From Kevin Williamson at National Review. Debating Obamacare, Again, and Again:

Because we have an election coming up, some people are shouting “Health care is a right!” while others are shouting that federal efforts to make insurance more affordable are “Socialism!” That kind of emotionally hyper-charged moralistic language almost always goes along with policymaking incompetence, and it is put forward as a substitute for thoughtful program design. It thwarts efforts to achieve consensus.

Consensus is a factor in good program design, too. Consensus is not about good feelings or being nice to the people on the other side of the aisle — it is a practical consideration, one that Barack Obama et al. were, unfortunately, too arrogant to account for in 2009. The ACA system was never going to be implemented as written, because there was no consensus supporting the program. There were partisan divisions, obviously, but there also were divisions within the party coalitions: It was Democratic interest groups, notably labor unions, that opposed the so-called Cadillac tax and other revenue-raising measures. It wasn’t Republicans in the pocket of Big Business who worked so hard to eliminate the medical-devices tax — it was Senator Elizabeth Warren, who just so happens to have a number of medical-device manufacturers in her home state. Republicans are split about having the government negotiate prescription-drug prices, reimportation, and other marketplace interventions. Even continuing Democratic control of Congress would not have saved the ACA from years of constant revision, because most Democrats object to some of what’s in it and many Democrats object to it fundamentally, preferring instead an NHS-style monopoly system. Democrats cannot even agree among themselves about whether there should be private health insurance; it is unlikely that they are going to be able to come to a consensus with more market-oriented Republicans on the matter of health insurance.

Because we have a federal system with 50 states, a federal government divided into three branches with the legislative branch further subdivided, and strong constitutional constraints on government action, it takes a high degree of consensus to get anything meaningful and stable done on big national social-policy questions. Even smaller countries with less social diversity and less robust constitutional constraints run into that problem: In Sweden, for example, is the archetypal Nordic welfare state, but it does not really have a national health-care system. It has a series of regional and municipal programs, locally administered and mostly funded with local taxes. Think about that: A country known for having effective public-sector administration and very high taxes still finds it sensible to do things at the local level, in spite of its having a population smaller than that of Ohio. It is easier to achieve a relatively high level of consensus and buy-in at the local level. That is part of the conservative case for federalism — the United States is big enough to have both Greenwich, Conn., and Las Vegas; Silicon Valley venture capitalists and Texas cotton farmers. And developing one model of health-insurance regulation, one model of education, one model of air-pollution regulation that serves the needs of all those very different communities and comports with all their social and economic priorities is close to impossible. The progressive mindset, which is trapped in an outmoded factory model of society, favors uniformity and homogeneity in policy and practice because it assumes that the economies of scale that are at work in a steel mill or oil refinery also apply to education and health care.


Healthcare does more to illuminate the divide in political ideology than any other issue. It merges the ideological and pragmatic limits of central power;  the dispersal of interests (and thus the difficulty of consensus) and the dispersal of knowledge, the ‘fatal conceit’ that any central power can know how to manage complex markets for a vast and diversified nation.  Health care challenges the authority and the competence of central power.

Another irony occurs to me.  The Progressives in the first Progressive Era sought to bust the trusts and monopolies because they feared the effect of the their concentrated power on society.  Yet they emulated their philosophy of concentrated power in the hands of the government and even replicated their structures in federal bureaucracies. FDR and the New Deal micromanagement agencies shared a disdain for the ‘wasteful competition’  of the free market, and its political equivalent, federalism.