Why 2009 Is the Year for Universal Health Care

In the best of circumstances, presidential libraries are a strange combination of leftover campaign literature and newfound architectural ambition. Even so, the Clinton Presidential Library, in Little Rock, Arkansas, is notable for approaching its subject with all the depth of a coloring book. Eight years of presidential policies, political battles, and world events are sorted into 20-odd "policy alcoves," all of which come complete with titles right from the campaign. The first, for instance, is "Putting People First." Here, behind reinforced glass tattooed with inspirational excerpts from Bill Clinton's speeches, the administration's entire record on social policy is condensed into a couple of blow-up photos and capsule summaries. And right there, between "caring for children" and "welfare reform," is the library's exhibit on the 1994 health-care battle. It gets 144 words.

Uncharitable observers might sneer that this is all it deserves. They would be wrong. The 1994 health-reform fight was a tremendous, courageous undertaking that the nascent Clinton administration approached seriously, substantively, and stupidly. Its defeat, which preceded an election in which the Democrats lost 52 House seats and control of Congress, inflicted enormous psychic trauma on every level of the Democratic establishment -- the politicians, the political consultants, the advocacy community, and the hundreds of wonks and experts who participated in the plan's creation. It taught many that health care is simply too big, too complicated, too dangerous to touch. Since the drubbing, Democrats have been afraid, as former Sen. Bill Bradley put it, "to go back into that room where that bad thing happened."

But Democrats need to return to that room -- and bipartisan universal health-care campaigns in Massachusetts, California, Wisconsin, and many other states have opened the door. In the Congress, Sen. Ron Wyden's Healthy Americans Act has attracted 10 co-sponsors, six of them Republican. In the presidential campaign, all of the major Democrats proposed comprehensive plans. Talk of reform once again floats through Washington.

But as the Clinton Library display attests, the moment has looked propitious for change before, and failure has been all the harsher for it. Health care, which now comprises a full one-seventh of the economy, is hard to reform. Harry Truman failed, as did Richard Nixon and Bill Clinton. Franklin D. Roosevelt didn't even try, believing any attempt would not only fail but take down Social Security, too. And the system has only grown larger and more entrenched in the years since. Health care is now a multi-trillion dollar industry that generates billions in profit streams for all manner of powerful actors. Medical coverage and its attendant costs are a source of acute anxiety for Americans. About 84 percent of the population has health insurance, and, crucially, 94 percent of voters do, but they are deeply afraid of losing what they already possess.

In 1994, reformers were hampered by the belief that the rules of bipartisanship were still in effect and a collection of public-minded senators would eventually come together to enact reform. They weren't prepared for a Republican Party animated by William Kristol's famous memo, "Defeating President Clinton's Health Care Proposal," which darkly warned that a Democratic victory would save Clinton's political career, revive the politics of the welfare state, and ensure Democratic majorities far into the future. "Any Republican urge to negotiate a ‘least bad' compromise with the Democrats," wrote Kristol, "… should also be resisted." Today, the basic arithmetic of the Senate remains unfriendly, with a 60-vote supermajority still required to move major legislation.

Even so, every major Democrat running for president has promised to make health-care reform the top domestic priority of their first term. And they will do so atop a community of advocates, analysts, organizers, and congressmen who are more battle-hardened than they, or their counterparts, were in 1994. Perhaps most important, they are working within a system much closer to collapse and much worse for business.

In sum, a new Democratic president should have the best shot in a very long time -- perhaps, ever -- to create, at long last, a universal health-care system in America. To do so, however, will mean avoiding the manifold mistakes of the past. And, happily, there's some evidence that health reform's champions are doing just that.

You can see it in the bills. The problem with Bill Clinton's health-care legislation was not its mythical complexity, or the size of the legislation, but that it placed the policy before the politics. Though the legislation accurately reflected the concerns of health economists and policy specialists, it did not accurately reflect the concerns of voters. Where the 1990–1991 recession, which hit white-collar workers particularly hard, left most Americans terrified that they could lose the health care they had, the Clinton bill promised they would lose that health care. The sort of comforting lines reformers offer today -- "if you like your current care, nothing will change," or "you'll get the same health care members of Congress have," or "it's just like Medicare" -- couldn't be uttered in 1994 because they weren't true. The line the Clinton campaign did use, "health security that can never be taken away," floundered because, before the plan offered that security, the health security that Americans currently trusted would be taken away.

