The Unhealthy Politics of Health Care
Respectable opinion takes it for granted that you can’t have too much politics. The model citizen of a healthy democratic nation is above all “engaged” -- informed, with strongly held views that he or she advances at every opportunity. Less politics means a passive, apathetic electorate. More politics must be good.
The U.S., if you ask me, casts doubt on this truism.
Here is a country divided. The split is not just between Democrats and Republicans, between center-left and hard right. The United States is also divided between a political class and an apolitical class. On one side, opinion shapers, policy makers and party disciples, engaged to the fullest; on the other, the bored and disenchanted, who’ve looked at the deeply committed and given up on Washington and all its works. Here’s the point, though: The sickness in U.S. democracy lies less with the disengaged, whose boredom is forgivable, than with the model citizens who are all politics all the time.
As a practical matter, the disconnect is aggravated because American politics goes beyond Congress and the White House. The civil service is also thoroughly politicized. Political appointees go several layers down across every agency of the executive. Even U.S. courts are politicized. This week, the highest court in the land -- four conservatives, four liberals and a swing vote -- will pronounce on the design of the country’s health-care system.
Compared with that of other advanced nations, U.S. civil society has a relatively shallow layer of nonaligned technocrats. Its think tanks, its economists, its scientists, its Supreme Court justices, almost everybody in the news media, almost everybody with an opinion about anything, take sides. Any member of the political class with a firm view on campaign finance will probably have one on public borrowing, stem-cell research, incarceration, climate change, states’ rights, you name it -- and strangely enough all these views will probably conform to one of just two available conceptions.
Tell me whether the individual health insurance mandate is permissible under the Commerce Clause, and I’ll tell you what you think about fiscal stimulus.
Total engagement, you could call it -- and the result is total paralysis.
Of course, engagement didn’t have to mean faction, a distinction that the country’s Founding Fathers understood very well. But faction, sorting by party, is what we’ve got, and how. That’s what political engagement means in the U.S. It’s permeated every fiber of government, and it’s making the country ungovernable.
Granted, this pessimistic line of analysis has to contend with the standing of the U.S. as the richest and most powerful country in the world. Maybe there’s something to be said for all politics, all the time? Actually, there is: That kind of government, together with a constitution that disperses power, either achieves dull centrist compromise or fights itself to a standstill -- and in ordinary times, government limited by factional dispute and institutional friction works pretty well.
Moreover, since the Civil War, American patriotism has always united the country at moments of real peril. When this country aligns its efforts and resolves to do something, watch out. The weakness of the system is in facing issues that are less dramatic, slower-acting and more complicated -- but nonetheless capable of undermining the country’s success and threatening its long-term prosperity. Health care, for instance.
The U.S. health-care system is a disaster. It fails in basic respects and at the same time is a crippling burden on the economy. A system costing nearly a fifth of the country’s entire output -- vastly more than any other advanced economy spends -- can’t even guarantee coverage for all its citizens. The Obama administration was absolutely right to confront this issue, and to make universal coverage the principal goal of the reform.
In my view, the Affordable Care Act takes big steps in the right direction. I hope the Supreme Court upholds the law. But whatever the court decides, the reform is far from the whole answer. Incentives in the proposed new system are still grossly misaligned. The measures to control costs are too timid.
In this case, you can’t say a more centrist approach would have worked better. Obama’s reform is centrist to a fault. Its most controversial element -- the mandate requiring people to buy insurance -- is a Republican idea. The complexity of the plan, which is its chief weakness, arises from the administration’s goal of leaving existing insurance arrangements mostly in place. The president’s pledge not to raise taxes was also intended to reassure. In effect, Obama promised historic reform without perceptible change. If voters found that prospectus hard to believe, you can’t blame them.
The problem wasn’t too little centrism, it was too much politics -- in the following sense. Reforming health care self- evidently involves intensely political choices, but the issues aren’t exclusively political. Getting to grips with such a complex issue also demands a widely accepted body of analysis. Never in control, but somewhere in the picture, must be the trusted nonaligned expert.
In this respect, the popularity of Daniel Patrick Moynihan’s saw that “Everyone is entitled to his own opinions, but not to his own facts” is all too revealing. There’s more to knowledge than facts, and more to wisdom than opinions. Those two categories don’t exhaust the intellectual space. Getting to grips with a policy question -- especially one as complex as health care -- requires not just facts and opinions, but also a body of agreed knowledge, of findings and understandings, to serve as a basis for discussion of choices. It requires disinterested analysis.
In the U.S., I’m wondering, does any such thing still exist?
Ultimately, fixing the health-care system will require a supporting consensus among the public. Without that, even if Obama’s reform isn’t repealed outright, it risks being strangled by a hostile Congress. If the reform were popular in the country, it would have bipartisan support in Washington, and the Supreme Court wouldn’t even be thinking about overturning it. Persuading the apolitical is vital, but it won’t be easy as long as every expert is a partisan, every guide to policy an activist, every judge a politician and every pundit a team player.
Memo to the American political class: For democracy’s sake, let’s have a bit more thinking and a bit less engagement.
(Clive Crook is a Bloomberg View columnist. The opinions expressed are his own.)
Today’s highlights: the editors on the Supreme Court’s Montana decision and the limits of Italy’s technocracy; Edward Glaeser on the troubling history of federal mandates; Vali Nasr on what Pakistan tells us about Egypt; Peter Orszag on natural-gas cars and trucks; Richard J. Carroll on why a president’s economic performance depends on his predecessor’s record; John C. Dugan and T. Timothy Ryan Jr. on why the Dodd-Frank law puts to rest “too big to fail.”
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