American Exceptionalism and the Healthcare Reform Debate

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Two generations ago, discussion of "American exceptionalism"--at least among social scientists--came down to one great question: Why no socialism in America? (1) By the 1980s, however, even self-described socialists in Western Europe had embraced the benefits of markets and privatization. (2) Soon after, the Soviet empire collapsed and full-scale socialism was largely discredited. (3) America no longer looked particularly unusual in its broader economic patterns. So the "exceptionalism" question dwindled down to: Why no national healthcare in America? (4)

The Obama administration tried to give an answer: Yes, we can! (5) Then we did--enact the Patient Protection and Affordable Care Act of 2010 (ACA). (6) The public reaction was: Maybe not. Public opinion polls have shown that a persistent majority of Americans do not favor ACA. (7) So the question about American exceptionalism can now be rephrased: Why is national health insurance still so controversial in America? I want to offer an answer in three parts, looking successively at background political culture, constitutional architecture, and constitutional culture.

One way to capture the distinctiveness of American political culture is to look at survey responses. The Pew Global Attitudes Project has tracked differences in outlook among peoples in various countries. (8) A few years ago, they asked respondents in a survey whether "success in life is pretty much determined by forces outside our control." (9) In every major country in Western Europe where they asked this question, the answer was (often by more than two to one): yes, success is determined by forces outside our control. (10) In the United States, people rejected that answer by nearly two to one. (11) The United States is one of the great outliers. It is one of the only two Western countries where an overwhelming majority insists that individual success in life mostly depends on the personal effort of the individual. (12)

That poll does not seem to be an anomaly. It tracks with a number of other findings. Even Europeans in these surveys acknowledge that Americans seem to work harder than people in other countries. (13) Americans believe this about themselves. (14) It is what you would expect of people who think their success depends on their own efforts.

Americans also are inclined to express a good deal of pride in their country--certainly far more than Europeans and, by some surveys, even more than people in developing countries. (15) Whereas sociologists often interpret "nationalism" as a response to feelings of insecurity, (16) that observation does not seem to be the pattern in the United States.

Perhaps this result, too, fits with the larger pattern of American self-confidence. Americans think they can succeed through their own efforts--and they think the country that assures them the freedom to succeed on their own is a fine country. People in other countries, who place more reliance on state bureaucracies to care for them, usually are disappointed with the results. Then they are more likely to think their government or their whole society is to blame.

Add it up and you might infer that Americans want a healthcare system that helps them make their own choices. The Obama administration seemed to recognize this in its initial characterization of proposed reforms: If you like the private insurance you now have, President Obama promised, "you'll be able to keep [it]." (17) Some part of the resistance to the huge and hugely complicated package of "reforms" Congress enacted seems to reflect the realization that this promise has not been honored: Whatever else it does, the new healthcare law constrains the choices of individuals. (18)

But such broad background attitudes are only one part of the story. Another part of the explanation for our current debates is the actual constitutional architecture of our government, federalism in particular. Here I particularly want to mention federalism. …