POSTED RESPONSE TO A COLUMN BY CLIVE CROOK IN THE FINANCIAL TIMES
One of the key facts in understanding American health care and the lack of support for serious reform is not widely understood outside of the United States.
That fact is that under the existing regime, the comfortable middle class almost universally receives very good health care.
Those who work at good corporate or government jobs receive good to superb insurance as a benefit.
This fact effectively removes society's most vocal and politically influential group of people from the debate. In fact, it actually puts them on the side against any change: "I've got mine, and I don't want it mucked up," is genuine if unspoken thinking.
The people who suffer most are the underemployed or those consigned to lives with low-level jobs - the great majority of clerks and retail employees and people who work at service work of many descriptions. They receive either no insurance or, often, insurance which is so poor in its coverage and rules that it can be close to useless. In effect, they are hard-working people who cannot afford to buy costly private insurance and have little prospect for a change in their circumstances over their lifetimes.
Of course, there are also the tens of millions who go entirely uninsured, but many of these are young and in a sense their plight isn't as serious as the underinsured.
So the total American population is highly segmented, as it were, into groups whose political importance also varies greatly. The politically important ones are pretty satisfied with their health care. The politically less important are generally not but tend to be inert.
When politicians are doing their electioneering (even outside of health care), middle class people are pretty consistently their target of first importance. They have the money, they have the voices, and they are statistically the most likely to vote. It’s fundamental part of “the calculus of consent.”
General ethical appeals have limited claim on many of them. America is not run as a society in which ethics, apart from self-interest, play a great role in politics. This is easily observed in many phenomena, but the words used by politicians and political commentators are especially revealing in this regard. People aren’t addressed as citizens or fellows but typically as consumers in America. There is a palpable theme of Social Darwinism that surges through most public affairs.
And, of course, as de Tocqueville observed a long time ago, “I know of no country in which there is so little independence of mind and real freedom of discussion as in America.” That characterizes every national election still, and Obama’s was no exception.