Generals are always fighting the last war is a standard political cliché, meaning that politicians have a tendency to overgeneralize from previous experience. Democrats who lost the 1993 health care reform fight vowed not to repeat the same apparent mistakes again when the window for reform opened again in 2008. For example, conventional wisdom argued that President Clinton lost political momentum and buy-in from Congress by drafting legislation in “secretive” White House committees, taking more than a year before unveiling a massive proposal. Partially as a reaction to this, the health reform strategists advising President Obama encouraged the President to adopt an arms length approach to reform – Obama would articulate the vision, Congress would draft the specifics.
Clinton’s top-down approach may have reflected different political necessities, however, and Obama’s gamble to leave reform in the hands of Congress could not be sustained when he lost a super-majority in the Senate. In his very lucid and even-handed book, “Remedy and Reaction,” Paul Starr revisits much of the conventional wisdom on American health reform. Starr has the right credentials – he wrote arguably the most important history of American medicine (the “Social Transformation of American Medicine” published in 1982), and was a policy advisor on Clinton’s reform team. Starr’s book corrects some important misconceptions about the apparent reason for the failure of Clinton’s reforms in 1993 (another example – the insurance industry’s notorious “Harry and Louise” ads probably did not substantially undermine public support). He also traces the emerging consensus that led to reform in the next Democratic presidency.
Here are some important lessons about social policy that stood out for me in the book:
Incremental programs builds consensus: between the signing of Medicare and Medicaid by LBJ in 1965 and the signing of the Affordable Care Act by Obama in 2010, Congress passed many smaller scale health care laws, and several states also overhauled their insurance programs (most notably, Mitt Romney’s Massachusetts in 2006). The legacy of smaller scale programs – expanded eligibility for Medicaid in the 1980s, the Children’s Insurance Program in 1997, the Medicare Modernization act of 2003 – is difficult to quantify. However, as Starr points out these smaller reforms both showed the viability of tweaking insurance markets and expanding public programs, and also helped to form consensus among centrist and liberal reformers that had previously embraced much different approaches (from single payer, to expanded Medicare, to tax credits).
…But incremental policies can also undermine systemic reforms: the “health policy trap” in the United States has always been that reforms mainly serve vulnerable subgroups such as the uninsured using resources from populations that are already protected. Ironically, this protection often is the legacy of previous public programs (like Medicare for seniors). Since leaders need to gain reelection, it is especially difficult to take steps that would improve health policy overall without alienating the elderly and those in the middle class that like their coverage. The new taxes and the minimum coverage requirement (“the individual mandate”) in the Affordable Care Act are good examples. These steps were needed to create viable insurance markets that pool risks between the healthy and the sick, but they also rock the boat for some populations that now feel that they are being coerced into helping others pay for medical care.
“Bipartisan politics” takes many different forms: the Affordable Care Act passed with a strong majority of Democrats in the House and Senate, but not a single Republican voted for the legislation. This is more than a bit ironic, since the stamp of Conservative ideas and policies is all over the legislation. That odious individual mandate, for one, was first championed by the rightwing Heritage Foundation and the overall legislative blueprint comes from Romneycare. They may deny it now, but several Republicans in the Senate – Olympia Snowe, Charles Grassley, and Mike Enzi to name three – had a heavy hand in drafting the legislation (which they ultimately did not vote for). Although this backchannel contribution of Republicans has not softened the partisan bickering about the law, it signals that there may be more bipartisan agreement around social policy than roll call votes reveal.
Thinks tanks build the foundation for social policy: Finally, it was heartening to see Starr single out several policy research organizations – like the Urban Institute, Family’s USA, and the Center for American Progress – as playing a central role in shaping ideas and conducting analysis for health reform. At their best, the policy research and advocacy organizations in Washington provide imaginative and original solutions to public problems. This role does not come automatically, however, and often think tanks are not in synch with the current constraints and ideologies of Congress. Still, the fact that many of the ideas that ultimately entered into the ACA were formed several years before the law was passed shows that even ideas that are on the shelf do not automatically expire, but can be revived when the window of opportunity opens.