an International journal. They had to be published between January 2005 and February 2013 in order to get recent results. Studies should address any type of health outcome (both morbidity and mortality measures) and preferably social inequalities in health (stratified by education, income or other relevant measure). Studies examining health inequalities based on ethnicity and minority groups were excluded. The study population could be from all age groups. Studies using data from industrial countries including East Asia were included.

Specific inclusion criteria for the ‘Regime approach’ were that studies should include cross-national comparisons of different health outcomes. The countries in the analysis could either be groups of countries or typical representatives of a welfare regime, or other cross-national country or regional comparisons. The number of countries used for comparisons had to be at least two countries.

A specific inclusion criterion for the ‘Institutional approach’ was that focus should be placed on welfare state indicators (replacement rates and coverage of specific social policies such as pensions and family benefits) and levels of generosity in social policy delivery, and look at to what extent variations in generosity and/or coverage are linked to variations in different health outcomes.

A specific inclusion criterion for the ‘Expenditure approach’ was that studies should examine different levels of social/health spending or social transfers measured as government health or social spending.

The total number of studies selected for this review is 54 [see Figure 2 ]. Thirty-four studies have been selected for the ‘Regime approach' , 14 studies for the ‘Institutional approach’ and eight for the ‘Expenditure approach’. One study [ 17 ] has been placed in all three approaches.

The three approaches used in comparative welfare research. Figure illustrating the three main approaches to comparative research as well as the authors of the studies included in each approach. The Regime approach is further divided based on main typology used.

The studies in the ‘Regime approach’ have been sorted according to different criteria; by outcome (both by morbidity and mortality outcomes, but also according to where health was found to be the best), by type of data used, and by the number of countries under study. Since no clear results have been found we have decided to analyse and summarise the characteristics and findings of the different groups of typology/country comparisons. A short section of the other results can be found after the Regime approach results.

The studies in the ‘Institutional approach’ have been sorted according to policy theme and the studies in the ‘Expenditure approach’ have been sorted by either social or public spending.

The Regime approach

The ‘Regime approach’ is the largest approach with 34 studies fitting the criteria. An Additional file shows the descriptive characteristics of the studies [see Additional file 1 ]. This approach is the most common way of examining cross-national welfare state comparisons of health and health inequalities and there seems to be a pattern of increased popularity with time. Detailed timelines of the studies’ publication year can be found in an Additional file [see Additional file 2 ]. Among the 34 studies in the ‘Regime approach' , 26 examined overall population health and almost two thirds of the studies (n = 21) examined socioeconomic inequalities in health (some studies look at both). More than a third of these (8/21) examine inequalities by social class, which is often based on two or more variables related to education and income. Different variables are used to measure health; self-rated health is the most common measure (13/34). When health measures are categorised as either mortality or morbidity related measure one finds that it is more common to use morbidity measures (32 compared to 18). Most studies use a typology approach (28), and those based on Ferrera’s typology [ 18 ] are most common.

Different typologies

The three main regime typologies dominating the ‘Regime approach’ are the typologies by Esping-Andersen [ 19 ], Ferrera [ 18 ] and Huber and colleagues [ 20 , 21 ] [see Table 1 ]. This has also been found in the review by Brennenstuhl et al. [ 3 ].

These three typologies have in the studies selected for this review often been modified by either adding a regime type or adding countries to existing regime types, thereby changing the set-up of the typology somewhat. For a full table of typologies used in the studies selected see an Additional file [Additional file 3 ]. The most influential typology by Esping-Andersen [ 19 ] is constituted by three regime types in which highly developed countries (mainly European) were fitted [see subsection ‘Theoretical description- Esping-Andersen’ for further information]. With time, additional regime types have been added by various authors. The typology by Ferrera is often described as being based on the work by Esping-Andersen but includes features that makes it stand on its own [see subsection ‘Theoretical description- Ferrera’]. Quite a few authors have chosen to base their modification on Ferrera’s typology rather than Esping-Andersen’s. For example, Eikemo et al. e.g. [ 22 ] add a fifth regime type, the Eastern European, and Karim et al. [ 23 ] add a sixth, the East Asian. The typology by Huber and colleagues [ 20 , 21 ] has also been modified by many [see subsection ‘Theoretical description- Huber and Stephens’]. Navarro for example, together with different co-authors, have modified it in different articles by removing one regime type and adding a new one [ 24 – 26 ].

Most countries, regardless of the typology used, remain in some sort of core regime cluster. Austria and The Netherlands sometimes move from the Conservative/Bismarckian/Christian democratic group to the Social democratic group but the majority of research tends to label these countries as Conservative. Australia sometimes moves from the Liberal/Anglo-Saxon cluster to a separate group called Radical/Targeted/Wage-earner.

Esping-Andersen

The original Esping-Andersen typology with three welfare state clusters is used by four out of nine studies [ 17 , 27 – 29 ]. The remaining five studies have used modified versions by adding a Radical regime [ 30 , 31 ], a Latin regime [ 32 ], or a Mediterranean and Eastern/Post-communist/Post-socialist regime [ 33 , 34 ]. Self-rated health and life expectancy are the most common health measures and are used in three studies respectively. Mortality measures are almost as common as morbidity measures. Descriptive characteristics of studies in the Esping-Andersen group are shown in Table 2 .

Seven studies examine population health. Four of these find that health is better in the Nordic countries. The measures of health are infant mortality [ 27 , 32 ] self-reported happiness [ 30 ] and mortality rate [ 28 ] (for women). One study finds that male mortality rates are better in Conservative regimes [ 28 ]. Other studies find that health is better in other regimes (mainly Southern and Central European regimes), regarding outcomes such as life expectancy [ 17 , 34 ] and self-rated health [ 29 , 34 ]. Four out of nine studies examine inequalities in health and results regarding differences between regimes vary. One study finds some evidence of smaller inequalities in Social democratic countries for men but not for women [ 29 ]. The three other studies find that health inequalities in mortality [ 28 ] and self-rated health [ 31 ] are smaller in Conservative regimes. Another finds that inequalities in self-rated health are smaller in Liberal and Eastern regimes, and inequalities in general wellbeing and health symptom load are smallest in Liberal and Southern regimes [ 33 ]. For further information on study characteristics and results see an Additional file [see Additional file 4 : Esping-Andersen].

Theoretical description- Esping-Andersen

Esping-Andersen’s (E-A) typology proposed in ‘The three worlds of welfare capitalism’ [ 19 ] in 1990 is the most well-known and has been criticised and modified by many (e.g. [ 18 , 35 ]). Eighteen Organisation of Economic Cooperation and Development (OECD) countries were categorised into ideal clusters of welfare states based on principles regarding unemployment, sickness and pension benefits [ 36 ]. The clusters of countries are classified according to three principles:

Decommodification: the extent to which an individual’s welfare is reliant upon the market, particularly in terms of pensions, unemployment benefit and sickness insurance

Social stratification: the role of welfare states in maintaining or breaking down social stratification; and the

Private-public mix: the relative roles of the state, the family, the voluntary sector and the market in welfare provision.

The operationalisation of these principles was based mainly on decommodification indexes and led to three ideal welfare regime types [ 19 , 36 ]:

Liberal countries where policies are based on the idea that people are responsible for their own welfare. In other words, state welfare provision is minimal, benefits are modest and the criteria for entitlement are often strict, and recipients are usually means-tested and stigmatised. The countries in the liberal regime type are Australia, Canada, Ireland, New Zealand, UK and the USA.

Conservative countries where access to social support is often earnings-related and administered through the employer. It is distinguished by its “status differentiating” welfare programmes which tend to maintain existing social patterns. These regimes are usually shaped by historical church traditions and the role of the family is emphasised. The countries in the conservative regime type are Finland, France, Germany, Italy, Japan and Switzerland.

Social Democratic countries which belong to the smallest regime cluster and are quite the opposite of liberal and conservative welfare regimes in that there is a public responsibility for welfare and that access to services and benefits is universal. Welfare provision is characterised by comparatively generous benefits, a commitment to full employment and income protection, and a strongly interventionist state used to promote equality through a redistributive social security system. The countries in the social democratic regime type are Austria, Belgium, Denmark, the Netherlands, Norway and Sweden.

This typology has offered an influential typology that has encouraged much research. E-A’s main goal was to describe relationships between states, labour markets, and families and his typology is based on characteristics that refer to both institutions and outcomes [ 37 ]. It is important to remember that it was not developed to account for cross-national differences in health or health inequalities [ 5 ] and one must therefore bear in mind that it does not necessarily mean that this typology should have an immediate and direct effect on health and health inequalities.

Modified version

Castles and Mitchell

Castles and Mitchell [ 35 ] have, in 1993, built on E-A’s typology and focus on welfare state differences in redistribution of social transfers and provision of welfare services [ 31 ]. Different countries levels of aggregate expenditure and degree of benefit equality were examined [ 36 ] and based on this analysis they argued that Australia, New Zealand and the UK made up a targeted welfare state, the Radical welfare state.

The original Ferrera typology is used by three out of 13 studies [ 36 , 38 , 39 ]. The remaining 10 have all modified the typology by adding Eastern Europe, and in some cases East Asia. Morbidity measures are more common to use. Self-rated health is the most common and is used in eight studies. Descriptive characteristics of studies in the Ferrera group can be found in Table 3 .

Nine studies report results related to population health. Two studies find that health (limiting longstanding illness, psychosocial quality of work and depressive symptoms) is better in Scandinavian countries compared to other regimes [ 38 , 40 ]. One study finds that health complaints are lower in Scandinavian regime and higher in Eastern and Southern regimes [ 12 ]. Two studies look at both infant mortality and life expectancy and both find that infant mortality rates are lowest in Scandinavian countries and that life expectancy is highest in East Asian countries [ 23 , 41 ]. Another study finds that life expectancy is higher in the Nordic countries for men, but for women it is higher in Confucian countries (East Asian) [ 11 ]. The same authors find that younger age mortality is lower in the Nordic countries but not for older age mortality. Four studies find that health is not the best in the Nordic countries. They instead find that self-rated health is better in Anglo-Saxon countries [ 22 , 42 ], in Bismarckian countries [ 43 ] or in Southern countries [ 12 ]. Limiting longstanding illness seems to be least reported in the Southern regimes [ 22 , 43 ].

Eight out of 13 studies look at inequalities in health and results regarding differences between regimes vary. Some find support of the Nordic countries performing better and having smaller inequalities while others find the opposite. Results vary by health outcome and gender making it difficult to draw any clear-cut conclusions. One study finds differences by welfare state regime, with inequalities being largest in Anglo-Saxon, Bismarckian and Scandinavian regimes [ 44 ]. They also find that women seem to be more affected by unemployment in the Scandinavian countries. Others find that health inequalities by income [ 22 ] and education [ 43 ] generally seem to be the smallest in Bismarckian regimes. Another study finds that inequalities in life expectancy are the smallest in the Southern regimes for women and are for men smaller in the Nordic countries, but the inequalities are measured as individual variation mainly [ 11 ]. Another study finds that social inequalities in sickness were lowest in the Southern regime for men and for women inequalities were lowest in Scandinavian regimes [ 40 ]. Drawing general conclusions are further complicated by results that vary by cohort and gender [ 36 ]. Some studies find no differences [ 12 ] or no consistent welfare regime patterning [ 39 ]. For further information on study characteristics and results see an Additional file [see Additional file 4 : Ferrera].

