As I was reading through this historical timeline on health reform it became quite obvious that this issue has not only persisted for over a century, but has morphed into several side debates. The nature of American health care delivery and health insurance has changed radically over time.
But the modern system of health care didn't really emerge until the late 1980s and early 1990s with the advent of "managed care" through HMOs, PPOs and other group-based, employer-covered (for the most part) health plans. These plans were designed to limit skyrocketing health care costs, which themselves were a product of a nation that lived longer, an industry that became more profitable and politically powerful, and more expensive new technologies.
In 1993 and 1994 the Clinton Administration tried to tackle the emerging problem of the non-insured and increasing costs with a "managed competition" plan. On one level, it is striking just how similar the debate between then and now is. Look through this August 1994 post-mortem on "What Went Wrong" and a few old familiar themes stand out:
- The committees. Just as in 1994, the biggest stickler is the House Energy and Commerce Committee. And like then, the Senate Finance Committee could not agree on a cost-containment plan, especially after an earlier deficit reduction bill.
- Other issues. In 1993-94, NAFTA, the budget deficit, the crime bill and even Somalia helped derail Congress's attention from the pressing matter of health care reform. The timing was often critical, as Congress was unable to really get moving on legislation until after these other issues sapped the political capital of a deeply unpopular Democratic Congress. Today the side issues are there but a bit less politically problematic; occasionally somebody will complain about the cap-and-trade bill or the stimulus bill sapping energy. And then there is TARP and the auto bailouts, which are both deeply unpopular with Independents.
- The CBO. Like Doug Elmendorf today, the CBO chairman at the time continually rebuffed all budget plans that purported to hold costs down.
- Powerful lobbyists. They're still here, though they are less unanimously opposed to reform than in 1993-94.
- Partisan gamesmanship. Bob Dole, like Charles Grassley, played a public role of seeking a compromise solution. Phil Gramm, like Jim DeMint, sees an advantage in killing the whole thing. Republicans end up supporting nothing.
- Democratic disagreements. Blue Dogs of today and conservatives of 1993-94. I never realized what a jerk Daniel Patrick Moynihan was in the debate. Was he the Max Baucus?
But there are some critical differences between then and now. And it's essential that we keep them in mind.
- Reality. Health care costs did, in fact, stabilize a bit in the mid-1990s as the "managed care revolution" worked its magic. But then in the late 1990s health care costs skyrocketed again. It had now become blindingly obvious that health care costs were eating away at the American economy, depressing real wages, throwing people into personal bankruptcy, threatening profitability, and hurting American global competitiveness. Also, as Ezra Klein has pointed out, most Americans still got their coverage through indemnity plans in 1993. Clinton's plan to ENCOURAGE the managed care movement really did mean loss of choice over doctors, treatments, etc. Of course, the lack of reform meant that the loss of choice had no countervailing positive effect for the underinsured. Now, managed care makes the "choose your doctor" language of the GOP completely moot. We already have "faceless bureaucrats" - demons in the "Harry and Louise" ads - deciding what care we can get. That was not necessarily the case in 1993-94. Also, there are a lot more people uninsured today than in the early 1990s. Much of this is connected to increased costs for coverage on small businesses.
- Leadership. Say what you want about the Clinton Administration, but their leadership over the health care issue was ham-fisted at best. Ira Magaziner, whose name strangely has disappeared from historical discussion over the issue, pushed an incredibly unwieldy process that angered everybody it touched. Hillary Clinton took much of the blame for a variety of reasons, but it was Magaziner's operation that did so much to alienate even the most progressive members of Congress. By early 1994 virtually no Democrats would support Clinton's plan.
Obama has learned from that lesson. Gone is the secrecy of the Magaziner group and the Presidential insistence that his plan was the only acceptable option. If there is criticism of Obama, it is that he has gone too far the other way in letting Congress work out the details. Jim Cooper, who complained so much about Clinton's heavy-handedness back then now whines that Obama is too hands-off. But as long as the big players - the Blue Dogs, the House and Senate leadership, the Administration, the progressives - agree that we are in 80% agreement on things, there is a great chance that Obama's conciliatory process will work.
