Policy Without Politics: The Limits of Social Engineering
January
2003, Vol 93, No. 1 | American Journal of Public Health 64-67
© 2003
Vicente Navarro, MD, DrPH, PhD
The author is with the
Department of Health and Public Policy, Johns Hopkins
University, Baltimore, Md.
Correspondence: Requests
for reprints should be sent to Vicente Navarro, MD, DrPH, PhD,
Johns Hopkins School of Hygiene and Public Health, Hampton
House, Room 448, 624 N Broadway, Baltimore, MD 21205 (e-mail: vnavarro@jhsph.edu).
ABSTRACT
The extent of coverage provided by a country’s health services
is directly related to the level of development of that
country’s democratic process (and its power relations).
The United States is the only developed country whose
government does not guarantee access to health care
for its citizens. It is also the developed country
with the least representative and most insufficient
democratic institutions, owing to the constitutional
framework of the political system, the privatization of
the electoral process, and the enormous power of corporate
interests in both the media and the political process.
As international experience shows, without a strong
labor-based movement willing to be radical in its
protests, a universal health care program will
never be accepted by the US establishment.
INTRODUCTION
A DETAILED ANALYSIS OF THE literature on comparative
studies of health care systems shows a certain naïveté
in the understanding of how a country’s health
care system comes about. Most authors tend to
analyze and describe the differences among health
care systems, trying to learn the good and not-so-good features
of each system and drawing conclusions about the need to
copy the positive features and reject the negative ones. Health
care systems are thus conceptualized as machines and organizations
consisting of different components that can be exported
to other countries. In these social engineering types of
studies, not much attention is paid to the political context
that determines the nature of health care systems.
The historical and political roots of health care systems
are rarely analyzed. And when they are, the
analyses tend to assume that health care systems,
at least those in democratic societies, are the
outcome of people’s desires. In other words, the health
care systems in democratic societies are supposedly the result
of what people express through their democratic institutions,
such that every country has the health care system that
the majority of its people chooses.
THE "DEMOCRATIC"
TRADITION
The best-known historical analysis of US medicine, that is,
Paul Starr’s Pulitzer Prize–winning The Social
Transformation of American Medicine, concluded
with the statement that "the future of
American [by which Starr means US] medicine depends on
the choices that Americans [i.e., US citizens] have still
to make."1
In this reading of our democratic process, Starr makes
the following assumptions: (1) popular values (and the choices
they determine) generate the policies developed by the US
government; (2) US political institutions are truly
representative of popular wishes; and (3) US public
policies (including the funding, organization, and
regulation of medical care) respond to popular
mandates.
What is remarkable in this uncritical reading of the
democratic process of the United States is that it
is constantly reproduced by the country’s
dominant means of information and persuasion that
define "the conventional wisdom," despite the robust
empirical evidence that challenges all three of
Starr’s assumptions. Actually, most US citizens
(whose wisdom is derived from their own experience
and perceptions) would question each one of those assumptions.
According to most polls that have asked people’s opinions
about their government, the majority of respondents believe
that US political institutions are not representative of
the overall population and that US public policies are a result
of the influence of major economic and financial interests
for whom the specific policies are being developed.
The evidence for popular distrust of US government is
overwhelming. And the perception that US democracy
is not working satisfactorily is widespread.
Democracy is indeed limited in the United States—and
so is its welfare state. Navarro and Shi
have shown that among developed capitalist
countries, there is a clear relationship between
the degree of development of the country’s democratic process
(and the power relations in that country) and the expansion
of its welfare state, including its health services.
THE LIMITATIONS OF US
DEMOCRACY
The United States, the only developed capitalist country whose
government does not guarantee access to health care as a
right of citizenship, has an underdeveloped
democratic process, rooted in the US Constitution.
In spite of its excellent opening—"We, the
people"—the Constitution establishes a political system
that seriously excludes (even today) large sectors of
our population. Indeed, owing to the allocation of
2 senators for each state (regardless of how
populous the state), we have a situation in the US
Congress in which half the US population (the half that
resides in the most progressive parts of the country) is represented
by just 18 senators, while the other half (primarily in
the conservative states) is represented by 82 senators. This
situation makes "the US Senate one of the most
under-represented legislative bodies in the
world," as it was recently put by Professor
Robert Dahl, former president of the American Political Science
Association.