Theoretical description- Ferrera

After an extensive debate about E-A’s typology, Ferrera [ 18 ] introduced a modified typology in 1996 by focusing more on differences in how the social benefits are delivered as compared to E-A’s, where quantity of welfare provided was emphasised [ 45 ]. In doing this a new regime type, the Southern, was included. This lead to a typology with four different regime types; the Scandinavian (Social democratic), the Bismarckian (Conservative), the Anglo-Saxon (Liberal) and the Southern European (Italy, Greece, Portugal and Spain). Southern welfare states are described as ‘rudimentary’ [ 18 ] because they are still characterised by a highly fragmented system of welfare provision and welfare services [ 46 ]. Another prominent feature is the reliance on the family and voluntary sector [ 18 , 36 ].

Modified versions

Eikemo and colleagues

Another advancement in the welfare regime research has been to include an additional fifth regime type, the East European, suggested by for example Eikemo et al. in 2008 [ 22 , 42 , 43 ]. For this, Ferrera’s typology was used and expanded by adding a category composed of the Czech Republic, Hungary, Poland and Slovenia [ 42 ]. Estonia and Slovakia are also included in some studies [ 22 , 43 ]. This group of countries has a history with economic instabilities and social reforms during the 1990’s [ 47 ] and were argued to form a fifth regime with similar characteristics.

Karim et al.

Karim, Eikemo and Bambra [ 23 ] have in 2010 argued that East Asian welfare states also form a cluster of countries and further modify the typology by Eikemo and add a sixth group which includes the East Asian countries (Hong Kong, Japan, Republic of Korea, Singapore and Taiwan). The welfare regimes of the East Asian countries are characterised by low levels of interventions by the government, low investment in social welfare, an underdeveloped provision of public service and a strong reliance on family (e.g. [ 23 ]).

In 2013, Popham [ 11 ] used Ferrera’s typology as inspiration and added more countries and extra regimes to the typology. Apart from the typical regime types: Anglo-Saxon; Bismarckian; Nordic; and Southern European, three new regimes are added. These are the Eastern European regime, the Ex-Soviet regime and the Confucian regime.

Huber and colleagues

The five studies in this group have used different modified versions of the typology by Huber and colleagues and they mainly examine European countries, with analyses based on data from nine countries [ 24 ] to 21 countries [ 48 ]. Morbidity measures are more common to use. Self-rated health is most common and used in three studies [ 24 , 25 , 48 ]. Descriptive characteristics of studies in the Huber and colleagues group are shown in Table 4 .

Three studies examine population health. Two of these find that health is better in Social democratic countries, one found this for infant mortality and low birth weight [ 49 ] and the other for self-rated health [ 24 ]. The third found that the Eastern European countries have the lowest levels of self-rated health and no significant differences between the other regimes [ 48 ].

Three studies have a health inequality approach. One study finds that inequalities in self-rated health and limiting longstanding illness are found in all three regimes (Social democratic, Christian democratic and Late democratic) but that differences between the social classes are more marked in Late democracies [ 24 ]. They also find that education based inequalities in the same health measures are larger in Social democratic countries compared to Christian democratic (for men). Another study also finds that inequalities exist in all regimes (Social democratic, Christian democratic, Liberal and Late democracy) but find gender differences across regimes [ 25 ]. For women, inequalities are larger in Social democratic countries compared to Late democracies and for men, inequalities are smaller in Social democratic compared to the three other regimes. Navarro et al. [ 26 ] find that Social democratic ideologies tend to implement redistributive policies which reduce social inequalities in health, which perhaps indirectly states that inequalities are smaller in Social democratic regimes. An Additional file shows further information on study characteristics and results [see Additional file 4 : Huber and colleagues].

Theoretical description- Huber and Stephens (and data by Huber, Ragin and Stephens [ 21 ])

The typology by Huber and Stephens [ 20 ] developed in 2001 is based on political traditions and the allocation of countries is based on the number of years that a country has been governed by a party belonging to a particular political tradition since the 1950’s. The four political traditions are Social democratic (Denmark, Finland, Norway, and Sweden: the most pro-redistributive) Liberal (Canada, Ireland, UK and USA), Christian democratic (Austria, Belgium, France, Germany, Italy, the Netherlands and Switzerland: the least pro-redistributive) and Wage Earners (Australia and New Zealand). Parties in each political tradition display a similar level of commitment to redistributive policies [ 26 ].

Different authors have developed this typology further by adding or removing countries or regimes. Navarro, together with different co-authors have removed one regime type, the Wage-Earner, and added another, the ex-Fascist regime or the Late democracies which include Portugal and Spain, and sometimes Greece [ 24 – 26 ]. Other authors have added a fifth regime type consisting of countries in Eastern Europe [ 48 ].

Other typology- Korpi and Palme

Sanders et al. [ 50 ] is the only study using this typology [see subsection ‘Theoretical description- Korpi and Palme’]. This study is the only study using oral health as a measure of health. They find that average dental health is better in Finland (representing the Encompassing regime/Social democratic) and worse in Australia (representing the Basic security regime/Liberal). Income-based inequalities were larger in Finland compared to Germany (Corporatist regime). Further information on study characteristics and results can be found in an Additional file [see Additional file 4 : Korpi and Palme].

Theoretical description- Korpi and Palme

In 1998, Korpi and Palme [ 37 ] based their typology on the institutional characteristics of welfare states by looking at different countries’ capacity to alleviate income inequality and poverty, specifically examining old age pensions and sickness cash benefits. The classification was based on coverage and generosity and generated five different ideal institutional types characterised as the Basic security, the Corporatist, the Encompassing, the Targeted, and the Voluntary State Subsidised types [ 38 , 50 ].

Geographical comparisons

The six studies in this group mainly examine differences in health between different European countries or regions and two studies include the United States as a typical Liberal country [ 51 , 52 ]. Countries/regions are not clustered and there is no apparent link to welfare state characteristics. Self-rated health is the most common health measure and is used in four studies [ 13 , 52 – 54 ] and morbidity measures are generally more common. Descriptive characteristics of studies in the Geographical comparisons group are displayed in Table 5 .

Four studies examine population health and all studies report that the Nordic countries have the best health, but findings differ by various factors. One study finds that young Icelandic people have better self-rated health than American people but that the opposite is found after age 50 [ 52 ]. Another finds that although the Nordic countries are still in the lead, the Southern countries are catching up rapidly regarding mortality related measures of health [ 55 ]. A third study finds that self-rated health seems to be the best in Sweden, Norway and Denmark but is actually the worst in Finland [ 53 ]. Finally, a fourth finds that self-rated health is the best in Social democratic countries compared to other European countries and this effect is largely mediated by more equal income distribution [ 13 ].

Five studies have an inequality approach to population health. The results vary in presentation and have different focus points, but four out of five studies point to positive results for Nordic/Social democratic countries. One study finds that the effects of affluence and self-rated health are weaker in Iceland [ 52 ]. Another finds that education based inequalities in self-rated health have between the 1980’s and 1990’s remained stable in the Nordic countries but have increased in for example Spain, Italy and the Netherlands [ 53 ]. A third uses the Gini coefficient as a measure of inequality and finds that the Nordic countries have the lowest scores which seems to be related to better self-rated health and a higher Gini coefficient score is negatively related to self-rated health [ 13 ]. Another study finds that education has more effect on health (morbidity) in Western and Southern Europe and that it is insignificantly related in Northern Europe [ 54 ]. Another study finds that inequalities in health are smaller in the United States than in Denmark [ 51 ], in contrast to the results of the studies mentioned above which all find positive results for the Nordic countries. An Additional file shows further information on study characteristics and results [see Additional file 4 : Geographical comparisons].

The Regime approach and health

There is great variation in the results presented in the studies when grouped according to what typology they have used, making it problematic to draw generalisable conclusions regarding where population health is better and inequalities in health are the smallest.

The variation in findings across studies applying a regime approach is not possible to understand as a result of the regime typology chosen or the amendments used and we still find a patchy picture with contradictory findings. Nevertheless, since the studies in this category also differ in several other aspects it is still possible that theoretical and empirical differences could account for the diversity in findings.

The studies were initially grouped according to the main outcome; i.e. where health was found to be the best, but no apparent common patterns could be found. Results differed in numerous ways, for example with time, by gender, by measures of population health and health inequalities, making it difficult to draw any conclusions.

The studies were then grouped according to use of health outcome. The studies in this review have used either morbidity- or mortality related measures and although these are both valid measures of health, they might give different results. The two big groups that are classified as mortality related measures are life expectancy and infant mortality. The studies that look at life expectancy find that East Asian countries have higher life expectancy than other regimes. The studies that examine infant mortality find that the Nordic countries have the lowest rates of infant mortality. Few studies examine inequalities and do not give any clear results.

Studies that look at morbidity measures such as self-rated health find mixed results. Some find that the Nordic countries have better self-rated health while others find that other regimes have better health. No consensus regarding which regime has the best health can be found; some find that Liberal countries have better health than Conservative, and others find the opposite. No clear pattern is seen for inequalities in self-rated health; there is no consensus of which regime has the smallest.

The studies were then listed according to the number of countries of which the studies are based but no apparent pattern could be found.

Finally, the studies were grouped according to the type of data used. All studies using ESS data, except for one, which does not find any significant differences between the typologies, find that other countries, and not the Nordic countries, have the best health. Most of these studies use self-rated health as health outcome. It seems as though other countries have smaller inequalities compared to the Nordic countries. Most of these studies are from one main group of authors, namely Bambra and Eikemo, and most look at Scandinavian/Social democratic, Conservative, Liberal, Southern and Eastern European countries. Most studies using OECD data conclude that Nordic countries have better health. Most of these use infant mortality as a measure of health. Regarding inequalities in health, it is difficult to draw any conclusions.

Institutional approach

The Institutional approach is the second largest of the three groups with 14 studies fitting the criteria. Five studies use a health inequality perspective, examining inequalities by socioeconomic position/status, type of mother (lone vs. coupled), education and income. The studies have been classified according to main type of policy area: family [ 15 , 16 , 56 – 59 ], pensions [ 17 , 59 – 61 ], economic assistance and unemployment benefits [ 58 , 62 , 63 ] and access to health care [ 64 – 66 ]. Two articles cover several policy areas [ 58 , 59 ]. The selected studies together use 12 different health measures (13 if including ‘immunisation’), some use several and some only one. It is more common to use mortality measures (used 15 times) as health indicator than it is morbidity measures (used 10 times). Descriptive characteristics of studies with an Institutional approach can be found in Table 6 .

Family benefits

There is general consensus that generous family benefits and the dual-earner family policy model are beneficial for health, both for adults’ self-rated health and also child mortality. Universal family policies seem to be beneficial for all, not only those who use it. One study [ 15 ] looks at inequalities in health and uses ‘type of mother’ as measure of stratification. They find that generous family policies provide protection from poor health, poverty and unemployment to mothers in general and particularly to lone mothers. An Additional file shows further information on study characteristics and results [see Additional file 5 : Family benefits].

