Show some sympathy for Ira Magaziner and Hillary Clinton

Harold Pollack, a University of Chicago professor and a former RWJF Scholar in Health Policy Research, takes a fresh look at past health reform efforts. 

At this writing, the Senate Finance and HELP (Health, Education, Labor and Pensions) Committees are wrangling over competing bills. HELP has released a 615-page version that, of necessity, leaves countless details to be determined later.

The House has a similarly humongous document, assembled by multiple committees. Both houses are struggling to assemble the required financing to manage intricate linkages across levels of government, facilitate new health information technologies, encourage preventive care and much, much more. All sides anxiously await Congressional Budget Office scoring that can make or break particular provisions in the bill. The Democratic Party struggles to unite a coalition that includes diverse constituencies ranging from disappointed single-payer advocates to centrist constituencies that favor market-oriented solutions and stringent cost controls. Things are moving forward, but it is a hard, hard climb.

I don’t know how this difficult process will end. I do know one thing: Many of us who favor health reform should take back some of the self-righteousness and scorn with which we condemned the Clinton Administration’s efforts to achieve the goal of restructuring our health care system.

I know. Hillary Clinton and Ira Magaziner, the architect of the 1994 plan, made many mistakes. They also made many decisions that look much dumber in hindsight than they did at the time. Clinton and Magaziner got many things right, and were less naïve, in political and policy terms, than is now widely assumed. These two people, in particular, were blamed for mistakes made by their ultimate superior in the Oval Office. They were also blamed for things that didn’t happen, as James Fallows recounts in a classic piece. With some justified bitterness, Paul Starr recently penned an essential piece that corrects the record on these points. Most of all, Hillary Clinton and Ira Magaziner were blamed because they took some big gambles and lost.

Fifteen years later, President Obama is trying to succeed where President Clinton failed. In many ways, he has a stronger hand. His personal popularity exceeds President Clinton’s in 1993. President Obama enjoys a more unified Democratic legislative majority. We are in the midst of an economic emergency which underscores the importance of activist government and which has deeply damaged the Republican Party.  Documentaries such as Michael Moore’s "Sicko" exemplify public anger and distrust of the private insurance system. President Obama also enjoys the benefit of his predecessor’s experience. There is no huge and specific Obama plan. The President is allowing Senate and House leaders to negotiate, and thus to own, many essential details.

This is the right general strategy, but it is still heavy-going. No one can really say whether a public plan option will be included in the final package, or what such a public plan option will really be. Different Congressional leaders express vastly different ideas about how to find slightly over $1 trillion over the next decade required to pay for reasonable reforms. Each specific proposed revenue source—including caps on the tax deductibility of employer-provided coverage, cuts in Medicare and Medicaid provider reimbursements, tax surcharges on wealthy people, tobacco and alcohol taxes—generates passionate opposition from affected constituencies and only lukewarm support from the diffuse advocates of health reform. The President’s decision not to present his own detailed package lessens his political vulnerability and probably lessens the probability of political catastrophe. It also lessens the probability of a truly coherent reform like the original Clinton health plan. And yes, this year’s final bill may well exceed the 1,342 pages that seemed so horrifying fifteen years ago.

Ezra Klein, associate editor of the American Prospect, is the latest in a long line of frustrated reformers and radicals who blame the founding fathers who created a system that so dramatically favors the defense over the offense in social policy legislation. Klein vents particular anger at the rules of the United States Senate, which gives Wyoming’s 532,000 residents the same two votes provided to California’s 38,000,000—and which requires a super-majority of 60 votes to enact most legislation.

I’m frustrated too. Montana Senator Max Baucus recently assembled seven Senators, dubbed the "coalition of the willing," to negotiate a centrist and bipartisan vision of health reform. The total population of these states is markedly less than the population of greater Los Angeles. These states are also in unusually strong fiscal health, and have a much smaller proportion of urban black and brown poor people than is typical in other states. Yet they may be positioned to make or break a final health reform bill.

Democrats who favor ambitious health reforms and Republicans who favor privatizing Social Security or rolling back New Deal programs—discover one sobering fact. Sweeping domestic policy reforms require large majorities in unusual times: 1932, 1964, not many others. These opportunities just don’t come along very often.

Hillary Clinton, Ira Magaziner and their minions failed in what they set out to do. On one account, they just blew it. On another, their political adversaries just enjoyed insurmountable strategic advantages rooted in the basic structures of American government. Some combination of both stories is probably correct.

Since 1994, health policy advocates--myself included--have been tempted to judge Magaziner and Clinton quite harshly for their failures. Watching the pushing and shoving of the last few months, I’d say that greater humility and compassion are now in order.