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What Went Wrong: How Wonks and Pols -- and You -- Fumbled Universal Health Care

By Abigail Trafford
Tuesday, August 21, 1994

IT WAS the fury of the crowd that was so stunning. Crammed into the parking lot before the Unitarian Church in Louisville, the protesters shouted "Go back to Russia!" and "Go Home Clinton!" They held up placards against abortion rights, against gun control, against tobacco taxes, against Big Government -- and especially against Bill and Hillary.

The target of this Kentuckian rage was a bus caravan of bedraggled riders -- people with cancer or epilepsy, some in wheelchairs -- who were crossing the country to promote health care legislation that would guarantee health nsurance to all Americans.

Public opinion polls consistently show that about eight in 10 Americans support universal coverage. But that didn't stop a man in the crowd from leaning over a woman in a wheelchair and screaming in her face.

After nearly 20 years of covering health care, I knew that the shouting was more about politics than medicine. But you have to wonder: How did health care reform go from being an apple pie issue with voters to a lightning rod for discontent? What happened over the past 18 months to kill the bold promise of President-elect Clinton to provide health care coverage to all Americans?

The scene in Washington is not much different, except that the shouters wear suits and have comprehensive health benefits through their employment in Congress or the federal government. Even if Congress passes a health bill -- and it's still an if -- it is certain to be a more modest plan than the one President Clinton proposed.

Meanwhile, everybody from members of Congress to Medicaid moms is getting bored with the health care debate. People want Congress either to sew up the patient and send a bill or pull the plug. With each day, the debate shifts.

"It isn't an argument about health care any more. It's about your political view of life and whether you like Bill Clinton," says Robert J. Blendon, polling expert from the Harvard School of Public Health.

History books will be written about what went wrong with the Clinton agenda. For now, the following reasons may help explain why the health care issue simply ran off course.

* A Stitch in Time Saves Nine. While Clinton officials were proclaiming this overworked homily of preventive health, they did not follow it as political strategy. Waiting nearly a year to unveil the administration's plan proved to be a fatal delay.

It frittered away the public's initial post-election enthusiasm for a major overhaul of the health care system. It allowed opponents to mount a counter-attack -- virtually unopposed -- hitting on people's fears that reform would mean less choice of doctors and higher health insurance costs.

The reason given by administration officials for the delay was that the subject was so complex -- it was better to take more time and do it right. Well, that's the same argument many members of Congress are raising in these last-ditch debates.

As Gail Wilensky, a health economist with Project Hope and former Medicare and Medicaid chief in the Bush administration, puts it: "We have passed through the biggest window of opportunity -- that was 1993."

* The Invasion of the Wonks. When the Clinton plan finally did emerge -- late and 1,342 pages long -- it was a dud. "Some people didn't understand what was in the plan. Those who did, did not like the plan," says Sidney M. Wolfe, head of the advocacy Health Research Group and supporter of a so-called "single payer" approach modeled after the Canadian or German national health system. "The industry didn't like it for one set of reasons. Patients and doctors didn't like it for another set of reasons."

The plan was the brainchild of quintessential wonk Ira Magaziner -- a class valedictorian, Rhodes Scholar and Boston business consultant. The health care task force of 500 "experts," a kind of policy ship of fools, labored in secret while divulging nightly news bites of misinformation. Key players from the American Medical Association to the scientific research community were alternately wooed and dissed. White House political experts never materialized.

"They never asked the question: Where is the consensus? Instead it was: How can we redesign the system? We have the magic formula," says Michael Bromberg, chief of the Federation of Health Systems, which represents for-profit medical facilities. "They never put a political grid on Ira's job."

In the end, polls showed, fewer than 30 percent of people had a good grasp of what was in the Clinton bill -- or in any of the other proposals floating around the nation's capital.

* Yo! Freud! What Do the People Really Want? Health care remains, with crime and the economy, a top issue with Americans. Yet more people think the medical system "just has problems" rather than being in "a crisis," according to a June Gallup/CNN/USA Today poll. As the economy grows, fewer Americans are afraid they will lose their health insurance if they lose or change jobs. "The assumption was that support was deeper than it was," says Ezekiel Emanuel, physician and ethicist at Harvard Medical School and member of the White House health policy task force. "There was a failure to educate the public and bring people along."

Only recently has the health care issue come on the radar screen for Middle America. One sign of the turning point was a conference of cancer survivors in 1990. A woman described how her insurance company dropped her after she was treated for breast cancer. "I feel I represent Middle America," she said. "I'm middle-aged and middle income. I pay the bulk of the taxes. But in my time of need the government says: Up the kazoo, lady! Don't get sick until you're 65, or very poor, or very rich."

The Clintons couldn't have said it better. But Middle America's support was in fact shallow. That's why President Bush told health writers, sure there were "some inadequacies" in the medical system, "but I haven't seen a great push {for health care reform} from the American people."

