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I'm as disappointed as anyone with the current health care legislation as it heads to conference.  If we end up with something resembling the Senate bill, which I think is highly likely, I consider it a far, far cry from the type of health care reform this country needs.  But with that said, I don't think President Obama and Congress could have gotten anything better.  And I think Obama made a number of smart moves that enabled him to do what no other president in the past 40 years has been able to do - moves that I think have gone underappreciated.  In particular, Obama clearly learned from President Clinton's key missteps in his failed health care reform effort in the early 90s, and took those lessons to heart.  Jump below to look at what Obama did right on health care reform, from this jaded progressive's perspective.


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In 2008, Ezra Klein wrote a great piece for the American Prospect that describes the three main reasons why the Clinton administration's health care reform effort failed.  President Obama avoided all three mistakes.

1. Obama put the legislation on a quick timeline.

According to Klein, Clinton's first big mistake was that his health care reform effort dragged on far too long - 20 months to be exact.  Clinton created the Presidential Task Force on National Health Reform shortly after his inauguration in January 1993, and the task force crafted a health care bill that was finished and presented to Congress on November 20, 1993 - almost 10 months later.  The bill then wound its way through Congress for another 10 months, until Senate Majority Leader George Mitchell declared the effort dead on September 26, 1994.

Klein notes that a key impetus for Clinton's health care reform effort was the 1990-1991 recession.  But by the time 1994 rolled around, the economy had improved and health care reform was not as much of a priority anymore for the American public:

The initial calculus of the Clinton plan was that Americans would be more afraid of their health coverage being changed by recession than reform. As the recession eased and unexpected economic changes looked less likely, reform grew scarier, and thus the "fierce urgency of now" that animated the 1991 discussion over health reform dissolved before a bill had even been presented.

But here we are less than a year into the Obama administration and a health care reform effort has passed both the House and Senate.  From the start, Obama has created a sense of urgency in getting a bill passed. Yes, Obama set a number of deadlines for Congress on health care reform legislation that came and went, but he still succeeded in creating a sense of urgency for passing a health care bill - a sense of urgency that continues to this day. He knows that the recession is going to end eventually and people's priorities will shift elsewhere, and they start feeling more comfortable with the status quo than with changing the system.

2. Obama let Congress take the lead.

Perhaps the biggest blunder that President Clinton made on health care reform was to create a task force that presented a fully formed health care reform bill to Congress.  

The task force was widely derided for being famously secretive and sprawling, splintering into more than 30 working groups involving more than 500 participants. But its great sin was not its secrecy or its size, but its very existence. For the White House to construct a thousand-plus page health care bill and then present it, fully formed, to Congress, was a tremendous demonstration of arrogance and political naivete. Congress may not make the best policy, but it makes the most politically viable policy. Crafting the plan independent of the congressional process proved to be a disastrous decision.
Over the past few months I have continually been amazed at how many people have criticized Obama for not getting more involved in the process of crafting the health care reform legislation.  But the lessons from the Clinton administration were exactly the reason why he shouldn't have done so.  Once Obama committed himself to a specific policy or implementation detail in the bill, it would have opened up that policy or detail for even more politicization, and would have made that policy or detail more about Obama and less about the policy itself.  So Obama set out some broad goals for the bill and left the details to Congress.  I have criticized Obama for a lot of things, but I'm not going to criticize him for staying out of the mire as Congress made its sausage.

Yes, perhaps if Obama had made a more public push for certain aspects of the bill (such as the public option), it could have helped.  But it's also highly likely that it could have hurt more than helped, as Clinton's failed effort clearly showed.

3. Obama involved everyone in the process from the start.

Clinton's third major misstep on health care reform relates to the other two.  By creating a detailed health reform through a closed, secretive process that dragged on for 10 months, it left a 10-month vacuum for critics to ramp up their opposition, and when the bill finally got to Congress the President found himself with no allies to back him up.

During the 10 months of silence when the Clinton administration was actually creating the policy, the opponents of reform were organizing to define the politics...The Health Insurance Association of America's first ads went up in the spring of 1993, the National Federation of Independent Businesses began organizing against vulnerable Senators at about the same time. Come September - two months before the legislation was finished - the Harry and Louise commercials were blanketing the airwaves. "By the time [the bill] got to the House," says (Rep. Pete) Stark, who chairs the Health Subcommittee, "we'd been beaten up for months on it, and we had already suffered the insults of the Harry and Louise ads, and I don't think any of my colleagues were ready to take more criticism."
And Clinton's allies were nowhere to be found.  
Where was Labor, the progressive movement, AARP? Essentially, nowhere. "Labor was split because it wasn't single-payer, and they were mad because of NAFTA," says one insider deeply involved in the process. "They held back on any kind of dedicated resources or substantial commitment to defending health care in the fall of '93. They came in later, but we were already taking on a lot of water. And the progressive movement, because it wasn't single-payer, ended up not really embracing the bill, and that lack of support really contributed to a one-sided, White House versus the world, dynamic." AARP was little better -- they didn't even endorse the possible bills until late in 1994.

Most damning, however, was not the absence of the allies, but the absence of the business community.

With the Obama administration, nobody can rightly claim they were left out of the process of creating health care reform legislation - just the opposite.  Obama has clearly engaged everyone and their grandmother in the process.  Endorsements from key groups like the AARP and AMA came early on, and Obama has been open to everyone's input and participation.

Of course, this strategy has often draw the ire of key consituencies like the progressive wing of the party, who are none too happy with Obama's early dealings with the pharmaceutical companies, for example. And if Obama did indeed take this lesson to heart, it could explain his maddening obsession with making health care reform a bipartisan effort this time around.

And the crafting of health care reform legislation in 2009 was hardly secretive.  Just the opposite in fact, sometimes painfully so.  We saw in painstakingly ugly detail how the sausage gets made in Congress, and we all had plenty of opportunity to let our voices be heard along the way.  It wasn't pretty, but it WAS inclusive, particularly when compared with the failed 1993-1994 effort.

As I said above, I have not been afraid to criticize President Obama this part year - I am hardly an Obama cheerleader.  But I think he deserves a lot of credit for doing things right in order to bring health care reform, or at least the start of health care reform, closer to reality than any president has been able to do for over four decades.  And for that I give him a big heap of kudos.

Extended (Optional)

Originally posted to davidkc on Sat Dec 26, 2009 at 07:30 AM PST.

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