单项选择题

For health insurance, the United States has taken the road less traveled. The United States is the only rich country without universal health insurance. People in the United States spend the most, rely heavily on the private sector, and obtain care from the world’s most complicated delivery system. While some supporters have expressed satisfaction, if not pride, in these remarkable qualities, others contend that the United States faces unique limitations in reforming health care.
In her exceptional book, Parting at the Crossroads, Antonia Maioni compares the formation of the U.S. and Canadian health-care systems for the years 1930—1960. The United States and Canada are often considered the most similar of Western democracies. They share a common border, are wealthy, and have federal government. Their trade unions are only moderately powerful, and their populations are diverse and young. Nevertheless, their health-insurance systems are nearly opposite. The United States relies on a mix of government plans, targeted to the elderly and indigent, and employment-based plans, which the government indirectly supports. Canada offers public health insurance to all qualified residents, with the private sector providing supplementary services in some provinces.
Labor organizations became strong advocates for health-insurance reform in both countries. Their impact partially depended on political institutions and how other actors, particularly organized medicine, wielded them. Canada’s governmental and electoral systems allowed labor to cooperate with a social democratic party in the Saskatchewan province, which established a universal program. The Saskatchewan program demonstrated universal insurance feasibility, spurring the dominant Liberals to introduce a national universal program. In contrast, the U.S. electoral system effectively precluded third-party formation, forcing organized labor to dilute its health-insurance goals because it was one of many interests represented by the Democratic Party.
Maioni suggests that economic vitality is important for the future of both countries’ systems, but the prognosis is uncertain. Despite recent concerns about the Canadian government’s budgetary health, Maioni contends that widespread support protects universal insurance. Conversely, Maioni seems pessimistic about options for U.S. universal health insurance. Despite economic buoyancy, dissension will likely prevent reforms. Although a devastating economic downturn would make health finance difficult in either country, the U.S. system seems especially vulnerable. Employment-based insurance and medicare both rely on labor market attachment. High, chronic unemployment could result in coverage loss and financial difficulties for employer insurance and medicare, swelling the uninsured pool. Such a crisis could provide an opening for universal health insurance. In any case, whether the United States relies on the public or private sector, escalating health expenditures figure into budgets of government, corporations, and families. The U.S. health care system’s future may depend on Americans’ willingness to devote more of their national income to health care.
The vulnerability of the U.S. insurance systems lies in