Why was the United States So Late to Enact (near) Universal Health Insurance Coverage?

Why was the United States So Late to Enact (near) Universal Health Insurance Coverage?


Hello. I’m Drew Halfmann from UC Davis Sociology. In this video, I consider some explanations for
why the United States was so late to establish something approaching Universal
Health Care Coverage as it did in 2010. I’ll begin with a few
standard arguments for why American Welfare State Programs
are generally stingier, and cover fewer threats to income
than those in other countries. One approach focuses on national values,
which is also known as political culture. It argues that the American
values include individualism, market fundamentalism, and
suspicion of centralized authority. As a result, most Americans oppose
government solutions to social problems. This national values approach
has several shortcomings. First, it focuses on values
established hundreds of years ago, but does not explain how or
why these values have persisted over time. My only answer to that question
would be to focus on institutions. The approach also cannot explain
the enactment of policies that run contrary to these
so-called American values. For example, the policies of FDR’s New
Deal, which established old age pensions, unemployment insurance,
and aid to the poor. The national value’s approach also treats
countries like they have a single culture, when they actually have many cultures. American values do include individualism,
market fundamentalism, and suspicion of centralized authority. But they also include many other values,
such as egalitarianism, democracy, civic republicanism, constitutionalism,
populism, and sexism, racism and nativism. Lastly, national values approaches
failed to recognize that values and symbols have multiple practical meanings. Political actors work hard, and
often successfully, to mobilize values and symbols for their own purposes. Broad national values do not determine
the content of policies, but instead provide a set of cultural
resources that political actors can use to promote their favorite policies. The challenge is to understand how those
actors deploy these values, symbols, and meanings, and
how institutions, events, and policies facilitate or
hinder that deployment. Still, I don’t mean to suggest that the so called American creed was irrelevant
to American health care policy. Instead, it’s main contribution
was the institution that the American founders left behind. Political institution such as private
health care, judicial review, federalism, and weak political
parties reflect at least in part, American traditions of anti-stateism,
individualism, and suspicion of authority. Another set of arguments about
the stingy American welfare state, focuses on the strength of social classes,
labor, and capital, and the political parties
that represent those groups. Scholars have argued that the United
States has a stingy welfare state, because American business is unusually strong and
American labor is unusually weak. This is definitely part of the story. Another set of arguments, to which I’m quite sympathetic,
focuses on institutional factors. Such as political fragmentation,
federalism, electoral institutions, judicial revue, and policy legacies. In the case of healthcare, Beland and Hacker argue that the legacy of
private employer-sponsored coverage in the United States has hindered
the enactment of universal coverage. The public got used to
the existing system, and people with coverage worry that
any new system might hurt them. In addition, Weissert and
Weissert argue that the existing system of third-party payments has insulated insured
people from the cost of medical care, and caused them to expect that no expense
will be spared for their medical care. The existence of private programs
has also caused policy makers to develop limited conceptions of
the appropriate role of government. And led to the establishment of organized
interests, who defend their profits. With the growth of health care costs,
it has become increasingly difficult to buy off such interests in
such a bloated sector. The American policy legacy has
also increased the complexity of the health care issue. It is already a complex issue
because it deals with scientific and technical knowledge and change,. But the public/private
mix increases complexity, by multiplying the number of actors and
programs in American healthcare. This complexity makes it more difficult
for the public to understand whether they will win, lose, or remain unharmed
by proposed healthcare reforms. It also makes it easier for healthcare
opponents to make misleading claims. In the case of the ACA,
many elderly people believe that it would deny them care and
that it cut benefits for all Medicare beneficiary,
beneficiaries rather than some. Former Vice Presidential candidate
Sarah Palin, was even claiming that Obamacare would establish death panels
to deny expensive care to the elderly. Paul Star argues that the question
of why the United States was so late to establish universal insurance,
is actually two separate questions. First, why did the United States fail
to cover industrial workers before World War II? And second,
after insuring the elderly in 1965, why did the United States fail to
