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Commentary: Political systems help explain why U.S. has limped along on health care

This article first appeared in the St. Louis Beacon, Aug. 10, 2009 - Why did Britain adopt a National Health Plan in 1948? Why hasn't the U.S.? Taking into account that the British are less afraid of large government and have not reified the private sector, a large part of the answer comes down to form of government. Although Britain and the United States are both representative democracies, each functions according to very different rules. These rules affect how political parties operate and the degree of difficulty in adopting new programs.

The Labor Party came to power in Britain during the last days of World War II. Labor sponsored plans for a welfare state that had its root in measures adopted in the 1910s and 1920s and was rooted in the Beveridge Plan for comprehensive social insurance (to read a 1942 commentary from the Guardian on the plan, click here .)  and the wartime coalition's 1944 White Paper on national health insurance. The ravages of the Great Depression and the world war, which touched civilians and combatants, may have made such measures desirable.

British political parties adopt their strategies and choose their leaders in annual conferences. Voters there select someone from their district to represent them in Parliament. The party garnering the most seats names the prime minister who then selects a cabinet. The prime minister and the cabinet are all parliamentary members. Because of what is known as party discipline, all Labor members would vote for Prime Minister Clement Attlee's health plan in 1948. In fact, any program he and his cabinet agreed to would be adopted. Britain's is a strong party system. Leaders of the national party -- Labor or Conservative -- select which candidate will run from which district. The national party also fronts the lion's share of election costs.

In the United States, political parties are not strong. Leaders do not select candidates and may assist in election costs but by far do not pay most of the freight. Parties were weakened here by Progressive reform, which introduced direct primaries, now used for almost every office, and the growth of interest groups. Separation of powers further weakens party strength. The presidency and the two houses of Congress do not move in unity. Congress is well aware of its prerogatives and does not take direction well.

Members of Congress and senators function as individuals. This is not to say that critical numbers cannot join together, but it has been difficult to adopt change-of-course measures such as civil rights or, currently, health care. Legislators have to raise their own campaign funds and frequently benefit from the largesse of interest groups such as insurance companies. (The Washington Post reported on August 31 that blue dog Democrats had received sizable contributions from insurance companies.) Their principal desire is re-election so they look to sentiment in their district or state as well as likely sources of campaign funds. Political scientist James Q. Wilson compared the American policy-making process to a barroom brawl that is never fully decided. On the other hand, Britain has a prize fight and the winner -- in the late 1940s Labor -- takes all.

Given the inherent systemic difficulties in legislating major change in the United States, it is a wonder anything of consequence is adopted at all. Some seasoned observers wonder if there ever could be a national system of health. The rules of the political game do make a difference and such rules clearly contribute to our being 61 years behind the British and the rest of Western Europe, which quickly adopted its social welfare measures after the Second World War.

Weak political parties and fragmented power as well as powerful interest groups have been strong factors as the United States failed to move toward universal health care in the 1940s, the 1990s and perhaps today. Policy adoption today is further affected by a 24-hour news cycle and blogging on the Internet, which can give rise to rumors that alarm the populace. Television advertising by any manner of groups can play a role as can direct action by political groups. All contribute to the barroom brawl atmosphere.

Lana Stein is a professor emerita of political science at the University of Missouri at St. Louis. 

Lana Stein is emeritus professor of political science at the University of Missouri-St. Louis. She is the author of several books and journal articles about urban politics, political behavior and bureaucracy.