Pension benefits

There seems to be general agreement of generous pensions being related to better health and higher life expectancy. Most studies suggest that basic security pensions are associated with lower old age excess mortality [ 59 , 61 ] and a higher life expectancy [ 17 ]. There is less evidence supporting income security pensions’ effect on health. The different pension benefits perhaps work differently for men and women: income security pensions seem more important for men’s health and basic security pensions seem more important for women’s [ 60 ]. For further information on study characteristics and results see an Additional file [see Additional file 5 : Pension benefits].

Economic assistance and unemployment benefits

Universal systems of economic assistance [ 62 ] and unemployment benefits [ 58 , 63 ] seem to be associated with a healthier population. This seems to apply to the whole population, not only to the health of the unemployed [ 58 ]. An Additional file shows further information on study characteristics and results [see Additional file 5 : Economic assistance and unemployment benefits].

Access to health care

Absolute inequalities in mortality by socioeconomic status (income and education) seem to decrease with universal health care. However, the relative gap seems to increase, i.e. advantaged people obtain disproportionate benefits of health care, and access, or perhaps adherence to health care seems lower for people in lower socioeconomic groups [ 64 , 66 ]. For further information on study characteristics and results [see Additional file 5 : Access to health care].

The institutional approach and health

Most studies in this approach seem to agree that generous policies and benefits are associated with health in a positive way for all people in a population, not only those who are directly affected or targeted and receive the actual benefit.

Expenditure approach

The Expenditure approach is the smallest of the three approaches, only eight studies fit the criteria. There is perhaps an increased tendency of using this approach for cross-country comparisons of population health (see Additional file 2 for detailed timelines of publication year). Two studies use a health inequality perspective and both examine inequalities by education and were published in 2012. One study covers both social and health spending, three studies cover social spending only, and four cover health spending only. The selected studies use various health measures, nine different in total. Some studies analyse several health measures and others look at only one. By categorising the health outcomes into either an outcome related to mortality or morbidity, one finds that different mortality outcomes are the most common (11 compared to 4). Descriptive characteristics of studies with an Expenditure approach are shown in Table 7 .

Health spending

Some studies find that health spending is associated with life expectancy and maternal mortality [ 67 ], general mortality and a reduction of life years lost [ 68 ], and lower infant mortality rates [ 69 ]. One study finds that social spending on health is negatively correlated with health for women and unrelated for men [ 48 ]. The authors suggest that a reason for this might be that additional spending on health might have little effect on OECD countries since expenditure levels are already high in many of these countries. One study [ 70 ] looks at inequalities and finds that in countries where the government spends a lot of money on healthcare (and has a highly modernised labour market) the relative risk of lower educated people being in poor health is smaller. An Additional file shows further information on study characteristics and results [see Additional file 6 : Health spending].

Social spending

Two studies find that social spending is associated with life expectancy, infant mortality, potential years of life lost [ 67 ], and mortality [ 71 ]. One study [ 17 ] finds conflicting results; the relationship between social spending and life expectancy vary from cross-section to cross-section. The study finds that initial investment in social policy leads to increases in life expectancy but after a certain level of spending, the extra spending does not contribute that much. The study looking at health inequalities [ 5 ] finds that social spending seems to be associated with lower education based inequalities in health among women and, to a lesser degree, among men. Additionally, those with primary education benefit more from high social transfers than those with tertiary education. For further information on study characteristics and results see an Additional file [see Additional file 6 : Social spending].

The expenditure approach and health

Most studies in the Expenditure approach agree that social and health spending is associated with increased levels of health in one way or the other. The studies that do not find these positive associations do not see consistent findings over time. These studies also show evidence that after a certain level of spending additional spending does not contribute that much, showing a curvilinear association. Both studies with the inequality perspective find that spending is beneficial for those with lower educational status. Both studies examine self-rated health and therefore no conclusions can be drawn regarding mortality (which is the most common use of measure in this approach).

The starting point for this review has been the mixed and contradictory findings arising from research on welfare state characteristics and health and health inequalities. These contradictions either suggest that 1) policies directed at the causes of the causes are much less important for health and health inequalities than we have been assuming, or 2) there are fundamental theoretical and/or empirical shortcomings in many studies in this field. This area evidently needs to be further explored in order to fully understand the inconsistent results and is of importance not only to welfare research but also to epidemiology. The results in this review add an important piece to the puzzle by clarifying and describing why previous studies have not been able to come to unequivocal conclusions.

Our analytical approach has been to sort the relevant studies found according to their approach to measure welfare state characteristics, something that to our knowledge, has not been done before. Of the three main types (regime, institutional and expenditure), the Regime approach is by far the most common. However, while the fundamental approach is the same for these studies we find large variations in the theoretical basis as well as the countries and regime types included. In Esping-Andersen’s original work [ 19 ] several clusters of countries are actually being suggested based on de-commodification, social stratification, and the private-public mix of social provision, respectively. Most followers are using de-commodification as their starting point. In addition, many studies in this public health field that employ Esping-Andersen’s work make amendments of clusters and countries and the theoretical underpinning is therefore not as strong as often assumed.

However, even when we sort studies according to the regime theory employed and the amendments made to these, results are diverse and contradictory. Hence, it is not inconsistencies between different theories or different empirical applications of these that is the only or main problem, but a more general problem with welfare state regimes when applied to outcomes such as health and health inequalities.

A further problem is that different health measures are used, which adds to the complexity of drawing conclusions about where health is the best and health inequalities the smallest since choice of measure will highly affect the outcome and the conclusions drawn. When stratifying our material according to type of health measure used some consistent results can be found regarding levels of mortality. Morbidity related measures show mixed results and may reflect data and reporting problems. However, in search for consistencies regarding health inequalities, not much added clarity is achieved.

Many researchers in comparative welfare regime and health research agree that welfare states cluster together into certain regimes. However, there is less agreement about which typology to apply and when, and this therefore remains an open issue. Since there is no total agreement about which typology to use, several classifications have emerged, many of which are rather similar and overlap each other, all intending to capture the essence of a welfare state. These typologies have sometimes emerged on unclear grounds, for example, it seems as though some have emerged based on the country data available to each author and not on strong theoretical grounds. Interpretations and comparisons of findings from these studies will be complicated by typologies that have been constructed differently and further used as an independent variable aiming to ‘explain’ variations in health and health inequalities across countries. By adding a regime such as the Eastern European regime, the picture becomes more complete, but it also becomes more complex and this tends to change the whole focus of the study. These studies tend to find that Central and Eastern European countries fare the worst. The health situation in former communist countries is an important and complicated issue in its own right. However, while this is likely to be linked to social and policy factors it is questionable if the addition of these countries to the existing and already conflicting research is especially helpful.

This field of research has a long history of debate. Many critics have pointed out that there are problems with typologising. One of the most outspoken is Baldwin [ 72 ], who in 1996 critically wrote that two countries in a regime cluster can be inconsistent among policy areas, and that welfare state studies have “exhausted its explanatory power and is no longer bearing fruit”. Kasza [ 73 ], is another who in 2003 concluded that “few national welfare systems are likely to exhibit the internal consistency necessary to validate the regime concept, and that policy-specific comparisons may be a more promising avenue for comparative research”. Mackenbach [ 74 ] is more recent and writes in 2012 that Esping-Andersen’s typology is not “suitable for distinguishing countries with different types of health care provision. Generousness or universalism in other parts of the welfare state, e.g. for income support, does not appear to predict generousness or universalism of health care provision”. The UK for example, is usually placed in the Liberal regime group, but at the same time, it has a universal health system free of charge. Mackenbach [ 74 ] suggests “that if we want to study the health impacts of welfare arrangements we might better not take Esping-Andersen’s classification as starting point”. On the other hand, many researchers refer to Southern, Northern and other groups of countries in a way that suggest an underlying idea about fundamental commonalities in those groups (including Mackenbach).

With time comes change, and all is well if all countries in each welfare state cluster move forward together, but this is seldom the case. Countries will have different experiences and might well move in different directions at different paces. A country can with time go through policy changes in eligibility, structures or financing that could technically and potentially reposition it from one regime cluster to another. Although these transformations might be “work in progress”, quite a few researchers agree that countries and their politics change with time. For example, Kvist et al. [ 75 ] concluded that the small changes found across policies for families with children, for the unemployed, for the ill, and for the older in the 2000s, when added together, challenge the concept of the Nordic welfare policies. Kuivalainen and Nelson [ 76 ] find that the social assistance in the Nordic countries is moving closer to some of the features and outcomes of other regimes in terms of benefit generosity and poverty outcomes. They conclude that the Nordic social assistance classification into a separate model of social welfare is not as distinct as it was 20 years ago. A recent OECD report about income inequalities finds that in Sweden, many times seen as the archetypical Nordic country, the relative income poverty rate has increased the most during the last 20 years and particularly among children and youth. In other words, Sweden’s capacity to protect the vulnerable groups against poverty has been weakened due to an inability to keep up with the increases in general income [ 77 ]. If this continues the Nordic countries might experience poverty rates similar to those in several Liberal and Conservative welfare states meaning that one of the most significant features of the Nordic welfare states will disappear [ 76 ].

Hence, our first conclusion based on earlier reviews and our own attempts to analyse the reasons for diverging and conflicting findings from the growing body of research on welfare state characteristics and health/health inequalities is that the welfare state Regime approach is not a fruitful way forward. We do not assert that this can be extended as a general conclusion. Rather, the Regime approach has been important for welfare state research, and especially so perhaps for analyses of the welfare state as a dependent variable. It can also be highly informative for descriptive purposes. But as a tool for analyses of how policies and institutions that impact on the wider social determinants of health actually affect health inequalities, it is simply too crude and imprecise. When adding the fact that few studies in practice adopt the same Regime approach (although many use the same labels), there is no wonder that the results produced are diverging and even conflicting.

In recent years there has been a theoretical and methodological development of welfare state models and regimes, where both the ‘productive’ and ‘protective’ dimensions of welfare state activities are included [ 78 , 79 ]. This allows for a more complex categorisation of strengths and weaknesses in different countries where both education and active labour market programmes (‘productive’), and employment and income protection (‘protective’) policies are considered. To our knowledge this has not yet been applied to health and health inequalities outcomes, but given that this approach produces a more nuanced picture where also countries outside the traditional OECD countries can be included [ 80 ], it seems more promising than more traditional ways of clustering countries. Another development in comparative welfare research is the “Varieties of Capitalism” approach [ 81 ] which compares countries based on type of capitalism. Both of these do, however, still represent a clustering of countries, and although they are likely to be more promising than the different ideal types typically employed in the studies included in our review, several of the caveats are likely to apply.

In contrast to regime types, the Institutional and Expenditure approach focus on the more specific “welfare outputs” delivered by the welfare state, either captured as the formal legislated rights that people have or the money spent on the programme. Hence, the approaches are much more able to study specific policies but can easily also study the total effort by combining different rights/spendings. Another major difference between these two approaches and the Regime approach is that where the Regime approach has to rely on country cluster average differences, the Institutional and Expenditure approaches give us a variable approach. This means that we can allow for countries to differ in their policies in different areas of interest (social protection, family policies, health care policies, labour market policies etc.). This, in turn, is likely to increase the policy relevance of studies as well as our understanding of the processes involved when health inequalities are generated.

