Monthly Archives: August 2009

what the public option means about our politics

The best reason to create a public health insurance option is to increase competition in the health insurance market and thereby lower premiums. No one can know how much money a public option would save, but the idea seems worth trying as an efficiency measure.

It is being treated as much more than that–as the central battle of the summer and perhaps of the whole 111th Congress. Some liberals (an explicit example is Paul Krugman) want to show that assertive governments can do good–thereby debunking modern conservatism, which holds that governments are the problem. Passing a public option would demonstrate that a ruling majority in America today supports activist government; the success of the new policy would then increase support for such activism. As Mark Schmitt observes, the origin of the public option was not research into which policy would cut costs, but rather a political strategy to get a victory for expansionist liberalism.

For that very reason, conservatives want to defeat the proposal. Defeat would demonstrate that there is no pro-government ruling majority in America today; it would also allow opponents to argue against the evils of the public plan without the risk that it might work in practice.

This kind of proxy battle is common today. For example, charter schools are promoted by libertarians, who want to demonstrate that choice can improve quality even in an area traditionally run by the state, and by moderate liberals, who want to show that the public sector can innovate and therefore doesn’t deserve to be cut. Charter schools are opposed by some traditional liberals who think that market-type competition is overrated and who want to draw the line at the schoolhouse. The decision whether to turn a given school into a charter thus becomes an ideological proxy battle rather than a rather complex, nuanced, fundamentally local question about which governance structure would work best in each situation. (See my analysis here.)

There are advantages to ideological politics. We must simplify by applying broad principles, or else the complexity, variety, and nuance of the world is overwhelming and we cannot act at all. Voter turnout rises when there is more ideological conflict because it is easier to engage when the lines are sharply and simply drawn. Ideological strategists, such as the libertarians of Victorian England and the activist liberals of the New Deal, have sometimes achieved great things.

But the drawbacks of ideological politics are obvious: oversimplification, suppression of worthy alternatives, manipulation of voters who aren’t attuned to the ideological game, and a tendency to confuse means with ends. We see these problems in today’s health care debate. The true goal for progressives is to provide all Americans with affordable health insurance. There are crucial provisions in the main Congressional bills for that purpose–notably, subsidies for low-income Americans and regulations to protect people who have pre-existing conditions. The details of these provisions are essential. Who is eligible for how much financial support are the most important questions for poor people. They are not, however, the focus of the great national debate–for two reasons. First, poor people are not organized or influential. Second, subsidies are not an ideological proxy issue. We already subsidize health care–it’s unexciting (but very important) to propose spending more.

The public option should be a means (a mechanism to cut costs and therefore make it easier to insure everyone), but it is becoming the end because of its symbolic role in ideological politics.

Meanwhile, liberals don’t seem interested in the potential of private co-ops, if appropriately designed and funded. That’s because co-ops have been portrayed simply as a compromise between liberals and conservatives, and therefore as a disappointing outcome for those–on both sides–who want an ideological “win.”

I suspect that the health care debate is less engaging for average Americans than it should be because it has turned into an ideological proxy debate that makes most sense to the “base” on both sides. By the way, the conservative ideological base is usually about twice as big as the liberal ideological base–26% called themselves conservatives versus 15% who identified as liberals in the 2004 American National Election Survey.

I noted above that ideologies can encourage participation by providing comprehensive worldviews that make decisions easier. But only certain kinds of ideologies work for that purpose. A vital ideology needs an impressive story arc, beloved and talented current leaders, moving examples, strong networks and organized backers, opportunities for grassroots engagement, and a coherent theory. New Deal liberalism had all those, at its peak. Paul Krugman’s ambition is to resurrect statist liberalism as a movement. Maybe that’s possible, but it certainly hasn’t happened yet. Thus I am not at all surprised that most people feel left out of the ideological proxy war that is taking place among political elites and strong partisans. I am also not surprised that conservatives are winning the health care debate–it is a proxy battle, and they have more true believers. If it could be about how to provide the best possible health care for all Americans, it would be a different story.

village democracy in India

One of the most remarkable innovations in democracy comes from India, where the Constitution requires every village (but not urban areas) to have both elected councils and empowered open meetings called “gram sabhas” (GS’s). Vijayendra Rao of the World Bank and Paromita Sanyal of Wesleyan write, “The GS has become, arguably, the largest deliberative institution in human history, at the heart of two million little village democracies which affect the lives 700 million rural Indians.” PDF

Apart from the scale of this experiment, its most remarkable features are (1) the right to active participation that is enshrined in the Indian Constitution, and (2) the steps required to promote equality of gender and caste.

