For me, the classic battle that tells the story about what progressives face in trying to change our country for the better is the fight over comprehensive health care reform and its bloody aftermath in the 1994 election results. I lived this fight, up close and personal because- outside of my time in the 1993 budget bill war room- my major assignment throughout most of 1993 and 1994 at the Clinton White House was to coordinate the White House strategy on, and relations with, interest groups in the health care battle. It is worth going into in-depth detail.
The reason health care reform is such an important story is that it was such a centrally important issue for the future of our country, and it was an issue where we were trying to make fundamental, comprehensive change rather than small, piecemeal reforms. Unlike most issue campaigns for such comprehensive change, we had a surprising number of advantages going for us as we went into the battle early in 1993:
• The basic macroeconomics facts were clearly with us: this country badly needs comprehensive health care reform and universal health coverage. We are the only industrialized nation in the world that does not cover all of its citizens, yet we spend dramatically more than most countries: In 2005, 15% of our GNP was spent on health care as opposed to between 8% and 10% for most of our economic competitors. Yet unlike all those other countries, not only are many Americans without any health insurance, the numbers are growing all the time. The numbers have jumped from 37 million in 1992 to 45 million today.
• There was broad public support for universal health care and comprehensive health care reform, with 70% to 80% of Americans consistently saying they favored it.
• A lot of important groundwork had been laid by organizations working on the issue over the previous several years. The AFL-CIO, AARP, Citizen Action, and several other important organizations had made health care reform their top priority. A coalition of major businesses along with some liberal interest groups had been in existence for several years to promote a plan for universal coverage and cost controls. Another coalition of unions and consumer groups had formed to promote Canadian-style single- payer health care. Health care reform had become the most talked-about issue as Congress began work in 1993.
• Even among more establishment and conservative groups, the need for some kind of comprehensive health care reform was increasingly acknowledged and accepted. More and more big business, especially old line manufacturing companies in the auto, steel, and airlines industries, were desperate for relief from the escalating costs of health care and were supporting universal coverage and cost controls. Even the American Medical Association (AMA) and some insurance groups had come out in support of universal coverage and an employer mandate for businesses, although not for any cost controls. The need for, and likelihood of, some kind of major health care reform had sent even the most long time opponents of reform scurrying to position themselves on the side of reform.
There was also political momentum for, and major political leadership committed to, comprehensive health care reform. Harris Wofford had scored the biggest upset of the early 1990s in Pennsylvania in 1991 in a special election for the U.S. Senate by riding the health care reform issue from 45 points down to a stunning upset victory. Bob Kerrey had run his presidential campaign based on his single player health care proposal. And while he hadn't won, he did help define the debate going into 1992. Clinton had made the health care issue his No. 2 issue in the campaign, after the economy. ("It's the economy, stupid...and don't forget health care," had been the sign on our war room wall.) Clinton had laid out his plans for health care reform in a fall campaign speech, and although the speech was general, he had committed himself to enough specific provisions and made it a high enough priority that it was clear that he was going to be committed to pushing health reform legislation in 1993. Shortly after taking office, he raised the stakes dramatically higher by appointing the new First Lady to chair the health reform efforts, a courageous and unprecedented commitment to the issue, making it clear to everyone that this would be a top priority. In addition to the President and First Lady, comprehensive health reform had some determined and passionate leaders on the Hill. The majority leaders of both the Senate (George Mitchell) and the House (Dick Gephardt) were committed to it as their top legislative priority of the 1993-94 session.
Among the committee chairs who would have jurisdiction over the bill, 4 of the 5 (Dingell, Rostenkowski, Ford, and Kennedy) were passionate proponents and determined to get it done in this congressional term. Other heavyweight congressional players such as Senators Rockefeller and Daschle made this their top priority as well, and were willing to go to great lengths to make it happen.
Even on the Republican side, there were key moderate Senators, including John Chafee, the Republican Senate caucus chair of their health care task force, whose goal was universal coverage.
Going into the fight, it seemed so likely that some version of health care reform would pass that part of the Clinton Administration's thinking was that we could negotiate with various interests from a position of strength--since something was going to pass, don't you want to be working with the people who are crafting the legislation, rather than be on the outside looking in?
