Health Care And The Constitution

David Adesnik is shocked -- shocked! -- to find liberals in a college town and none too pleased with Hendrik Hertzberg:

The subject of Hertzberg's prepared remarks was the conservative bias in the United States Constitution. Instead of one government, we have three: House, Senate and presidency. Things only get done when all of them agree. That is why, Hertzberg said, we don't have national healthcare even though most people want it and every other modern democracy has it.

Now, I'm more than willing to agree that the Founders designed the Constitution to make our government resistant to change. But I'm not sure how much that has to do with today's healthcare debate.

I'm not sure how much that has to do with today's healthcare debate, either, but based on David's paraphrase Hertzberg didn't say it had anything to do with today's healthcare debate, so I'm not sure what kind of criticism that is. As far as what Hertzberg (according to David) actually said, as David Lewis would tell you there are epistemic problems inherent in assessing any counterfactual claim ^[1]. Still, as far as these things go, Hertzberg is pretty clearly right.

The main piece of evidence to support his thesis is that we've had five presidents -- Truman, Johnson, Nixon, Carter, and Clinton -- who've support universal health insurance. All saw their proposals defeated in congress due to some combination of conservative opposition and intransigence on the part of liberals who were prepared to make the perfect the enemy of the good. In a parliamentary system with tight party discipline as seen in Canada or the UK, a Prime Minister who favored a universal health care plan would have simply pushed it through the parliament, the misgivings of some be damned. Now, of course, these counterfactuals get complicated, and there's no telling who would have become Prime Minister had we had such a system. Nevertheless, the fact that half the presidents elected in the postwar period (Ford wasn't elected) proposed universal health care strongly suggests that this is the sort of idea that was bound to be supported by an election-winner at some point.

Further evidence in favor of the Hertzberg thesis can also be adduced. Notably, the fact that every other rich democracy has a universal health care system seems to indicate that some oddity of the American system should be produced to explain this odd policy outcome. A simple appeal to public opinion as the explanatory variable doesn't work very well in light of (a) the frequent election of presidents who favor universal health care, and (b) the fact that, at a suitable level of abstraction, polling consistently shows majority support for the notion. Last but by no means least, the government's role in health care has slowly but steady increased ever since the Johnson administration, so the directionality is clearly moving toward such a system. It moves slowly because, as Hertzberg notes, there's a lot of small-c conservatism built into the US constitution.

Now as for today's health care debate, while I seriously doubt that the public understand's either candidate's proposals (as far as I'm aware there's never been an election in American wherein most voters actually understood any of either candidate's proposals and health care's been a relatively low-profile issue this year), John Kerry's plans are clearly more popular. This is typical, structurally the American people trust the Democrats more on health care issues. Unfortunately for Kerry, the American people structurally trust the Republicans more on security issues. They also like Bush better on character/personality questions. So Kerry may well lose. Or else he may win. But either way, on today's debate the people side with Kerry. Nevertheless, even if he wins not all of his ideas will be implemented because of the aforementioned small-c conservatism of the US constitution.

On the Bush side, as I've noted before the Bush years have witnessed a shift toward government provision of health care and away from private sector provision. This has been masked by the fact that private sector insurance is shrinking faster than public sector insurance is growing, but the blob-like State grows nonetheless. The health care issue Bush likes to talk about most is malpractice liability reform, an issue which is 85 percent or so bogus. He talks less about his more interesting idea of Health Savings Accounts. This has to be one of the worst domestic policy proposals that's ever been made by a president of the United States. It's such a bad idea that, as Mark Schmitt explains, it's almost worth supporting from a liberal point of view, since it will wreck such utter devastation on the private health insurance market as to make universal care all-but-inevitable.

Almost. Universal public sector coverage is probably inevitable anyway, since that's where the trends are headed and since genetic testing will make private insurance non-viable in the not-too-distant future anyway.

UPDATE: Political Scientist Scott Lemieux directs me to "It's the Institutions, Stupid: Why the United States Can't Pass Comprehensive National Health Insurance," Journal of Health Politics, Policy and Law, 20:2 (1995), 329-372 by Sven Steinmo for a similar argument defended at greater length with more evidence. As long as we're talking political science I should note that Theda Skocpol, in whose class I was introduced to this material, would kill me if I didn't note that there's also interest group politics at play. In the aftermath of the Truman administration's failure to enact universal health insurance, most of America's labor unions acquired health insurance for their members through the collective bargaining process. This eliminated the major pro-health care lobby, and left the interests of insurance companies essentially unchecked by any organization representing large numbers of uninsured people. We have universal coverage for the elderly specifically because in the early 1960s this -- and not universal insurance for everyone else -- was still a major union priority.

^[1] As he would also tell you, this is not a good reason to condemn people who make counterfactual claims, as claims about causation (which we could hardly do without making) are inextricably bound up with claims about counterfactuals.