Featured Post


If you're a student looking for syllabi, click the "Academic Home Page" link on your right, and start there.

Monday, March 22, 2010

On Health Care, Parliamentary Democracy, and the Tyranny of the Majority

Lots of excellent "Day After" thoughts out there, as the final hurdle in the way of establishing some kind of (still too minimal, still private-insurer-based, still poorly funded...yet still, I think, very much worth passing!) national health coverage system retreats into history. I am intrigued by Jacob's idea here (will the positive freedom enabled by the greater security provided by health care reform weaken other forces which similarly push for security against the free market?), Matt's observation here (by standing on their principles and refusing to compromise whatsoever, are the Republicans the unsung heroes of pushing the Democrats towards comprehensive reform?), and Ross's question here (will health care reform will turn out to be the last peak liberal egalitarianism will be able to climb before an era of global retrenching forces a long, slow, climb-down?). All are worth reading. But let me focus on something which comes up on Megan McArdle's and Laura McKenna's blogs.

Has the long and often ugly struggle over health care reform in essence made our national government (or at least Congress, or at least the Democratic party) more parliamentary? Megan thinks so:

Are we now in a world where there is absolutely no recourse to the tyranny of the majority? Republicans and other opponents of the bill did their job on this; they persuaded the country that they didn't want this bill. And that mattered basically not at all....I hope Obama gets his wish to be a one-term president who passed health care. Not because I think I will like his opponent--I very much doubt that I will support much of anything Obama's opponent says. But because politicians shouldn't feel that the best route to electoral success is to lie to the voters, and then ignore them. We're not a parliamentary democracy, and we don't have the mechanisms, like votes of no confidence, that parliamentary democracies use to provide a check on their politicians. The check that we have is that politicians care what the voters think. If that slips away, America's already quite toxic politics will become poisonous.

This is, to be blunt, stupid. Laura knows it:

Not everything that gets passed in Congress needs to be bipartisan. This vote represents a major failure of the Republican party to come up with a better idea for how to deal with rising health care costs and how to deal with the millions of uninsured Americans waiting in line in emergency rooms across the country. With the lack of policy imagination, all they had left was a "no" vote and that's what they did. It was the cowardly way out of this problem.

That's all that really needs to be said...but I like to talk, so let's pick apart Megan a little bit more. First "lie to the voters, and then ignore them"? The first part is simply false; while obviously the sausage-making process which is legislation has contorted the promises and specifics which many people, both Democratic and Republican, debated regarding health care reform over the past year, President Obama's basic intentions were laid out from the very beginning of his campaign. No one doubted that this was going to be a priority of his (and of Pelosi's and Reid's) from Day One. As for the second part...ignore which percentage of voters, at what point, regarding which issue? The best measurements suggest that the opinion of the American people in regards to the specific bill voted on last night breaks down at about 50% opposed, 42% in favor. A significant difference, but not a huge one--and moreover, a difference moderated by the fact that increasing awareness of the bill's specific provisions increases its popularity across the board.

Second, Megan seems to do be making use of a strange double-standard here. On the one hand, we clearly do not have a direct, plebiscitarian democracy in the U.S.; we have an indirect, representative one. Political representatives obviously should be expected to attune themselves to the will of their constituents, but--as Megan herself notes--we do not have the structural mechanics in place for voter approval or disapproval to be directly (or, at least, more directly) rendered via popular party actions like votes of no confidence. All we have are, well, elections--the most recent one of which gave the Democratic party enough votes (though just barely) in both houses of Congress to push through their agenda. But, on the other hand, Megan seems to consider this "tyrannical," and attacks the Democratic party's rule by majority as failing to "care what the voters think." Does she actually want our system of government to be a direct and plebiscitarian one? Because, if she does, the types of reforms that would make it so are...parliamentarian, with the pursuant lessening of the power of the Senate and its filibuster, the very thing which most slowed health care reform down (and forced strange compromises in it) in the first place. I could, perhaps, get on board with that.

