By Wiener, Joshua M.
Brookings Review , Vol. 13, No. 1
In January 1993, enactment of comprehensive health care reform was widely believed to be inevitable. By September 1994, not even incremental change could be enacted. In the recent election, health care was barely an issue. How did health reform go from being a certainty to an impossibility?
The Clinton administration and the Democrats bear some responsibility. The secrecy of the infamous health reform task force (of which I was a staff member) unnecessarily raised media and public suspicions. The administration never explained clearly to the American people its complex plan or the logic behind its design. Nor did it ever develop a strategy to combat the massive advertising and lobbying by opponents of reform. To top it off, congressional Democrats were undisciplined, attacking the administration's plan from both the right and the left.
Sensing a weakened president, Republicans in both the House and Senate added a strong level of partisanship to fundamental disagreements in principle. Their protestations that they were only combating "bad" legislation would have been more compelling if their own substitute proposals had credibly controlled costs or provided universal coverage.
But while Democratic ineptitude and Republican obstructionism played a role, the principal reasons for health reform's demise reside in more fundamental factors.
In the first place, Americans are schizophrenic about health care. They believe that the U.S. health care system needs major reform, but they are quite content with their own health care. In a January 1994 U.S. News and World Report poll, three-quarters of respondents were satisfied with their health insurance coverage, but three-quarters also felt that the system needed a major overhaul. Americans want the problems fixed without making any major changes in the way their own health care is financed and delivered. But the problems cannot be fixed without significantly changing the way health care is financed and delivered.
Second, much of the debate boiled down to whether government should expand its role in health care. Americans have low regard for their governments and do not want them to play a more important role.
Proponents of managed competition tried to finesse this political problem by retaining private insurers, but changing the rules by which they compete. To the surprise of many, making the market work better turns out to be complicated, cumbersome, regulatory, and bureaucratic. While the Clinton bill was ridiculed for running 1,300 pages, the so-called "mainstream" proposal, which would have done a lot less, ran nearly 1,100 pages, and Senator Robert Dole's bill, which proposed only minor reforms, was more than 600 pages. …