While the Institutional and Expenditure approaches are more promising in principle for health inequality research, there are to date a limited number of studies of this kind. Yet, the clear impression from taking these studies combined is still that more social spending and more generous social rights lines up with lower mortality, better health and, probably, smaller health inequalities. We would like to see more studies using these approaches, but on basis of the ones that exist it is tempting to suggest a solution to the ‘Nordic paradox’; while welfare policies of a ‘Nordic’ kind is indeed promoting better health and smaller health inequalities, it not the case that such policies are mainly found in the Nordic countries. When looking at country clusters, ‘better’ and ‘worse’ policies for public health and health inequalities are found in many clusters, and the results becomes highly dependent on the countries actually included. When looking directly at institutional social rights or social spending the relations between policies and health outcomes becomes uncovered in a much clearer way.

It is important to stress that the Institutional approach to a large extent was formulated as a critique of the Expenditure approach. The latter has been accused of being faulty since it does not address two of the main features of a welfare state; social citizenship and social rights. There have also been doubts regarding that high spending means nothing more than extensive social problems. The level of spending might therefore not tell us much about the characteristics of a welfare state’s social or health programmes. Kangas and Palme [ 8 ] find that the advanced rich countries seem to use roughly the same amount of their GDP on welfare. Even though spending levels are similar, the distributional consequences can be greatly divergent. However, this critique has also led to adaptations and procedures to take differences in need into account, thereby closing the gap between the two approaches in empirical terms at least [ 5 , 82 ].

But, the Institutional approach focusing on legislated social rights has shortcomings too. It tends to capture the principles for certain type cases, while the lived experience of people in need of social protection can be something else. It might also be important to include several dimensions of social rights, like coverage and replacement rates, to get a balanced picture. In contrast to spending data, such data on the legislated rights are not produced routinely but requires large efforts to collect. Hence, there are weaknesses and strengths to both approaches, and in relation to outcomes like health inequalities, they are likely to be complementary rather than mutually exclusive.

Limitations

This review was based on empirical studies published in peer-reviewed journals. There is a small risk that other studies of welfare states and health inequalities are to be found in e.g. the grey literature, but if so these have been overlooked.

We have set the starting point for the literature search to 2005 and relevant studies prior to this year have been missed in our search. However, we started off by revising the three large reviews [ 3 , 4 , 9 ], which are based partly on studies prior to 2005, and their results are also somewhat inconsistent regarding welfare research and health inequalities. This indicates that studies prior to 2005 would not contribute much to the overall picture. In addition, the Publication timelines [see Additional file 2 ] indicate that the number of studies increases over time, which means that the risk that we have missed important studies prior to 2005 is small.

Most importantly, however, it is necessary to notice that the three approaches identified are unbalanced; the Regime approach is by far the largest. While this means that our conclusions regarding the Regime approach are fairly well underpinned, conclusions regarding the merits of the Institutional and Expenditure approaches are based on a small number of studies. While this reflects the reality, it is important to keep in mind when evaluating our conclusions. For example, if more studies are produced using these two approaches it may well be that less consistent results emerge also for them.

The wider social determinants of health, the causes of the causes, are of great importance for health and well-being, and the collective resources in terms of social protections and services provided by the welfare state are likely to be more important for those that have fewer resources in their own control. From this follows that a range of welfare state policies are important for health and health inequalities, but the question is how we best can study this in more detail. Most likely, there is not one answer to that question. However, earlier reviews and our own attempts to find some consistency strongly suggest that further studies of the Welfare Regime approach and health inequalities do not seem to lead us much further.

Instead, we will need a multitude of different types of studies, including larger analyses of social spending and social rights in various policy areas and how these are linked to health in different social strata. But, we also need more detailed evaluation of specific programmes or interventions, as well as more qualitative analyses of the experiences of different types of policies among the people and families that need to draw on the collective resources. There are many roads that will take us forward towards a better understanding of how health inequalities are generated and how policies directed to the social determinants of health can prevent or amplify these processes.

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Acknowledgements

We are grateful to Jennie Bacchus Hertzman for support with literature search, and to colleagues within the DRIVERS project, in particular Peter Goldblatt and Espen Dahl, for comments on an earlier draft.

The research leading to these results was carried out within the framework of the DRIVERS project ( http://www.health-gradient.eu ) coordinated by EuroHealthNet, and has received funding from the European Union (FP7 2007–2013) under grant agreement n° 278350, and (to MÅY) by The bank of Sweden Tercentenary Foundation (grant agreement no: P09-0908:1), and (to OL) by the FAS Center grant Human Society as a Life-long Determinant of Health (grant agreement no: 2006–1518).

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Kersti Bergqvist, Monica Åberg Yngwe & Olle Lundberg

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The authors declare that they have no competing interests.

Authors’ contributions

KB, OL and MÅY all made important contributions to the manuscript. KB had the main responsibility for drafting the manuscript. OL and MÅY contributed substantially to the design of the study. KB conducted the literature searches, screened all potentially relevant studies as part of the preliminary inclusion/exclusion and reviewed papers obtained for inclusion, wrote the methodology and results section, and part of the background and discussion. OL wrote part of the introduction and discussion. OL and MÅY reviewed papers for which there was disagreement as to whether they should be included. All authors participated in discussions regarding methodology and findings, and reviewed drafts of the manuscript and approved the final version.

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12889_2013_7630_moesm1_esm.docx.

Additional file 1: Descriptive characteristics of the studies with a regime approach (n = 34). This file contains a table with descriptive characteristics of the articles included in the Regime approach. It includes details of publication year, countries under study, health inequality measures, health outcome variables, and number of times each typology group has been used. (DOCX 20 KB)

12889_2013_7630_MOESM2_ESM.docx

Additional file 2: Timelines of publication year. This file contains four timeline figures of publication year of the selected studies. The first shows all studies included in the review, the remaining timelines display the publication dates of the studies selected for the three main approaches to comparative welfare research; the Regime approach, the Institutional approach, and the Expenditure approach. (DOCX 66 KB)

12889_2013_7630_MOESM3_ESM.docx

Additional file 3: Table of the different typologies used in the studies included in this review. This file contains a table illustrating the different welfare regime typologies used in the studies. It shows the different clusters, which countries are included in each, and the number of studies that have adopted each. (DOCX 29 KB)

12889_2013_7630_MOESM4_ESM.docx

Additional file 4: Tables of studies used in the review sorted by welfare regime typology. The tables in this file illustrate the data used, the number of countries looked at, health outcome/s, measure of health inequality, typology and main results for each of the main groups; Esping-Andersen, Ferrera, Huber and colleagues, Korpi and Palme and Regional comparisons. (DOCX 45 KB)

12889_2013_7630_MOESM5_ESM.docx

Additional file 5: Tables of studies used in the review sorted by Institutional approach. The tables in this file illustrate the different institutional approaches used in the studies. They are sorted by type of policy (pension benefits, economic assistance and unemployment benefits, family benefits, and access to health care), the data used, health outcome/s, measure of health inequality, and main results for each of the main groups. (DOCX 24 KB)

12889_2013_7630_MOESM6_ESM.docx

Additional file 6: Tables of studies used in the review sorted by Expenditure approach. The tables in this file illustrate the two Expenditure approaches used in the studies. They are sorted by type of spending (health spending or social spending), the data used, health outcome/s, measure of health inequality, and main results for each of the main groups. (DOCX 20 KB)

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Bergqvist, K., Yngwe, M.Å. & Lundberg, O. Understanding the role of welfare state characteristics for health and inequalities – an analytical review. BMC Public Health 13 , 1234 (2013). https://doi.org/10.1186/1471-2458-13-1234

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Welfare States: How They Change and Why

First Online: 05 October 2016

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Fiona Dukelow 3 &
Mary P. Murphy 4

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In this chapter, Fiona Dukelow and Mary Murphy sketch the landscape of research on welfare state change and set out some of the ways the impact of the economic crisis and the prospect structural change need to be informed by the lessons of previous research on how welfare states change and why. The chapter then proceeds to discuss a set of core structural drivers of welfare state change and their bearing on Irish welfare state change, including neo-liberalisation, internationalisation and the politics of welfare. The final section develops a framework for understanding and tracking the variety of ways structural change may be occurring, outlining four key questions: What is welfare for? Who delivers welfare? Who pays for welfare? Who receives welfare?

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Employment: 75% of the 20–64-year-olds to be employed; Education: Reducing the rates of early school leaving below 10% and at least 40% of 30–34-year-olds completing third-level education; Fighting poverty and social exclusion: at least 20 million fewer people in or at risk of poverty and social exclusion.

While we do not develop the methodology here, it is plausible to think that the framework could lend itself to comparative methodologies such as fuzzy set. It is also possible to understand shifts in dynamics and functions in Polanyian terms as a function of three dynamics; state redistribution; market production or commodification; and reciprocal societal relations and to assess structural change in terms of the relative shifts between these three sources or dimensions of welfare (Buroway 2015 ).

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Dukelow, F., Murphy, M.P. (2016). Welfare States: How They Change and Why. In: Murphy, M., Dukelow, F. (eds) The Irish Welfare State in the Twenty-First Century. Palgrave Macmillan, London. https://doi.org/10.1057/978-1-137-57138-0_2

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v.61(12); 2007 Dec

Going beyond The three worlds of welfare capitalism : regime theory and public health research

International research on the social determinants of health has increasingly started to integrate a welfare state regimes perspective. Although this is to be welcomed, to date there has been an over‐reliance on Esping‐Andersen's The three worlds of welfare capitalism typology (1990). This is despite the fact that it has been subjected to extensive criticism and that there are in fact a number of competing welfare state typologies within the comparative social policy literature. The purpose of this paper is to provide public health researchers with an up‐to‐date overview of the welfare state regime literature so that it can be reflected more accurately in future research. It outlines The three worlds of welfare capitalism typology, and it presents the criticisms it received and an overview of alternative welfare state typologies. It concludes by suggesting new avenues of study in public health that could be explored by drawing upon this broader welfare state regimes literature.

International research on the social determinants of health and health inequalities has increasingly begun to draw upon the comparative social policy literature. Specifically, research has concentrated on examining, and to some extent explaining, differences in health outcomes between and within developed countries by comparing different types of welfare state regimes and their respective politics and policies. 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 Recent calls for further analysis of the political nature of health (and indeed the creation of “political epidemiology”) suggest that it is likely that such research will grow in the future. 11 , 12 However, public health research has to date relied extensively on the typology of welfare state regimes proposed by Esping‐Andersen in his 1990 publication (which used 1980 data), The three worlds of welfare capitalism . 13 This is despite the fact that within the discipline of social policy, Esping‐Andersen's typology has long been the subject of extensive scholarly criticism and there is in fact a number of competing welfare state typologies that may also be of use in public health research. 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 The purpose of this paper is to provide public health researchers and epidemiologists with an up‐to‐date overview of the social policy literature on welfare state regimes, so that our research can reflect and benefit from the more contemporaneous insights on offer from the “welfare modelling business”. 20 , 21

This paper begins by summarising Esping‐Andersen's seminal work, The three worlds of welfare capitalism ; it then presents the various criticisms that this theory received and outlines the resulting alternative welfare state typologies that emerged. It concludes by suggesting new avenues of study in public health that could be explored by drawing upon this broader welfare state regimes literature. Although there are existing reviews of welfare state regime theory, these are somewhat outdated and, perhaps more importantly, they were not written specifically for or publicised to a public health audience. 20 , 21

The three worlds of welfare

In The three worlds of welfare capitalism (1990), 13 Esping‐Andersen presents a typology of 18 Organisation of Economic Cooperation and Development (OECD) welfare states based upon three principles: decommodification (the extent to which an individual's welfare is reliant upon the market, particularly in terms of pensions, unemployment benefit and sickness insurance), social stratification (the role of welfare states in maintaining or breaking down social stratification) and the private–public mix (the relative roles of the state, the family, the voluntary sector and the market in welfare provision). The operationalisation of these principles, largely using decommodification indexes, leads to the division of welfare states into three ideal regime types (Esping‐Andersen; Table 1 1): ): Liberal, Conservative and Social Democratic. 13

GDP, gross domestic product.