In a recent discussion on Front Porch Republic, talking again about the possibility of "Red Tory" ideas here in the U.S. in connection with Phillip Blond's visit, one commenter observed that those who really want to see a more subsidiarian and communitarian politics emerge in America ought to note that "Front Porch or Red Tory principles are more congruent with parliamentary rather than presidential democracy, with coalitions rather than majority rule, and with variable decentralisation based on subsidiarity rather than rigid federalism." I agreed, commenting that parliamentary democracy is one way of bringing to life certain populist democratic principles: namely, that "that people can form coalitions, that coalitions can create majorities on appropriate levels of government, and that said majorities ought to be able to rule...Parliamentary democracy arguably strikes a better balance between the needs to respect individual rights and to empower majority coalitions than does our own separation of powers system." Now, to be sure, the great bulk of those (at least in American history) who have styled themselves as "populists" have not spoken a parliamentary language. But the overlap is, I would argue, undeniable: the populist demand for local empowerment against distant entities invariably involves an expectation of democratic accountability and responsiveness--that a majority of people can rightly control their government, express their views, and defend their places through collective action....such as a coalition of those being rendered insuranceless because of pre-existing conditions and their sympathizers demanding access to insurance markets, perhaps? Some people, of course, might call that "tyranny of the majority"; I wonder if it would have been the sort of tyranny (a tyranny much more responsive to "what people think," such as what they thought when they elected the health-care-reform-supporting Barack Obama over John McCain by 53% to 45%--which, interestingly, is about the same percentage spread over health care approval today--in the first place) that Megan would have been more approving of.

The United States of America, with its size, its consolidated and corporate media, and its atrophied party system, is arguably not particularly well suited to parliamentary rule; very likely any such reforms would, in our present socio-economic and geo-political context, simply result in a change in the structure and nature of political representation, not make our representatives markedly more democratic. But still, it would be more direct; it would be more responsive, and more accountable, to "what voters think." If Megan thinks the lack of direct plebiscitarianism in our democracy, and the ability for an elected majority to pass laws in the face of an up-to 8% point range in relative popular disapproval--if, that is, she thinks the lack of a parliamentarian democratic attitude amongst our representatives--is a serious problem, there is a easy way to fix that: embrace parliamentarian reforms! But somehow, if the matter involves legislation she doesn't like, I suspect Megan would find "tyranny" in that as well.

[Update, 3/23/10, 3:57pm CST: Nate Silver runs down 14 different arguments which people like Megan make to argue that there was something "tyrannical" about the passage of the health care bill; I don't agree with all of this comments, but his last one, #14, is dead-on accurate, not to mention specifically germane to this post here:

[W]ere the Congress closer to a direct democracy--such as by having proportional representation of Senators, non-gerrymandered congressional districts, and a norm for majority-rules procedures in the Senate [in other words, needless to say, if it were more...parliamentarian!]--health care reform would have been signed into law months ago and would likely be substantially more liberal and sweeping than the reforms that have in fact been enacted.]


Jacob T. Levy said...

I wish to clarify that the normative spin Russell gave to his paraphrase of my post represents his sentiments, not mine. *I* was offering possible *good* news. :-)

Russell Arben Fox said...

Was I that obvious, Jacob? Perhaps I was. My apologies...

Jacob T. Levy said...

Yes, but no apologies necessary. It made me laugh-- though it also made me feel slightly dirty for having had an idea that even *could* be rewritten like that.

Anonymous said...


But wait Russell, you forgot to note the stupidity of Laura's comment and thereby missed out on half the fun.

Her recitation of the all too common tripe that Republicans failed to come up with health care alternatives leads me to believe one of two things: either her ignorance stems from the sad fact that she has no internet access (free internet for all, anyone?), or she is simply not interested in informing herself of the actual facts. A simple Google search, for instance, could have zapped the following Republican bullet points on to her very own monitor in nanoseconds:

-- Let families and businesses buy health insurance across state lines;
-- Allow individuals, small businesses, and trade associations to pool together and acquire health insurance at lower prices, the same way large corporations and labor unions do;
-- give states the tools to create their own innovative reforms that lower health care costs (I'll give you the fuzziness aspect of this particular point);
-- End junk lawsuits that contribute to higher health care costs by increasing the number of tests and procedures that physicians sometimes order not because they think it's good medicine, but because they are afraid of being sued.

