Study Guide #4
Remember when I asked you to write a memo on "what is the smallest change in American history that would have resulted in national health insurance"? For some, the answer is that the whole structure of American government would have to be changed! Sven Steinmo, for example, argues that national health insurance proposals have been doomed from the start by the fragmentation of American government. Opponents of health care reform, especially the doctors, have taken advantage of the many “veto points” in American government to block any major reforms. I think Steinmo’s argument is too deterministic and insufficiently attentive to episodes (the mid-60s, the Nixon Administration) where major health care reforms either were enacted or apparently came very close to enactment. Veto points, I argued, are obstacles, but not insuperable obstacles--under the right conditions they could be overcome. In other words I favor a more "contingent," less "deterministic" view. Judge for yourself! Oberlander is a nice bridge between the two halves of the course, summarizing some of the main themes of the first half, and introducing some of the main themes in the second half. Oberlander points to the importance of "political feasibility analysis," and that is the skill we're going to be working on in the remainder of the course. As our in-class presentations have suggested, there are many imaginable health care reforms, and many that policy analysts would consider an improvement on the current system. The trick is to figure out whether and under what conditions they can be enacted into law. So in the balance of this course we'll be sharpening your skills in political analysis.
Steinmo On what bases does Steinmo reject culturalist explanations for no NHI? On what bases does Steinmo reject interest-based explanations for no NHI? What is historical institutionalism? How is it different from, say, a culturalist approach to analyzing politics? Steinmo re-analyzes each of the episodes in American health care history that we first read about in Starr. How does a historical institutionalist approach (grounded in an emphasis on veto points) explain these outcomes? Steinmo analyzes the failure of the Clinton health care reform plan in 1994. (The article was written in 1995.) What newer features of American politics does Steinmo point to in explaining this outcome? What (radical) advice does Steinmo offer would-be health care reformers at the end of his article? Do you agree?
Oberlander reviews the three main explanations for the failure of NHI in the U.S. What are they? Oberlander says that while other nations have effectively controlled costs, American approaches have failed miserably. How does the American approach differ from that of other nations? On what bases does Oberlander conclude that proposals to expand coverage and cut costs are hopelessly unrealistic? What are the current political difficulties of modest incremental reforms that attempt to extend coverage? Why does Oberlander argue that focusing on Canada as an example for the U.S. is a mistake? What three lessons can be drawn from the history of American health care policy according to Oberlander? What (rather faint!) hope does Oberlander offer health care reformers at the end of his article? How does Oberlander's view differ from Steinmo's? Discussion Question Under what circumstances could you imagine major health care reforms in the United States? What is the likely shape of such reforms? |