In the Liberal regime countries, state provision of welfare is minimal, benefits are modest and often attract strict entitlement criteria, and recipients are usually means‐tested and stigmatised. The Conservative welfare state regime is distinguished by its “status differentiating” welfare programmes in which benefits are often earnings‐related, administered through the employer and geared towards maintaining existing social patterns. The role of the family is also emphasised and the redistributive impact is minimal. The Social Democratic regime is the smallest regime cluster. Welfare provision is characterised by universal and comparatively generous benefits, a commitment to full employment and income protection, and a strongly interventionist state used to promote equality through a redistributive social security system. 13

Going beyond The three worlds of welfare capitalism

The three worlds of welfare capitalism typology has sparked a volatile and ongoing debate and, indeed, much of the burgeoning comparative social policy literature since 1990 can be seen as a “settling of accounts” with Esping‐Andersen. 21 , 23 This process has led to the development of alternative typologies, many of which are intended to reflect aspects that were not examined in Esping‐Andersen's original typology, that extend the range of countries included in the analysis, and that take more account of gender, politics or the role of public services. 4 , 16 , 17 , 18 , 19 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 The criticism has been on three fronts: theoretical, methodological and empirical.

Theoretical critiques

The range of countries and regimes.

The range of countries used to construct Esping‐Andersen's typology has met with criticism. 17 , 18 , 19 , 22 Esping‐Andersen only examined 18 OECD countries and in doing so he placed both Italy and Japan within the Conservative regime. Some commentators assert that when the Latin rim countries of the European Union (Spain, Portugal, Greece) are added into the analysis, a fourth “Southern” world of welfare emerges into which Italy can also be placed (Bonoli, Ferrera, Liebfreid; Table 1 1 ). 17 , 18 , 19 The Southern welfare states are described as “rudimentary” because they are characterised by their fragmented system of welfare provision, which consists of diverse income maintenance schemes, ranging from the meagre to the generous, and a healthcare system that provides only limited and partial coverage. 19 Reliance on the family and voluntary sector is also a prominent feature.

Furthermore, research into East Asian welfare states (South Korea, Taiwan, Hong Kong, Singapore) has suggested that these countries, including Japan, form a further Confucian welfare state regime. 24 , 28 , 37 The Confucian welfare state is characterised by low levels of government intervention and investment in social welfare, underdeveloped public service provision, and the fundamental importance of the family and voluntary sector in providing social safety nets. This minimalist approach is combined with Confucian social ethics (obligation for immediate family members, thrift, diligence, and a strong education and work ethic). 37 Overall, the Confucian welfare state regime could be considered as combining some elements of the Liberal, Conservative and Southern regimes.

In addition, Castles and Mitchell (1993) cross‐classified the same 18 OECD nations used by Esping‐Andersen and examined their high‐ and low‐aggregate expenditure levels, and their high and low degrees of benefit equality. On the basis of this analysis, they argued that the UK, Australia and New Zealand constitute a Radical, targeted form of welfare state, one in which “the welfare goals of poverty amelioration and income equality are pursued through redistributive instruments rather than by high expenditure levels” (Castles and Mitchell; Table 1 1 ). 22 In the same vein, Korpi and Palme describe the existence of a Targeted welfare state regime (Korpi and Palme; Table 1 1 ). 32

The gender‐blind “worlds of welfare”

It has been argued that the analysis behind The three worlds of welfare capitalism typology was “gender‐blind” (androgynous). 34 , 35 Aside from the overt absence of women in Esping‐Andersen's analysis, the critique revolves around three other issues: the gender‐blind concept of decommodification, the unawareness of the role of women and the family in the provision of welfare, and the lack of consideration given to gender as a form of social stratification. 33 , 34 , 35 These criticisms suggest limitations to the comprehensiveness and generalisability of the Three Worlds thesis – especially in regard to any claims about women, welfare and the family.

The gender‐blind critique of Esping‐Andersen has led to both theoretical attempts to “gender” his analysis, and also, the construction of alternative welfare state typologies in which gender has been a more overt and centralised part of the analysis. 16 , 25 , 29 , 31 , 34 , 35 , 36 Most notable amongst these new typologies are the defamilisation approaches that examine the extent to which welfare states, and welfare state regimes, facilitate female autonomy and economic independence from the family. 16 , 25 , 29 , 31 The difference made to the composition, and number, of welfare state regimes made by the addition of a defamilisation‐based analysis, however, is contested and is rather dependent on how the concept is operationalised. 16 However, to date, there has been no exploration of defamilisation and health or indeed how the relationship between gender and health varies by welfare state regime.

The “illusion” of welfare state regimes

This critique focuses on Esping‐Andersen's decision to organise the principle of classification around the study of social transfers: pensions, sickness benefits and unemployment benefits. 20 , 26 , 27 , 30 This ignores the fact that welfare states are also about the actual delivery of services such as healthcare, education or social services. 30 It is suggested that countries vary in terms of the emphasis that they place upon welfare state services and/or social transfers. 27 , 30 However, Esping‐Andersen's regimes concept generalises about all forms of welfare state provision on the basis of social transfers. 38 This has led some to question the validity of the regimes concept itself as it assumes that most of the key social policy areas within a welfare regime will reflect a similar, across the board, approach to welfare provision; and second, that each regime type itself reflects “a set of principles or values that establishes a coherence in each country's welfare package”. 38

This has resulted in the production of alternative typologies based on the extent of services provided by different welfare states. 26 , 27 , 30 These are often substantially different in composition from The three worlds of welfare capitalism . For example, Kautto's comparison of the balance between expenditure on social transfers and welfare services in 15 European countries concluded that welfare states could indeed be divided into three regimes but these were very different in composition and emphasis from Esping‐Andersen's The three worlds of welfare capitalism (Kautto; Table 1 1 ). 30 Similarly, a typology based on the comparison of the decommodification of healthcare services and social transfers in 18 OECD countries led to a fivefold typology suggesting subgroups within both the Conservative and Liberal regimes (Bambra; Table 1 1 ). 27

Taking the logic of this critique further still, researchers from the field of political economy have suggested that analysing “political” regimes may prove to be a more fruitful research paradigm. 4 , 7 In addition to criticising The three worlds of welfare capitalism , 4 , 7 they have also highlighted the limited nature of the other alternative typologies, which, in common with Esping‐Andersen, focus too much on the characteristics of welfare states to the exclusion of a thorough examination of the policies and politics underpinning and supporting them. Subsequently, a more historical–political analysis led to the development of a fourfold political typology of welfare states (Navarro and Shi; Table 1 1) ) in which Greece, Spain and Portugal form an ex‐Fascist regime. 4

Methodological issues

The limitations of Esping‐Andersen's methodology have also been exposed. Attention has been placed particularly upon the additive nature of the decommodification indexes, weighting within the indexes, the reliance upon averaging, and the use of one standard deviation around the mean to classify the countries into regimes (which meant that only a threefold classification was possible: regime classification is either above [Social Democratic], below [Liberal] or within [Conservative] one standard deviation around the mean). 13 , 14 , 22 , 39 , 40 , 41 This method has a noticeable impact on the classification of certain countries, eg. the UK which, if a different cut‐off point was used, may not have fallen within the Liberal regime. 14 , 42 These concerns led to the utilisation of more statistically robust methodologies (most notably cluster analysis), the results of which have challenged the accuracy of the threefold typology by identifying four or five different types of welfare state (Kangas, Ragin, Pitzurello; Table 1 1 ). 39 , 40 , 41

Empirical validity

Somewhat inevitably, this has led to the questioning of the ongoing empirical validity of The three worlds of welfare capitalism typology. Recently Esping‐Andersen's study was replicated and the results differed substantially from the original. 43 In addition, it has been found that the miscalculation of the mean and standard deviation in the original Three worlds of welfare capitalism data led to the misclassification of three borderline countries (Japan, UK and Ireland). 10 Furthermore, an updated analysis of decommodification using data from 1998/9 has suggested that the relationships between the 18 OECD countries have changed significantly and that the composition of welfare state regimes is not static. 10 Taken together, these pieces of research bring into question the extent to which The three worlds of welfare capitalism still exist, and indeed, at least in empirical terms, the extent to which they ever did. 14

Public health research beyond The three worlds of welfare capitalism

In light of this overview, it seems somewhat bizarre that public health research has been near oblivious to these substantial developments in social policy research since the publication of The three worlds of welfare capitalism in 1990 and that, with the notable exception of work by the political economy school, 2 , 3 , 4 , 7 epidemiological research utilises Esping‐Andersen's typology in a surprisingly uncritical manner. Indeed, a recent overview of welfare states and health inequalities makes scant mention of the existence of alternative regime typologies. 6 Furthermore, Esping‐Andersen's typology is often used to justify the choice of case study countries and subsequent findings are implicitly applied to all other countries in that particular regime. 1 Although The three worlds of welfare capitalism is clearly an acceptable starting point in terms of examining within and between welfare state differences in health, it is vital for the ongoing utility of public health research in this area that in the future it is able to more adequately reflect, and therefore benefit from, the evolution of welfare state regime theory. More awareness of the wider regimes literature and going beyond The three worlds of welfare capitalism will be a useful first stage and one to which hopefully this paper has contributed.

Looking further ahead, there needs to be more critical engagement with the concept of regimes starting with an awareness that they are in fact “ideal types”. In practice, welfare provision varies extensively between countries of the same regime type. 38 For example, research has indicated that some countries are more central to a particular regime than others (eg. Sweden or the USA) and offer a more coherent approach across both social transfers and welfare services. 27 Other countries' profile (and therefore regime type) can vary extensively depending on which factors are used in regime construction. One avenue for future research would therefore be to examine the competing typologies and establish which works best in terms of health outcomes and public health research. For example, cluster analysis techniques could be used to create health‐based taxonomies of welfare states which could be compared with existing welfare state typologies (Table 1 1 ). 16

This work would also enable more theoretical advancement in terms of how welfare state regimes are expected to impact on health and health inequalities. 6 This is especially the case in terms of welfare states, gender and health where, for example, there is the opportunity to develop both theoretical and empirical accounts of how welfare state regimes may moderate the relationship between gender and health status. Indeed, concepts from the wider comparative social policy literature, such as defamilisation, could also be unpacked and operationalised in relation to health. 16 , 25 , 29 , 31

To date, much of the engagement by public health researchers with the regimes literature has been at the overall population level. 1 , 2 , 3 , 4 , 7 , 8 , 9 , 10 There has been little research examining how different population subgroups fare in different welfare state regimes (for example, women, immigrant groups, lone mothers, etc.). 5 , 44 Furthermore, the political economy of health research could be progressed by comparing countries that are the most similar in terms of welfare state provision, identifying areas of difference and exploring how these may contribute to cross‐national differences in health and health inequalities. These types of research would help overcome some of the more banal generalisations inherent within regime research and would perhaps provide the opportunity for better advice to policy‐makers on specific interventions. Similarly, the life course approach to health inequalities could be extended to examine variation in countries from different welfare state regimes. 45 Ultimately though, for this area of research to expand, there is a clear need for increased dialogue and more joint research between social policy analysts and epidemiologists.