"They couldn't defend it in simple terms," says Yale political scientist Jacob Hacker, "because it actually meant a complex set of changes for most Americans." There was no concrete reference point because the legislation was building something that didn't yet exist. The administration's argument, in essence, was "trust us." But when it comes to health care, it's one thing to make the system better and a whole other to remake it anew. You can ask Americans to walk forward, slowly, knowing they can scramble back to the ledge if need be. You cannot ask them to jump.

By contrast, all the major Democrats currently campaigning for president have proposed essentially similar health-care plans based on three planks: Universal access, an expansion of something like the Federal Employees Health Benefits Program that includes a public insurance option, and the preservation of current insurance choices. This is not, from a purely policy standpoint, the best way forward. These plans do not fully integrate the system, and initially, they will not do enough to control costs. But politically, they're just about the only way forward. What those three planks translate into are three arguments that will undergird the case for reform: If you like your current health-care coverage, nothing will change; if you're not satisfied with your current coverage, you can buy into the same health-care plan that members of Congress use; and no matter what you decide, you will have more choices than you have now. That is how health care will be explained: no forced changes to your current insurance, the same coverage that those fat cats in Congress enjoy, and a broad menu of new choices offering an unprecedented array of options to those who want them.

The Democrats' understanding of the political process required to enact health-care reform has improved as well. "I was the biggest error [of the Clinton health-care bill]," says Sara Rosenbaum, who was one of a handful of executive branch officials who drafted the legislation. "It was a terrible error to have the president doing what Congress was supposed to do. It was a misuse of the relationship between the legislative branch and the executive branch. The executive branch is supposed to generate action, and the committees are supposed to actually take the action. By sending a 1,300-page bill, you're writing a detailed blueprint for the policy rather than using the congressional process to create a consensus." By constructing the president's bill within the executive branch, rather than with the Congress, the administration opted out of a policy process dedicated to finding workable political compromises and instead created a brain trust of wonks who, as wonks will, sought to construct the perfect policy compromise. The problem is they mistook the policy compromise for a political compromise, which their handiwork manifestly wasn't.

This time, the process has already started within the halls of Congress. Wyden's Healthy Americans Act, a universal-coverage bill that opens up menus of regulated insurance choices to everyone in the country, subsidizes coverage up to 350 percent of the poverty line, and slows spending growth is co-sponsored by six Republicans: Judd Gregg, Mike Crapo, Chuck Grassley, Robert Bennett, Lamar Alexander, and Norm Coleman. None are names you customarily see attached to Democratic bills. "I think we're building the sort of coalition that can break 60 years of paralysis," says Wyden.

For the first time in decades, congressional power players are talking seriously about concrete health-reform legislation. "To grow a healthy crop, you have to prepare the soil," says Sen. Max Baucus, now chairman of the Senate Finance Committee. "The Finance Committee will hold an aggressive series of hearings next year [2008] on comprehensive health-care reform. … Next year can be a prime time for ideas, a time to lay the groundwork for immediate action when a new president and a fresh Congress take the field in 2009." Whatever the legislation that may emerge from this process, the momentum for change is certainly building.

Additionally, the Democrats know they need to actually pass a bill, rather than simply fight for their perfect plan. "It will take full-court press by the White House," says Rep. Pete Stark, chairman of the Health Subcommittee in the House, and a longtime champion of Medicare-for-All, "and a lot of compromise, even from people like me. It couldn't be single-payer or raise a huge amount of taxes." Seeing all this, former Senate Majority Leader Tom Daschle can only marvel in appreciation. "I don't think there's any question that more and more members on the Democratic side are aware of, and committed to, the need for health reform," he says. "It's a better legislative environment than we had before."

You can also see the increased savvy in the coalition building, in the early organizing. The unions are onboard early. "Our forces are stronger, smarter, have learned lessons, and understand the need to address [the public's concerns] from the start," says Heather Booth, who is coordinating the AFL-CIO campaign. "And I think the right wing is fracturing, less confident, and the public is more aware of their false solutions."

