We used to say that South Africa shared the distinction of being one of the few industrialized nations without universal health insurance. We don’t have South Africa anymore to point to. Nearly 20% of the country’s population is without health insurance. The disparities in care and outcomes in health are much higher in the United States than elsewhere in the world.
The political issues surrounding health care are relevant because the American system’s high-quality health care system is comparable to that of other countries. A significant portion of total knee replacements performed worldwide is done in the United States. If you are a resident of certain areas and develop certain types of tumours, you can get the best treatment available anywhere. The outcomes will be at least as good as those in other countries. Large areas of the population have access to healthcare and can see the results. These outcomes are more comparable to the Third World, which is often poorer and less prosperous.
These disparities do not save us money, and we spend significantly more on healthcare than any other country. In fact, Americans are 65 and overspend more on healthcare than they do for the whole population.
The United States is, by international standards, quite unusual. Now the question is: Why? This isn’t an academic question. To understand how the United States got to this point, it is important to know how it got there. Freud stated that all psychiatric phenomena were overdetermined, which means that more explanations are needed to produce the result. This is likely true for most social sciences. There are 10 reasons why the United States is so unique. All of these explanations are true, and anyone would likely be sufficient. These explanations fall into two broad categories: historical-cultural and structural-political.
Americans have a more negative attitude about government than Americans do in any other country than citizens of other democratic countries. Since at least the 18th Century, this has been a constant theme in American history. There are many explanations for this. The first is the self-selection and selection of immigrants to the United States. This was back in colonial times when only the bravest or most desperate were willing to risk the unknown. Draft dodging in European nations was a significant source of immigration during the 19th Century. Other waves of immigration came after failed attempts at political rebellion and revolt. This history also has a religious component, as many immigrants opposed established churches or all hierarchical ones.
De Tocqueville offers a variant to the first explanation: The absence of an aristocracy in the New World and its attendant social hierarchies created a culture that was less accepting of authority and more independent than any other.
While the United States has a socioeconomic situation that is not as uneven as other industrialized nations, a large portion of the world’s population is classified as working-class or working people. Everyone in the United States self-identifies as being middle-class. This leads to an easy syllogism regarding why the United States does not have universal health insurance. There is no self-identified working class, no labour party, or national insurance. This syllogism is difficult to confirm, leading to the fourth point.
Why was there no successful labour party in the United States of America? The United States likely had a greater amount of quasi-free or free land in its history earlier than most other countries. An even higher percentage of Americans with low incomes owned real estate. This land abundance allowed middle-class self-identification and allowed geographic mobility that gave “exit” the option to “voice” for those who had grievances about the status quo.
The fifth cultural-historical explanation for America’s lack of universal healthcare insurance is the absence of a labour party. This is due to the persisting historical cleavage of American politics–race. There was never a labour party because we were unable to unite Black and White workers in large-scale political movements.
I believe all five historical-cultural reasons why universal healthcare insurance hasn’t been introduced to the United States are correct. However, political-structural explanations also play a significant role.
The most fundamental political-structural explanation for James Madison’s genius is that he was an extremely smart man. His constitution accomplishes much of what he desired. In a democratic country, it is almost impossible to implement policies that redistribute substantial resources from the wealthy to the many poorer and middle-income citizens. This design includes other constitutional features, such as the division of power among the branches of government, differences between the Senate, House of Representatives, or the role of an independent judiciary.
Madisonian politics was based on the fundamentally centrifugal forces of American politics, but it can be distinguished from them. The United States is a large, diverse country, and it lacks the religious, ethnic or class identity that can be used to build national political movements. All politics in the United States are local, more than in any other democratic nation. Despite the increased homogenization of culture in America (and worldwide) due to mass media, the United States is becoming more diverse politically and socially and like our health care system.
These Madisonian-style tendencies and other aspects make the United States one of the most corrupt political systems in the world. Rarely does a party’s platform have a significant impact on the health policies that it follows? Since 1965, the electoral success of one party has not produced major changes in health policy. However, a similar shift was almost possible in 1995 with another partisan victory.