What is already known on this subject

It is well known that population health in the developed world varies within and between countries.
More recently, within social epidemiology, it has been suggested that these international differences may in part be a result of different types of welfare state arrangement (welfare state regimes).
This research has almost exclusively focused on Esping‐Andersen's 1990 publication, The three worlds of welfare capitalism .

What this study adds

This paper outlines Esping‐Andersen's influential Three Worlds welfare state typology and the important criticisms it received within the comparative social policy literature.
It overviews a number of alternative welfare state typologies with the intention of enabling the welfare state regimes approach taken by social epidemiologists to be broadened.
It concludes by suggesting how research on welfare state regimes and health could be developed in the future.

Abbreviations

OECD - Organisation of Economic Cooperation and Development

Competing interests: None declared.

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Three Worlds of Welfare State Research

2000, Comparative Political Studies

This article reviews three important clusters of recent research on the comparative politics of the welfare state. The three clusters focus on political economy, gender and social policy, and the investigation of long-term developmental processes. The article argues that in each area there has been significant progress and that there are increasing opportunities for intellectual exchange across these clusters. Research in this important empirical sub field of comparative politics has been pluralistic and eclectic, both methodologically and theoretically. Overall, this stance has yielded substantial benefits.

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What’s the future of the welfare state?

One issue is how governments can set up sustainable tax regimes across Europe.

‘The revenue of the state is the state,’ said Professor Åsa Gunnarsson from Umeå University in Sweden. She coordinates a project called FairTax, which is developing recommendations for a new EU fiscal policy where fair and sustainable reforms increase the economic stability of EU Member States.

Prof. Gunnarsson sees Europe’s fragmented fiscal landscape as the prime example of how connecting the EU’s market while keeping other responsibilities national lets down the very people that need protection.

Divergences in national tax laws and difficulties in enforcement across borders make it easier for citizens to stash their savings in bank accounts abroad. It also offers private companies leverage to negotiate their contributions to government coffers.

Although the European Union is the world’s largest economic bloc, its limited tax harmonisation allows international companies to cherry pick where they set up shop on the basis of which country offers them the best tax deal.

This lack of solidarity increases the burden on citizens and companies that abide by the original rules, eroding both financial contributions and faith in the welfare system as a whole.

‘FairTax is undertaking a comprehensive revision of EU fiscal policy to help put an end to this race to the bottom and establish a fair and sustainable tax system across the European Union,’ said Prof. Gunnarsson.

Voluntary codes

Although most taxation remains beyond the remit of EU institutions, Prof. Gunnarsson points out that voluntary codes, such as in business tax, have succeeded in initiating fiscal changes across Member States. Among its activities, FairTax is researching the legitimacy of such tools to build a common consolidated corporate tax base that would hold all companies in the EU to account by bringing together experts from different fields.

“ ‘Austerity, migration and mobility are just some of the realities that welfare states will have to face in 21st century.’ Professor Ellen Immergut, Humboldt University, Germany

These advances are driven in part by necessity, in part by means. Never before have Europe’s welfare states faced such demographic or financial strains.

According to Professor Ellen Immergut, from the Humboldt University in Berlin, Germany, the solidarity on which European economies were rebuilt after the Second World War is coming under unprecedented pressure.

‘EU workers are growing older and the world around them is changing,’ she said. ‘Austerity, migration and mobility are just some of the realities that welfare states will have to face in (the) 21st century.’

Prof. Immergut is the scientific coordinator of Welfare State Futures, a network of 15 research projects which are looking at the design, delivery and experience of welfare in the 21st century. It is jointly funded by the EU and a network called NORFACE, which consists of funding agencies from no fewer than 15 countries.

The projects explore stresses ranging from austerity and demographics to European integration. Some projects have adopted small discussion groups and directly engaged with citizens and social workers to understand how they cope with social changes.

Others are focusing on the hot topic of migration, engaging with immigrant communities to gauge their sentiment about crossing national borders, and hearing how they are integrated into pension schemes, healthcare services, and unemployment and training schemes.

To date, there is little empirical evidence that can help estimate how welfare state benefits encourage immigration from within and beyond Europe’s borders, and on what will be the long-term economic consequences.

Prof Immergut’s own project in the network, HEALTHDOX, is aiming to assess how healthcare reforms across the EU have affected inequality, how much they cost taxpayers and how well they were received by patients.

Researchers are foraging through government records, parliamentary debates and ministry archives from every country in the EU in order to map out which healthcare measures were undertaken and why, before comparing these records with budget expenditures and the results of public opinion surveys.

‘Rigorous data is needed to understand how privatising health services changes public support for the health system,’ said Prof. Immergut. ‘There could well be cases in which it is both cheaper, and enhances social belonging for a community to mutualise them. We currently do not have the tools to check.’

She says that international collaboration has boosted the firepower of her own project as well as Welfare State Futures by allowing the comparison of data across EU Member States.

Interest in the recommendations the researchers come up with may also cross borders. As the world economy staggers out of its first recession since 1929, people everywhere remain anxious about their future well-being. According to Prof. Immergut, governments from Beijing to Washington are all looking in the same direction for inspiration on how to care for their populations.

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Why the Welfare State Looks Like a Free Lunch

The econometric consensus on the effects of social spending confirms a puzzle we confront in the raw data: There is no clear net GDP cost of high tax-based social spending on GDP, despite a tradition of assuming that such costs are large. The paper offers five keys to this free lunch puzzle. First, the costly forms of transfers usually imagined have not been practiced by real-world welfare states. Second, better tests confirm that the usually imagined costs would be felt only if policy had strayed out of sample, away from any actual historical experience. Third, the tax strategies of high-budget welfare states are more pro-growth and less progressive than has been realized. Fourth, the work disincentives of social transfers are so designed as to shield GDP from much reduction if any. Finally, we return to some positive growth and well-being benefits of the high social transfers, and suggest how democratic cost control relates to budget size.

Acknowledgements and Disclosures

MARC RIS BibTeΧ

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15th Annual Feldstein Lecture, Mario Draghi, "The Next Flight of the Bumblebee: The Path to Common Fiscal Policy in the Eurozone cover slide

The U.S. Built a European-Style Welfare State. It’s Largely Over.

By Claire Cain Miller and Alicia Parlapiano Updated May 11, 2023

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In the early, panicked days of the pandemic, the United States government did something that was previously unimaginable. It transformed itself, within weeks, into something akin to a European-style welfare state.

Congress rapidly fortified the social safety net, making it much stronger than at any point. It made policies like Medicaid and food stamps more generous. It created new federal benefits like paid sick and caregiving leave, and free school lunches. And it made some pandemic benefits, like stimulus checks and child allowances, nearly universal. The government is estimated to have spent about $5 trillion helping individuals and businesses since March 2020.

Most Safety Net Programs Started During the Pandemic Have Ended

A much more generous safety net was rapidly constructed, starting in 2020, but most of the programs have ended or are set to expire soon..

Since then, most of it has been disbanded. When the public health emergency ends Thursday night, certain benefits, including free Covid tests and extensions for food stamp recipients, will begin to expire. Last month, Medicaid began unenrolling an estimated 15 million Americans who were guaranteed coverage during the pandemic, one of the longest-lasting benefits. A few policies — including rental assistance, child care grants and more generous health insurance credits — won’t expire until next year or the year after. But for the most part, the pandemic-era American welfare state is over.

This was by design: The policies were created as a response to the crisis and wound down as the acute phase of the pandemic ended and the economy reopened. Efforts to extend certain programs — or to formally create a more generous safety net, as President Biden laid out in his large social spending bill — have failed .

Children and Families

Many of these policies expanded existing programs, but it was the first time the federal government added a paid leave requirement for certain employers..

There has been little political will to make policies permanent because they did not emerge from a deeper shift in how Americans view the role of government or the rights of citizens, said Sheri Berman, a political science professor at Barnard College who has studied social democracies.

“The set of goals — protecting people from the downsides of unemployment, helping families with children and ensuring access to health care — are totally accepted in Western Europe,” she said. During the pandemic, she added, “we looked more like that, in our own patchwork way.”

“But people did not have an ideological conversion, a new view of what American citizenship could be,” she said. Rather, it was a recognition that during the crisis, “without these things, the entire system could go under.”

Yet the country’s brief flirtation with a much more generous safety net left its mark, researchers said.

In March, North Carolina opted to expand Medicaid , following other states that had reversed their opposition since 2020. Some Republicans have joined Democrats in proposing policies like a child tax credit or paid family leave. A few of the new benefits, originally temporary, have become lasting, including the option for states to extend Medicaid for 12 months postpartum; an increase in the maximum SNAP allotment; and summer grocery money for school-aged children who qualify for free or reduced lunch during the school year.

Food Assistance

One pandemic-era benefit that will continue: around the time that states were ending an increase in the maximum food stamp benefit, the biden administration prompted a lasting increase by revising the program’s nutrition standards..

None of these represent big, structural change, the way that other large-scale crises have reordered societies throughout history. But they suggest that pandemic policies may have made way for incremental changes in the role of government in supporting people during hard times, Professor Berman said, by showing what is possible.

“I’m not making the argument that we have a budding Western European welfare state, but I also don’t think we’ve gone entirely backward on some of these issues,” she said. “And I’d expect in the next election for a lot of these issues to be more prominent.”

The United States has historically been opposed to the large government programs and high tax rates seen in much of Europe. As a result, it is unusual among its peers in not providing universal health care, entitlements for children and generous cash assistance to the poor, said Robert A. Moffitt, an economics professor at Johns Hopkins. The benefits it does provide are narrower, vary by state and have more restrictions on who qualifies.

Political polarization and congressional gridlock have made a permanent expansion of social benefits more difficult. So has the current economic climate, with high inflation and interest rates. While Republicans argue that the increases in government spending during the pandemic fueled inflation, people in the Biden administration have countered that other factors have played a bigger role, like the oil shock from Russia’s invasion of Ukraine, and pandemic-related challenges like supply chain tangles and shifts in what Americans have wanted to buy.

“The politics of trying to make these programs permanent just isn’t there today, not to mention budget constraints,” said Samuel Hammond, an economist at the Lincoln Network, a right-leaning think tank. “The macro environment has turned in a way that has sort of reaffirmed the fiscal conservatives.”

Health Care

A policy that did not allow medicaid enrollees to lose coverage during the pandemic began phasing out this week , though states could take up to 14 months to redetermine who is eligible., the government started a new rent and utility assistance program during the pandemic, but the funds expire in september 2025..

At the same time, there’s a growing divide on the right between conservatives who want to limit government spending and encourage work and the social conservatives who are open to spending on families. This has hastened as the party has gained working-class supporters, and as some Republicans have emphasized family policies in the wake of the Supreme Court ruling that ended the national right to abortion.

