Governmental efforts to control alcoholic beverages go back as far as recorded history. The Code of Hammurabi included regulations of prices, taverns, and sellers. That the laws often failed to produce the desired effects—temperance and good public order and perhaps revenue exceeding the social costs of excess—is inferred from the frequent legislative attempts at total prohibition in numerous lands throughout history, all apparently without lasting success. The most resounding failure was that in the United States from 1919 to 1933. Current prohibitions in parts of India appear to be equally ineffective.
Less totalitarian efforts to control the use of alcohol include licensing systems that limitthe number and locations of places of sale; restriction of days and hours of sale; prohibitions of sale to the young, with ages varying in different parts of the United Statesand across the world; and regulation of the strength of beverages, the size of containers, advertising, prices, or profits. Some governments—for instance, those of Finland and several states of the U.S.—have sought to eliminate the private-profit motive from the sale of alcoholic beverages by reserving a monopoly in the trade to themselves. Communist countries have government monopolies. But indications that this has made any difference in the kinds, degree, or severity of problems are lacking; apparently problem drinkers do not need to be persuaded by profit seekers. Some governments—for instance, those of Sweden, Finland, and the U.S. state of Ohio—have attempted to control individual drinking by a system of personal ration books for purchases. In Sweden this system was abandoned after 38 years of trial; evidently, those who needed to drink a lot could find supplies—even when their ration books were withdrawn. The most universal regulation of alcoholic beverages takes the form of taxation (or, in government monopolies, an added profit), which is often quite heavy. Usually, however, though the taxing policy may have the ostensible purpose of reducing consumption or controlling licensees, the real object is revenue. In any event, none of the common forms of government control have proved themselves able to promote temperance in those whose need to drink heavily is uncontrollable. The persistence of massive restrictions and regulations, with costly enforcing bureaucracies, reflects the tendency of legislatures to give some satisfaction to the substantial minority of convinced opponents of alcohol and the tendency of segments of the drinking population—and even of some people in the liquor trade—to accept the naïve notions of the anti-alcoholists that these regulations do some good.
Though not significantly influenced by governmental efforts, the rate and severity of alcohol problems have indeed been influenced by nongovernmental movements and agencies. The most obvious example is the success of religious movements, such as Buddhism, Isl(m, and numerous Christian denominations and sects, in confirming their followers as total abstainers. The Methodist and Baptist denominations, the Quakers, the Mormons, the Christian Scientists, the Seventh-day Adventists, and the Jehovah’s Witnesses are examples of Christian churches that have made abstinence a condition of loyal membership, though the Methodist Church has modified its stand in recent times. Other Christian denominations, such as the Congregationalists, have advocated abstinence without making it a requirement. Though not formally allied with these churches, the Woman’s Christian Temperance Union (WCTU) and other temperance societies, particularly in the United States, once drew much support from them. In several European countries the abstinence movement also drew some support from the Socialist-influenced labour movement and found some organizationalexpression in the form of fraternal orders, particularly the Order of Good Templars. The importance of the religious orientation is indicated by the relatively larger proportion of abstainers in the United States than in countries where the ideal was more largely politically motivated. The decline in the numbers of abstainers in recent times may reflect the changing character of religious adherence.
The new scientific orientation
In the past generation the character and influence of citizen movements have changed markedly. Whereas in former times the personnel, teaching aids, and ideologies of the temperance movement had generally dominated the research and education regardingalcohol, the tendency now is toward deriving objective information from academic and scientific sources. Among the major efforts to bring a scientific orientation to bear on the consideration of alcohol problems has been the founding of a systematic documentation and publication of the biological and social-science knowledge of the entire world; this is now a function of the Center of Alcohol Studies at Rutgers Universityin New Brunswick, New Jersey. The new trend had its repercussions also on international cooperation. The International Bureau Against Alcoholism, founded in 1907, became, in 1964, the International Council on Alcohol and Alcoholism—more recently renamed the International Council on Alcohol and Addictions. The change of name represented a change in aims and policies, from total opposition to any drinking to advocacy of an objective consideration of alcohol problems. This change was manifested also in the
character of the international congresses convened by anti-alcohol organizations since 1885 and by the International Bureau since 1925. Formerly devoted essentially to descriptions of the horrible effects and denunciations ofthe evils of alcohol, beginning with the 26th Congress in 1960 the program has been infiltrated by presentations from the scientific-academic world, and the 28th Congress in Washington, D.C., in 1968 was marked by the total absence of representation from the remnants of the old temperance movement; the papers and lectures offered by representatives of religious organizations and societies were on an equal level of scholarship and objectivity with those from the scientific and academic community.
