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.
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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).
The Legacy of the Crash Page 30