Moreover, the majority system of the electoral process in
the United States (in which "the winner takes
all"—that is, gets all the seats) preempts
the possibility of establishing new parties
(besides disenfranchising those voters who chose the
losing candidate and thus do not have any representation),
as occurs in proportional systems.
Further limiting the democratic potential of the
country’s representative institutions, the US
political process is the only one among Western democracies
that is privatized—that is, the funding of political
parties and candidates is primarily private, giving
enormous power to those who finance the process.
Most of this funding comes from major economic,
financial, and professional groups, who hold a
disproportionate influence in determining public policies.
All these factors (the nature and funding of the US
political system), plus the limited diversity of
the US media (clearly tilted toward conservative
biases), lead to the conclusion that US democracy
is one of the most limited democracies among the developed
capitalist countries. This is why the United States is
the only major country without a national health program.7
THE
INTEREST GROUP TRADITION
Because of the clear limitations of the complacent and
uncritical view of US democracy that claims that
the lack of a national health program is based on
popular opinion and choice, another school of
thought has arisen that roots the absence of a national health
program in the different levels of influence of various interest
and power groups over the executive and legislative branches
of the US government. These types of analyses have produced
very valuable information, especially the journalistic accounts
of who pays for whom in the political process (what we
may call the "hanky-panky" of politics).
There are many books and articles on this "power
group" type of analysis. Among the classics is
that by Marmor;
within the radical tradition, the best known is by
Ehrenreich and Ehrenreich.
What these analysts miss, however, are the structural
elements that configure the political context in
which these various influences occur. In other
words, the members of these interest groups are
also members of a class, a race, and a gender that define
the context in which political interactions take place. It
would be wrong, for example, to try to understand the health
policies of a country like South Africa during the
apartheid regime—in which race was a foremost
category of power—by looking only or primarily at
the influence on the South African government of
the pharmaceutical, insurance, hospital, and other interest
groups. Obviously, these interest groups should be analyzed
within a political context in which a critical group—the
White race—historically wielded enormous power over
another group—the Black race.
Similarly, it is limiting to study the health policies of
the United States by looking primarily or
exclusively at the power of interest groups in
shaping these policies. However powerful these
interest groups might be, they still operate within a context
in which class power, as well as race and gender power, has
an even larger influence. These power relations determine
the context in which interest groups interact and
influence the US government.
Indeed, the limited degree of democracy in the United
States and the absence of a national health program
are the consequences of the enormous power of what
in the United States is called the corporate class
and in other countries is called the capitalist class.
If we arrange countries along a spectrum, with at one pole
"capitalist-friendly" countries, in which the
corporate class is very strong, and at the other
pole "worker-friendly" countries, in
which the corporate class is weak and the working class
is strong, we find that the latter countries have
comprehensive, universal health care programs and
the former have weak, limited health benefits
coverage.
Countries where the working class is strong (with strong
unions and long periods of government by social
democratic parties) and the corporate class is
weak, such as the Scandinavian countries, have
national health systems that tend to be run by the counties
and municipalities. In these countries of social
democratic tradition (Sweden, Norway, Denmark, and
Finland), social democratic parties have governed
for most years during the period 1946 to 1998. An
average of 70% of the labor force is unionized, with
highly centralized and powerful unions negotiating collective
bargaining agreements (which cover almost the entire
labor force) with employers’ associations.
These worker-friendly countries are also those with large
public social expenditures (31% of gross national
product [GNP]) and a large percentage of public
employment in the health care, education, and
social service sectors (18% of the adult population work
in these services). These countries have highly redistributive
public policies, the smallest wage differentials and
family and household income differentials, and the
least poverty.
The worker-friendly countries are also the most
womenfriendly. Consequent to the social democratic
commitment to equality of the sexes, women are
provided with family supportive services, such as
child care and home care services, that enable them to
combine their family and professional responsibilities. As
a consequence, 70% of women are in the labor market.
Moreover, there is an effort to change gender
roles, such that men are educated in traditionally
defined women’s roles and vice versa. For
example, men spend on average 16 hours per week performing
family chores, and while there are still differences
(women spend on average 22 hours on family chores)
that need to be corrected, the differences are
minor. The worker-friendly countries are also those
with greater public coverage of medical and social care,
greater public employment in health care, and lower infant
mortality rates.
