The political candidates, policymakers, and social advocates who call for the radical restructuring of U.S. health care into a single-payer system, or a tightly focused chase after the social determinants of health, are championing concepts likely to fail in the U.S., because they’ve failed everywhere else in Europe, according to a new book by University of Pennsylvania political scientist and LDI Senior Fellow Julia Lynch, PhD.

The new work from Cambridge University Press, Regimes of Inequality: The Political Economy of Health and Wealth, is a comparative study of three of Europe’s industrialized democracies — Finland, England, and France — that have, for half a century, tried and failed to solve essentially the same problem. That problem, according to Lynch, is the artificial framing of “health inequities” as a separate, isolated issue in place of a national acknowledgement of the much larger root problem of broad socioeconomic inequities.

Permanent inequality

In her book, Lynch writes, “I have set out to explain why rising inequality has become a more or less permanent feature of life in most of the rich, industrialized democracies of Europe in the last thirty years. This has occurred despite public opinion in European societies that is staunchly opposed to inequality and supportive of state efforts to create more equitable societies, and despite a growing consensus among experts that current levels of inequality are undesirable and even dangerous. My approach has been to study the politics and policy-making surrounding health inequalities, which most public health experts believe are closely linked to socioeconomic inequalities, but which policy-makers have tended to try to solve using different kinds of tools from those designed to impact directly the distribution of income and wealth.”

Lynch, who has been a faculty member at Penn’s School of Arts & Sciences since 2001, first began researching the politics of inequality in 2003 as a Robert Wood Johnson Health Policy Scholar at Harvard University. Her first book, Age in the Welfare State: The Origins of Social Spending on Pensioners, Workers and Children, was published in 2006.

A decade-long project

A decade ago, the Penn Associate Professor began studying the politics of inequality in health. “When I came back from Harvard in 2005, I engaged with the Health and Society Scholars Program inside Penn’s Leonard Davis Institute and was exposed to a community of people who were centrally focused on health and the policies that drive inequities,” said Lynch. “That’s when I started developing the ideas that became this book.”

Able to work in six languages (English, Italian, French, Spanish, Dutch, and Portuguese), Lynch is a member of the Scientific Advisory Board to the Health Equity Status Report Initiative (HESRI) in the World Health Organization’s Regional Office for Europe. “The Health Equity Status Report provides policymakers with a suite of tools that says if you want to have an impact on health equity in your country, here are some of the policy levers that you can try to activate,” she explained.

Lynch’s new book is also a look at the rise of the neoliberal government and economic structures and politics that have come to dominate industrialized democracies including the U.S. in the last few decades.

Neoliberal philosophy

Lynch describes neoliberalism as “a set of economic ideas and policies that aim to promote economic growth within a country by making sure of two things: First, that government policies allow firms to be competitive in international markets; and second, that international financial actors see the government as trustworthy and credit-worthy.”

“About 30 years ago,” Lynch said in an interview with LDI, “politicians across much of the industrialized world made a choice to back off the old redistributive and regulatory mechanisms they had been using in the post-World War II period to create more equitable societies. Then, they decided to talk about equity in a tamer, more technocratic way embodied in such things as the drive for ‘health equity.’ So by moving away from the idea of inequity being a maldistribution of economic resources, to thinking about inequality as a collection of problems like the distribution of social determinants of health, they also introduced a level of policy complexity and reframed the definition of inequality itself.”

“What I show in the book,” she continued, “is that none of these three European countries, despite their really serious commitment to doing ‘health care for all’ policies and to improving health inequalities through work on the social determinants of health, were able to pull it off. So I think it’s not so much the political system as the decisions by political actors to deemphasize the old sort of regulatory and redistributive tools. The new policy tools are much harder to use and draw attention away from how the broad socioeconomic inequities of the countries continue to increase along with the health inequities driven by those larger economic inequities.”

U.S. neoliberalism

“Throughout these European countries,” Lynch said, “there’s a very strong commitment to the idea that there are certain basic fundamental rights of humans that live in those societies that is a precondition for a well-functioning society that can be competitive on international markets. So there are different flavors of neoliberalism and I think the flavor we have in the United States tends to be more radical — people, economic policymakers, and market actors in the U.S. tend to see anything that places higher regulatory or tax burdens on corporations or wealthy individuals as being detrimental to competitiveness. And so, in that sense, the Affordable Care Act as originally conceived — a broad set of ideals expanding coverage and spending the money that we need to spend to make sure that we live in a society where people have access to healthcare — would run counter to that U.S. version of neoliberalism.”

However, she says “the ACA as enacted was done in a way to make it as friendly as possible to markets. There are many alternative versions of universal health coverage that could have been far more threatening to the kinds of interest and ideas that we normally think of as part of the neoliberal package than the ACA was. I think you’re starting to see some of those proposals come front and center in the current presidential campaign. I’m not entirely sure what ‘Medicare For All’ means in policy terms from all of these candidates and I’m not sure they know either. Today’s ACA is not what I would call anti-neoliberal health care reform. But certainly, if you make a single payer or the abolition of private insurance markets a feature of some of those candidates’ proposals, that would be anti-neoliberal health care reform.”

Potential for change

Despite her years of work studying why health reforms have not worked and how large populations within many countries still lack adequate health care, Lynch remains upbeat about the potential to ultimately change things.

“In a weird way,” she said, “I am more optimistic about the state of American politics than I’ve been in my entire adult life because I feel like people are activated, people know that inequality is out of control, they’ve made it a priority in their lives and in their voting behavior, and they’re starting to hold people to account for it. I think the rise of Bernie Sanders is really a very strong expression of how activated the progressive part of the American political spectrum has become, although whether he’s the right candidate to bring those views into national office, is another issue. But I am seeing a level of engagement with politics on the part of stay-at-home moms and people who just hadn’t been engaged before, that is really new to me as a political scientist.”

Lynch ends her book this way: “If politicians, including but not limited to those on the center-left, want to be ‘for’ equity, they must insist on using the policy levers that they already know can work to reduce inequality: redistributive taxation, public spending, and market regulation. It will require some boldness to break with so many years of taboo, but politicians should take heart in the knowledge that the public, the pontiff, and the IMF all agree that inequality needs to be brought to heel. And if Brexit, the resurgence of reactionary right-wing nationalist parties, and the election of Donald Trump have taught us anything, it is that taboos can be broken.”

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BOOK TOUR: Lynch’s book tour kicks off Feb. 6 at Boston University and then goes on to Yale, Stanford, The London School of Economics and Political Science (LSE), Oxford, the Max Planck Society in Germany, and the European University Institute in Florence, Italy.