My favorite part of Laura's comment, however, was her bit about Republican failure to "deal with the millions of uninsured Americans waiting in line in emergency rooms across the country." Someone should have given Laura a heads up that insured Americans always have and will continue to have wait in line in emergency rooms. Insurance coverage is not a fast track ticket to the doctor's office. This oversight is particularly egregious in her emergency room example, where Laura failed to understand that uninsured Americans already had access to emergency rooms.

But to her credit, Laura is dead-on that everything needn't be bipartisan in Congress. And that is exactly what happened here. The Democrats didn't care what measures the Republicans pushed forward, because they didn't need to. They had the votes and that was all that mattered.

"It was the cowardly way out of this problem." Someone please pass the bowl.

mak said...

I want to add something important to those who think that "access" to an emergency room means the same thing as access to health care. Emergency rooms are only required by to perform emergency care. The details of what this means vary from place to place, but if you have a chronic health problem, or something like cancer, you aren't likely to get good treatment through your ER. You certainly can't show up for chemo there.
I will say that the worst time in my life was when I had cancer and was uninsured. Try finding anyone who will take you, even if you have money. Oncologists' receptionists couldn't hang up fast enough when I said I was "self pay." Ultimately I had to wait 5 months for a social worker to get me in for self paid treatment. I hate to think of what would have happened if I had no money. It also cost me more, as the treatment had to be more extensive due to the delay.

Anonymous said...


"I want to add something important to those who think that "access" to an emergency room means the same thing as access to health care."

Yes Mak, this is true, but no one ever said access to an emergency room is the same as access to health care. This is a misinterpretation. The point is that insureds had access to the emergency room in the same way that uninsureds had access to the emergency room. And each party had to wait in line. The health care bill doesn't change this. It was just an illustration of the "stupidity" of her comment because she chose a poor example.

If she wanted to draw a distinction between insureds' and uninsureds' access to office visits or to ongoing specialist treatment for chronic pain, that would have been another story entirely. But sadly, she didn't.

Russell Arben Fox said...


Who is "WJ"? William Jennings? I'm honored, but not worthy.

Your list of "Republican bullet points" seem to me mostly to be issues where there was no compromise available, because the Democratic plan already incorporated essentially the same idea as the listed point, only under a different name (for example, through the health insurance exchanges), or because the point isn't really a reform idea at all, but rather some fuzzy boilerplate that sounds good but just wasn't actionable in regards to policy. The one point I'll grant has real force is the lack of any kind of real tort reform in the final HCR bill. I think the claims made on behalf of the costliness of lawsuits is overstated myself, but I recognize its importance, and even an establishment liberal like Tom Daschle (who, at one time, was slated to lead the administration's reform effort) thought that two needed to go together. So it's a shame that the Democrats never gave it serious thought. But the answer as to why they didn't goes right to the heart of the post: the Republicans were playing a filibuster-everything, all-or-nothing game. Since there was, in the end, no real chance of picking up Republican votes, what incentive did the Democrats have to alienate trial lawyers, one of the their biggest donor bases?

The Democrats didn't care what measures the Republicans pushed forward, because they didn't need to. They had the votes and that was all that mattered.

As I said, in the end, that was the case--and as that's what our particular democratic rules allow, it's wrong to call it tyranny as Megan does. But even your comment seems to imply some disrespect or dislike for the Democrats' procedural choices...which, if true, suggests that your are forgetting about the months spent by Senator Baucus and others in the spring and summer of 2009, desperately trying to come up with something that Republicans would be willing to claim partial ownership over. It's not as though the Democrats didn't give the Republicans a chance.

Aloysius said...

A worthwhile link: http://reason.com/blog/2010/03/22/should-glenn-instapundit-reyno

Aloysius said...

