The bias of American politics: rationing health care in a weak state.

• Author: Morone, James A.
• Position: The Law and Policy of Health Care Rationing: Models and Accountability

Americans, we are often assured, do not like their government.(1) The assertion is partially truth and partially myth. This Article offers a more detailed map of the American political processes, and applies it to the debate over rationing health care.

Three forces shape our public policies: the first is a distinctive tendency to bash the state. The scope and intensity of anti-governmental ideology are exaggerated by a second feature of the American political landscape, the organization of our government. Fragmented, overlapping, often incoherent institutions blunt political action--more or less as the Founders intended.(2) Thirdly, Americans are swift to mobilize politically. Interest groups, organized lobbies, and ad hoc "action" committees all find this government comparatively easy to influence. Taken together, ideology, institutions, and interests systematically bias our public policies and public debates toward the status quo.

This bias of American politics shapes the paradoxical debate over health care rationing. The very notion of rationing alarms people on all sides, yet few health care systems anywhere are as heavily rationed as the American.(3) The first procedure in any health care setting is the inevitable "wallet biopsy," a stringent rationing tool.(4) I contend that the American political system fosters contradictions in the ways we ration health care and in the ways we frame potential alternatives. Ultimately, our health care debate proceeds backwards. My purpose here is to show how and explain why this is so.

1. PATTERNS OF AMERICAN POLITICS

   1. Ideology: The Distrust of Government

      Americans do not like government.(5) The state occupies an unusually ambiguous place in our society. Public power has long been viewed as a threat to liberty--James Madison contrasted the American Constitution with the European legacy of Magna Carta as a charter of power granted to liberty rather than a charter of liberty granted by power.(6) The preoccupation with limiting government has remained a vivid feature of American political life. Tocqueville reported, "the society acts by and for itself.... so feeble and restricted is the part left to [government] administration."(7)

      Even as the American administrative state began to take its contemporary form, somewhere between the two Roosevelt administrations, the anti-governmental impulse remained. For example, Americans developed their social insurance programs far more reluctantly than did most Western democracies. In Europe, benefits were generally proffered from the political center by statesmen bidding for the allegiance of workers. Bismarck, Lloyd

      George, and Napoleon III each sought to coopt the working classes with social insurance programs.(8) In the United States, the political payoffs from such programs are not often noted and new social-welfare programs not often won. The American social-welfare debate focuses more on the dangers from prompting laziness than the opportunities of promoting loyalty.(9) When new programs are proposed, they provoke the same anti-governmental reflex that shackled the government's early development. Throughout most of the twentieth century, great cries about looming socialism accompanied the government bashing.

      Louis Hartz described the result as "American exceptionalism," a distinctive opposition to the state that weakens every move toward government programs, let alone toward class-based politics or socialism.(10) Granting old age benefits, financing health care publicly, legitimating labor unions, legislating civil rights, fluoridating water, regulating industry, and a multitude of other policies all elicit a similar response. New forms of state authority, even those that extend narrow benefits to broad constituencies, evoke the charge that an overreaching state threatens the people's liberty.(11)

      At times, the ideology is articulated with great gusts of hyperbole. For example, school desegragation left Southern editorialists speculating how "[t]he communist masses of Russia and Red China must have howled with glee."(12) The Kennedy administration's scaled back Medicare program would lead us to "awake to find that we have socialism.... [O]ne of these days you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free."(13) Recently, the dread of government has been articulated in more sober, but equally passionate terms: "no new taxes."(14)

      Observers of American health care are familiar with this theme of government distrust. It is, we are frequently told, the reason Americans have no national health insurance; it is the reason a national health scheme such as Canada's remains "'off the radar screen of American possibility.'"(15) Although this ideology runs long and deep in American political history. Hamilton's "energy" in government,(16) Lincoln's "political religion of the nation,"(17) and Franklin Roosevelt's "four essential human freedoms"(18) are all familiar visions of a radically different nature--visions of a strong and active state.

      Indeed, anti-statist rhetoric failed to bury any of the examples noted above--social security, Medicare, protecting voting rights, business regulation, and water fluoridation are all unexceptional duties of the American state today. The American fear of government matters, but it is only part of the political story.

   2. Institutions: Fragmented Government

      Anti-statist ideology is built into the chaotic fragmentation of American political institutions--and commonly celebrated as checks and balances. "No other nation," report Peter Marris and Martin Rein, "organizes its government as incoherently as the United States."(19) The political chaos "leaves most reforms sprawling helplessly in a scrum of competing interests."(20) The President and both houses of Congress pursue their own agendas; in the past century and a half, the three bodies have been divided by party forty percent of the time, by region and institutional loyalty constantly.(21) Together, they compete to oversee a federal bureaucracy that is in many ways beyond their control. The President, for example, names little more than one-tenth of one percent of federal office holders.(22)

      Political programs must pass through the presidency, Congress, the federal bureaucracy, and then negotiate the layers of American federalism--regional governments, state government, sub-state regional bodies, counties, and local governments, each of which is divided by function.(23) The courts intervene at every stage. To pass this gaunlet, proposed programs are typically oversold (promising all kinds of benefits to all sorts of constituencies) and, at the same time, heavily compromised.(24) The combination creates an often-sampled recipe for disappointment.

      The chaos of checks and balances is rooted in the Constitution and was exacerbated by succeeding reform generations. In the vain hope of getting beyond politics, wave after wave of American reformers have organized new agencies designed to be independent, expert, and apolitical. For example, reformers organized the civil service in 1883 to meet these specifications, promising that the result would be honest and efficient government.(25) Additional examples range from independent regulatory agencies (beginning with the Interstate Commerce Commission in 1887)(26) to the Health Care Finance Administration (formed in 1977).(27) The new agencies swiftly added to the uncoordinated, fragmented character of the American regime; they quickly found themselves bogged down in the politics they were designed to avoid.(28) The result is a political framework geared towards narrow incremental changes best negotiated by individual, independent agencies with narrow jurisdictions. The system is especially maladroit at securing broad policy changes that require coordination from the political center. For instance, when the Supreme Court took a leftward turn and championed desegregation, it was frustrated for more than a decade by Congress, executive agencies, state governments, county and municipal officials, and local school boards.(29) By contrast, our government is well-designed for granting agricultural subsidies or damming rivers.

      The bias of our political institutions can easily be misread as an American bias against government action. National health insurance offers a familiar example. Americans may be skeptical of their state, but Harry Truman was elected, in 1948, touting universal government health insurance as his major domestic issue.(30) While his promise to "remove the financial barrier to health care" played well on the campaign hustings, it was repeatedly rejected in Congress.(31) In a parliamentary system free of checks and balances, one party (or coalition) would control the legislature, the executive office, and...