Some of the largest new benefits directly addressed the circumstances of the pandemic: Stimulus checks cost $ 859 billion , and federal spending related to unemployment was $697 billion. Other, smaller programs — like food assistance and the child tax credit expansion — patched long-existing holes in the safety net. Now that the patches are being removed, the problems are more apparent.

During the pandemic, “the federal and state governments really responded to economic instability and poverty in ways they historically have not,” said Dr. Rita Hamad, a social epidemiologist at the University of California, San Francisco, who is building a database of policies enacted in response to the pandemic. “There were still lots of holes. But there was a lot of action to fill in gaps in the safety net that have been known for some time.”

Unemployment insurance is one area in which some experts would like to see changes become permanent. More than 15 million people who aren’t typically covered — like part-time workers, independent contractors and the self-employed — were covered for a year and a half.

Unemployment

All of the major unemployment program changes, which expanded eligibility and smoothed differences between state programs, ended by september 2021, though many states stopped providing expanded benefits before that..

Another is support for families with young children. The expanded child tax credit — given monthly for half a year so families didn’t have to wait until tax time — reduced child poverty by one-third.

A third is health insurance access. A policy decreasing health insurance prices for people who buy their own insurance and making it free for the lowest earners is one reason the uninsured rate has dropped to a record low of 8 percent , and Congress has already extended the subsidies through 2025.

“We allow working conditions, and have a set of public benefits around people, that allow an enormous amount of instability and insecurity,” said Sharon Parrott, president of the Center on Budget and Policy Priorities, a left-leaning think tank. “What we did show is we actually can help people stabilize their situations quite a bit if we’re willing to provide assistance.”

2024 Theses Doctoral

Microeconomic Heterogeneity and Macroeconomic Policy

Morrison, Wendy A.

This dissertation is part of a growing body of research studying the implications of micro heterogeneity - differences between different types of households and workers - for macro economic policy. By incorporating heterogeneity into monetary and fiscal policy frameworks, I am able to study both the distributional consequences of policy and uncover ways in which differences between households change policy transmission mechanisms. In the first chapter, I show that growing differences across the income distribution in workers' substitutability with capital alters the strength of a key monetary policy transmission mechanism. In the second chapter, I highlight and measure a new trade-off between redistribution policies and long-run investment stemming from differences in households' propensity to save out of permanent income. In the third chapter, joint with Jennifer La'O, we show that when the degree of labor income inequality changes over the business cycle, and fiscal policy is unable to respond to these changes, optimal monetary policy should take this inequality into account. Chapter 1 examines how heterogeneity in worker substitutability with capital affects the labor income channel of monetary policy. Empirically, I show that workers performing routine tasks see smaller labor income gains than other workers following a monetary expansion and have higher marginal propensities to consume (MPC). I show that this relationship dampens the role that the labor market plays in monetary policy transmission. I embed capital-task complementarity in a medium-scale HANK model calibrated to match the respective capital-labor elasticities and labor shares of routine and non-routine workers. This worker heterogeneity reduces the size of the labor income channel 25 percent. Chapter 2 studies the trade-offs associated with income redistribution in an overlapping generations model in which savings rates increase with permanent income. By transferring resources from high savers to low savers, redistribution lowers aggregate savings, and depresses investment. I derive sufficient conditions under which this savings behavior generates a welfare trade-off between permanent income redistribution and capital accumulation in the short and long run. I quantify the size of this trade-off in two ways. First, I derive a sufficient statistic formula for the impact of this channel on welfare, and estimate the formula using U.S. household panel data. When redistribution is done with a labor income tax, the welfare costs associated with my channel are around 1/3 the size of those associated with labor supply distortions. Second, I solve a quantitative overlapping generations model with un-insurable idiosyncratic earnings risk in which savings rates increase with permanent income calibrated to the U.S. in 2019. In this setting, I find that around 17 percent of the trade-off between labor income redistribution and average consumption can be attributed to my channel. In Chapter 3, joint with Jennifer La'O, we study optimalmonetary policy in a dynamic, general equilibrium economy with heterogeneous agents. All heterogeneity is ex-ante: workers differ in type-specific, state-contingent labor productivity, yet markets are complete. The fiscal authority has access to a uniform, state-contingent lump-sum tax (or transfer), but linear taxes are restricted to be non-state contingent. We derive sufficient conditions under which implementing flexible-price allocations is optimal. We show that such allocations are not optimal when the relative labor income distribution varies with the business cycle; in such cases, optimal monetary policy implements a state-contingent mark-up that co-moves positively with a sufficient statistic for labor income inequality.

Geographic Areas

United States
Employment (Economic theory)
Employees--Economic conditions
Saving and investment
Income distribution--Econometric models
Fiscal policy
Households--Economic aspects--Econometric models

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Oral Presentations Session 5: Interdisciplinary Studies, Chicano Education, Political Science, Education, Philosophy, Gender, Women’s and Sexuality Studies

Faith in Flux: The Interplay of Neoliberalism and Religion

Jenna L. Fliesen , Eastern Washington University Follow

Faculty Mentor

Majid Sharifi

Presentation Type

Oral Presentation

5-7-2024 9:30 AM

5-7-2024 9:50 AM

Primary Discipline of Presentation

Interdisciplinary Studies

This research analyzes the complex interplay between neoliberalism and religion, particularly Islam. There has been a significant shift towards minimizing the state's role in social welfare, which has propelled faith-based organizations (FBOs) to step in as primary service providers. This transformation has led to the commodification of welfare services, affecting how religions and FBOs operate within society.

A pivotal aspect of the research is the intricate relationship between neoliberalism and Islamic social values, especially with the rise of "'pious neoliberals" who aim to meld market-driven development with Islamic ethics repackaged as market commodities. This fusion has redefined religious authority and practices, emphasizing the importance of economic resources and entrepreneurialism within religious circles.

This paper illustrates the varied effects of neoliberalism on religion through the examples of Egypt and Turkey. In Egypt, the intersection of economic liberalism with Islamic social values has transformed religious education and the provision of social services. Conversely, in Turkey, the advent of "Islamic capitalism" and the commercialization of religious services highlight the profound impacts of neoliberal policies.

This research underscores the necessity of understanding the linkage between neoliberalism and religion to grasp the extensive societal shifts underway while emphasizing the adaptive strategies religious groups might employ in the face of neoliberal challenges.

Recommended Citation

Fliesen, Jenna L., "Faith in Flux: The Interplay of Neoliberalism and Religion" (2024). 2024 Symposium . 1. https://dc.ewu.edu/srcw_2024/op_2024/o5_2024/1

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Rishi Sunak stands at a podium at the Centre for Social Justice.

Sunak accused of making mental illness ‘another front in the culture wars’

Charities say high rates of people signed off work are caused by crumbling public services after years of underinvestment

Rishi Sunak has been accused of making mental ill health “another front in the culture wars”, as critics warned his plan to curb benefits for some with anxiety and depression was an assault on disabled people.

In a speech on welfare , the prime minister said he wanted to explore withdrawing a major cash benefit claimed by people living with mental health problems and replacing it with treatment.

However, charities said treatment was not available now for many, with 1.9 million on the NHS waiting list for mental health services and some experiencing worsening conditions while they remain without help.

Scope, the disability equality charity, said the proposals were “dangerous and risk leaving disabled people destitute”, as well as making people’s ill – health worse by increasing their anxiety. James Taylor, the charity’s director of strategy, said the speech “feels like a full-on assault on disabled people”.

Launching a review of the personal independence payment (Pip), a non-means-tested benefit helping disabled people with the extra costs of their health problems, Sunak said Britain was suffering from a “sicknote culture”.

He added the review would consider asking for more medical evidence before awarding the benefit, look at whether some payments should be one-off rather than ongoing, and examine whether to stop cash payments for some mental health conditions.

The prime minister said it would seek to be “more precise about the type and severity of mental health conditions that should be eligible for Pip”, and that it was “not clear they have the same degree of increased living costs as those with physical conditions”.

Sunak added: “When you look at the numbers, half of people becoming inactive over the last year citing depression and anxiety, tripling in the number of people that have been signed off as sick in the last decade, that doesn’t quite strike us as right.”

The announcement led to an outcry from disability charities, which said the rates of people being signed off work and claiming benefits were caused by crumbling public services, poor quality jobs and high rates of poverty among disabled households.

Charities also raised the alarm about Sunak’s rhetoric on mental ill health, after the prime minister said there was a “risk of over-medicalising what are essentially the everyday worries and challenges of life” in the welfare system.

Dr Sarah Hughes, the chief executive of the mental health charity Mind, said rhetoric that conjures up the image of a “mental health culture that has gone too far … is harmful, inaccurate and contrary to the reality for people up and down the country”.

“The truth is that mental health services are at breaking point following years of underinvestment, with many people getting increasingly unwell while they wait to receive support,” she said.

Labour said people were already crying out for NHS mental health support, and there was an “unprecedented crisis in mental health care”.

Wes Streeting, the shadow health secretary, said: “For the Conservatives to be attempting to make mental ill health another front for their culture wars is not just tone deaf, it’s shameless and irresponsible. Instead of attempting to cover up the scale of the problem, the next Labour government will give people the support they desperately need.”

Sunak set out his proposed changes to disability benefits at the Centre for Social Justice thinktank in London. He said “something has gone wrong” since the pandemic to increase the number of economically inactive people who are long-term sick, especially with mental health conditions.

“Most worrying, the biggest proportion of long-term sickness came from young people … parked on welfare,” Sunak said.

He said the country could not afford the “spiralling” disability welfare bill of £69bn, which was now more than the core schools budget, and claimed the Pip budget was forecast to increase by 50% in the next four years.

Other measures he set out included:

Shifting responsibility for issuing fit notes, formerly known as sicknotes, away from GPs to other “work and health professionals” in order to encourage more people to return to work.

Confirming plans to legislate “in the next parliament” to close benefit claims for anyone who has been claiming for 12 months but is not complying with conditions on accepting available work.

Asking more people on universal credit working part-time to look for more work by increasing the earnings threshold from £743 a month to £892 a month, so people paid below this amount have to seek extra hours.

Confirming plans to tighten the work capability assessment to require more people with “less severe conditions” to seek some form of employment.

Mel Stride, the work and pensions secretary, told Sky News on Friday: “If you go to the GP and say you are feeling a little bit depressed, and you’re signed off, in 94% of occasions, a box is ticked that says you’re not capable of work whatsoever.

“What we want to do is change the system so that that individual will be referred to – the government is setting up something called Work Well – where they will get both the healthcare support they need, but also a work coach who will be involved to either help them stay in work if they are in employment, or to help them get into work if they’re not.”

Trade unions for doctors and nurses expressed concerns about Sunak’s suggestion that there was a risk of “over-medicalising” mental health conditions, although he insisted that clinical decisions about diagnoses were always a matter for professionals.

The British Medical Association said the prime minister should focus on getting people access to the medical help they needed to get back to work rather than “pushing a hostile rhetoric on ‘sicknote culture’”.

Prof Pat Cullen, the general secretary of the Royal College of Nursing, said: “Nursing staff are the largest single workforce in health and care, but they themselves are suffering from increasingly poor long-term health.

