Five foreign policy lessons from healthcare

by | Mar 22, 2010

First, other governments will now be well aware that is becoming increasingly hard for the American political system to make major decisions.

None of their analysts predicted that health care would drag on so long – or make it so hard for the Obama administration to focus on its crowded foreign agenda. Financial regulation, climate change, and nuclear proliferation have all been forced to take a back seat to domestic policy.

And the logjam is sure to continue. Due to the vastly increased use of the filibuster, American presidents will govern with what is effectively a permanent hung parliament.

Reform is badly needed if the US is to remain a decisive voice on the world stage. It is on the cards – but it looks to me like a distant prospect.

Second, countries are heavily exposed to the US’s bitterly partisan politics.

Bush speechwriter, David Frum (of axis of evil fame) may argue that Republicans made a strategic mistake in trying to make healthcare Obama’s Waterloo, but he’s an isolated voice on the right.

Here’s our friend, Mark Steyn, with a view that is much more reflective of the anti-healthcare mainstream:

It’s a huge transformative event in Americans’ view of themselves and of the role of government..

More prosaically, it’s also unaffordable. That’s why one of the first things that middle-rank powers abandon once they go down this road is a global military capability…

Longer wait times, fewer doctors, more bureaucracy, massive IRS expansion, explosive debt, the end of the Pax Americana, and global Armageddon. Must try to look on the bright side . . .

Healthcare is not the cause of US political divisions, simply the latest reflection of them. Pick an issue – Iran, Israel, energy, climate, even China – and you see similarly deep chasms. Make any long-term deal with America and you have to be prepared for a new administration to come along that has a diametrically opposed world view.

Third, it’s clear that much of the healthcare debate were being driven by forces inaccessible to the mainstream media or to elite opinion.

Take this video asking those demonstrating against healthcare why they’re opposed to reform:


Sure, the editing slanted to make these protestors look as dumb as possible, but notice the memes that recur – that the bill will lead to the elderly being euthanized with a ‘little pill’ for example.

Canny populist leaders, Sarah Palin for one, have been adept at fuelling these fears – but they don’t control them. People’s views are now shaped more by email chains, chat rooms and bulletin boards, and talk radio, than by more established communications channels.

This is tough for domestic policymakers, but even harder for the foreign policy priesthood which continues to believe it controls key policy debates. Increasingly, it doesn’t.

Fourth, change on most important issues is going to be increasingly hard and time-consuming to achieve.

The Obama administration seriously underestimated the effort that healthcare reform was going to take. This applies equally to key global risks. As Bruce Jones, Alex and I argued in our recent paper for Brookings, The Long Crisis:

On any complex international issue, transformation will be ‘sticky’ with considerable force needed to push the system from one equilibrium to another…

Those governments that aspire to global leadership also need to develop a new appreciation of how to influence and organize for change.

They must invest in the skills needed to bring together diverse networks of foreign policy actors – including publics, international organizations and other non-state actors – in frameworks that allow them to manage global risks.

In other words, governments need to stop believing that they can achieve change on the cheap. A massive, and coordinated, shift is needed in the way that countries do foreign policy if they are to achieve any meaningful results at all.

Finally, the healthcare bill itself provides an interesting model of the compromises needed to deliver radical change.

Ezra Klein – for my money the best navigator to healthcare’s complexity (and what is he going to do with his life now?) captures the balance well [emphasis added]:

The legislation builds a near-universal health-care system, but it only uses the materials that our system has laying around. It leaves private insurers as the first line of coverage provision, but imposes a new set of rules so that we can live with — and maybe even benefit from — their competition.

On global issues, we need a similar approach, blending strategic ambition with tactical bricolage, repurposing and reincentivizing existing institutions and structures, thus allowing them to deliver new outcomes, however imperfectly.

Ultimately, healthcare rested on two leaders – Obama and Pelosi – maintaining a common purpose despite having only partially aligned incentives. On most global issues, a handful of leaders (less than half a dozen) will need to create a similarly high-bandwidth platform for driving change. It happened during the acute phase of the financial crisis, but probably hasn’t since.

Update: Laura Rosen argues that foreign leaders – she means you, Bibi – will now be confronted by an empowered Obama. Steve Benen:

Global players base their U.S. interactions, at least in part, on their perceptions of presidential standing. If the American head of state is perceived as weak — faltering domestic support, stalled legislative agenda — friend and foe alike will take those cues seriously. If the chief executive is perceived as strong, that matters, too.


  • David Steven is a senior fellow at the UN Foundation and at New York University, where he founded the Global Partnership to End Violence against Children and the Pathfinders for Peaceful, Just and Inclusive Societies, a multi-stakeholder partnership to deliver the SDG targets for preventing all forms of violence, strengthening governance, and promoting justice and inclusion. He was lead author for the ministerial Task Force on Justice for All and senior external adviser for the UN-World Bank flagship study on prevention, Pathways for Peace. He is a former senior fellow at the Brookings Institution and co-author of The Risk Pivot: Great Powers, International Security, and the Energy Revolution (Brookings Institution Press, 2014). In 2001, he helped develop and launch the UK’s network of climate diplomats. David lives in and works from Pisa, Italy.

More from Global Dashboard

Justice for All and the Economic Crisis

Justice for All and the Economic Crisis

As COVID-19 plunges the world into its most serious economic crisis for a century, a surge in demand for justice is inevitable. Businesses face bankruptcy – and whole industries may be insolvent. Similar pain is being felt in the public and non-profit sectors....

Who Speaks for the Global South Recipients of Aid?

Who Speaks for the Global South Recipients of Aid?

The murder of George Floyd and the resurfacing of the Black Lives Matter movement has led to heightened discussions on race in the international development sector. Aid practitioners in the North have not only condemned the systemic racism that they (suddenly) now see...