At the other pole of the class power spectrum is the United
States, the least worker-friendly and most
capitalist-friendly society. In the United States,
the working class is very weak and what is called
the corporate class is enormously powerful. The
latter class has a dominant influence in the US Congress and
media (and academia). Only 14% of workers are unionized, and
less than 20% of the labor force is covered by collective
bargaining agreements negotiated by trade unions. Labor
rights are very limited. Social public expenditures are low (14% of GNP),
public funding of health care is low (5.1% of GNP),
and public medical care coverage is also very low (48% of
the total population). Wage, household, and family income
differentials are very high, and poverty is also very
high. The United States also has the highest infant
mortality among the developed capitalist countries.
The private, employer-based type of health insurance in the
United States was a result of the Taft–Hartley Act of
1947, which forced the working class and its unions to
bargain with their employers for their health
benefits coverage. The act forbade the US working
class from acting as a class by making sympathy
strikes illegal—forcing them instead to act as an
aggregate of interest groups. The huge variety and irregular
coverage of health benefits in the United States is
rooted in the enormous power of the corporate class
and the disaggregation of the working class and
popular social movements. In the absence of class
mobilizations, the social movements tend to focus on age,
race, and gender rather than on class, weakening their own
impact. The United States, for example, has a seemingly very
powerful elders’ group, the American Association of
Retired Persons. Yet, lacking a social democratic party and
movement that could relate this elders’ movement with
other sectors of the working and middle classes, the
elderly in the United States are less protected by
health benefits than are those of other
democracies—where elders may not have a special
association but do have strong labor and class-oriented social
democratic movements.
Similarly, the United States has a very strong feminist
organization, the National Organization for Women.
Yet the system of family-oriented public services
is much less developed than in countries with strong
labor and social democratic movements. In the United States,
the disaggregation of the rebellious forces is their major
weakness. This is why the United States will not have a
universal health care program until a strong labor and social
democratic movement develops that can push for this
objective.
Occupying an intermediate place on the class-power spectrum
is the Christian democratic tradition (or conservative
tradition rooted in the Christian tradition). In
this tradition, the welfare state, established by
Bismarck, was based on an insurance system in which
health benefits coverage, for example, was based on contributions
from employers and workers into social security trust
funds that paid for health care. Since the health care benefits
depended on the contributions of employers and workers, these
countries (Germany, France, the Netherlands, Belgium, and
other continental European countries) did not provide
universal health benefits coverage, nor was their
coverage the same for all insured people. Only the
pressure of labor or social democratic parties
forced a change to the comprehensive, universal coverage that
now exists in these countries.
CONCLUSION
From this understanding of our realities, it appears that
unless a better balance between the corporate and
working classes is achieved in the United States,
the country is most unlikely to adopt the principle
of universal health care benefits. It is erroneous,
therefore, to look at our realities from a social engineering
perspective, analyzing what we can learn from specific features
of other health care systems without looking at the political
contexts that shaped those systems.
The maximum expression of this erroneous social engineering
approach appears in Putnam’s latest book, Bowling
Alone, in which he makes the extraordinary
claim that the major reforms that took place in the
United States during the Progressive Era were the
result of the great foresight of elites who realized the
importance of what he calls "social capital" for
building up cohesive communities.
Putnam bases social change in the existence of
enlightened social engineers, completely ignoring the
enormous class pressures of that time from major labor
rebellions and agitation (and from women in the
suffragette movement). (See reference
for a critique of Putnam’s thesis.)
Change in the United States has taken place as a
consequence of enormous struggle. Further change
will occur only with large mobilizations (similar
to the Civil Rights movements of the 1960s) to
force change. Such change can start in one state—as it
did in one Canadian province under pressure from a social
democratic movement that later became a social
democratic government—and then extend to other
states. And in this mobilization, the labor movement
will have to play a major role. I am not minimizing the
important role of progressive professionals in providing valuable
information and support to these movements. But the most
important historical lesson is that without a strong,
labor-based movement that is willing to be radical
and outrageous in its protests (as in Seattle, with
the antiglobalization mobilization), the principle
of universal health care will never be accepted by
the US establishment.
Footnotes
Peer Reviewed
Accepted for publication September 10, 2002.
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