Liberalism a la Mode

The “patients’ bill of rights” is the perfect piece of legislation for our time. Is that good?

Are we going through a liberal period in American politics or a conservative one? Even though the Democrat won a plurality in the past three presidential tallies and actually got to govern after two of them, it still feels like we’re still in the conservative age that began with Reagan in 1980 or even Nixon in 1968. Almost no politician, for example, admits to being a “liberal,” while many who may or may not deserve it claim the label “conservative.” But an equally dyspeptic conservative might say that’s just the point: For a generation now, politicians have clamored to be called conservative without actually dismantling any significant aspect of big government.

So we must look for cues elsewhere. One thing we can say for sure about almost every politician and every voter at the moment is that they favor a “patients’ bill of rights.” So, what does that tell you about the current flavor of American politics? The answer is that this, too, sends interesting mixed signals.

A massive new regulatory system imposed on one of the country’s biggest industries (health care)? Supported in theory, while quibbling over details, by the Republican president and Republican congressional leadership? It seems to me that even the GOP version is a pretty impressive piece of meddling in the free market. But even if, as some say, the bill backed by President Bush is all empty pretense, the fact that he feels obliged to pretend to favor a patients’ bill of rights suggests that the atmosphere at the moment is pretty liberal. Republican complaints about the Democratic bill are limited to the issue of lawsuits. It’s hilarious—and, I suppose, inspiring—that no major Republican is out there saying, “No. This violates my most basic free-market principles. Insurers should be free to offer any deal they want and consumers should be free to take it or leave it.”

On the other hand, look at what this bill is about. The No. 1 priority of the new Senate Democratic leadership, floating on a sea of rhetoric about resurgent liberalism and a renewed appreciation for the government’s role in helping people, is about marginal improvements for people who already have health insurance. It not only ignores but actually thumbs its nose at what is obviously the biggest gap in the social safety net: the millions of people with no health insurance at all.

What’s striking is not just the modesty of this ambition but its direction: It’s aimed at the problems of the majority, not at the more serious problems of a smaller group. It’s hardly fair, of course, to call it pandering for politicians in a democracy to cater to the demands of the majority. But social welfare schemes used to be salable to the majority on a sort of psychic insurance theory: I may not have this problem, I may not even worry that I may some day have this problem, but at least it could have been me having this problem. Today a new government program, if it’s going to get anywhere, has to scratch the majority right where it itches at the moment.

In this and several other ways, the patients’ bill of rights represents liberalism a la mode, which is one way of characterizing the dominant politics of our current period.

For example, the patients’ bill is aimed at a particular kind of majority: what might be called a “grandfather clause” majority. Guaranteeing that people who already have some benefit don’t lose it is a big theme of liberalism a la mode. President Clinton’s health-care plan (which was not a la mode) foundered on the issue of whether people would be allowed to keep the same doctor. The later Kennedy-Kassebaum bill (which did become law) allegedly guaranteed that once you had insurance, you couldn’t be cut off. Even while campaigning somewhat courageously for his (misbegotten) Social Security reform, Bush emphasizes that the benefits of current and imminent retirees won’t be touched. In fact, he misrepresents his entire plan as a matter of guaranteeing Social Security benefits into the distant future.

One nice thing about liberalism a la mode is that it’s free! Or rather, the cost is hidden. The idea of people agreeing to be taxed in order to finance some benefit—even for themselves—remains utterly out of fashion. There are many ways to make it all look like a freebie, though. Bush, in his budget and in his Social Security scheme, favors straightforward accounting tricks. The patients’ bill achieves its goals through regulation, rather than tax-and-spend. Nobody denies that the cost of these new benefits will ultimately hit the beneficiaries in the form of higher insurance premiums. But nobody who supports the bill plays this up either.

There’s also an a la mode way to impose rules on the private economy while avoiding the big-government stigma. That way is called lawyers. Republicans charge that Democrats are in the pocket of the Trial Lawyers Association, and it’s pretty true. But there are also strategic and even philosophical reasons why proposals like the patients’ bill of rights rely on lawsuits to do their dirty work. Strategically, this protects you against being portrayed as the hobnailed boot of big government crashing down on individual freedom. Philosophically, it frames the issue in terms of individual rights, which is very American, rather than standards imposed by society, which is not. The downside of this approach includes the enormous, though hidden, cost of litigation (the lawyers, the punitive damages, etc.), the inconsistent standards of judge-made law as opposed to uniform rules, and—vague but real—a misplaced emphasis on justice in individual transactions over justice in general. Your HMO can’t screw you if you don’t have an HMO.

Liberalism a la mode is flawed for all these reasons. But still, it’s better than nothing.