The Legacy of the Crash

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The Legacy of the Crash Page 30

by Terrence Casey


  Conclusion

  Overall, therefore, in both the US and UK ambitious reform agendas have been advanced in the health policy arena. The ensuing arguments reflect that the stakes are high for all involved in both political and substantive policy terms. On the other hand, it is not all change. Thinking back to the typologies discussed earlier in the chapter, the ACA makes more of a difference if looking at the OECD’s (1987) typology than Moran’s (2000) model. The expansion of Medicaid and the subsidies to people buying insurance through the insurance exchanges means that government will be, either directly or indirectly, helping to pay for the care of a greater number of people. Simply put, a significant reduction in the number of uninsured will move the US towards a system of universal care. This should not be overstated since access and treatment levels will be far from equal, but as David Leonhardt (2010) writes, the redistributive aspects of the ACA make it the most significant measure tackling inequality in the US in a generation. But the measures to control costs look less certain and clearly established. It is interesting that the Obama administration has been more vocal in its criticism of the primary payers in the system, that is the insurance industry, rather than doctors, hospitals or even pharmaceutical companies (see, for example, Sebelius, 2011). Insurers make for a more convenient political fall-guy than doctors and hospitals, but while insurers may raise premiums higher than necessary, it is the provision of health care that really drives costs. And in this context it is not fully evident that the measures in the ACA about the regulation of providers are decisive enough to guarantee that cost increases will be slowed in the long term. Most obviously, in comparison with the NHS, whatever the plans to control public sector spending, there is no global cap and providers are not dependent on contracts with government. Thus if, for example, there are meaningful cuts to payments to providers for Medicare treatments, then these providers may simply absent themselves from treating Medicare beneficiaries as many already have stopped doing Medicaid work because of the lower reimbursement rates paid by government for treating Medicaid patients (Newhouse, 2010, p. 8). In short, the ACA might have further diminished the extent to which US health care acts a true market, but it has far from ‘socialized’ American medicine.

  With regard to the UK it is tempting to ask why the Coalition government embarked on such an ambitious reform program at a time when the NHS was recording high satisfaction levels. Why fix something that was not obviously broken? When explaining the rationale for the plan the prime minister emphasized the need to improve health care outcomes in an era of fiscal pressures: ‘the NHS faces enormous financial pressures in the years ahead – driven by factors ranging from ageing and obesity, through to the cost of new drugs and technologies. Sticking with the status quo and hoping extra money will meet the challenges is not an option. If we want to deliver better results for patients, we need modernisation’ (Cameron, 2011). Understanding the potential significance of the reform plans in this instance is best done by employing Moran’s typology rather than the OECD’s. The latter, with its emphasis on patterns of funding and access, would downplay the Coalition government’s proposals. Yet the changes to the status of GPs and hospitals, and the further opening up of the NHS budget to private providers, means that the NHS has decisively left the 1948 settlement behind. In December 2010, Nigel Edwards, then the acting chief executive of the NHS Confederation, reflected that rather than the ‘centrally planned and managed’ organization of 1948 the NHS would resemble ‘a regulated industry’ (Edwards, 2010). Nevertheless, given the commitment to continued government funding and equality of access it is a rhetorical step too far to talk of the Americanization of the NHS.

  What is clear is that health care politics is unlikely to wane in its intensity. For one thing, the problem of providing comprehensive care at an acceptable cost is not going to go away. Moreover, health care consumes a huge chunk of economic activity and brings into play fundamental values about individual responsibility and social solidarity. As such, political figures can hardly leave it alone.

  Notes

  1. Medicare Advantage (MA) is a scheme whereby private managed care plans compete for business against traditional fee for service Medicare. Yet, rather than this competition lowering costs it transpired that MA cost ‘an average of $1,000 more per beneficiary per year than it costs to treat the same beneficiaries through traditional Medicare’ (Angeles and Park, 2009, p. 1).

  2. The NHS Confederation is an independent body made up of the various organizations in the NHS as well as other independent health care providers.

  References

  Angeles, January, and Edwin Park (2009) Curbing Medicare Advantage Overpayments Could Benefit Millions of Low-Income and Minority Americans (Washington, DC: Center for Budget and Policy Priorities).

  Barr, Nicholas (2004) Economics of the Welfare State (Oxford: Oxford University Press).

  BBC (2011) ‘Cameron backs wholesale changes to NHS plans’, 14 June, www.bbc.co.uk/news/uk-politics-13757380.