As the government itself explains, Article 40 of the original Indian Constitution required “that the State shall take steps to organise village panchayats [councils] and endow them with such powers and authority as may be necessary to enable them to function as units of self-government.” But there were problems with the representativeness, fairness, and power of the panchayat system. As a result, in 1992, the Indian “Constitution was amended to … provide for, among other things:

  • direct elections to all seats in Panchayats at the village and intermediate level, if any, and to the offices of Chairpersons of Panchayats at such levels;
  • reservation of seats for the Scheduled Castes and Scheduled Tribes in proportion to their population for membership of Panchayats and office of Chairpersons in Panchayats at each level;
  • reservation of not less than one-third of the seats for women;
  • devolution by the State Legislature of powers and responsibilities upon the Panchayats with respect to the preparation of plans for economic developments and social justice and for the implementation of development schemes;
  • [funding for the Panchayats from] grants-in-aid [and from] designated taxes, duties, tolls and fees;
  • barring interference by courts in electoral matters relating to Panchayats.

There must be a gram sabha in each village at least once per year, although I think that is a statutory provision and not contained in the Constitution itself. “A Gram Sabha may exercise such powers and perform such functions at the village level as the Legislature of a State may, by law, provide.” Apparently, some make substantial decisions about spending and planning.

The most remarkable impact of this reform has been to strengthen the confidence, standing, and voice of the poor, of women, and of low-caste individuals. Rao and Sanyal conclude that the “GS facilitate the acquisition of crucial cultural capabilities such as discursive skills and civic agency by poor and disadvantaged groups. … The poor and socially marginalized deploy these discursive skills in a resource-scarce and socially stratified environment in making material and non-material demands in their search for dignity.”

questions for Sen. Grassley

    “I think that he is a good person, and good-intentioned. But I believe he didn’t serve in government long enough to understand really how things work… He really does not have an understanding of how Congress operates.”

    — Sen. Charles Grassley (R-IA), in a radio interview, about President Obama.

Senator, do you think that the Congress you understand so thoroughly (having served in it since 1974) operates well? Do you think that the American people hold its processes and leaders in high regard? What have you done as a sometime committee chair and leader to improve how it operates? If you had a chance to “explain” the process to our relatively young president, would you be able to justify what you explained?

health co-ops from a civic perspective

Senator Conrad and some others are promoting health insurance co-ops as alternatives to a government-run insurance option. The liberal critique is that they would be small and ineffective competitors to private insurers, many of which enjoy quasi-monopolies. In today’s New York Times, Bob Herbert advises, “Forget about the nonprofit cooperatives. That’s like sending peewee footballers up against the Super Bowl champs.” It has also been noted that we already have non-profit health insurance options, like Blue Cross/Blue Shield, that charge high rates and dominate local markets. So the problem is not profit, per se, but the lack of competition, regulation, and accountability.

On the other hand, there is a movement that sees major potential in co-ops and other alternative economic arrangements. According to, there are 21,840 co-ops in the United States, with annual revenues of $273 billion. So this is not a marginal or amateur sector, although there are only a few significant examples in the health field.

Co-ops can be structured so that they are forbidden to move, thus addressing the problem of capital mobility that undermines democratic governance. They can also be structured so that interested citizens have opportunities to become leaders. To be sure, some co-ops end up looking exactly like regular for-profit firms, without the actual profit line. Ace Hardware is a co-op owned by the store owners; I’m not sure that makes any difference to its customers. But a health co-op could have by-laws that encouraged participation, and the federal subsidies that are being considered on Capitol Hill could be contingent on such rules. If the start-up subsidies were big enough, I doubt there would be an insuperable barrier to gaining a large market niche.

Here are some advantages of a more participatory structure:

  • People deeply distrust government, so it may be smart politics to build a more progressive infrastructure that includes mechanisms for enhancing trust, such as local ownership.
  • In numerous cases around the world, public participation has been found to reduce corruption and waste. When people have decided what to spend money on, they watch to see if it is spent as promised. When the money vanishes, they rebel.
  • Participation in co-ops would increase people’s civic skills and their expectations that other major institutions will treat them respectfully.
  • Health decisions involve complex scientific and technical issues–but also irreducible value judgments that cannot be made “scientifically.” Co-ops can include deliberative bodies that make value judgments and tradeoffs, accountably and transparently. Moreover, those decisions can be made differently in different parts of the country, thus reducing the intensity of our cultural battles. (Yet co-ops would also be regulated by the federal government to protect rights that Congress deemed essential.)
  • Co-ops could contribute to political pluralism by lobbying in the interests of their members.

Of course, “co-op” is not a magic word that solves all political and social problems. Everything depends on what the co-ops are like. But we have considerable experience now with alternative economic arrangements inside of capitalism, and we could seize on the health co-op idea to make real progress.

[As a note to my fellow proponents of active citizenship, deliberative democracy, etc.–I really think we need to drop our neutrality and start supporting policies that would enhance citizenship. If health co-ops are not the right examples, because the liberal economic critique is correct, we need to look for other openings. We can’t be for abstract procedures alone.]