The power of money in politics increases when there are no strong parties. Although individual politicians can be successful in the American political system, they cannot succeed without the support of the political party apparatuses. However, except for very rare exceptions, they cannot succeed without substantial personal wealth and significant contributions. The government of the United States is a significant source of wealth, and it has built canals, subsidized railroad construction, and purchased munitions. Political contributions are often evaluated by simple return on investment. Universal health insurance has been long opposed by groups with substantial economic resources.
Our political system is so good at finding the middle ground that there have been long periods when the parties were essentially in control of the power in the national governments. There is no significant difference in the policy between each president’s election, which is not an unusual phenomenon in American history. Our experience since 1972 mirrors that of the 1876-1899 period.
WHERE POLITICAL CHANGE IS COME FROM
After identifying the main barriers to political change in America, I now want to know how that change can be achieved. There are three ways that change can occur in the United States. “Realigning elections” is the first. Although political scientists continue to debate the relative importance and impact of the 1928 and 1932 elections in ending long periods of Republican hegemony in the United States, one or both of these elections directly led to the 1935 enactment of the Social Security Act. Medicare and Medicaid were created in 1965 by the Lyndon B. Johnson victory of 1964.
A 1994 realignment election completed the 1980 election, replacing a Democratic structural majority in Congress with a Republican one. Some realigning elections do not go in the same direction, and some may not allow for the expansion of government health programs. In 1995-96, we were dangerously close to making Medicaid a block grant program, which would have set us up for permanent privatization of Medicare. The next major shifts may be in one direction or another, and this should be considered when determining the strategy and tactics for advocates of universal healthcare insurance.
The domestic fallout from war is the second reason that America experiences change. Many of the positive changes in the American health care system in the 1950s and 60s were due to programs created by World War II. Social change happens much faster during wartime than it does in peace. This kind of sociopolitical transformation requires a real war that involves substantial mobilization of the people. Recent evidence suggests that the U.S. elites might have learned to fight wars without mobilizing people.
Every once in a while, the United States experiences a third type of change. This is marked by a significant cultural shift that causes rapid changes in public policy. Perhaps the most important example of our time and perhaps the only one of its magnitude is the change in public attitudes toward tobacco. A very popular consumer product that plays a significant economic role was stigmatized over a short period, leading to changes in public policy. This was a unique and rare set of events, giving hope for radical changes.
It is possible, but not impossible, to make positive changes. Based on my experience over the past several decades, it is clear that change is possible when there are opportunities. Success will be for those who are ready and able, and willing to make the changes they have been planning and working towards for a long period. Although it will certainly happen one day, it will be hard to predict when exactly. Advocates need to be prepared. Here are four strategic recommendations.
First, reform has been based on the belief that the system must be reorganized to increase access to care. This belief has been the cornerstone of reform for the past 30 years. Because the American health care system is so large and inefficient, it has been assumed that simply changing its structure will solve the access problems. This syllogism doesn’t work. If you cut spending for one part of the population, someone else will get the money. Money is not always fungible in politics. Moreover, if you attempt to make the system more efficient than it should be, this act can lead to lower incomes and a reduction in the perception of well-being for some people. They will resist any changes.
The president’s promise to create a universal plan for health insurance that would not involve new federal taxes was one of the fatal flaws of Clinton’s health reform efforts. He believed that there was enough money in the system. Although he was correct in principle, the Rube Goldberg-like processes required to get from here and there were so complicated, cumbersome, and confusing that they took the rest of his proposal with them.
The United States saw an incredible increase in wealth over the 1990s. This was not only for the richest 5%, although they were the biggest gainers, but also for the entire wealthiest half. While many people are now more wealthy than they were 10 years ago, none of this wealth has been used to fund health care for those who do not have it. Reform advocates will fail if they continue to try to be efficient and prudent in reallocating money to finance universal services. This is a wasteful, expensive country, and let’s just spend the money.
