Why American Health Care Reform is So Tricky

Cohu, who took a break from eating chocolate isopods (Cymothoa exigua can keep you slim during the holidays by eating your tongue!), practically challenges me to do some good old-fashioned two-fisted Texas policy analysis:

I was hoping you'd have an explanation for the incoherent views of many Americans re: healthcare. Instead you seem to be just as puzzled as I am! I've had the suspicion that Americans tend to think everyone is, prima facie, in charge of their own health, whereas Europeans are more fatalistic and tend to accept everyone will be dependent on others at some point, and conclude there needs to be a system to help them out when they get sick themselves. Or are there any other explanations for the US healthcare dilemma? I realize Americans are much more anti-statist than Europeans, but in this area, their libertarianism simply seems crazy and not at all evidence-based.

Here goes:

1. America has never had a Socialist party (g) or, for that matter, an explicitly working-class party. These parties have generally been the driving force behind erecting European social welfare states, either by creating them (the UK), or by scaring the powers-that-be into creating them (Germany). Working-class Americans are renowned for their lack of class consciousness, and, with the steady shrinkage of American unions, have only gotten harder to organize on this basis in recent years.
2. The present American health-insurance system, in which you're expected to get coverage through your job, evolved during World War II as a way to evade wartime salary restrictions. After the war, American unions and employers generally worked together to expand the system to cover most people who had a job. So there's a path-dependence angle to the current situation -- it evolved from a somewhat random set of circumstances that then became reified and grew roots in the public consciousness. Plus, it worked just well enough for a couple of decades. That stifled development of alternative models, and prevented the creation of a critical mass of hugely dissatisfied reform-seekers.
3. The employer-provided model -- coupled with Medicaid for the poor and Medicare for the elderly -- ensure that the people without health insurance were generally members of the working-class and marginally-employed populations. These people have little organized institutional influence and aren't very politically active. They are crushed by much more powerful lobbies.
4. Speaking of which, the current American health-care system throws off enormous profits for various branches of the health-care industry, such as pharmaceutical companies, specialty clinics, medical device manufacturers, certain health insurance providers, etc. These are concentrated, extremely sophisticated, well-funded interest groups. Pharmaceutical pricing is probably an instance of regulatory capture. And as we know (.pdf), concentrated, easily-mobilized interest groups have a huge advantage over diffuse interest groups -- here, the motley collection of unemployed people, working stiffs, freelancers, and others who aren't well-served by the present system. Of course, strong unions or a social-democratic party could bind these interests together and counterbalance industry, but see #1.
5. Further, these lobbies know that Americans tend to be suspicious of proposals to increase the size of government, but as soon as the government does create a broad new social welfare benefit that includes the middle class, that program becomes hugely popular and politically untouchable -- even in America. Thus, 80% of Americans believe the government has an obligation to ensure that the elderly can live in dignity, a concept embodied in Social Security, the national pension scheme.  Therefore the anti-reform lobby has every reason to throw all of their resources into the fight right now, because any truly ambitious reform scheme may well begin to induce Americans to think of health care as an important government obligation as well.
6. The nature of the political opposition to health care reform has changed. The U.S. Republican party used to have a moderate, Christian Democrat/Tory wing: they were generally hawkish and fiscally conservative, but still felt an obligation to provide for the social good. Richard Nixon, for instance, expanded many government welfare programs, created the Environmental Protection Agency, and also almost created universal health care in a compromise measure with Senate Democrats in the early 1970s. Since then, the 'moderate', noblesse-oblige tinged wing of the Republican party (Sam Tanenhaus calls it the 'Burkean' wing) has been crushed. The modern Republican party is much more anti-government, and just as closely aligned with corporate interests as ever. Expanding access to health care simply isn't on their agenda, as can be seen by the fact that Republicans dominated all three branches of government for 6 years in the early 2000s, and did nothing about the problem of the uninsured. Today's Republicans are simply flat-out opposing any bill.
7. The quaint custom of the filibuster means that when your opponents flat-out oppose a bill, you need a 60-vote supermajority in the United States Senate to pass legislation. I'd love to get rid of this stupid custom whenever it impedes legislation I like, but then again, there's a lot of legislation I don't like! And that goes for the parties -- nobody can limit or abolish the filibuster without it looking like abject special pleading.

So those are a few of my thoughts on why it's so hard to get health care reform passed. I'm sure commenters will add their two cents, though, so fire away!

Comments

[generic viagra]

I realize Americans are much more anti-statist than Europeans, but in this area, their libertarianism simply seems crazy and not at all evidence-based.

[orangeshow]

You know so little about the Republican party....it is a shame.

[joanna]

Also Barbara Ehrenreich, Fear of Falling: The Inner Life of the Middle Class (New York: Pantheon Books, 1989)
This is a great list for anyone interested in post 60s background on class in America:
http://chnm.gmu.edu/hardhats/hindsight.html

[joanna]

The issue is history and the lack of a labor party. That's what Mike Davis painstakingly addressed in Prisoners. It's meticulous attention to history, not ideological theory. We are talking unions and labor. Are there any Australians out there who can speak to the difference between that large land of immigration's labor history and that of the States? Also, we can't ignore the 60s when those agitating class consciousness were systematically murdered.

[M. Möhling]

Ravi, yes, of course. To be fair, this blog has dealt delicately with related subjects, however, that's a "can of worms" that we don't "want to open too far". That's why we have prof Andrew Hammel with full regalia on one side and an anonymous 'fellow law prof' on the other. It's all about some worms not wanting to be eaten by the fish--fair enough. To quote good prof Roediger, who thinks he's a Marxist, though he's become a post-colonial lefto-regressive homo activista vulgaris pseudo-scientificens like most of his peers, the "wages of whiteness" sometimes don't pay off. Boy, some folks need to check on what good old (btw: racist and utterly islamophobic) Mr Marx had to say about this world's noble native, non-western vulnerable groups and globalisation... those were the days.

Come to think of it, one wonders what effect decreased waging whiteness (soon < 50% according to the Att. General) will have on health care and social security, whether reformed or not by then.

[Ravi]

Someone already beat me to it with the Mike Davis reference. I am a long time reader of this blog (and originally found this through David Dow and found him through Mark Dow and the New Politics journal) but I must say while I love the majority of posts, there is a bit of irony because Andrew sometimes pokes fun at Europeans on race/immigration issues. Yet it seems obvious that the class consciousness point is directly related to the long standing racial issues in the US.

A fellow law prof

[cohu]

Wow, that answers my questions, I guess. Thanks for the analysis!

[Joanna]

MIke Davis, Prisoners of the American Dream: Politics and Economy in the History of the United States Working Class (Haymarket) is essential reading for Point #1 and for a background to "Working-class Americans are renowned for their lack of class consciousness..." Also The Wages of Whiteness by David R Roediger (Haymarket).

Does the filibuster operate like the House of Lords ("reformed" not abolished)?

[Michael]

8. In the USA a representative does, what his voters and donors want. A representative in Europe does, what his party tells him to do.

[J.]

But can't the Democrats at least force the Republicans to actually stand in the Senate and read the phone book, Mr Smith Goes to Washington style? That way, at least they'd have to work for their obstructionist agenda, instead of just saying "we, the minority, hereby declare that having 50% of the seats doesn't mean a thing in our democracy". The "procedural filibuster" seems like bullshit to me.

[The Honourable Husband]

Succinct and to-the-point, as usual.

"Working-class Americans are renowned for their lack of class consciousness..."

We would love to hear you expand on this point, Andrew.