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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.

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.

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

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Comment Preferences

  •  Reforming healthcare (13+ / 0-)

    is like trying to land a crippled 757 on a two lane blacktop in the middle of a hurricane with no rudder control while being attacked in the cockpit by vipers.
    This monstrosity has just touched down and is now bouncing along that blacktop trying desperately to successfully finish this nightmare flight...where is Sully when you need him?

    This is close to completion,but could still blow up before the end.
    And yes, this type of process is always open for second guessing,but the last 7 attempts have blown up in the air,not even getting close to landing.

    I do think it is obvious that the President made a concerted effort to avoid the Clinton errors and that just makes sense.
    Now, lets finish strong,and then start tinkering.

    •  I call the current bill "tinkering" not "reform" (0+ / 0-)

      So pass the bill and then continue to tinker.  I guess that's the best we can hope for right now.

    •  Anything this big happens in stages (9+ / 0-)
      As a practical matter, it's impossible to get anything this big right the first time around.  Whether it's an engineering project or a legislative project, the system under construction is simply too big to be fully debugged on the drawing board.  So you plan for that, creating the best system you can that will do something useful and adding to it over time as things are learned from the mistakes inevitably made the first time around.

      Another diary I saw this morning indicated that the French system took something like 15 years and 4 tries before it reached the general outlines of its current state.  Social Security also evolved over time; the initial implementation was very weak and didn't cover very many people (and consciously discriminated against women and non-whites).

      It will be the same here.  This is simply a way station.  A big one, I believe, but it's not the starting point and won't be the ending point.

      I think we progressives also underestimated just how difficult it would be.  Perhaps we shouldn't have -- after all, this has been on the table for 100 years -- but we did underestimate our opposition's tenacity and even the objections of some Democrats.

    •  Brilliant! (3+ / 0-)
      Recommended by:
      Vicky, davidkc, kafkananda

      What a superb analogy for this process -- especially the vipers.

      Dude, your statistical average, which was already in the toilet, just took a plunge into the Earth's mantle. ~ iampunha

      by ETF on Sat Dec 26, 2009 at 08:58:21 AM PST

      [ Parent ]

  •  Amen. (7+ / 0-)
    Recommended by:
    mll, Vicky, davidkc, NewDealer, Hawkjt, ETF, SoCalSal

    "Someone who does not see a pane of glass does not know that he does not see it." --Simone Weil

    by AgnesBee on Sat Dec 26, 2009 at 07:57:39 AM PST

  •  I agree. This was a tough challenge, (5+ / 0-)
    Recommended by:
    Vicky, davidkc, Hawkjt, ETF, caduceus4

    particularly with blatant obstructionism from Republicans.  I really don't see any other path that would have led to 60 votes in the senate.  (I'm pretty amazed that ANY path led to 60 votes!)  I'm relieved that it has gotten this far with enough good stuff in it to win support, however grudging, from people like Paul Krugman.

  •  That it got this far (9+ / 0-)

    Is a huge achievement for this President. I commend him and the Speaker and Senate Majority Leader on this.

    Its not perfect, but it is a foot in the door, and we need this to happen if anything can happen.

  •  Great synopsis of positives, thanks! (3+ / 0-)
    Recommended by:
    Vicky, kafkananda, msmacgyver

    "If by a Liberal, they mean someone who cares about the welfare of the people, then I am proud to say I'm a Liberal". Ted Kennedy

    by caduceus4 on Sat Dec 26, 2009 at 08:54:51 AM PST

  •  Excellent diary! Here is where everyone (3+ / 0-)
    Recommended by:
    askew, Vicky, davidkc

    forgets yet blames him:

    "2. Obama let Congress take the lead."

    He knew that if he were involved they would stall and stal.  The fact that he's not a senator doesn't cross the minds of those who are irrational and emotional.  

    I also believe the public failed to acknowlege his strategy.  To show the voters who is or is not representing them on both sides of the house and senate.  He wants to show the citizens of this country what happens when Senate and House are left to work on their own.  Seems the House is closer to the people than the Senate.  Time to get rid of every republican in hiding.

    •  I hope the Dems spin the do-nothing Repugs (2+ / 0-)
      Recommended by:
      Vicky, kafkananda

      If the Dems play this right, they can effectively portray the Repugs as the obstructionist, hyperpartisan, do-nothing failures that they are.

      •  I think this battle has laid the groundwork (1+ / 0-)
        Recommended by:

        for major pushes on many issues. Sometimes it can be frustrating 'getting the ducks in a row' but it will pay dividends down the road. Because many people have health care via their employer, it was natural to have a lot of skittish folks out there.

        Some of the other coming battles will cut a lot deeper into the Repugs obstructionist tactics.

        More than a few have noted that the financial industry regulations will be a great populist hit. And the meme that Obama is 'out to get Wall Street' will ring very hollow. :-)  Thanks Rahm, you are the perfect cover for that.

        The path forward on LGBT rights has been set, although not widely publicized, and this will be accomplished.

        Obama's statements on re-legalization of cannabis have inoculated him from easy smearing and the path is laid out for a re-scheduling (was the AMA statement suggesting that a result of side talks about HCR?).

        On immigration reform, the Repugs will still be split between the teabaggers and the corporations' need for cheap labor.

        New laws to clarify and protect women's rights will be outlined and moved forward.

        Obama likes to set the table way in advance. The 'duh' factor when Obama points out where the obstruction is coming from will be huge. It is a bank account that we will have to draw upon until further notice, seeing as the Repugs kept adding to it.

        Please don't dominate the rap, Jack, if you got nothing new to say. If you please, don't back up the track, this train's got to run today.

        by kafkananda on Sat Dec 26, 2009 at 11:37:02 AM PST

        [ Parent ]

  •  Excellent thought provoking Diary - Thanks n/t (2+ / 0-)
    Recommended by:
    Vicky, davidkc

    An error does not become truth by reason of multiplied propagation, nor does truth become error because nobody sees it. Mohandas Gandhi

    by msmacgyver on Sat Dec 26, 2009 at 09:22:48 AM PST

  •  Very fair, sensible diary (2+ / 0-)
    Recommended by:
    Vicky, davidkc

    I would like to compliment you on the fairness and tone of this piece.  The point  that so many criticized Obama for not being more involved was correct.  If he would have come out, it would have given the nuts even more of a target.  I too am disappointed but not with Obama.  I know the real problem was with just a handful of senators who had D's behind their names but acted like R's.  

    too soon old--too late smart

    by idahospud44 on Sat Dec 26, 2009 at 09:57:06 AM PST

  •  It's way too soon to know (1+ / 0-)
    Recommended by:

    what he actually did; so much happened behind the scene. It's usually the case that it takes at least several years before people start writing about what went on behind closed doors.

    And of course there are some things we will never know. It will always be a matter of speculation what might have happened if different strategies were employed.

    "There -- it's -- you know, one of the hardest parts of my job is to connect Iraq to the war on terror." --GWB

    by denise b on Sat Dec 26, 2009 at 11:02:25 AM PST

  •  Thank you (0+ / 0-)

    for such a needed dose of common sense.

    "Statistics are people with the tears washed away." Sociologist Ruth Sidel

    by Vicky on Sat Dec 26, 2009 at 12:17:22 PM PST

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