Pay special attention to the comments on that link.

Anonymous said...

"The point is that insureds had access to the emergency room in the same way that uninsureds had access to the emergency room. And each party had to wait in line. The health care bill doesn't change this. It was just an illustration of the 'stupidity' of her comment because she chose a poor example."

This strikes me as poorly connected to the world we actually live in. I recently drove my stepson to the emergency room because he had a kidney stone. He had no insurance. So he leaves the hospital a few hours later hopped up on pain meds, with a prescription, and with the little kit they give you to strain your urine for when the stone passes.

And he gets a bill in the mail for $8,000.

Now, in the intervening weeks he hasn't passed his stone. Occasionally he gets the pain again, and he more-or-less rationed out his pain meds so he could take one when it comes back.

He could of course go back to the hospital. They discussed the surgical option with him the first time he went.

But that doesn't seem like much of an option to him because he feels like a few hours there equals years of crushing debt.

Of course, that calculus depends on whether someone is planning to pay the bill. If you're not, however, you may be dealing with collectors, your credit destroyed, perhaps bankruptcy.

With those kinds of looming consequences, I don't think it's quite right to say access to the emergency room is the same.

Clark Goble said...

Jacob, I think what Republicans never offered a serious proposal on was how to deal with the uninsurable. i.e. those with pre-existing conditions that make health care practically unaffordable. The typical approach is to either pretend the problem doesn't exist or else shrug the shoulders and say, "thems the breaks."

That said I think there are some fantastic conservative solutions to health care. Too bad Republicans never embraced them.

Further, as many have pointed out, there's really not a lot of difference between Obama's plan and Romney's. Romney's opposition once again comes off as purely opportunistic. Unfortunate given how frequently Romney comes off as opportunistic. (Sad, as I once had high hopes for him - even sadder because he still remains the best Republicans are offering for the Presidency)

Aloysius said...

I too am disappointed with Romney but Obama, Biden, Pelosi and Read could stand on shoulders four deep and never reach the little toe of Mitt Romney. That isn't praise for Mitt Romney.

Jacob T. Levy said...

Clark, why's that comment addressed to me?

Clark Goble said...

I think I just misread who wrote the comment. Sorry.

Unknown said...

I will note that I thought "lie to the voters, and then ignore them" was exactly right; Obama campaigned strenuously against a mandate, which is a key feature of this plan.

Unknown said...

OK, I want my name with my comment. That's SamChevre above.


Russell Arben Fox said...

SamChevre, thanks for commenting here. It's always a pleasure to read your stuff at CT and elsewhere.

I thought "lie to the voters, and then ignore them" was exactly right; Obama campaigned strenuously against a mandate, which is a key feature of this plan.

I will grant you that if you really can reduce the Patient Protection and Affordable Care Act--or more relevantly to this post, if you can reduce President Obama's own explanations of and justifications for, and Megan's consequent complaints about and disagreement with, the Patient Protection and Affordable Care Act--entirely to the matter of the individual mandate, than your conclusion is both completely accurate and entirely on point. However, because I do not think you can so reduce things (and I seriously doubt either Obama or Megan would agree that you can so reduce things), I'd have to say you're in the wrong here, Sam.

Barry DeCicco said...

Jacob (referring to Megan McArdle): "This is, to be blunt, stupid. "

Jacob, Megan isn't stupid; she's a liar. She spent months writing about the efforts to pass this bill. Anybody who made even a casual honest effort to keep track of this struggle was aware that we didn't have a 'tyranny of the majority'; there were multiple choke points which needed to be passed in the Senate, choke points where Senator A, from small state B, bribed by special interests C, could and would stop things until paid off (or his special interest paid off).

Second, Megan was largely a gloating Bush supporter during his administration; she not only had no problem with 'tyranny of the majority', but was comfortable with 'Bush is president, so STFU'.

Jacob T. Levy said...

It was Russell, not me, who wrote the line about "stupid."

Russell Arben Fox said...

Thanks right, Jacob. Sorry I didn't correct Barry's misreading sooner.