By Kent Garber Kent Garber – Tue Aug 11, 4:27 pm ET
Back in August 1993, as Congress was preparing to break for summer recess, President
Bill Clinton was trying to drum up support for his healthcare plan, even though most of its details were still under wraps. For months his special White House healthcare task force, spearheaded by first lady Hillary Clinton, had been huddling behind closed doors, calling in experts, wading through proposals, promising to have something for the country to examine. Attacks from special interest groups were growing. Speculation about the proposal's contents trickled through the nightly news. Congressional committees were waiting to see legislation.
It wasn't until late September that the president appeared before a joint session of Congress and revealed his proposal. It was another year before its fate--failure--was decided.
[See photos of healthcare town hall meetings]
Last week, the Senate left for August recess, and
President Obama, like Clinton 16 years ago, is throwing himself behind healthcare reform. His effort also is in legislative purgatory, although one of a completely different sort. Four of the five committees that must approve a healthcare bill have already signed off. The holdout is the Senate Finance Committee, typically one of the more conservative committees. Though Obama failed to get a congressional vote by August as he promised, he clearly learned from Clinton's failure that quick action is key.
[Read Senate Considers Alternative to Public Option]
Still, his attempt is not sailing boldly ahead. It's caught up in a political fight, a philosophical fight, and a messaging fight, all swirling around what experts say is arguably the most ambitious effort by the federal government in decades. "This really makes or breaks the Obama presidency," says James Morone, a political science professor at Brown University and coauthor of a new book,
The Heart of Power: Health and Politics in the Oval Office . "Every Democratic president--Roosevelt, Truman, Kennedy, Carter, Clinton, every Democrat except Johnson--tried this in one way or the other, and they've all come up short." So far, Democrats have managed to broker compromises to keep their party in agreement. So the question now is perhaps as much, "Will healthcare reform happen?" as it is, "What will it look like if and when it does?"
[Read Opponents of Healthcare Take Glee in Democratic Anger]
Part of the answer will come in September, when lawmakers who went home and met with constituents at town halls or coffee klatches to hear gripes or praise come back to Washington and report back to Democratic leaders. Thanks to a hard-fought compromise late last month between liberals and conservative "blue dog" Democrats, the House could hold a vote as soon as it returns and merges the different versions of its bill, assuming the deal holds. It's no wonder that some Republicans are delighted by the intensity of the protests breaking out at town meetings across the country. "The huge thing is the first week back," says Morone. "If the blue dogs start to talk about dumping the public option, if the deal they went home with falls apart in the House, Obama is in big trouble."
To keep healthcare reform moving, the White House has been forced to take a trial-and-error approach to reading the nation's pulse. For decades, Democrats have talked about the plight of the uninsured as a moral imperative. To that President Obama this spring added the issue of cost: Healthcare is really, really expensive, is getting more expensive, and is eventually going to bankrupt the country, he argued. But as the administration has learned, these arguments don't excite Americans. So the White House is adapting. "It was clear that neither of those messages were reaching the middle class," says David Kendall, a health policy expert for the progressive think tank Third Way. "What we have seen in just the last month and a half is a shift toward the question, 'What's in it for me?' " Now, the White House talks about reform less as a scary if sterile economic problem and more in terms of personal "stability," promising Americans that reform will help them keep insurance if they lose a job or develop expensive medical conditions. In other words, it's social security for the body.
Of course, "What's in it for me?" raises another question: "What's actually in the bill?" It's there that the desire to fix healthcare can get snuffed out by the massively technical nature of healthcare itself and by the easy distortions that can accompany it.
So far, the debate centers on two levels: political and technical. Politically, what's gotten the most attention is the dispute over the role of government in health insurance, an ideological fight played out in the battle over a public option. The issue, put simply, is whether the federal government should sell health insurance and compete with private insurance companies, which in theory could make insurance cheaper. This gets a rise out of people, and it also tends to provoke caricature and exaggeration. In fact, as far back as 1948, when President Truman proposed healthcare reform, Republican critics retaliated with cries of "Communist!"
[Read AMA: Healthcare Reform Bill a Starting Point
The second track includes the wonky, messy, but incredibly important policy challenges, such as changing how hospitals get paid, rewarding doctors for making their patients happy, or finding other ways to stop healthcare costs' continued climb. Here, reasonable people can disagree about what to do, often for lack of data. "Almost everything that has been tried has failed," says Harvard Business School's Regina Herzlinger, a leading healthcare economist and a senior fellow at the Manhattan Institute. "The things that may work have not been tried in sufficiently large numbers, so honest economists like those who work for the Congressional Budget Office would be very uncomfortable scoring them" for savings.
Herzlinger says she supports the idea of giving subsidies to the poor to help them buy insurance but says the biggest challenge is addressing dysfunction in health insurance market. "How can it be a market if the consumer is completely ignorant or if I have a choice of only one policy?" Hertzlinger says. She points abroad to an alternative: "The Swiss have 87 different private health insurers in a country the size of Massachusetts, tremendous number of competitors." In Alabama, by contrast, BlueCross BlueShield controls 90 percent of the insurance market.
But examining healthcare shortcomings in the United States inevitably leads back to questions about the role of the federal government in this arena and what the consequences may be for lawmakers who vote one way or the other. Herzlinger says the government should focus on two areas: giving consumers more data about doctors, hospitals, and treatments so they can make better choices, and providing stronger regulation of monopolies and fraud. This would help unleash competition among healthcare providers, she says. Progressives, of course, envision a much larger federal role.
This all presages a boisterous autumn. As Morone points out, in 1993, Democrats in Congress became increasingly divided as the year wore on. First there was a nasty budget spat that involved a highly unpopular energy tax, then a fight over NAFTA, then healthcare. A similar problem could arise this fall, since the Senate has promised to follow the House's lead and pass climate change legislation, too. Republicans who see healthcare reform in purely political terms won't make things easier for them. "This is a battle for control of Washington," says Morone. "The danger for Democrats is that they argue details about healthcare reform, whereas Republicans go out and swift-boat everything."
One option that's still available is a procedural move known as reconciliation. Approved as part of the president's budget last spring, it basically allows Democrats to pass healthcare reform with only 51 Senate votes, rather than the usual 60. If Democrats get desperate in late October, watch for them to use it.
