On Health Care, Congress Must Navigate Tricky Political Terrain

By Shailagh Murray
Washington Post Staff Writer
Wednesday, June 10, 2009

The new president stood before a joint session of Congress and called for health-care reform in the most urgent terms possible.

"Our families will never be secure, our businesses will never be strong, and our government will never again be fully solvent until we tackle the health-care crisis. We must do it this year," Bill Clinton declared on Feb. 17, 1993.

Less than two years later, "Hillarycare" would become mired on Capitol Hill and would help to send Democrats to a historic 1994 election defeat. Congress would go on to tinker around the edges of health care, including adding a Medicare prescription drug benefit under President George W. Bush, but reform on the grand scale that Clinton imagined fell off the national agenda until President Obama addressed a new Congress on Feb. 24 and outlined goals virtually identical to Clinton's, such as controlling costs while expanding coverage.

"The cost of our health care has weighed down our economy and our conscience long enough," Obama said. "So let there be no doubt: Health-care reform cannot wait, it must not wait, and it will not wait another year."

The great unknown of the health-care debate as it unfolds in the months ahead is whether the current political landscape will prove more hospitable to mandates, cost controls and tax increases -- all measures now on the table that helped doom the Clinton plan.

Even Republicans concede that Obama enjoys some key advantages the last Democratic president did not. The economic crisis has made health-care stakeholders more receptive to change. The broad outlines of the president's blueprint were vetted by voters last year during a protracted series of debates between Obama and Hillary Rodham Clinton in the Democratic primary race, and between Obama and GOP rival John McCain in the general-election campaign.

And unlike President Bill Clinton, who turned to his first lady to craft a plan, largely in secret, this White House is allowing House and Senate committee chairmen to design the legislation with a heavy dose of administration input.

Passage of a health-care bill of the scope Congress is contemplating would be an extraordinary feat, but it is fraught with political peril, win or lose. It may require Obama to backpedal on his campaign pledge not to tax employee health benefits. The Democrats' House and Senate majorities are only slightly larger than 1993 margins and may prove just as illusory, given the large number of Democratic moderates who are trying to hold on to swing seats.

Congress has been riven by increasing partisanship in recent years, and both sides have shown an appetite for tackling policy challenges in incremental bites rather than bold strokes. Big, ambitious bills need big, bipartisan margins not only to pass but also to earn credibility with voters. Republican lawmakers know that the more GOP votes Obama can secure, the more he will shield Democrats from another electoral backlash in 2010.

Given the stakes, Democrats are surprisingly upbeat about their prospects for delivering a bill to Obama this fall, as the president has requested. "It's a given. It's inevitable," said Senate Finance Committee Chairman Max Baucus (Mont.), a lead negotiator. Baucus said yesterday that he expects to unveil a measure next week that would tax employer-provided benefits above a certain threshold.

In the early 1990s, veterans of the earlier battles contend, the status quo on health care was still tolerable. Employer health coverage was often generous; its escalating cost to beneficiaries was more or less hidden. But today, the iconic ads in which the fictional couple Harry and Louise reminisced about the good old days of health care before "government bureaucrats" got involved seem a throwback rather than a threat.

"Harry and Louise are now 58 years old, Harry is a diabetic, needs prescription drugs and has no health insurance," said Sen. Barbara A. Mikulski (D-Md.), a member of the Senate health committee who is helping negotiate a deal. "It's the economics of it, as well as the compelling human need."

But Republicans are betting that the specter of "big government" can still unsettle voters. When Senate Minority Leader Mitch McConnell (Ky.) spoke on the chamber floor Thursday morning, his remarks sounded as if they had been pulled from an early-1990s focus group.

"Americans want reform that addresses the high cost of care and gives everyone access to quality care," McConnell said. ". . . But creating a government bureaucracy that denies, delays and rations health care is not the reform they want. They don't want the people who brought us the Department of Motor Vehicles making life-and-death decisions for them."

Pollsters have gathered extensive health-care-related data in recent months, and the message is mixed. A Washington Post-ABC News poll in December found that about seven in 10 respondents had high expectations for Obama to improve the health-care system, a figure on par with expectations for Clinton as he took office in 1993. And a May survey by the Pew Research Center for the People & the Press found that 86 percent of Americans agree that government "needs to do more to make health care affordable and accessible." But half also said they were "concerned that the government is becoming too involved in health care."

"One of the real tensions here is to get people to live with the idea of less" coverage, said Pew Center Director Andrew Kohut.

Like individuals, major employers, providers and even insurers have come to view reform as essential to righting the economy. "There are economic realities within the health-care industry, organizations that have opposed reform in the past that are more inclined to support it now," said Geoff Garin, a Democratic pollster whose clients include Baucus and who was an adviser to Hillary Clinton's presidential campaign. "Americans are much more open to the reality that there are not easy answers or perfect solutions. We're in a moment of greater realism."

Others who have studied health-care reform are more skeptical. "I have a pretty powerful feeling of deja vu," said Colin Gordon, a University of Iowa history professor whose book "Dead on Arrival" charts failed reform efforts throughout the 20th century.

Bill Clinton also stressed the economic imperative of reform, Gordon noted. And he pledged to seek a bipartisan bill. But as the former president found, "when the pencil hits the paper, and there's actually a concrete proposal, then all of a sudden things fall apart," Gordon said.

Sen. Ron Wyden (D-Ore.), a Finance Committee member and author of his own bipartisan reform plan, said the sense of crisis has caused ideological differences to winnow to the point where a bipartisan core is beginning to form.

"It's built around a large majority agreeing with the Democratic argument that you can't organize the market unless you cover everyone, and the growing recognition that Republicans have a point as well, that there has to be a role for the private sector," Wyden said. "You meld them together, you're on your way to a genuine philosophical truce in the Senate."

Sen. Orrin G. Hatch (Utah), a senior Republican member of the Finance Committee, contrasted Obama's consensus-building approach with Clinton's decision to put his wife in charge of writing a plan behind closed doors and with little Republican input.

"The environment's about the same, but the point is, instead of having a secretive group of hundreds try to put together a bill, you have real, live legislators who are really working together to try to do it," Hatch said. "There were a lot of interesting ideas that came out of Hillarycare. We can't ignore the good ones. But overall it was a disaster, and this could be, too, if we can't get together on it."

Yet for all their optimism, Democrats have long memories. Garin cited the flowchart unveiled on the Senate floor in January 1994 by Sen. Arlen Specter (Pa.), who was then a Republican, showing the intricate web of new government entities that the Clinton plan would require. It was the turning point in the debate, Garin said, as the image stuck. "That's an example of lessons learned," he said.

His prediction: "Compared to any other time in the last 30 or 40 years, there's a better chance of success than ever before. But this is going to be like a Indiana Jones movie, where we kind of slip through a lot of narrow escapes."