Thursday, June 28, 2012

The unhealthy politics of healthcare

America Divided

by Clive Crook

Todayonline Jun 28, 2012

Respectable opinion takes it for granted that you cannot 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 United States, if you ask me, casts doubt on this truism.

Here is a country divided. The split is not just between Democrats and Republicans, between centre-left and hard right. The US is also divided between a political class and an apolitical class.

On one side, opinion shapers, policymakers and party disciples, engaged to the fullest; on the other, the bored and disenchanted, who have looked at the deeply committed and given up on Washington and all its works.

Here is the point, though: The sickness in US 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 politicised. Political appointees go several layers down across every agency of the executive. Even US courts are politicised.

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, US civil society has a relatively shallow layer of non-aligned 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 did not have to mean faction, a distinction that the country's Founding Fathers understood very well.

But faction, sorting by party, is what we have got, and how. That is what political engagement means in the US. It has permeated every fibre of government and it is making the country ungovernable.

Granted, this pessimistic line of analysis has to contend with the standing of the US as the richest and most powerful country in the world. Maybe there is 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. Healthcare, for instance.


The US healthcare system is a disaster. It fails in basic respects and at the same time is a crippling burden on the economy.

It costs nearly a fifth of the country's entire output - vastly more than what any other advanced economy spends. Yet, it cannot 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 cannot say a more centrist approach would have worked better. President Barck 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, Mr Obama promised historic reform without perceptible change. If voters found that prospectus hard to believe, you cannot blame them.


The problem was not too little centrism, it was too much politics - in the following sense.

Reforming healthcare self-evidently involves intensely political choices, but the issues are not 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 non-aligned expert.

In this respect, the popularity of Mr Daniel Patrick Moynihan's saw that "everyone is entitled to his own opinions, but not to his own facts" is all too revealing. There is more to knowledge than facts, and more to wisdom than opinions. Those two categories do not exhaust the intellectual space.

Getting to grips with a policy question - especially one as complex as healthcare - 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 US, I am wondering, does any such thing still exist?

Ultimately, fixing the healthcare system will require a supporting consensus among the public. Without that, even if Mr Obama's reform is not repealed outright, it risks being strangled by a hostile Congress.

If the reform was popular in the country, it would have bipartisan support in Washington, and the Supreme Court would not even be thinking about overturning it.

Persuading the apolitical is vital, but it will not 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 us have a bit more thinking and a bit less engagement. BLOOMBERG

Clive Crook is a Bloomberg View columnist.

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