These developments, in turn, have had repercussions in government activities. In the United States and Canada they have led to the establishment of some 55 state and provincial agencies, some independent, most attached to departments of health or mental health, with missions chiefly to provide treatment for alcoholics but often also to participate in education and occasionally to engage in research. A few county and city agencies have also been created. On the federal level in the United States, a National Institute on Alcohol Abuse and Alcoholism has been established, and the Department of Transportation is engaged in a program aimed to reduce the alcohol-and-traffic problem. Other governments have shown recognition of the potential of newer, science-oriented approaches and have supported research and education as well as therapeutic activities, sometimes through special institutions such as the Canadian Addiction Research Foundation, supported by the province of Ontario; the Finnish Foundation for Alcohol Studies; the Norwegian National Institute for Alcohol Research; and the Northern Committee for Alcohol Research, with membership from all the Scandinavian countries. The new ferment discernible in the late 20th century in the fieldof alcohol problems is thus far stimulated mainly by concern over the human and economic costs of existing problems and the aim to alleviate them. The idea that only the prevention of alcohol problems or that only the reduction of the numbers of personswho become newly involved in alcohol problems can effect permanent gains is universally given lip service but rarely is the object of direct effort. This is owing to two facts: those who have been chiefly involved in bringing about the new ferment have been inspired mainly by the humanitarian and economic motive to bring relief to those who are already suffering from the consequences of alcohol problems, and practical new methods of prevention, going beyond scattershot education, have yet to be invented.
The rising cost of social security
The cost of social security rose substantially in the period after World War II both in real terms and as a proportion of rising gross domestic product. While social security spending amounted to less than 10 percent of the gross national product in nearly all countries in 1950, it had risen to 20 to 30 percent or more in many European countries by 1980. Among the reasons were the extension of the coverage of social security, the widening of the risks covered, the indexing of benefits, and the greater generosity of benefits, which moved up to or near 100 percent replacement of earnings for certain contingencies in some countries. But also of major importance was the maturing of pension schemes. Many of them were recast in the 1940s and ’50s, and therefore it was not until the 1980s that people had had the opportunity to contribute on the new basis for all or most of their working lives and thus could draw pensions approaching or reaching the maximum for which these schemes provided. Three further factors were the increasing proportion of aged persons in the population, the decline in pension ages, and the lower proportion of working population.
The costs of health care also rose sharply after World War II. Several reasons contributed to this trend. First, the higher proportion of elderly in the population influenced health care costs as well as the costs of cash benefits. Persons over pension age require two to three times more health care than persons of working age, and the difference is still greater for those over 75, the fastest growing age group. A second factor was the decline in working hours, which meant that more persons (e.g., nurses) were needed in order to staff 24-hour services. A third factor was the continuous development of medical technology, such as new equipment and labour-intensive procedures. Instead of replacing labour, as in industry, innovations in health care normally required more labour for their operation. A further reason was the removal of supply restraints with the provision of more doctors and dentists, a major growth of medical auxiliaries, and the construction of new hospitals, which were more expensive to run. A fifth reason was the financial incentives to supply more services, which underlay many of the systems of paying providers under health insurance.
The final and critical factor that destabilized the finances of social security schemes was the rapid growth of unemployment beginning in the 1970s. In those countries that included unemployment benefits in their social insurance schemes, this phenomenon created both unpredicted higher costs for benefit payments and a loss of revenue from those who were unemployed. The
on social assistance programs were also substantial in some countries, coming at a time when unemployed persons were no longer in a position to contribute to tax revenue.