  Blumenthal, David, and James Morone (2010) The Heart of Power: Health and Politics in the Oval Office (Berkeley: University of California Press).

  Cameron, David (2011) ‘PM Article on the Health and Social Care Bill’, 27 January, www.number10.gov.uk.

  CBO (2010a) The Budget and Economic Outlook: Fiscal Years 2010 to 2020 (Washington, DC: Congress of the United States).

  CBO (2010b) ‘H.R. 4872, Reconciliation Act of 2010’, 18 March 2010.

  Cole, Andrew (2009) ‘More Spending on NHS has Led to Highest Satisfaction Rates in 25 Years’, British Medical Journal, 338, 7 February , 315.

  Cutler, David, Karen Davis and Kristof Stremikis (2010) The Impact of Health Reform on Health System Spending, The Commonwealth Fund and the Center for American Progress.

  Delamothe, Tony (2008a) ‘A Centrally Funded Service, Free at the Point of Delivery’, British Medical Journal, 336, 21 June, 1410–12.

  Delamothe, Tony (2008b) ‘A Comprehensive Service’, British Medical Journal, 336, 14 June, 1344–5.

  Delamothe, Tony (2008c) ‘How the NHS Measures Up’, British Medical Journal, 336, 28 June, 1469–71.

  Department of Health (2005) A Short Guide to NHS Foundation Trusts (London: Department of Health Publications).

  Dixon, Anna, Ruth Robertson, John Appleby, Peter Burge, Nancy Devlin and Helen Magee (2010) Patient Choice: How Patients Choose and How Providers Respond (London: The Kings Fund).

  Dolowitz, David, David Marsh, Fiona O’Neill and David Richards (1996) ‘Thatcherism and the Three “R”s: Radicalism, Realism and Rhetoric in the Third Term of the Thatcher Government’, Parliamentary Affairs, 455–70.

  Edwards, Nigel (2010) ‘Is Whitehall Ready to Let Go of the NHS?’, Guardian, 15 December.

  Esping-Andersen, Gosta (1990) The Three Worlds of Welfare Capitalism (Cambridge: Polity Press).

  Glendenning, Caroline (2003) ‘Health Policies’, in Nick Ellison and Chris Pierson (eds), Developments in Social Policy 2 (Basingstoke: Palgrave Macmillan), pp. 194–210.

  Greener, Ian (2009) Healthcare in the UK: Understanding Continuity and Change (Bristol: Policy Press).

  Ham, Christopher (1994) Management and Competition in the New NHS (Oxford: Radcliffe Medical).

  Harrison, Stephen, and Ruth McDonald (2008) The Politics of Health Care in Britain (London: Sage).

  Howard, Christopher (2007) The Welfare State Nobody Knows: Debunking Myths About US Social Policy (Princeton: Princeton University Press).

  Ipsos Mori (2010) ‘Best Party on Key Issues: Health Care’, www.ipsos-mori.com. Jacobs, Lawrence (1995) ‘Politics of America’s Supply State: Health Reform and Technology’, Health Affairs, 14(2), 143–57.

  Jacobs, Lawrence (2005) ‘Health Disparities in the Land of Equality’, in James Morone and Lawrence Jacobs (eds), Healthy Wealthy and Fair: Health Care and the Good Society (New York: Oxford University Press), pp. 37–63.

  Kaiser Commission on Medicaid and the Uninsured (2010) Medicaid’s Continuing Crunch in
a Recession: A Mid-Year Update for State FY 2010 and a Preview for FY 2011 (Washington, DC: Kaiser Family Foundation).

  Kaiser Family Foundation (2010) Health Insurance Coverage of the Total Population, States (Washington, DC: Kaiser Family Foundation).

  Klein, Rudolf (2006) The New Politics of the NHS: From Creation to Reinvention (Oxford: Radcliffe Publishing).

  Leonhardt, David (2010) ‘In Health Bill, Obama Attacks Wealth Inequality’, New York Times, 23 March.

  Marmor, Theodore R. (2000) The Politics of Medicare, 2nd edn (New York: Aldine de Gruyter).

  Marmor, Theodore R., and Jonathan Oberlander (2010) ‘The Health Bill Explained at Last’, New York Review of Books, 19 August, electronic edition, www.nybooks. com/issues/2010/aug/19/.

  Mazzone, Jason (2010) ‘Can Congress Force You to be Healthy?’ New York Times, 16 December.

