Politicians, as a group, are not well-known for their courage or responsibility. Instead, they like to give passionate speeches about broad, simple principles that are overwhelmingly popular in their districts. In other words, they like to campaign. This is to be expected, given that winning elections is both a necessary and sufficient condition for holding the job. But the desire to be popular can conflict with the need to address serious, long-run problems of the country.
We knew this to be true, yet we were shocked and dismayed by the epic collapse of health reform last week. With the loss of a single Senate seat as an excuse, the most liberal Democrats chose en masse to give up on critical reforms that were on the brink of passage. Their stated positions sounded principled, but made no policy sense. Meanwhile, President Barack Obama backed away from health care and changed the subject to banking. The desire to implement a real policy response to a major problem simply evaporated.
Why were we surprised? Perhaps we were drawn in by the rare display of responsibility on the part of Democratic leaders and Obama in 2009. Their attempt at comprehensive health care reform revealed knowledge and commitment to the issue. Our mistake was to believe that rank-and-file members of Congress shared their leaders’ interest in governing. Last week the truth was exposed. Was our earlier optimism foolish? Is health care reform simply too difficult for elected leaders to tackle?
Looking at other countries, we don’t think American politicians are less courageous, responsible, or knowledgeable about policy than politicians in other countries. We don’t believe that health care policy is fundamentally more complex or that interest groups are more entrenched in the U.S. than elsewhere. And yet every other advanced, industrialized nation has done a better job controlling health care costs while delivering more equitable access to care. Why can they do it and we can’t?
One reason could be that American politicians almost never have any power–they aren’t used to governing and they don’t want the responsibility. Tackling long-term problems like health care reform means extracting concessions from interest groups and that makes reelection more difficult.
Most other industrialized nations have parliamentary systems where the party that wins the majority in parliament forms the government and has the votes to govern. Responsibility is inescapable and it lasts until the government falls and a new election is called. Governing is routine, and elections are intermittent.
In the United States, the reverse is true. On the rare occasions when one party controls both branches of Congress and the presidency, major policy changes are possible, but only if the other party doesn’t dig in and use the filibuster. Obstruction is easy and profitable for the opposition and elections are frequent, reducing the likelihood that party control will last long enough to legislate. The rules of American political institutions were designed to keep government weak, and they work very well.
To be clear, we don’t think this is all bad. As economists, we generally prefer markets to bureaucracies. We believe that America’s weak government contributes to its dynamic and flexible economy. But the problems of our health care system will not simply take care of themselves.
Cost growth is steadily bankrupting the public treasury, and more than 45 million Americans lack insurance, and face poor quality care and financial ruin if they get sick. If policymakers fail to make constructive changes, the ranks of the uninsured will grow and the quality of public coverage through Medicare and Medicaid will be forced downward, threatening the financial viability of our hospitals. There will be a lot of angry, suffering people who can’t see a doctor when they need one.
So what can be done? Responsible people in government have to do the best they can. Even with all the structural impediments to governing created by our separation of powers and frequent elections, the alternative is just too frightening. Despite last week’s hysteria, health care reform might not yet be completely dead. Maybe Obama will return to the issue and start leading again. Maybe House Speaker Nancy Pelosi will succeed in getting the hyperventilating members of her caucus to start breathing again and to think about the long-run consequences of their failure to vote.
But if they don’t, we won’t be surprised. Our system of government is designed to produce an abundance of great speeches about sweeping reforms and a pittance of actual reform delivered. Except for frustratingly brief moments, we really have no government, just a collection of perpetual campaigners, focused on the next election and accepting no responsibility for the country’s long-term problems.
In 2009, it was comforting to believe that the leaders of the majority party would use their power to govern responsibly. They tried and failed. The campaigners have taken over, again.
Steve Pizer and Austin Frakt are health economists. The former is an Associate Professor and the latter an Assistant Professor at Boston University’s School of Public Health, Department of Health Policy and Management. Austin blogs at The Incidental Economist.