I BLAME JAMES MADISON. At her other online venue, J. Goodrich has a good discussion of American political culture and its role in the fact that the United States maintains an irrational health care system that provides much narrower coverage for much more money (including more state money) than other comparable liberal democracies. While this is important, I think that the single most important factor (both going forward and going backward) is the institutional structure of American government, with its unusually high number of veto points. In a Westminster system, having Bill Clinton (or LBJ or Harry Truman) support national health insurance with a legislative majority is enough to get it done, and such programs are virtually impossible to repeal once enacted. In the American system, you need not just a President who supports it, but a liberal (as opposed to merely Democratic) majority in both houses of Congress (and in the Senate, you need a supermajority of an institution that disproportionately represents small conservative states, very rare occurrence.) And you also have to worry about having a Max Baucus chairing a crucial legislative committee. And so on. Although both certainly matter, I think political institutions, not political culture, is the most important reason why the U.S. has such an awful health care system.

--Scott Lemieux

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