Why U.S. Health Care Reform Is So Difficult

Health care reform now heads the U.S. domestic agenda, but this generation of policymakers may be less successful than its predecessors in effecting major changes. The president wants universal coverage and a wider array of services. Key members of both parties, such as Senators Dole and Moynihan, resist anything so grandiose. "Yes, there are problems," declared the Republican congressional leadership. "But there's not an emergency that requires a complete overhaul of the medical system."[1] The current debate pits visions of justice and fairness against fears that reforms may prove more costly and cumbersome than maintaining the status quo. Promoting "the general welfare" is tough in a country where progress is measured incrementally. Advances occur in fits and turns, watersheds" alternate with retrenchments. "The two parties which divide the state, the party of Conservatism and that of Innovation are very old.... Reform is affirmative, conservatism negative," Ralph Waldo Emerson observed in 1841. "The Conservative assumes sickness as a necessity, and his social frame is a hospital.... Reform converses with possibilities, perchance with impossibilities." In this dialectic, "Innovation is the salient energy; conservatism the pause on the last movement."[2] Reformism's ebb and flow was not a uniquely American characteristic; liberals fought conservatives everywhere. But Emerson claimed that U.S. politics had generational underpinnings. Fresh ideas came from new blood, from reformers surmounting old ways and vested interests--"rest, conservatism, appropriation, inertia; not newness, not the way onward."[3] Partisan battles here were ideological, waged by forward-looking members of a rising generation against the elderly guardians of the established order. Sometimes, of course, members of the same cohort represented the interests of innovation and conservatism. Debating among themselves a generation earlier, for instance, the Founding Fathers wrestled with how to balance the creative policy recommendations advanced by leaders coming into their own and the prudent voices of those who valued the steady hand of tradition. From the late 1780s until his death, Thomas Jefferson stressed that each generation had "the right to direct what is the concern of themselves alone, and to declare the law of that direction ... to make the Constitution what they think will be best for themselves." Jefferson wrote in a letter in 1816 that the Constitution should make provisions for its own revision every nineteen or twenty years, "so that it may be handed on, with periodical repairs, from generation to generation, to the end of time."[4] James Madison, in contrast, stressed the importance of continuity in transferring rights and responsibilities from generation to generation. "There seems then to be a foundation in the nature of things, in the relation which one generation bears to another, for the descent of obligation from one to another," Madison wrote to his neighbor at Monticello in 1790. "Equity requires it ... [and] good is promoted by it."[5] Given humans' innate capacity for selfishness and opportunism, Madison relied on "traditional" conventions--instilling a sense of duty in the citizenry, honoring contracts that were legitimately made by representative governments--to dilute the naivete of political neophytes and to mitigate the establishment's abuse of power. At still other critical moments in our history, U.S. politicians have muted inter- and intragenerational disagreements over policy differences. Lawmakers in the depths of the Great Depression emphasized that "relief, reform, and reconstruction" actually offered the best way to preserve the core of the American experiment. Thus, in bringing together experts to draft social security legislation, Franklin Delano Roosevelt declared: Our task of reconstruction does not require the creation of new and strange values. …