* Yo! Marx! There's a Revolution in the Medical Marketplace. While the country's attention was focused on various legislative proposals, radical changes were sweeping through the health care system. This revolution, with the pedestrian name of "managed care," has already altered the way most Americans get health care. For consumers, it means joining a health maintenance organization or a group health plan with limits on the choice of physicians and hospitals. Today about 64 percent of employees with insurance are covered by a managed care plan, according to a Kaiser Family Foundation/KPMG Peat Marwick survey completed last month.

The medical industry can already point to some success in restraining costs. All this created the impression that the private sector is cleaning house and doesn't need Big Government to come in and regulate how the marketplace spends the country's health dollars.

Meanwhile, the Clintonian agents of change failed to address the downside of the managed care revolution for consumers. Most important, they lost the rhetorical war about choice. Opponents charged that a Clinton-like plan would take away people's right to choose their own doctor. Too late, reform advocates tried to point out that the managed care revolution, unchecked by government regulation, was a greater threat to choice. The July Kaiser/Marwick study found that more than 80 percent of firms with fewer than 50 employees offer only one choice of plan. The Clinton plan would have offered a minimum of three types of plans to choose from.

* The Day of the Anecdote. Much of the debate was carried on by Harry and Louise, the fictional Middle America couple featured in the television ads of the Health Insurance Association of America. On the other side were John Cox and Daniel Lumley, two "reform riders" on the Health Security Express bus tour with their health "horror stories."

John Cox, a former newspaper editor and religious broadcaster, was without a job and without health coverage when his wife was diagnosed with a rare stomach cancer. Lumley lost an arm, leg and spleen in a motorcycle accident. If he takes a job, he loses his Medicaid health benefits.

The problem is that horror stories may illustrate the need for universal coverage but they don't tell lawmakers how to achieve the goal.

* Shhhh! Health Care Reform is NOCD. Americans don't like to talk about class differences but a not-so-subtle current in the health care debate is best described by that obsolete phrase, Not-Our-Class, Dear.

A recent Princeton Survey Research/Newsweek poll found that more than three-quarters of Americans believe that if a health care bill is passed, their taxes will go up, they will pay more for their coverage, they will have fewer choices of doctors and hospitals. Nearly 60 percent are convinced the quality of medicine would go down.

This has built up tremendous opposition to major legislation. "It is an issue of social class," says Princeton economist Uwe Reinhardt. It is not surprising, for example, that the Business Roundtable and IBM came out against President Clinton's initiative. "They voted as members of a social class."

Americans are also concerned concern that legislation might harm prestigious medical centers and hamper research innovation. "It's as though eternal misery at the bottom of health care is the price of excellence of health care," explains Reinhardt.

* Every Dog Gets One Bite. As Joseph A. Califano Jr., health secretary under President Carter, has said of Clinton: "He's only got one vote where he can say to {members of Congress}: 'You've got to vote for me to save my presidency.' They'll never do that for him again. He's used the biggest chip he has."

Califano was referring to the Clinton budget, passed last year. Since then, the president has used his teeth to pass the North American Free Trade Agreement and is baring them again on the crime bill. As a result, the public -- as well as Congress -- has gotten a mixed message about priorities. Now, the president is running out of time. Califano put it this way: "The closer {members of Congress} get to reelection, the less influence he's going to have on them." Cherchez la Femme. It is true that Hillary Rodham Clinton impressed insiders in Congress and the medical community with her expertise as she carried the health care banner for her husband. She also impressed consumer groups with her sympathy for the plights of the Medical Have-Nots. The death of her father softened her, at least for a while. Her obvious friendship with Tipper Gore sustained her.

But the Hillary Card did not galvanize public support or swing votes in Congress. In part this was due to what might be called the "Wofford Victory Delusion."

The political establishment only discovered health care as a Middle America issue with the surprise victory of Democrat Harris L. Wofford in the 1991 Senate race in Pennsylvania. He simply hammered at the injustice of the status quo: "If criminals have the right to a lawyer, I think working Americans should have the right to a doctor."

The First Lady picked up on the Wofford mantra. But there was a second, more subtle lesson in the Wofford victory: Stay away from details. Championing the cause of health care reform is easy. Working out the specifics is where political crusaders fall on their swords.

The trouble is that the Clintons, along with the Democratic Party, thought that the mantra would be enough to convince people to support the administration's plan. Once the plan was unveiled, they failed to present the public with a coherent message based on the details of the bill. "Instead of getting in a legislative mode, they stayed in a campaign mode," says Bromberg.

As a result, Hillary Clinton ended up as the guardian of the flame for sweeping reform -- but increasingly isolated from the legislative realities in Congress and the shift in the public's mood. In trying to sell reform, she became a target for the burgeoning wave of negativity.

Whatever emerges from the ashes in Congress, it will fall short of original precepts of reform. Universal coverage is gone for the immediate future. "There's no cost containment," adds physician Harvey I. Sloane, former Louisville mayor. "It's a false messiah," says Wolfe. "It worsens the doctor-patient relationship and will fatten the insurance industry."

Still, those who have worked in the medical vineyards for a while are starting to take the long view. As Harvard's Emanuel says: "Health care reform is not one act."

© 2010 The Washington Post Company



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