I can guarantee you that everyone involved in that awful, ugly 18-month failure has analyzed why we failed from a million different angles. I can tell you in spite of our advantages going in, that it wasn't that we were over-confident going into it--we knew how FDR, Truman, JFK, LBJ, and even Richard Nixon had tried to get universal health care passed, and they all had failed. We knew the array of forces lined up against us, and the amount of money they would spend. We knew that there was a minefield full of tricky individual issues--is abortion covered in the standard benefits package? Do you tax cigarettes and alcohol? What do you do about tort reform? How do you structure funding for the medical schools? What about medical reimbursement formulas for the states? How do you deal with the explosive major issues of employer mandates and cost containment, without driving away the crucial business and provider constituencies? We went ahead anyway because it seemed as good a time as we were going to get, because of the President's, Hillary's and congressional leaders' strong commitment, because we knew if we succeeded the pay-off for the country and for us politically was enormous over the long haul, and simply because it was the right thing to do. Whatever else my colleagues in the progressive community have to complain about with Bill and Hillary Clinton, I will admire them greatly until the day I die for their courage in taking on this great challenge in spite of the odds.
The challenge facing us was in every sense overwhelming. Finding a clear, simple, compelling message to talk about an incredibly complicated issue was a problem we never found the right answer to, and when we came close we didn't have the political will to do it until too late (more on that later); dealing with the jurisdictional morass the bill was subject to when we submitted it to Congress, and having five different idiosyncratic committees dealing with the legislation made determining a Congressional strategy incredibly complicated. How to deal with all of the differences in ideology and the turf battles within the administration was a never ending source of frustration. We were trying to balance the health care issue, as vital as it was to the President and Congressional leadership, with all of the other tough issue battles we wanted to take on (the budget fight, NAFTA, welfare reform, campaign finance reform, the crime bill, etc.); and we were facing some of the biggest, most determined, intransigent, well- financed, and strategically savvy special interests in American politics. The right-wing infrastructure was in full scale howl against us. Only an Administration with incredible focus, discipline, experience, plus a fair amount of luck could have pulled it off, and we obviously didn't have enough of any of those qualities.
Our Opposition
Our array of opposition, as I have already alluded to, was formidable. But the key to the defeat of health care reform was a decision early on by top right-wing Republican and conservative leaders to be total obstructionists every step of the way. Their approach was to defy conventional wisdom, the polls showing broad support for comprehensive health care reform and the instincts of their Congressional leadership (Dole in the Senate and Bob Michel in the House) and launch an all-out, take no prisoners, support no compromise approach to beating any Clinton-supported health care proposal. They knew how important health care was as a defining issue for Clinton and the Democrats, and feared that universal health care, if passed, would become as popular as Social Security and Medicare as symbols of the good things government could do. They were pushed hard to do this by the leaders of the right-wing infrastructure. Led by politicians like Newt Gingrich and Phil Gramm, and strategists like Bill Kristol and Grover Norquist, they played defense, stall, slow down, obstruct, and blocking strategies to near perfection.
They were supported with a vast array of financial and grassroots resources supplied by the interest groups most violently opposed to any health care bill, primarily:
• The National Federation of Independent Businesses, the National Restaurant Association, and other right-wing small business groups. These groups hated the employer mandate or any other proposal that would tax employers not currently providing health care. Even though the Clinton package was structured so that 60% to 70% of small businesses would have actually saved money compared to what they pay now, any mandatory new costs on business were opposed by these groups out of hand, simply because of their far right, anti-government ideology.
• The Health Insurance Association of America, which was mostly composed of small to medium sized, traditionally structured insurance companies who were frightened to death of any kind of cost controls or new government oversight, and were frightened as well by any proposal which might encourage the trend toward managed care. A lot of these companies made their money by "cherry picking"--only insuring young, healthy people who were likely not to run up any medical costs, so a proposal to make them take all comers sounded horrible. This was the group that launched the infamous "Harry and Louise" ads. Ironically, they were officially in favor of universal coverage and an employer mandate, although they were adamantly opposed to any form of cost controls, so there wasn't much ground to compromise with them.
• For-profit hospitals groups. For-profit hospitals were also unalterably opposed to any kind of discussion of compromise. This lobby included huge hospital chains such as Columbia HCA, whose CEO, Thomas Frist, Jr. (the brother of now Senate Majority Leader Bill Frist) had made $127 million in salary and stock options in 1992, and unlike HIAA, they didn't even make a pretense of being for universal coverage.
