• Can America ever escape rationing by “wallet biopsy”? Should it?

    This is a TIE-U post associated with Jonathan Oberlander’s Political Dynamics and Policy Dilemmas (UNC’s HPM 757, Fall 2011). For other posts in this series, see the course intro.

    [F]ew health care systems anywhere are as heavily rationed as the American. The first procedure in any health care setting is the inevitable “wallet biopsy,” a stringent rationing tool.  […]

    The American social-welfare debate focuses more on the dangers from prompting laziness than the opportunities of promoting loyalty. When new programs are proposed, they provoke the same anti-governmental reflex that shackled the government’s early development. Throughout most of the twentieth century, great cries about looming socialism accompanied the government bashing. […]

    Granting old age benefits, financing health care publicly, legitimating labor unions, legislating civil rights, fluoridating water, regulating industry, and a multitude of other policies all elicit a similar response. New forms of state authority, even those that extend narrow benefits to broad constituencies, evoke the charge that an overreaching state threatens the people’s liberty.’ […]

    It is, we are frequently told, the reason Americans have no national health insurance; it is the reason a national health scheme such as Canada’s remains “‘off the radar screen of American possibility.””

    That’s from a 1992 paper by James Morone [1]. No matter what you think about the merits of a “national health scheme,” does he not speak the truth about the nature of the opposition to one? Whether it is a threat to liberty or not, that’s the claim, no?

    And yet, as Morone explains, despite American anti-government rhetoric and tradition, government has expanded its purview, including in the very areas noted above: social security, Medicare, protecting voting rights, business regulation, and water fluoridation. Still, the limits to and limitations of government are baked in the cake. There’s a status quo or incremental bias, by design.

    Political programs must pass through the presidency, Congress, the federal bureaucracy, and then negotiate the layers of American federalism-regional governments, state government, sub-state regional bodies, counties, and local governments, each of which is divided by function. The courts intervene at every stage. To pass this gauntlet, proposed programs are typically oversold (promising all kinds of benefits to all sorts of constituencies) and, at the same time, heavily compromised.  The combination creates an often-sampled recipe for disappointment. […]

    Morone writes so well and nails so much that is true about the American political system, I can’t help but to keep quoting.

    [I]deology, institutional design, and the politics of both interests and groups all cast the same biases into American politics. Change is difficult to introduce, and the broader the change, the more difficult the task. Large scale innovations require the construction of broad coalitions among both private groups and public agencies; opponents can successfully resist in any of the political arenas through which all reform must pass. On the other hand, organized interests can far more easily win discrete benefits from legislative committees or bureaucratic agencies. The overwhelming bias is toward incremental adjustments to the status quo. […]

    What has this all got to do with rationing, however? Well, nothing exists that is not rationed. So, health care will be and is rationed. The manner in which it is so is influenced by the nature of the political forces Morone described.

    The American way of rationing is to decentralize (in political terms, hide) the choices; the result is rationing through an accumulation of narrow public policies, private decisions, and luck. Access to health care depends, most importantly, on where a citizen falls in the extraordinarily complex pastiche of health insurance programs. […]

    Insurers, in turn, influence the prospects for coverage by deciding how aggressively to manage their risk pool; the consequences range from higher premiums, to no coverage for preexisting medical conditions, to no coverage at all. […]

    The issue is not whether to ration health care. Rather, the debate is about replacing a typical American policy pattern of fragmented, hidden, and private decisions with the kind of choice our system is especially ill-geared to make-conscious, collective decisions made at the political center.

    If the American system is ill-suited to nationalized health care or even, perhaps, single payer, then it is no surprise we do not have it. Moreover, it is reasonable to ask if we should even want the American system to attempt it. Is this a square peg, round hole problem? Even if a government can be a solution, can our government ever be the solution?

    But there is a hidden assumption in the forgoing paragraph. It’s that the forces that drive American politics are static. They are not. Medicare passed. Single payer is coming to Vermont. Morone is correct that the bias is toward the status quo and incremental change. But that’s a bias, a tendency. Every so often you get an outlier. And even if an outlier is “deviant” it does not make it wrong.


    [1] James Morone. 1992. The Bias of American Politics: Rationing Health Care in a Weak State. University of Pennsylvania Law Review 140: 1923-1938.

    • Perhaps a first step to get national healthcare, like in Canada, in the USA would be to replace state regulation of healthcare and health insurance with regulation at the national level. Otherwise it seems to me that changes should be made at the state level. The difficulty at the state level is that it is too easy to move from state to state and states are more revenue constrained than the federal government. The ease of moving from state to state adds needed complexity to any system.

    • I remember vividly a conversation that I had with my father in the late sixties. I, an idealistic teenager, was hugely disappointed with the molasses-like pace of civil rights reform. And even more discouraged by the seemingly minor effect that young people had on the Vietnam War discussion. He told me that the system was DESIGNED to ensure any changes were slow and incremental. The idea was that our institutions are so incompetent that most proposed changes would make things worse, not better. Unanticipated consequences, inappropriate implementation, etc.

      I wasn’t particularly satisfied with answer, but it did make an impression on me. Living now in a very different culture (Switzerland), I still wonder if the “design” of the US system has perhaps overdone the status quo bias.