establish universal coverage through some combination of private and
public insurance. On the first question he argues that
during the progressive era, the weakness of labor allowed insurers, employers, and
doctors to dominate health care politics. During the early new deal,
labor gained strength and Roosevelt believed in active government. But he had other priorities, unemployment
insurance and old age pensions. The power of the AMA and its skillful use of anti-communist
rhetoric further discouraged action. During the late New Deal, Roosevelt had
a tremendous congressional majority. But he made the mistakes of
trying to pack the court and balance the budget,
sending the economy back into recession. He was also operating in
a politically fragmented system in which the conservative southern chairs
of congressional health committees wielded great power. Starr also focuses on the sequence of
American welfare state development. In Europe, health insurance was
enacted before old-age pensions, but in the United States,
the order was reversed. As a result, American health care
reformers made the strategic error of trying to copy successful
elements of old-age pensions, the program we call social security. Every expansion of social security added
new contributors, and this improved the programs finances, but expansions
of health care had a different logic. New beneficiaries worsened
the program’s finances. In 1965 the founders of Medicare
had avoided cost controls in order to gain the cooperation of doctors. But later reformers were reluctant
to expand such a costly program. In addition, the 1960 reform had
created two programs, Medicare for the elderly, and Medicaid for the poor. This helped create
a powerful elderly lobby and encouraged the elderly to see themselves
as more worthy than Medicaid recipients. Finally, labor unions were also
reluctant to build on Medicare, because its coverage was not as generous
as the employer-provided plans that the unions had won through
collective bargaining. Finally, those who are already covered,
whether by employers or by Medicare, came to see coverage
expansion as just another tax increase. My own approach to the question of
why almost universal coverage took so long combines several arguments. I share Starr’s focus on
the weakness of American labor. But note that the under democratization
of the South, and the fragmentation of the American political system
mattered a great deal as well. The American constitution
established federalism and the separation of power in part to protect
slavery and ward off threats from below. But once slavery was abolished, these institutions continued
to protect white supremacy. And northern Republicans aband-, I’m sorry, after northern Republicans
abandoned Reconstruction, southern planters and
their allies disenfranchised blacks and poor whites to establish
a one-party authoritarian regime. That utilized the many veto points in
the fragmented American political system to block national measures for
African-American equality. These political institutions
aided racial exclusion and discrimination, but also the defeat of
measures to promote class inequality- class equality- I’m sorry. Southern elites block unionization,
depressing wages nationally and allowing non-southern businesses to threaten
that they would move to the South. Along with Republicans, southern elites
used fragmented political institutions to defeat national measures that
increased the power of unions or expanded social welfare provision. And the national weakness of labor reduced
wages and support for full employment, macroeconomic policies, progressive
taxation and social welfare policies. I also share Hacker and
Starr’s focus on policy legacies. The development of private
employer-provided insurance and coverage for the elderly strongly
conditioned later policy-making by reducing support for reform among those
who were already covered, creating and strengthening powerful interest groups
who opposed reform, insurers and the elderly, in establishing a system
that was too expensive to expand. I also share… and Hacker’s emphasis on the power
of medical interest groups. But I stress that these groups were
empowered by the combination of a fragmented political system and
weak party discipline or cohesion. For example, the Clinton reform
attempts of 1993-94 was defeated by the combination of
interest group opposition. The power of Democratic Congressional
committee chairs and infighting among the Democrats. The key to Obama’s 2010 success was
that he bought off interest groups or persuaded them that the existing
system was untenable. In addition, the Democratic party was
much more cohesive as the result of several decades of party polarization. The development of a democratic
healthcare consensus during the 2008 presidential primaries. Finally, federalism offered points
of access and demonstration. Health reform reached the agenda
during Clinton’s presidency in part, because the come-from-behind
special election victory of Senator Harris Wofford in Pennsylvania. Who had emphasized healthcare reform,
put it on the agenda. And Massachusetts governor Mitt Romney’s
health reform was the key precedent for Obama’s proposal, though Romney
later tried to deny this was true.

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