Expect A Year of Debate
By Lawrence R. Jacobs, PhD
Opponents of health care reform as well as many political observers have overestimated the parallels between President Barack Obama’s drive for health reform and President Bill Clinton’s failed attempt in 1993-94. This flawed exercise in historical analogy has produced a series of hasty obituaries that may leave many Americans unprepared for negotiations and discussions in Washington that could continue until the November 2010 elections. The premature rush to judgment misses four critical differences between the Clinton and Obama efforts.
For one thing, Obama’s timeline is nearly a year ahead of Clinton’s. Because of Clinton’s insistence on using a 500- person task force to design the details of his plan, he did not submit legislation until the fall of 1993. Congressional committee hearings did not even start until his second year in office.
Another difference is that Obama dropped Clinton’s mistaken presumption of presidential control over domestic policy. Today’s White House has accommodated the legislative process and its predictably circuitous route to finding the policy parameters that can draw sufficient support in both the House and Senate. The House is now grappling with health care reform legislation. If it approves a bill, this would represent the first time that comprehensive reform was passed by a congressional chamber since Medicare’s passage in 1965. In the Senate, Sen. Max Baucus has been deeply enmeshed in constructing legislation in the Finance Committee that he hopes will draw bipartisan support—something that Sen. Daniel Patrick Moynihan, who chaired the same committee in 1994, openly scorned. Senate Majority Leader George Mitchell, was forced to step into the breach in the final months of the 1994 session to seek a compromise bill that could pass. If the Senate efforts break down, today’s Democrats have reserved the option of using the budget reconciliation process to avoid the need for 60 votes to override a Republican filibuster. This option was not pursued during the Clinton effort.
A third difference is a kind of silence. In 1993-94, a broad coalition of health care providers, insurers, pharmaceutical interests, and other stakeholders allied with Republicans and conservatives to launch a highly public and well-funded onslaught against reform. In 2009, the antireform coalition is far narrower, as Democrats in Congress and the White House have cut agreements in exchange for stakeholder support or neutrality. Indeed, the infamous “Harry and Louise” advertisements that were used to lambast health reform in 1994 have now been resuscitated by stakeholders to laud the need for reform. The fervent opposition on display at townhall meetings and on talk radio and the Internet lacks the same degree of organized support it had in 1994 and has been less damaging.
A fourth and critical difference is that Obama and Congress retain the flexibility to enact a range of reform packages that vary considerably in their scope. In 1994, Clinton presented a “take it or leave it” proposal for systemic reform of financing and delivery and chose to walk away from reform when it became clear that his all-encompassing package would not be passed as the session wound down. In contrast, the Obama White House and today’s lawmakers retain the option of falling back on sensible and less-costly incremental reforms that would expand Medicaid to indigent populations not currently covered, establish significant insurance market reforms, and rationalize record keeping and provider reimbursement. This incremental fallback option would build on systems with proven track records while providing a platform for the next major reform debate. Taking more incremental steps will also make it more feasible to make adjustments if problems with cost or other issues develop. Indeed, President Obama’s address to a joint session of Congress noticeably lacked Bill Clinton’s veto threat for legislation that did not establish universal health insurance coverage; the Obama administration has instead preferred to maximize its degrees of freedom.
Although the prospects for health care reform remain uncertain, it is exceedingly premature to declare Obama’s efforts as failed or facing an imminent do-or-die moment. There still is a lot of time to enact workable reform, and the odds favor passage of legislation before the 2010 elections, although its form and scope remain quite open. MM
Lawrence Jacobs is the Mondale Chair at the University of Minnesota’s Humphrey Institute and a longtime health policy analyst.