The rapid growth of social security expenditure attracted little attention during the periodof rapid economic growth up to 1973. It began to cause concern after the steep rise in oil prices checked economic growth in oil-importing countries. The revenue that financed social security ceased to be buoyant at the same time as new major demands were made on the system. From the late 1970s there was talk of a crisis in social security financing.
By 1980 social security expenditure amounted to 32 percent of the gross national product in Sweden, between 25 and 30 percent in Belgium, Denmark, France, and The Netherlands, and between 20 and 25 percent in Austria, West Germany, Ireland, Luxembourg, and Norway. These figures were much higher than for Australia (12 percent), Canada (15 percent), Japan (11 percent), New Zealand (14 percent), the United States (13 percent), or the United Kingdom (18 percent). The cost was much lower in developing countries. High costs are associated with high levels of social security benefits and also with costly systems of providing health care. Some countries,such as Sweden, have allowed health care costs to continue to rise because of the capacity of this service sector of the economy to provide further jobs and thus avoid high rates of unemployment.
The aim in many industrialized market countries came to be the containment of the costs of social security. This requires that program costs not grow faster than the yield of contributions. Various devices were introduced to help secure this result. Systems ofindexing benefits and pensions to prices or earnings were revised downward, or adjustments were made less frequently. Pensioners were made to pay contributions toward health-care benefits. In France tax income was brought in to supplement the yield of contributions. In the United Kingdom the earnings-related additions to short-term benefits were abolished.
A series of measures was introduced to limit the cost of health care. Charges and copayments were increased or new charges were introduced. Payment for drugs was introduced in West Germany (1977), Italy (1975), and Portugal (1982). Portugal and Luxembourg joined France and Belgium in charging for consultations with doctors. Charges for hospital care were introduced or extended in Belgium, West Germany, Portugal, and France. By 1984 there was no country in western Europe that provided free care to all its insured population.
Payment systems under health insurance were revised to reduce incentives for overservicing. The aim in West Germany was to pay the doctor more for the consultation and less for medical procedures. Payments for diagnostic tests were sharply reduced in Belgium. As part of the introduction of a national health service in Italy, payment to all general practitioners was changed from fee-for-service to capitation, and the bulk of specialists began to receive full-time or part-time salaries. Budgets for each hospital were introduced in Belgium, France, and The Netherlands, inpart to discourage unnecessary retention of patients paying per day of care. Countries in which hospitals were already paid on a budget basis reduced the budgets. In the United States hospitals began to be paid under Medicare and Medicaid according to a schedule of costs for various groups of diagnoses.
Countries maintained strong controls over new hospital construction or expansions, and incentives were created in a number of countries to transfer beds from general useto the care of the long-term sick. Several countries took measures to develop alternatives to hospital care, such as outpatient surgery, outpatient hospitals, nursing homes, residential homes, and home care by domiciliary teams. The United Kingdom closed some 400 hospitals over a period of 10 years. Restrictions on the installation of major new medical equipment went into effect in Belgium and France. By 1955, 10 of the 12 countries of the European Economic Community had instituted quotas for medical schools. In Denmark, France, Ireland, Portugal, and Spain the number of medical students was cut substantially.
Most countries in western Europe introduced restrictions as to what medications a doctor could prescribe under the health service or health insurance system. Most of these countries exercised tight control over pharmaceutical prices and pharmacists’ margins. New measures were introduced in the effort to control overprescribing.
Social security spending tends to vary between countries in direct proportion to their respective standards of living; in other words, the more affluent a country is, the more it is likely to spend on social security. Spending also tends to vary according to the proportion of elderly people in the population. Third, it varies according to the year in which the first legislation was adopted: countries with older social security programs tend to spend more. There are, of course, exceptions to this pattern. For example, the United States and Japan are low spenders both for their standard of living and for their proportion of elderly, and New Zealand is a low spender for a country that introduced pensions as early as the end of the 19th century.