A tweep asked me to comment on Alex Gourevitch’s brief essay on health care politics. Not surprisingly, it’s much better on the policy than on the politics.
To start with the points of agreement, Gourevitch (and Bob Kuttner, in the piece Gourevitch discusses) are certainly correct about the Obama administration’s failures on the rollout of the ACA. Whether these initial failures will affect the politics of the ACA going forward — I think that if the website and other administrative issues are fixed the initial disaster will be as forgotten as the disastrous rollout of the prescription drug addition to Medicare — but it was a major failure of what is supposed to be a strength of technocratic liberalism, so no argument there. And, certainly, Gourevitch and Kuttner are correct that Medicare for all would be much more efficient than the ACA’s ungainly public-private hybrid.
The political analysis…that’s another story. Before we get to the core argument, let’s deal with this, a very bad sign for an analyst of contemporary American politics:
Other liberals began to join in. William Galston, a political philosopher who worked in the Clinton administration and now at the Brookings Institute, recently wrote in the Wall Street Journal that “Every experienced manager knows that, left to its own devices, the system will not always behave this way… So the president must lean against these perverse tendencies… [but] it has become clear that President Obama failed to institute such arrangements.”
Eventheliberal Bill Galston engaging in rare criticisms of Barack Obama!
That aside, the bigger issue is with the increasingly familiar form of political analysis. It takes the tone of a tough-minded left-structuralist critique of Obama, but the content is an echo of the middlebrow liberalism it purports to detest, a combination of naive black-box pluralism and the great man history found in bestselling presidential biographies and Aaron Sorkin scripts. There’s essentially nothing in this political universe but the will of the president:
The health care law was not just Obama’s signature initiative — it was also the single best representative of his general post-political approach to politics. Obama thought he could rise above partisanship by taking an essentially Republican plan and then leaving it up to Congress to manage the details of compromise. He thought he could avoid all semblance of ‘class warfare’ by taking single-payer off the table and by eliminating any talk of redistribution. He thought he could find a consensus plan by working with, rather than taking on, the insurance companies.
In other words, the belief was that he could get something done without taking any sides or even acknowledging that there were significant conflicts of interest and principle. The result was a public-private partnership that yielded a measure of agreement not so much because everyone could see their interests represented in the final result as because nobody could understand that result. It was legislation by stupefication.
I’m not even sure where to begin. Well, first, the ACA is not a “Republican plan” in any meaningful sense. The idea that Obama thought that health care politics would somehow transcend partisan divisions and didn’t involve questions of principle is trivially easy to disprove. Leaving the initial stages of the process to Congress doesn’t reflect a belief that politics no longer exists but rather is just presidenting 101 — Obama, unlike too many of his critics from the left, learned from the failures of Bill Clinton’s strategy of developing a health care plan and then trying to get Congress to pass it by “going public.” The idea that Congress would have rolled over for whatever Obama wanted if only Obama had the will to do so is simply an alternate universe with no relationship to American politics. FDR, for all intents and purposes, didn’t get any major legislation passed that wasn’t favored ex ante by Southern Democrats, and the moral compromises this necessitated makes the handouts to various rentiers associated with health care look like nothing. The fact that Medicare for all would be superior policy to the ACA is completely irrelevant to the politics of 2012.
Now, it may be true that Obama overestimated the possibility of getting some token Republican support for the ACA in the Senate. But, as we’ve been through before, Gourevitch fails to think the implications of this through. The presence of liberal Republicans was a major source of leverage for a deal-cutter like LBJ. Once we concede that zero Republican votes was the maximum for the ACA, then every single conservative Democratic senator has a veto. Joe Lieberman would have blown up the ACA over lowering the buy-in age for Medicare, but we’re supposed to believe that he — and Ben Nelson and Evan Bayh and every other greasy conservative Democrat in the Senate — would have been perfectly OK with eliminating the private health insurance industry altogether had Obama just been more…political? Gourevitch doesn’t specify how Lieberman could have been made the extension of Obama’s will, which is probably for the best.
But what’s missing Gourevitch’s analysis above all else is any sense that American political institutions place any constraints on health care policy at all. The power of Congress over domestic policy and the fact that American social programs get passed by buying off vested interests are not things that Barack Obama created because he disdains politics. They’re permanent features of American politics that have affected every element of the federal welfare state even in the rare periods in which major progressive reform is possible. Any good analysis of health care politics in the United States has to start at this structural level, rather seeing legislative enactments as essentially unfettered presidential choices.
..one additional point. The failure to do any kind of institutional analysis is also a problem for Gourevitch’s subsequent argument that the problems with the ACA have their roots in Obama’s alleged hostility to state as opposed to private power. But if we compare the ACA to the relevant baseline — the status quo ante — it obviously increases the federal role in health care substantially. And in particular, I don’t see how Gourevitch can account for the huge expansion of Medicaid, and it seems to me that the Supreme Court inventing new doctrine to make the part of the law that gave the most direct benefits to the poor less effective should be the kind of institutional feature that any tough-minded critique of American politics really should take into account.