Health Care Reform: Another Victim of US Presidentialism

The vote by the US House of Representatives on health care reform has been hailed by many as a victory for those many million Americans deprived of any sort of medical coverage. True, there are important, new developments, which Rose Ann DeMoro of the California Nurses Association does a very good job of explaining. Some of these measures were part of Obama’s electoral manifesto during the 2008 campaign.

Still, the conceiving of a tax-financed single-payer system, let alone a “socialized” one, is nowhere in sight. It still sounds bizzarre to people like myself, who live on the other side of the pond (where systems, it should be pointed out, differ both in terms of organization, financing and quality, but still rest on the principle of free, or almost free health care for all), that the largest economy in the world would choose not to grant what is considered as a right (generally enshrined in the Constitution) in most of the world’s advanced countries. Autocratic Germany passed the Health Insurance Bill in 1883, which was gradually extended to cover the entire population; Britain created the NHS in 1948; Italy officially created its in 1978, to make just a few examples. Too often have I listened to horror stories concerning many Americans (including personal friends) who developed serious illnesses and thanked fate for residing abroad, thus obtaining free health care in their new country of residence.

Now, the way this US bill was elaborated and passed represents, in my opinion, further corroboration of the fact that the US presidential system was devised, more than 200 years ago, to attain a specific goal: that is, preventing “radical” legislation from being passed by the political system. As I argue in my book The Roots of Contemporary Imperialism: The Founding Fathers, the U.S. Constitution, and 200 years of corporate dictatorship, the Founding Fathers were cunning enough to devise a system which would create “a path strewn with obstacles in the belief that it would encourage the kind of slow, deliberate politics that were their ideal,” as Daniel Lazare has argued; or, as Charles Beard has put it, “disintegration of positive action.” The political system they devised aimed at preserving the status quo, that is, domination by an already powerful business elite over the people. Only overwhelming popular pressure, extreme crises and the risk of implosion of the system have led to major legislative breakthroughs (or, rather, “concessions” from the elite), such as, to make just a few examples, the Sherman Antitrust Act of 1890, the National Labor Relations Act of 1935, the Minimum Wage Act of 1938 and the Civil Rights Act of 1964. Indeed, as street riots or a widespread popular rebellion directed toward obtaining a national health care system appear as a remote possibility, the vicissitudes of the health care bill show the truthfulness of such assertions.

Constitutional engineering alone does not explain the shortcomings of the presidential system.

There are three additional elements, not strictly related to the US Constitution, which nevertheless overlap and help create a situation in which:

* party nominees are not necessarily their parties’ leaders (as a result of primaries), and thus their political platforms do not necessarily tally with their parties’;
* with very few exceptions, only those “eager to ‘go along to get along,’ ” as William Domhoff has put it, that is, those willing to accept massive corporate donations will win a Congress seat or the presidency, a phenomenon which is obviously not just Republican, but regards Democrats as well, thus further alienating Democratic voters as well as potential ones;
* the electoral system, in joint action with the size of the US territory, stimulates fragmentation and therefore party weakness, thus resulting in lack of party discipline, a situation made even more serious by the influence of corporate interests on elected politicians.

These three elements overlap with constitutional ones, such as the rigid separation of powers: two separate Houses, elected in different ways and at different times; and an executive (that is, the President), elected by a state-based electoral college. Thus, the President is not guaranteed a majority in one House, let alone in both; or, the President might have a majority for a limited time, and then lose it at mid-term elections; or, he may have a majority for his entire term of office, but that does not guarantee party discipline or a common plan on specific issues (with Democrats being a perfect example, supporting, for instance, emancipation in the North and Jim Crow in the South). Also, the President is not even allowed to introduce bills into Congress, and therefore has to rely on Congressmen for that; and Congress is fragmented into countless committees and sub-committees, which in most cases do all the work and leave just the final yea or nay to the whole Chamber. Besides, once a bill is passed by one House, the other House will not vote on the same bill, but present its own and, after voting on it, a conciliation committee will meet to find an agreement between the two Chambers (further delaying as well as watering down legislation). Such a complicated, fragmented system cannot help becoming a prey to lobbies. The same applies to the European Union, where the system is absolutely unintelligible even to experts, and the overlapping of different bodies and levels of governance complicates things, and has paved the way for massive lobbying by corporate interests. In my book, I argue that a parliamentary system might mitigate this phenomenon. That is not to say that lobbying and compromise would disappear, far from that. In many parliamentary systems, committees are very powerful and bills are elaborated in closed committee meetings; filibuster is common practice (for example, by introducing hundreds or thousands of amendments, both within a committee or on the floor of the House, or giving endless speeches on each one of these amendments); there are coalitions and minority governments, which may slow down a government’s action, as this would need to reach compromises with its majority partners or other parties in Parliament; lobbying and electoral financing may be aggressive; and often bills have to be passed by both Houses of Parliament, although often the Upper House can only delay the passing of the bill, but not prevent it, and the government needs the confidence of the Lower House alone). After all, the existence of economic pressures on the part of powerful interests influencing the work of elected bodies is inborn to capitalistic systems, whether they are parliamentary or presidential democracies. However, when a party or coalition of parties presents a clear platform before an election, and wins a majority, and has the power to present a bill, the government’s bill, and defend it on the floor of a House wherein parties, rather than individual MPs, are the leading actors, then, things will be more clear and responsibility for failing to pass a certain piece of legislation will be more easily ascribable.