“The prime minister’s overtures about ‘sicknote culture’ will be deeply offensive to a profession hit hard by long Covid and a spiralling mental health crisis. Issues of population health are not ones that a government can simply instruct away.”

The Institute for Fiscal Studies said the current and next government would have to find a way of either funding the rising bill for disability benefits or cutting them but that it was still unclear what was behind the increase in claims.

Sam Ray-Chaudhuri, an economist at the IFS, said: “A year or so ago, it seemed plausible that the rapid rise in numbers claiming health-related benefits was a transitory pandemic-related phenomenon. That explanation now appears unlikely, and today’s new forecasts reflect this fact.

“The rising cost of these benefits, and what might be done in response, will be a pressing concern for the next government and make the already tough fiscal situation harder still. Unfortunately, designing the right policy response is made much more difficult by the lack of clarity on what is fuelling the rise.”

Rishi Sunak
Mental health
Universal credit

More on this story

Sunak accused of launching ‘full-on assault on disabled people’

Half a million unpaid carers in UK not claiming £4,200 a year benefit

Thousands of disabled people ‘will get £2,800 a year less under universal credit’

Iain Duncan Smith urges ministers to pause carers’ fines

UK state pensions and benefits: what do the changes in April mean for you?

Labour urged to end two-child benefits cap as research reveals policy pushing families into poverty

UK families to benefit by up to £3,000 from changes to child benefit tax

Young carers in England and Wales ‘forced out of education’ by benefit rules

Child benefit: budget changes mean more cash for families

Upcoming Forum Brings Applied Science to Issues of Canine Welfare and Dog Breeding

Make a gift support the college.

The Canine Welfare Science Forum will be held June 14 and 15, 2024 at the Courtyard Marriott in Lafayette, Indiana.

The 2024 Canine Welfare Science Forum organized by the Purdue University Center for Animal Welfare Science ( CAWS ) will explore the changing landscape for dog supply and demand during a two-day program in June. Sessions will address the urgent need for innovation, collaborative problem-solving, and use of best-practices to get dogs into homes and keep them there. With both in-person and virtual attendance options, the forum will be held June 14-15 at the Courtyard by Marriott in Lafayette, Indiana.

“Participants will learn about factors that are creating new challenges and opportunities for commercial breeders and other stakeholders aiming to do their part to support canine welfare through responsible practices,” said Dr. Candace Croney, director of CAWS and a featured speaker at the upcoming forum. “Presentations will review evidence-based practices for physical health, genetic screening, and behavioral management of dogs and how breeders can apply this knowledge, with special emphasis on the implications for successful rehoming,” said Dr. Croney, who holds a joint appointment in the Colleges of Veterinary Medicine and Agriculture as professor of animal behavior and well-being. “The need for community-building and future-proofing for sustainability and responsibility in sourcing and supply of dogs also will be discussed.”

Other special speakers will include:

Bret Marsh, DVM, Indiana State Veterinarian with the Indiana Board of Animal Health
Emily Pieracci, DVM, MPH, DACVPM, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC)
Martha Boden, SPCA Tampa Bay
Chris Fleming, Pinnacle Pet and A Dog’s Dream
Katie Hornberger DVM, DACT, Janssen Veterinary Clinic – Repro Center
Jenna Dockweiler, MS, DVM, DACT, CCRT, CVAT, Embark

The Canine Welfare Science Forum will begin in the mid-afternoon on Friday, June 14 and conclude in the afternoon on Saturday. Friday evening will feature a reception and awards program. The event is designed for dog breeders, pet industry representatives, shelter personnel, animal care specialists, veterinarians, veterinary nurses, scientists, students, legislators, NGOs, and members of the general public.

Major funding for the Canine Welfare Science Forum is generously provided through a grant from Life of Riley at Spring Point – a signature program of Spring Point Partners, which advances animal welfare by investing in diverse leadership and community-driven solutions.

Click here for more information and to register . There is a registration fee, with a discount for students. Early registration ends May 30, 2024. Prices will increase by $10 as of June 1, 2024. For those wishing to participate virtually, a ZOOM link will be provided after they complete the registration.

Writer(s): Kevin Doerr | [email protected]

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IMAGES

Understanding the Welfare State and Its History
Welfare State
(PDF) The Economic Psychology of the Welfare State
(PDF) The Welfare State
1 A proposed new conceptual model for the welfare state
(PDF) Economy and the Welfare State

VIDEO

The Welfare State Is a FAILURE
Welfare and wellbeing in an age of responsibility Part 4
The Welfare State
History about welfare state #truth #short
What is the meaning of welfare state
The Entrepreneurial State as a Welfare State

COMMENTS

Development, Welfare Policy, and the Welfare State
The first generation of welfare state research was very much occupied with the question of why welfare states emerge, rather than why welfare states differ and how they differ. Instead of making explicit claims about what explains welfare state variations, the exercise was one of "devising laws" that could account for welfare state ...
Welfare State Policies and Their Effects (Chapter 31)
Welfare state scholarship in the early twentieth century focused primarily on sources of welfare state development and expansion. By the turn of the century, the literature shifted toward examining the effects of welfare states, and the policies that compose them, on societal outcomes. Initially, this research examined the effects of welfare ...
The Welfare State and Human Well-Being Around the World: A Cross
Does the welfare state affect human well-being outside the developed OECD world? For decades scholars have assessed the impact of the welfare state on a variety of outcomes, largely economic and social (for reviews see Kenworthy, Social Forces. 77:1119-1039, 1999; Kenworthy & Pontusson, Perspectives in Politics. 3:449-471, 2005; O'Connor, Review of Behavioral Economics. 4:397-420, 2017 ...
Gaps in the welfare state: A role-based model of poverty risk in ...
Further, we quantify specific gaps in the welfare state in the U.S., focusing on five key areas that prior research in the field of economics has indicated may be important to consider: child benefits, older age pensions, the short and long-term disability and sickness insurance system (including paid leave from work), the unemployment ...
(PDF) ROLE OF THE WELFARE STATES IN TACKLING SOCIAL ...
This research paper examines the nature of the welfare state as an instrument of redistributive justice. Critiques of the welfare state are explored, followed by an analysis of justifications for ...
America's Wars on Poverty and the Building of the Welfare State
One of the key findings by political scientist Jacob Hacker in his 2002 The Divided Welfare State was that in the United States a large portion of social spending and the make-up of the American welfare state is nonpublic. 69 Looking at the history of the American welfare state, there was no Beveridge report or equivalent starting point for a ...
Needs and Risks in the Welfare State
It illustrates how welfare state theories have treated needs and risks, and makes some suggestions as to how they can do so more systematically. The article then turns to the empirical literature to portray the major challenges facing welfare states today. The policy challenge confronting post-industrial societies arises from the coexistence of ...
Understanding the role of welfare state characteristics for health and
The past decade has witnessed a growing body of research on welfare state characteristics and health inequalities but the picture is, despite this, inconsistent. We aim to review this research by focusing on theoretical and methodological differences between studies that at least in part may lead to these mixed findings. Three reviews and relevant bibliographies were manually explored in order ...
Full article: The State of the Welfare State: Advice, Governance and
This research was (part) funded by [grant number ES/M003825/1] from the Economic and Social Research Council of the United Kingdom for the project 'An ethnography of advice: Between market, society and the declining welfare state', which we gratefully acknowledge; FP7 Ideas: European Research Council [IDEAS-ERC FP7, Project Number: 323743].
Welfare States: How They Change and Why
Abstract. In this chapter, Fiona Dukelow and Mary Murphy sketch the landscape of research on welfare state change and set out some of the ways the impact of the economic crisis and the prospect structural change need to be informed by the lessons of previous research on how welfare states change and why. The chapter then proceeds to discuss a ...
Welfare systems without economic growth: A review of the challenges and
Dilemma 5: political barriers to welfare state transformation. The final dilemma that emerged from the literature is the question of how it might be possible to achieve a transformation of the welfare state, in line with the goals and guiding principles of a post-growth economy, given the strong growth-orientation of most governments, today.
PDF History of The Welfare State
Recent historical welfare state research has pointed out the inner diversity and fragmentation of modern welfare systems. Non-governmental institutions such as non-profit associations, private enterprises or public corporations exercise central functions in most European social security systems, especially in health insurance and old-age insurance.
Going beyond The three worlds of welfare capitalism: regime theory and
International research on the social determinants of health has increasingly started to integrate a welfare state regimes perspective. Although this is to be welcomed, to date there has been an over‐reliance on Esping‐Andersen's The three worlds of welfare capitalism typology (1990). This is despite the fact that it has been subjected to extensive criticism and that there are in fact a ...
An illiberal welfare state emerging? Welfare efforts and trajectories
Following Marshall (1950), social rights are the last part of the holy trinity of civil, political and social rights that collectively constitute citizenship - the very foundation of liberal democracy.Many scholars conceptually link the welfare state to democracy and most research focuses on rich democracies. However, the relationship between democracy and the welfare state is ambivalent.
[PDF] Three Worlds of Welfare State Research
Three Worlds of Welfare State Research. This article reviews three important clusters of recent research on the comparative politics of the welfare state. The three clusters focus on political economy, gender and social policy, and the investigation of long-term developmental processes. The article argues that in each area there has been ...
Three Worlds of Welfare State Research
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Article contents

“Fighting Man’s Ancient Enemies”: The War on Poverty and Lyndon Johnson’s Great Society

Maximum Feasible Misunderstanding: The Community Action Program and the Divisions of the 1960s

From Community Action to Compassionate Conservatism

Community Action and Modern American Social Policy

Conclusion: America’s Wars on Poverty and Welfare State

Table 1 Net total social expenditure (public and private), % of GDP, OECD countries 2011. 67

Table 2 Public social expenditure, % of GDP, United States, Japan, EU-21, and OECD, 1960–2014. 68

Discussion of the Literature

Primary Sources

Further Reading

11 Needs and Risks in the Welfare State

Introduction

Conceptualizing Needs and Risks

Needs, Risks, and Theories of the Welfare State

Socio‐Economic Challenges, Needs, Risks, and Welfare States

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Understanding the role of welfare state characteristics for health and inequalities – an analytical review

Conclusions

Search strategy

Inclusion criteria

The Regime approach

Different typologies

Esping-Andersen

Theoretical description- Esping-Andersen

Modified version

Theoretical description- Ferrera

Modified versions

Huber and colleagues

Theoretical description- Huber and Stephens (and data by Huber, Ragin and Stephens [ 21 ])

Other typology- Korpi and Palme

Theoretical description- Korpi and Palme

Geographical comparisons

The Regime approach and health

Institutional approach

Family benefits

Pension benefits

Economic assistance and unemployment benefits

Access to health care

The institutional approach and health

Expenditure approach

Health spending

Social spending

The expenditure approach and health

Limitations

Pre-publication history

Acknowledgements

Author information

Corresponding author

Additional information

Authors’ contributions

Electronic supplementary material

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Authors’ original file for figure 1

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BMC Public Health

Welfare States: How They Change and Why

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Going beyond The three worlds of welfare capitalism : regime theory and public health research

The three worlds of welfare

Going beyond The three worlds of welfare capitalism

Theoretical critiques

The gender‐blind “worlds of welfare”

The “illusion” of welfare state regimes

Methodological issues

Empirical validity