- The interest groups. It's truly shocking that the AMA has supported Obama's health reform efforts. Look at the NYT timeline again and notice how often the AMA fought health care reform. Small businesses are also less opposed to reform today, mostly because they have been so punished by the rising health care costs up to now. And while the Health Insurance Association of America is gearing up to launch opposition this August, they carry far less support today (even with their contributions to Baucus) than they did back then. For one thing, people who already have insurance today either hate their insurance or dislike it more and more every year. The moral authority is gone; when the Lewin Group was outed as a UnitedHealth front, it really did help to undermine the anti-reformer cause.
- The media. No, not the traditional media, which is as obsessed with process stories and "Democrats bickering" as ever. It's the alternative media, which proved so powerful in the 2006 and 2008 elections. In 1994 the opposition was able to muster up large-scale grassroots rallies against reform. Clinton was literally heckled everywhere he went. Today, with the organizing power here and elsewhere in the blogosphere, even Blue Dogs can expect to hear 10-to-1 chants in SUPPORT of reform this August (thanks to slinkerwink among others). Just look at the energy here in Murfreesboro, Tennessee, where citizens pressured Blue Dog Bart Gordon for health care reform. In 1994, the protesters would have been on the other side. As long as we keep up the pressure, we help to drive the narrative - ESPECIALLY at Congressional home offices.
- Politics. Here is the biggest difference. In 1992, Bill Clinton became President with 43 percent of the vote. The Reagan Revolution ran into a bump with the recession and the massive deficit, but there was still enormous political energy on the Right. Democrats, from Clinton on down, were playing defense, conceding basic elements of Reaganism while trying to steer the course toward health reform that Reaganism explicitly opposed. When the GOP stood in opposition to Clinton, it could count on a still powerful anti-government narrative that had been building since 1980. Moreover, the GOP had some very effective spokesmen against reform, including especially Gingrich.
Today, the story is completely different. The GOP's victory in 1994 and again in 2000 gave them a chance to show their stuff. And the American people were not amused. Adding to the demographic shifts against the Party of Dixie, the recent history of Bush-DeLayism has effectively destroyed the current Republican Party. This weekend's departure of Sarah Palin from the Governor's Chair in Alaska only underscores how out of step politically the GOP is. There may be doubts and concerns out there about Democratic health reform plans, but the GOP is so far in no position to take advantage.
On the Democratic side, the overall caucus is more liberal than in 1993. The old Dixiecrats were largely purged from the rolls. And moderate Republican districts of the North have gone blue. Yes, there are annoying figures in annoying places (Baucus and Ross, for example), but they are far less than in 1993. There was no Henry Waxman back then in position to bypass the C&E Committee. The Senate already agreed to allow budget reconciliation to get health care passed. Obama is far more popular now than Clinton was at this point.
- History. I think the single most important reason health care reform will pass is the Lesson of 1994. We've already seen what happens when nothing gets done. The problems of access and cost continue. Democratic voters get demoralized and stay home at Election Day. The right wing gets emboldened and clears out the very conservadem obstructors of reform. And health care reform isn't raised again as a politically palatable issue for a long time.
Keep these similarities and differences in mind. The differences are greater, I think, than the similarities between 1994 and today. But much of that difference has to do with us - the activists in the blogosphere who keep up the pressure on Congress. Maximalist demands and Debbie Downerism will not help; no need to demoralize ourselves with every twist and turn from Max Baucus's mouth. But we must keep up the pressure - especially this August recess when wavering legislators will look to see what their constituents think. Silence this August would be deadly. A strong, positive and united voice for reform - for the 80% of reform that even Jim Cooper concedes is already there - will get this done.