  Mechanic, David (1995) ‘The Americanization of the British National Health Service’, Health Affairs, Summer, 51–67.

  McKinsey Global Institute (2008) Accounting For the Cost of US Health Care: A New Look at Why Americans Spend More, McKinsey and Company.

  Moon, Marilyn (2006) Medicare: A Policy Primer (Washington, DC: Urban Institute Press).

  Moran, Michael (1999) Governing the Health Care State: A Comparative Study of the United Kingdom, the United States and Germany (Manchester: Manchester University Press).

  Moran, Michael (2000) ‘Understanding the Welfare State: The Case of Health Care’, British Journal of Politics and International Relations, 2(2), 135–69.

  Morris, Charles (2006) Apart at the Seams: The Collapse of Private Pension and Health Care Protection (New York: Century Foundation Press).

  Newhouse, Joseph (2010) ‘Assessing Health Reform’s Impact on Four Key Groups of Americans’, Health Affairs, 29(9), 1714–24.

  Nix, Kathryn (2010) ‘Top 10 Disasters of Obamacare’, Heritage Foundation Web Memo, 30 March, www.heritage.org.

  NHS Confederation (2011) Liberating the NHS: What Might Happen? (London: NHS Confederation).

  Oberlander, Jonathan (2003) The Political Life of Medicare (Chicago: University of Chicago Press).

  Oberlander, Jonathan (2010) ‘Long Time Coming: Why Health Reform Finally Passed’, Health Affairs, 29(6), 1112–16.

  Oberlander, Jonathan, and Joseph White (2009) ‘Public Attitudes Towards Health Care Spending Aren’t The Problem; Prices Are’, Health Affairs, 28(5), 1285–93.

  OECD (1987) Financing and Delivering Health Care: A Comparative Analysis of OECD Countries. (Paris: OECD).

  OECD (2010) Directorate for Employment, Labor and Social Affairs, OECD Health Data for 2010 (Paris: OECD).

  Politics Daily (2010) ‘HHS Secretary Kathleen Sebelius on NBC’s Meet the Press’, 7 March, www.politicsdaily.com.

  Pollock, Allyson (2005) NHS plc: The Privatisation of Our Health Service (London: Verso).

  Ramesh, Randeep, and Rachel Williams (2010) ‘NHS Trusts Aim for Private Profits’, Guardian, 2 August.

  Saldin, Robert (2010) ‘Healthcare Reform: A Prescription for the 2010 Republican Landslide?’, Forum, 8(4), Article 10.

  Sebelius, Kathleen (2011) ‘Everyone Prospers Under Health Law’, Politico, 14 March, www.politico.com.

  Secretary of State for Health (1989) Working for Patients (London: HMSO).

  Secretary of State for Health (2000) The NHS Plan (London: HMSO).

  Secretary of State for Health (2002) Delivering the NHS Plan (London: HMSO).

  Secretary of State for Health (2010) Equity and Excellence: Liberating the NHS (London: HMSO).

  Simon, Kosali (2010) Implications of Health Care Reform for Employers (Washington, DC: Center for American Progress).

  Stolberg, Sheryl Gay, and Robert Pear (2010) ‘Obama Signs Health Care Overhaul Bill, with a Flourish’, New York Times, 23 March, p. A1.

  Thorne, Deborah, and Elizabeth Warren (2008) ‘Get Sick, Go Broke’, in Jacob Hacker (ed.), Health at Risk: America’s Ailing Health System and How to Heal It (New York: Columbia University Press), pp. 66–87.

  Timmins, Nicholas (2011) ‘Pros and Cons of a Delicate Operation’, Financial Times, 20 January, www.ft.com.

  US Census Bureau (2010) ‘People without Health Insurance Coverage by Selected characteristics, 2007, Current Population Survey, 2008 and 2009 Annual Social and economic Supplements’.

  Washington Post (2010) Landmark: the Inside Story of America’s New Health-Care Law and What It Means for Us All (New York: Public Affairs).

  12

  From 9/11 to 2011: The ‘War on Terror’ and the Onward March of Executive Power?