Practically, it is possible to reform both the health care delivery system and the health insurance system, but not both. The political task is too difficult and the policy implications too complex. This principle is consistent with the experience in other countries, and it has been demonstrated in our Medicare program. While there are many problems with the system and access issues, there is no reason to believe that these problems can’t be addressed (or at least remediated) in a systematic manner. Medicare was established in 1965. Its proponents tried to limit the changes required of health care providers and allow existing practices to continue, however inefficient. It was possible to reform systems later, which it did. Proponents of Medicare knew that expanding coverage would change the existing system and provide the impetus to make further changes. However, in the brief time available, it is impossible to accomplish many things at once. It is impossible to have universal coverage while also reforming the delivery system.
Second, universal health insurance advocates need to remind themselves and their fellow citizens of their position’s ethical and moral roots. The religious groups that oppose progressive social benefits expansions have been the main supporters of the infusion of spiritual and religious values into the country’s political process over the past generation. This is for a variety of complex reasons. While moral appeals play an increasing role in the political system, universal health insurance advocates, whose beliefs are generally grounded within a broad value framework and not narrow self-interest, have been reluctant about joining the fray.
Universal health insurance advocates, for example, have not sought to form a coalition with religiously-sponsored institutions, particularly those affiliated with the Catholic Church. This may be because universal health insurance programs in many other countries have been approved despite the opposition of providers. However, the American political system is a stronghold of entrenched interests, and universal insurance will not be able to come to the United States unless there is significant leadership from the American health care provider community. Universal health insurance advocates should approach the Catholic Health Association as a key provider group.
Third, it is troubling to see how much universal health care discussion takes place outside of those already committed. We are preaching to converts to continue the analogy from the previous point. The conversation takes place in certain parts of the country, namely on the two coasts and some isolated Midwestern outposts. Since World War II, the country’s population has been moving southward and westward. The population has been moving from areas that share the views and proponents of universal health insurance to those areas where there are not many. It is difficult to achieve anything if there are not many coalitions with a national reach. The problems of access to healthcare and the uninsured are much more severe in communities with less political support for universal coverage. This makes it a good target for building coalitions and organizing.
Advocates of universal health insurance must reject the idea that they can achieve their goals through incremental steps. The Social Security Act was the first to use incrementalism in American political science. It was a very limited model that began in 1935. Although it provided old-age benefits and aid to families with dependent children, the original law didn’t provide benefits for survivors, federal disability benefits or benefits for spouses. It didn’t include Medicare or Medicaid. It has been amended 40 times in the 67 years that the Social Security Act has existed. Most years, however, have seen some improvement. It is not surprising that the founders of Medicare, Medicaid and other social security systems adopted a similar approach to health insurance.
This particularist strategy became a normative imperative for how politics should be done in America over time. This view holds that incremental change is the only way to make health insurance affordable. However, over the past 35 years, the incremental expansions of public health insurance have not been enough to decrease the number of uninsured. The private health insurance system has been unravelling at a pace roughly equal to expansions in public programs. In contrast, population growth has largely been driven by immigration–immigration to a country in which a widely disproportionate share of new Americans lacks health insurance.
While proponents for universal health insurance are incrementally moving “sideways”, advocates of non-incremental strategies within other spheres have enjoyed some notable success, at least from their perspective. In the mid-1990s, the Economic Opportunity Act and many valuable remnants from the Great Society’s legislative eruption of 1965 to 1966 were repealed. Large parts of civil rights infrastructure used in the 1970s and 80s were destroyed. From 1995 to 1996, Congress abolished the entitlement for cash benefits for low-income mothers and their children. Additionally, Congress was very close to ending Medicaid’s entitlement status. Other areas of public policy have also seen significant, non-incremental changes.
People who worked hard for those changes didn’t have patience with incrementalism as a prescriptive theory. They believed it was better to be broke than work for them. They demanded too much and overreacted based on the belief that you would only get a small fraction of what you ask for. However, if you donâ€™t ask enough, you wonâ€™t get enough.