• National Independent Insurance Agents Association. The Clinton plan would have pretty much eliminated insurance agents from selling health insurance, so they had little incentive to work with us. They used their grassroots lobbying skills, and their members' small business client lists to stir up opposition back home in Congressional districts.
• Fast food chains such as Pizza Hut and McDonald's hated our bill. Since they employed tens of thousands of employees and were huge multi-billion dollar conglomerates, they got none of the incentives our plan gave to small business, and with a low wage, mostly uninsured workforce, our legislation would have cost them millions.
• The Christian Coalition, Norquist's Americans for Tax Reform, and the other groups that make up the core of the right-wing infrastructure. Even though they didn't have much of a direct self-interest in the legislation, they were only too happy to lend their money and power to opposing "big government" and the Democrats. Their goal was never particular single issues- it was all about power and politics, and they played it to perfection. Joined with the rest of the right-wing communications machine- Limbaugh, Robertson, etc. al- they attacked our health plan every step of the way.
The Clinton Strategy
What was our strategy in the face of that kind of opposition? First, we hoped to develop a clear, compelling message that the Clintons and other administration surrogates could take all over the country in campaign-style media events to sell the program. Second, we planned to develop legislation that had a core that could not be compromised but that had lots of wrinkles and layers that could be tinkered with or traded away during the Congressional process. Third, we put our faith in the Democratic leadership and committee chairs to guide us and carry the legislation on their backs. And fourth, we hoped to put together a powerful interest group coalition that could effectively do battle day-in and day-out with our opponents and, we hoped, to neutralize business and provider groups in the middle, so that they would keep working with us and Democratic Congressional leaders throughout the process. What happened to each part of this strategy is illustrative of why fundamental progressive reform is so difficult on any issue in American politics.
We made a big mistake early on at the strong urging of the Congressional leadership. They wanted us to write detailed legislation to submit to them, rather than just giving them our general legislative program and letting them worry about the details. (In submitting legislation, a President can do it either way.) By agreeing to this approach, we hurt ourselves in multiple ways. It slowed the whole process down to a crawl, reversing our momentum and giving our opponents time to build the opposition. It allowed the media to focus for a lengthy time on the process rather than on the issue debate. It forced us into painful, exhausting, and frustrating (for everyone) line-by-line negotiations with all of the interest groups we were trying to win over, as well as those we were trying to keep from joining the ranks of the opposition. And it made us defend and explain hundreds of little details about the legislation at the beginning of the process rather than at the end.
What about the rest of the strategy? Both the message strategy and the coalition strategy ultimately failed in spite of our and our allies determined efforts.
Message
There were two messages that had the potential to carry the day, one of which we used early and then was mostly dropped. The other one we finally agreed to use only after it was too late. Our decisions about message were in part reflective of the dissension and indecisiveness within the Administration, but were far more a reflection of the inherent contradictions any politician or constituency faces when pushing for major progressive reform in the United States.
The first message that we might have used but backed away from early in the process was a tough populist message going after the insurance industry and the big for-profit hospital chains. In the 1992 campaign, Clinton's rhetoric about health care had a decidedly anti-insurance and populist ring to it. It was a message which excited our activist base and had a deep resonance within the American public, especially blue collar swing voters. It also went after industries that we knew were going to oppose us anyway.
Relatively early in the fight, before we had decided clearly on a message strategy, we made a couple of major forays into populist waters. And in each case, it was almost by accident. The most famous of these incidents came one morning when Mrs. Clinton, getting ready for a speech, saw one of the "Harry and Louise" ads on TV. It made her so mad that she went after the commercial in her speech that morning. The media, loving conflict, ate it up, and those ads quickly became the most famous ads of the entire health care debate.
The other populist speech that Mrs. Clinton gave that got a lot of attention was a fiery speech to a convention of the Service Employees International Union, the country's biggest health care union. Again, it was almost by accident. I was the lead staffer with her at the event, both going with her to the event and writing a briefing paper, including talking points, for the event. I had assumed in writing the talking points, which I had made very populist and fiery because I knew the labor crowd would love it, that one of our communications people would look at the talking points and make whatever revisions they saw fit to give the right message for the day. That somehow didn't happen, and Mrs. Clinton--who has a wonderful populist streak in her--looked at the talking points and decided to let them rip.
