How to Misread the Lessons of 1994 Health Reform Failure
It makes sense for today’s Democrats to compile the lessons of the 1994 failure to enact health care reform in hopes of avoiding a similar fate.
So the New York Times tracks down veterans of that earlier effort, along with those Congressional and Administration aides working on reforms today, and compiles a list of the lessons learned.
Unfortunately, the Times’ reported Democratic list is mostly conventional pablum from the unsuccessful centrists from both efforts. Instead of showing us how to succeed where they failed before, the lessons point to the same outcome. And they miss the common obstacles that were responsible for failure then and are driving towards failure now. Consider, for example, these lessons:
Lesson 1: Failure Is Not an Option.
This line was probably fed to the Times to warn concerned Democrats to vote for whatever bill the Administration can salvage. But the underlying lesson is if you commit to do something very difficult, and publically make it a high priority, you’d better have a strategy with a high probability of success. We don’t seem to have one.
Lesson 2: Know your audience — insured taxpayers.
Sure, know your audience, but the Administration is in serious political trouble not just with insured tax payers but with Medicare recipients. It dawned too late on Administration wonks that telling the elderly you’d extract money from Medicare to help subsidize the uninsured was a dangerous message that was bound to be misunderstood even if the Republican demagogues were vacationing on Mars.
The first priorty should have been to assure seniors, over and over and over that "reform" would start with "preserving, protecting and strengthening Medicare," while making sure it would be adequately funded instead of allowed to careen towards bankruptcy and benefit cuts. Tell them over and over and over you’ll keep the Republicans from hurting them just to avoid taxes to help others. Did the 1994 veterans and 2009 aides not know this?
Lesson 3: Move before the honeymoon ends.
Uh, what honeymoon? When did Boehner/Gingrich offer Clinton a honeymoon? And since before Obama’s inauguration, the Republicans and the rightwing media/Fox/talks shows have been unanimous and relentless in their virulent opposition to anything Obama does. Only three Republicans voted for the stimulus, and none for the budget, and health reform initiatives. You can’t have a honeymoon when the opposition denies the legitimacy of your Presidency and openly works to have you fail.
Lesson 4: Leave the details to Congress
This conventional wisdom is gibberish. Bill Clinton told NN09 (as the Times reported) that the Committee chairs demanded the Clinton Administration hand them a bill to work with. He did, but it didn’t matter. This time, three House Committees and the Senate HELP Committee drafted detailed legislation, with general principles forwarded by Obama. Once again, it didn’t matter.
And the Times statement on this tradeoff is incoherent:
Mr. Obama went to the other extreme. He produced no plan, only fairly specific directives.
Obama’s statements have been sufficient to describe the main features of the current Committee bills: expanded access to Medicaid and insurance; retain the current employer-based system; mandates with exemptions; subsidies to help affordability; regulations and a public option to help reenforce the regulations or provide an alternative. That’s plenty of guidance and probably more than the general public can follow.
The concern arises not from the lack of detail but from the Administration’s contradictary statements of principle: Will we provide universal insurance, or cover only as many as we’re willing to pay for and remain "deficit-neutral"? Will we cover the costs more with Medicare savings or increased taxes, and on whom/what? Will there be a public plan, or will he give it up, or delay it, or opt for some vague substitute? These choices aren’t lacking detailed legislature language; they need clear policy decisions.
Lesson 5: Co-opt the opposition.
Yeah, that would be swell, but the Times doesn’t explain what’s wrong with the White House efforts to keep the major insurers, drug companies and providers happy. If the problem you’re trying to solve requires reforms in how these vested interests function, and if reducing health care costs requires extracting massive rents from those same interests, then "co-opting" the opposition probably means preserving huge business/profit opportunities and not really challenging the stranglehold they have on the dollars flowing to the health industry. In short, the veterans’ lesson 5 translates to not attempting reforms that would go to the core problems.
Lesson 6: Take what you can get.
Fine, but that implies you actually got something worthwhile, and the cost you paid is worth it. Otherwise, it’s a meaningless platitude. The problem the Administration has now is that there are serious questions whether the package that will be left after all the compromises will still be a net plus for the American people and, more important, fair to those subject to the mandates. The Times never raises these questions.
Some Lessons the Times and Health Care Reform Veterans Missed
1. The Republican Party is no longer willing or able to help solve the problem. Instead, they will do everything to block reform and capitalize on the failure. You can’t work with a party that’s irresponsible and driven by crazies.
2. The industry segments that need to be reformed are so deeply entrenched, and so massively invested in financing Congressional campaigns, that it will take an overwhelming public uprising to weaken their stranglehold enough to achieve meaningful reform.
3. The United States Senate is a corrupt, unaccountable, and wholly dysfunctional institution that will stifle any major reform effort unless overwhelmed by a public tsunami demanding reforms.
4. There are no ethical boundaries on the lies, distortions and vicious scare tactics that vested interests, right-wingers, and just plain stupid people (Beck, McCaughey, too many Republican officials) will inject into the public discourse. They will poison the debate and must be ostracized at every opportunity.
5. The US media is mostly inept and will, both through design (Fox News, Limbaugh et al.) and incompetence (most others) feed and magnify the lies, distortions and scare tactics. It will take a Herculean effort to overcome this message disadvantage, using mostly alternative means to get out a counter message.
6. Any genuine reform effort against such an entrenched industry, malicious opposition Party and complicit media must create and sustain massive public backing and remain loyal to the core principles that create the emotional energy and moral support for the reform effort.
It would be helpful next Wednesday if the President showed he understands these lessons, and not just the useless platitudes printed in the Times.
James Fallows, Atlantic, 1995, The Triumph of Misinformation
John B. Judis, American Prospect, 1995, Abandoned Surgery: Business and the Failure of Health Reform