Friday, July 28, 2017

Twitter Politics: Health Care and Being Voted Off the Island

I was going to begin this post by saying that at least American politics is interesting but it really might not be. I suspect it is interesting both to the partisans of American politics and to those interested in the changing character and nature of US public life. In a previous series of blogs, I tried to suggest that one should avoid the pro/con dialogue on Trump in favour of an analysis that looked at what his rise (and I would have said this whether or not he "won" the presidential election) told us about the changing nature of US politics. I suggested that it said something about: the nature of American Christianity, the public culture of economics in the US, and disturbing trends in the increased legitimacy of racialized politics. Trumpism, in other words, benefited from a series of cultural changes that overtook a section of the US population.

A year later I see no reason to change my mind. The recent debate over health care and the tweet regarding trans-gendered people in the military epitomizes these changes and the culture that upholds them. What do I mean?

Before getting into that I should say that I am no expert on the United States or American politics and I think this is an important consideration. Canadians can find it all too easy to look across the border and make quick comments about the bizarre and retrogressive character of American politics. The fact that this retrogressive character actually seems to be ringing true lends some force to these comments. But, we also need to understand why Canadians make these comments on a regular basis when, in fact, they are often preaching to converted. This can be the subject of another blog. For now, it is a warning.

Instead of criticizing Trumpism, it is important to understand it, at least from an academic point of view, because that is what we do. Our analysis should strive for the same level of nuance, care, and precision that we bring to other analyses. That is: instead of simply dismissing Trump and his politics, we need to grapple with what motivates them. (I fully concede, too, that sometimes what motivates these politics can be disturbing.)  In this light, what is going on?  Let's take a quick look at healthcare first to illustrate what I am arguing is a broader trend.

The debate over health care illustrates a disjuncture between reality and discourse that pervades part of American public life. Make no mistakes about it. The Republicans will eventually get rid of Obamacare. It has not been saved. By this time next year millions of Americans will be without healthcare insurance and those that have it will be paying higher premiums. The Affordable Healthcare Act has a reprieve but that is all.  The key to the disjuncture here is that millions of Americans have now discovered that (a) while they don't like Obamacare, they (b) don't actually know why and, (c) no one can really tell them, and (d) the alternatives aren't very good (and hence the interest in single payer).

Republicans, for their part, have discovered that the United States is divided on this issue. For political reasons, they will try to blame Democrats (and politically, Democrats might be wise to let them but that is a discussion for another day), but they have also discovered that the Democrats are not going down without a fight, that they -- the Republicans -- don't really have an alternative policy that withstands close scrutiny (why? because their plan to lower premiums involved un-insuring people: the poor, the ill, the elderly). Hence, the idea that Obama had somehow personally screwed Americans and taken money from their pockets for no good reason ... well ... that idea has run aground on the reality of the contemporary economics of health care.

In this sense the question is not "is there a disjuncture between reality and discourse" but which prevails? Republicans sold their plan on health care to their constituents -- not all Americans -- by promising lower premiums and by working with a bit of nostalgia for a world that no longer exist. They never explained why those premiums would be lower and hearkened back to an ideal of a small town doctor charging reasonable prices to middle class people just so long as the government did not get involved and "force" him to charge more. A kindly man in a white coat fixed you and your kids. The fact that that world no longer existed does not really matter in the politics of image.  They said over and over again that Obamacare had destroyed America ... but how had it? What was actually wrong with it? Like most matters of public policy, the issue is not white and black and there are pros and cons. But what are those? Could the average Republican voter actually tell you?

What is wrong with this disjuncture is not just that it is politicized but that it is dishonest and prevents a real engagement with the issue of health care and its meaning and importance. How is it dishonest? Without being shocked that a politician stretched the truth, it is dishonest not just because it claims that Obamacare had destroyed America without explaining why but because it never explained why healthcare costs money. After all, recall that nice nostalgic image of the kindly town doctor. He didn't charge too much, did he?

Maybe he didn't, but that is not the healthcare world in which we live today. In the US, some healthcare costs are high because some people are making mega profits off of it. There is an expectation of remarkable wealth, at least on the part of some people, and there are a chain of people who actually benefit from the mega healthcare profits (again, something we can get to later). But, another reason healthcare has increased in cost is because ... well ... it got more expensive. I know that sounds simple but consider how high tech medicine has gotten.

For good or ill, I've had some health problems of late and have had to go through some tests over the last few years.  The tests I get are remarkably more sophisticated than they were when I was a kid. People are, by and large, living longer.  The machines we have in our hospitals tell us more than the machines we used to have and the medicines we have do more for us than the ones we used to have.

All of these things cost money. I cited Canadian data above re life expectancy, but US data will show us the same thing. This is a good news story that is not just happening by itself. It has happening because society -- through their governments -- are investing a lot of money into keeping people alive. There is much more that we could do and I am not talking about heroic and unusual intervention here. I am talking about progress on improving survival rates for people who have serious diseases that would have killed in a short time when I was a kid.

These are good costs. I am glad we have paid for them and I hope we -- and the folks in the US -- continue to pay for them. I think investing in people's lives is a good thing to do viz investing in, say, more consumer goods that we don't really need. But, and this is the point I want to make, these things cost money. The machines we use for tests are expensive. Training the highly qualified people who look after these tests and who provide care to us is expensive. My complaint is not that they are expensive. In fact, I'm not even complaining. I am analyzing. And, what this analysis points to is this: many Americans don't understand why healthcare is so expensive. They work with an idealized and antedated (even if nostalgically pleasing) image of what healthcare actually is. They don't understand that the money we have paid for healthcare on a social level has worked. It has improved quality of life and it has improved life expectancy. It is not perfect, but if one understood reality, one might start to think again about those promising to "fix" a problem that, in reality, might not exist in the fist place. Or, more exactly, not in the same way it has been presented.

What does all this have to do with American public life. It highlights the problem of the disjuncture between reality and discourse. Because Americans are not grappling with the real reasons why healthcare has increased in cost, they cannot have a real -- as in potentially effective -- debate about good healthcare policy. Hence, rather than celebrating the improved quality of life and longer life and socially broader health care, they see only problems that are not the problems that they really need to address. Instead, they approach a healthcare debate not in a manner that looks forward and asks "how do we keep the ball rolling?" but instead in a manner of trying to figure out who will be voted off the island.
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