And this time, labor will have allies that simply didn't exist in 1994. "One of the big problems with moving health care," says Eli Pariser of MoveOn.org, "is that there haven't been health-care constituency organizations in the way there are on the environment, civil liberties, and so forth." But the new progressive groups are multi-issue, able to refocus quickly and in response to the demands of their members. Health care is a major issue for their members. That's why MoveOn partnered with unions and other groups to force a major battle over the expansion of S-CHIP. "The Bush years have taught progressives how to do political campaigns in a different way," continues Pariser. "It's not enough to state your argument and hope for the best. You have to get out into the country and build constituencies in key districts and have the apparatus and enforce discipline." Which they've done. House Democrats, unable to overwhelm the president's veto, haven't blinked on S-CHIP, haven't rushed to the table, haven't begged for compromise. And many are calling this "spring training" for universal health care. "The true story of S-CHIP won't be written until next fall," predicts Pariser, "when Republicans are facing their constituents and getting thrown out of office. If that's what happens in November, that's what sets the terms for the next fight."

Think of it as the Harris Wofford strategy in reverse. Where Wofford's 1991 upset victory in the Pennsylvania Senate election taught politicians that there's a potential upside in supporting universal health-care reform, the progressive movement is readying a massive campaign to teach the lesson that it's dangerous to oppose it. Internal Democratic Congressional Campaign Committee polling leaked to Roll Call offers support for this strategy: Polling in Michigan's 9th District showed that advertisements criticizing Republican Rep. Joe Knollenberg's vote on S-CHIP had knocked him down 5 points in the polls and that a push question underscoring his opposition to the program's expansion produced a 14-point swing toward the Democratic candidate.

Perhaps most important, business seems both exhausted by the ceaseless march of health-care costs and ready for reform. In 1994, when managed care was just beginning to squeeze cost growth, health spending grew by a mere 4.1 percent. It looked as if the private sector might prove able to control costs just fine. But the gains from managed care dissipated as the 1990s wore on, and in 2005, health spending grew by 7.4 percent. Much of that cost was borne by the business community.

"It's a global competitiveness issue," says Charles Kolb, president of the Committee for Economic Development, a business coalition. "Even if it weren't, it's a cost issue. Health-care costs are growing at a rate that's simply not sustainable. [Our members] are in the business of business, not the business of health care."

"Our first health-care report came out in 2002," says Kolb. "We were trying to shore up the employer system. But now we're saying it's not fixable. Five years ago, we thought it was."

Even the National Federation of Independent Business (NFIB), which was militantly anti-reform in 1994, has joined a prominent health-care coalition organized by the Services Employees International Union. Indeed, NFIB president Todd Stottlemyer writes, "We must find a way to fundamentally alter the forces driving costs. … We will do nothing less than commit every resource to fight for a health-care system that makes affordable, quality health care available to everyone." An offhand comment by Sen. Wyden suggests Stottlemyer may mean business. "The businesses, in 1993, that said they couldn't survive health-care reform are now saying they can't survive without it. I talk to Todd Stottlemyer, the president of the NFIB, once a week!"

None of this is to underplay the obstacles that still stand before reform. Business can still grow skittish, the Republicans can still unite in opposition, and the Democrats can prove cowardly or incompetent. But the forces pushing reform are not, at bottom, political. They are not to be found in the Congress or the advocacy groups. They are to be found within the accelerating deterioration of the health-care system itself.

In 1994, 37 million Americans were uninsured. In 2007, 47 million are. Between 1996 and 2005, an employee's spending on health premiums for his or her family has shot up 85 percent -- and incomes, of course, have not followed.

"My [personal] index," says Len Nichols, director of the New America Foundation's health-policy program, "is the ratio of family premiums to median family income. In 1987, it was 7 percent. Today it's 17 percent. That fundamental dynamic, that health-care costs are growing so much faster than economic productivity, means that even though unemployment is so low and the macroeconomic indicators are good, there's still intense, acute anxiety." In economics, there's a famous dictum known as Stein's Law, which states that when something cannot go on forever, it will stop. Our health-care system, as currently composed, cannot go on forever. It will wreck our economy, collapse our businesses, render both private and public insurance unaffordable. And so, it will stop. Reform is not a question of if, but when and how. And just think what a library exhibit it will make.