Now, Obama used to be in favor of single-payer when he was a state Senator. In a Youtube video, apparently dating back to 2003, he claimed that “I happen to be a proponent of a single-payer universal health care program. I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its gross national product on health care, cannot provide basic health insurance to everybody. And that’s what Jim is talking about when he says everybody in, nobody out. A single-payer health care plan, a universal health care plan. That’s what I’d like to see. But as all of you know, we may not get there immediately. Because first we’ve got to take back the White House, we’ve got to take back the Senate, and we’ve got to take back the House.” Apparently, he has changed his mind. Changing one’s own mind is legitimate, obviously. However, what is strange is that Obama became less and less convinced about single payer as his political career went on, first at the US Senate, then as a candidate for the Democratic Party’s primaries, and then as party nominee (source). Obama’s change of heart, however, does not sound too outlandish. Money certainly talks: insurance companies contributed with some $2.3 million for his electoral campaign, and the health sector with almost $19.5 million. In the end, Obama’s platform on health care fully reneged on what he had previously backed as an Illinois senator, that is, single-payer.

The bill’s history is particularly telling in order to show US presidentialism’s shortcomings.

When Bill Clinton was president, the business world was adamantly opposed to health care reform. Thus, Bill’s plan was knocked down even by wide sectors of his own party.

Obama’s plan, however, is not really clear, because the US presidential system does not allow presidents to bring forward a clear and final proposal, “take it or leave it or I’ll ask the President/King/Queen to dissolve Parliament and we’ll go to new elections”, as might be the case in a parliamentary system. Obama made some more or less clear proposals during the electoral campaign, sure. However, the bill, or, better, bills dealing with health care reform have sprouted like mushrooms, in different centers of power. Obama may talk to Congressmen, visit Congress in order to convince recalcitrant Democrats (as he did on 7 November, a pretty unusual move), but still, he can hardly impose his will (if he has one on the issue) on his Congress majority.

The New York Times has given a detailed account of the bill’s history.

Thus, at the end of March 2009, and with the consent of the insurance industry, concerned about the growing costs of health care, the (all) Democratic chairmen of five Congressional committees had reached an agreement on legislation requiring everyone to carry insurance that employers should be required to help pay for, and allowing the government to offer a public health insurance plan as an alternative to private insurance.

However, while House Democratic leaders introduced a bill on 14 June, “which in addition to a public plan included efforts to slow the pace of Medicare spending, a tax on high-income people and penalties for businesses that do not insure their workers,” the seven members of the so-called Blue Dog coalition, consisting “of fiscally conservative Democrats, threatened to block the House bill. After a 10-day impasse, an agreement was reached that would cut the bill’s cost and exempt many small businesses from having to provide health benefits to workers. The bill was passed by the House Committee on Energy and Commerce on July 31 by a vote of 31 to 28, with five Democrats joining all the panel’s Republicans in opposition”. The agreement still envisaged the creation by the government of “a public insurance plan to compete with private insurers, but would negotiate rates with health care providers instead of using Medicare fee schedules to pay doctors and hospitals. States could, in addition, set up nonprofit cooperatives to offer coverage to individuals, families and small businesses.”

In the meantime, the Senate went its own way, as “the Health, Education, Labor and Pension committee worked on a bill with a public insurance plan, while the Senate Finance Committee, led by Senator Max Baucus, Democrat of Montana, worked on a bill that sought to avoid one, which Mr. Baucus thought was necessary to gain bipartisan support.” The Health Committee’s proposal saw the light of day on 2 July: “employers with 25 or more workers would have to provide coverage or pay the government an annual fee of $750 for each full-time worker and $375 for each part-timer. The government would pay the start-up costs for the public insurance option as a loan to be repaid, and premiums would be set up so that the option was ultimately self-sufficient.” The bill was passed on 15 July. However, Senator Baucus introduced another bill at the end of August, which “did not include a new government insurance plan to compete with private insurers,” and, “unlike the other bills … would impose a new excise tax on insurance companies that sell high-end policies. The bill would not require employers to offer coverage. But employers with more than 50 workers would have to reimburse the government for some or all of the cost of subsidies provided to employees who buy insurance on their own.” This proposal was passed on 14 October.

In the meantime, Obama, the President and therefore Head of the government, limited himself to a speech to a joint session of Congress in September, and to the aforementioned visit to centrist Democrats on 7 November.

So, the bill was passed at the House. However, further compromises had to be reached before the House could actually give its approval. In order to assuage conservative Democrats’ fears of losing their Congress seats, it was decided that the public option plan “will have to negotiate rates just as private insurers do, rather than offering a rate set slightly above what Medicare pays,” and “the plan will also confront strict controls on abortion. After heavy lobbying by Catholic bishops, the measure was amended to tighten restrictions on abortion coverage in subsidized plans bought through the insurance exchanges, to insure that no federal money is used to pay for an abortion. Both changes angered Ms. Pelosi’s base of liberal Democrats, but they chose to support the bill nonetheless.”

What will happen next? Senate majority leader Harry Reid has already “finessed the difference between a health committee bill that included a public option and a Finance Committee bill that favored a system of co-ops by announcing that the merged bill would include a government plan that would let states “opt out.” A Republican filibuster, however, is not too remote an option, as independent Senators such as Joseph Lieberman have already announced opposition to any bill containing a public option, and support from conservative Democrats is not guaranteed. There is widespread fear that the reform will lie dormant in Congress for a long time to come.

The future of the health care reform in the US is therefore still unclear. Anything might happen: a different version might be passed, after further negotiations between the two Chambers; or the reform might even be put off till doomsday. Still, that is exactly the kind of chaos the Founding Fathers wanted in order to preserve order and stability. Whatever happens at the Senate, health care is not the first victim of US presidentialism, nor will it be the last.

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