  John E. Owens and Mark Shephard

  Over a decade ago, 9/11 became the iconic event in US and UK politics. The atrocities in New York and Washington represented not only a new type of terrorist phenomenon but also one that signaled new aggressive assertions of executive power by the Bush administration and the Blair government at the expense of Congress and Parliament, and new dangers to the rule of law and protection of civil liberties (Owens, 2010; Shephard, 2010). Both President Bush and Prime Minister Tony Blair accepted the imprimatura of a global ‘war on terror’ (Owens and Dumbrell, 2008, p. 2). In the United States, the Bush administration worked with Congress to formulate and implement revised legal definitions of terrorism; new search, arrest and surveillance powers; and to legislate huge increases in federal spending on the military, law enforcement, surveillance, database management, border control, capital control, and intelligence capacities. Claiming ‘inherent’ and ‘plenary’ powers, Bush administration officials also effectively authorized and organized state kidnapping of alleged terrorists both in the US and abroad (‘extraordinary rendition’), interned suspects in military facilities in the US and abroad without legal redress, and sanctioned abuse and torture of detainees by US personnel, private contractors and foreign governments. Although Congress undertook a considerable amount of oversight of the so-called ‘war on terror’, the effects on policy were marginal, whether under Democratic or Republican congressional majorities. In Britain, Tony Blair ‘quickly established himself as the most visible and prominent international supporter of Bush’s “war on terror”’ (Dumbrell, 2008, p. 236). Taking advantage of Britain’s strongly majoritarian governmental structure, Blair’s government invented new executive powers and on an incremental basis enhanced the power of the British executive in response to 9/11 and the 7/7 bombings in London, and frequently sought to shade his government from public and parliamentary scrutiny. Typically, British MPs were inactive and ineffective overseers of the Blair government, as security needs trumped demands for effective parliamentary oversight and influence.

  Ten years on from 9/11 and notwithstanding the killing of the alleged perpetrator of these and other atrocities in May 2011, the threat from terrorism, emanating primarily from jihadists, continues. We ask, to what extent has the momentum towards greater executive power and discretion ushered in by US and British counterterrorism efforts been maintained by the Obama administration and the Cameron government and/or checked by Congress and Parliament? Did the policy thrust of the US ‘war on terror’ change significantly with Barack Obama’s election? With the return to Democratic unified government, did Congress become less acquiescent and more challenging on ‘war on terror’-related issues? Or did the Democrat-controlled House and Senate essentially follow Obama’s lead in changing the tone of the US ‘war on terror’ without changing the policies or the balance of executive–legislative relations? For the UK, did the election of a Conservative–Liberal Democrat Coalition government maintain or reduce executive discretion in respect of counterterrorism policy, and did parliamentary control and checks over the government’s administration of policy strengthen significantly?

  Obama, Congress and the ‘ongoing struggle’

  In his 2008 election campaign, President-elect Obama promised to ‘turn the page’ on the policies of the Bush Administration and inaugurate a new era of moral and civic renewal. As a senator, Obama had criticized the ex
pansive nature of Congress’ 2001 and 2003 ‘use of force’ resolutions and the Bush administration’s assertion of ‘inherent’ and ‘plenary power’. In answers to the Boston Globe’s questionnaire, he rejected ‘the view that the President may do whatever he deems necessary to protect national security’ and disavowed ‘extreme and implausible claims of presidential authority’ (Savage, 2007). In office, Obama rejected the ‘war on terror’ nomenclature in favor of the ‘enduring struggle against terrorism and extremism’ or the ‘ongoing struggle’ (Obama, 2009a), and nominated as head of the Office of Legal Counsel and Solicitor General prominent constitutional lawyers fiercely critical of the Bush administration’s expansive view of executive power. Within two days of his inauguration, moreover, the new president signed executive orders revoking the Bush administration’s severe limits on public access to presidential records, closing Guantánamo (albeit with some caveats), ending military tribunals, and prohibiting the Central Intelligence Agency (CIA) from maintaining its so-called ‘black sites’ overseas. Bush’s Executive Order (EO) 13440 (2007) and every executive directive, order, and regulation relating to the detention or interrogation of individuals issued by any executive branch lawyer after 9/11 was also revoked and primary authority over detention policies was transferred to the Justice Department. The new president also signaled a much less aggressive and more respectful approach to Congress. During Senate confirmation hearings, Obama’s nominees for Attorney General and CIA Director, Eric Holder and Leon Panetta, repeatedly stressed their wishes to work with Congress to write new detention and other anti-terror legislation and keep legislators better informed of their activities. Echoing Obama’s election pledge, Holder categorically rejected the view that the president possessed ‘inherent’ power to override congressional statutes: ‘[N] o one is above the law’, he insisted. ‘The president has the constitutional obligation to make sure that the laws are faithfully executed’ (US Senate Judiciary Committee, 2009, pp. 23, 30).

 

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