Why is it so hard to reform health care? Political structure

A country’s health care system reflects its character, ethics, and cultural values. Politics, medicine, and economics may shape the particular design of a system, but when it comes to deciding who will be included, that’s a moral question.

The United States is the only industrialized democracy that does not guarantee health care to all its citizens. For some Americans, this is consistent with our Jeffersonian heritage of a limited and frugal government. The wealthy should not have to pay for the poor, even in matters of life and death.

For many Americans, however, our health care system is disturbing. 45,000 Americans die every year from treatable diseases because they lack health insurance. We’re the only country with medical bankruptcies. This feels morally wrong, just as some wars seemed wrong and made it difficult to feel good about being an American.

In two recent posts, I’ve looked at how a traditional distrust of government and other historical factors explain our current situation. This post considers elements of our political structure.

The Constitution was not designed to redistribute wealth

The US constitution establishes a particular division of powers. In the Senate, for example, the vote of the smallest state is equal to that of the largest. The constitution provides for an Electoral College system, which many bemoan each time a presidential candidate wins the popular vote but loses the election.

Bruce Vladeck comments on the constitution and the inability to redistribute wealth:

James Madison was a really smart guy, and the constitution he designed largely accomplishes what he wanted: that is, within the confines of a basically democratic nation, policies that would redistribute significant resources from the wealthy to the more numerous poor and middle-income citizens are almost impossible to effect.

An example is the constitutional power of the Supreme Court, the ultimate arbiter of congressional legislation. The Court is liberal or conservative depending on the president who appointed the justices. Currently the majority of the Court is conservative.

The Court is now considering a case that would allow corporations to funnel direct and unlimited support to Congressional and presidential candidates (as opposed to using PAC’s, which have restrictions). According to Fred Wertheimer, of the public interest group Democracy 21, if the court overturns current campaign finance laws, corporations would gain the ability to determine legislation on health care and global warming. “It’s not that the sky’s the limit,” he says. “The universe is the limit.”

Large companies and industries would be able to fund campaign ads that support or oppose candidates. The health insurance industry could target for defeat those lawmakers who supported the public option. Banks and investment firms could target candidates who favor stricter regulation of the financial industry. This could happen as soon as the 2010 congressional campaign.

According to Theodore B. Olson, a lawyer representing the corporate view, “Corporations are persons entitled to protection under the 1st Amendment.” The law should make “no distinction” between corporations and individuals, he argues.

This is the conservative position, which a conservative Supreme Court can impose. Our political structure, based on the Constitution, does not put this up for a vote.

Weak political parties

The US is a very big country with a wide assortment of citizens. Because we lack a unifying religious, ethnic, or class identity, no single national party can unite us in agreement on important issues. All politics are local. Although we have a potentially unifying mass media, it divides us even further. An excellent book on this subject is Bill Bishop’s The Big Sort.
Political parties in the US are weak. Once elected, it’s rarely possible for a party to act on the health care policies it endorsed during a campaign. There has been no major shift in health policy since 1965.

Money changes everything

Because political parties are weak, money is exceptionally powerful. You can run for president without the support of the traditional party apparatus (Nader, Perot, John Anderson, Eugene McCarthy). But you won’t get anywhere without either considerable personal wealth or significant financial contributions.

The government is a major source of wealth in this country, whether it’s building infrastructure or buying fighter jets. A political contribution is an investment: If you pay to get someone elected, then that politician will do your bidding because he or she needs your continued financial support just to remain in office. That’s one reason the current Supreme Court case is so important.

Money is at work in the current health care debate. The insurance industry, the pharmaceutical industry, and other business interests can buy health care policy. Major groups in this country, with significant economic resources, have been opposed to health care reform for a very long time.

This is the reality of our political structure.

Related posts:
Why is it so hard to reform healthcare? Rugged individualism
Why is it so hard to reform health care? The historical background
Why is it so hard to reform health care? National identity
Why is it so hard to reform health care? The issues are complex
‘Mad Men,’ the sixties and the culture war over health care
Your insurance industry at work
Health care reform: Politics and substance
Importing drugs from Canada: Will lobbyists win or lose this round?