In both cases, we got the same reaction: excitement and applause from the Democratic base groups, and an extremely negative, fearful reaction from providers and business groups. In spite of the advantages, in the end we avoided a populist, anti-insurance and for-profit hospital route because it scared off those other business and provider groups in the middle we were desperately trying to win over. In retrospect, if we would have decided to take the hit with these groups in the middle, and go for that message consistently, it might have had enough punch to carry the day.
The other message that might have worked had a populist appeal to it as well, but this one was anti-politician rather than anti-corporate. Several of the progressive activist groups were using the message that Congress ought to give the American people the same kind of health care package they got, and the big pro-health reform coalition that had been formed was urging that the Clinton Administration spokespeople, and advocates in Congress, all use that message. Polls showed it to be a winner and a message that spurred people to call their member of Congress.
The problem was that Congressional Democrats hated the message, feeling that it would fan already high anti-incumbent flames in an increasingly angry electorate. After a bitter argument, it was decided that the Administration wouldn't use the message. Later, close to the end, when desperation had set in, we started using it more often, but it was way past too late by then.
In the final analysis, we were never able to settle on a simple, compelling message that would not only appeal to voters in the middle, but also inspire activists to call and write Congress. Our failure to do so was another nail in the coffin.
The Coalition
The pro-universal coverage, pro-cost control coalition we hoped we could build consisted of the following groups and constituencies, most of whom had positions in favor of those provisions and all of whom would have gotten major benefits if the Clinton health plan had passed:
• The AFL-CIO and its affiliate unions
• The National Education Association
• AARP, National Council of Senior Citizens and other senior citizens groups
• Consumer groups like Citizen Action, Consumers Union, and Consumer Federation of America
• American Nurses Association and other nurses groups
• Pharmacists groups such as the retail druggists and the chain drug stores
• General practice and family practice doctor's groups
• Civil rights organizations
• Women's groups
• Voluntary health groups such as the American Cancer Society and the American Heart Association
• Big manufacturing companies whose health care costs had sky-rocketed in recent years such as automakers, steel companies, and airlines.
• Certain non-profit hospital groups, such as the Catholic Health Association and the Children's Hospitals
Such a business-labor-provider-consumer coalition, we reasoned, should have the ability to go toe-to-toe with the opposition and at least be competitive with the other side. It didn't work out that way.
Why it didn't work has a lot to do with the nature of coalition politics in this era. What happened? Some of the breakdown went back to the first fatal mistake of writing our own detailed legislative language rather than submitting a general proposal to Congress and letting them work it through. In the course of writing legislation on as complex a topic as health care reform, especially while trying to hold together such a diverse coalition and still give enough to the groups in the middle that they don't go to the opposition camp, you inevitably have lots of details that irritate even the closest of your friends. Because we gave them two bites at the apple--a chance to first lobby us over the details, then lobby Congress over the same details--we dissipated both the momentum and the enthusiasm of our coalition. When they finally moved from lobbying us to lobbying Congress, the conversation usually went something like, "The Clinton bill is fine, especially that stuff about universal coverage, but let us tell you about these 4 provisions we don't like..." and then 90%+ of the conversation would be about the problems.
Because Washington, D.C. interest groups spend most of their time lobbying about legislative details, it is hard to get them to focus on more fundamental reform: they tend to get bogged down in their little piece of reform. In the end, in terms of their time and resources, groups tended to spend far more on their specific interests within the health legislation than on getting the entire package passed. In the meantime, our opposition wasn't worried about the details: they just wanted to kill the whole thing, and were willing to use every weapon in their arsenal--doubt, delay, confusion, fear, and whatever else they could think of.
The other great disappointment was the lack of grassroots and communications strength all these groups could bring to the table. Admittedly, a significant part of the problem was an overly complicated plan and the message decision to reject our two most popular themes: it's tough to organize around a muddled message and all those details. Even so, we had a plan that would provide something progressives had been dreaming of and fighting for 60 years: universal health care. Yet compared to our foes, we just didn't have much in the way of enthusiastic ground troops.
A lot of it was that old infrastructure problem. Pat Robertson and Rush Limbaugh would go on the air, and within 24 hours the Capitol switchboard would be overwhelmed with hundred of thousands of callers. Right-wing business and churches all across America were handing our postcards and flyers. We had a little of that, but it just wasn't enough to compete. Our side, which had very limited resources compared to the opposition (opponents of reform outspent proponents by at least 5 to 1 and probably more, depending on how you add it up) had to spend far more energy getting the troops stirred up and organized than the other side's ready-made electronic and organizational infrastructure.
