THE CONTEMPORARY POLITICS OF HEALTH REFORM
THEDA SKOCPOL AND PATRICIA SELIGER KEENAN
The past decade has witnessed some amazing twists and turns in U.S. health care politics. Starting in 1993, President Bill Clinton attempted to push through a comprehensive reform that would have guaranteed health insurance to all Americans, extending coverage to low-wage workers who predominated in the ranks of the uninsured. Yet within a year, public opinion turned as interest groups and partisan forces mobilized against the reform proposals, leading Clinton to abandon them (Broder and Johnson 1996; Skocpol 1997). After the 1994 midterm elections, Republicans took control of Congress and redefined health care reform to mean containing costs and restructuring Medicaid and Medicare. But Republican proposals, too, proved unpopular and largely failed (Peterson 1998).
Health reform proposals then concentrated on incremental adjustments until 2003, when Republicans in control of the presidency and both houses of Congress just barely pushed through a major enhancement and restructuring of the Medicare program, which covers 40 million elderly and disabled Americans (on the politics of this episode, see Skocpol 2004). In one of the most extraordinary episodes in U.S. health care politics, Republicans sponsored the addition of a prescription drug benefit to Medicare, a public-sector program they had long questioned, while most Democrats criticized and opposed the legislation even though it mandated expanded benefits.
How are we to understand the contemporary politics of health reform? How do issues rise on the agenda, and what forces determine the shape and fate of legislative proposals? We use insights from political science research on agenda setting and policymaking to examine key episodes and trends, especially the Clinton health reform episode of 1993–1994, the attempted Republican cutbacks of the mid–1990s, and the enactment of Medicare restructuring in 2003. Proposed reforms that make headway, we argue, build on existing public-private arrangements and are more likely to be successfully enacted if they are inherently ambiguous and stress benefits and subsidies rather than cost-constricting regulations or funding cuts. We then draw upon knowledge of past episodes to speculate about the future course of health reform politics.