Obama's struggle with health-care reform echoes Clintons' failure in 1994

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By Abigail Trafford
Special to The Washington Post
Tuesday, February 2, 2010

Obamacare in trouble? I've seen this story before. It may not end in the way the Clinton effort imploded in 1994. But a look back helps answer this question: How does health-care reform go from being an apple pie issue with voters to a lightning rod for discontent?

Here are a few reasons, gleaned from the past, that may help explain Obamacare's troubles.

Time bomb

The Obama and Clinton initiatives had very different strategies. Hillary Clinton and her team of wonks labored in secrecy to design a perfect bill; early on, they dissed members of Congress. They also dissed the major players in health: insurers, hospital and physician associations, and drug manufacturers.

This time, the Obama administration did the reverse. The White House turned to Congress to design the bill. Meanwhile, the president courted the health-care industry and won over organizations that had opposed the Clinton plan. Chip Kahn, president of the Federation of American Hospitals, pledged his support: "From my standpoint, we're all on the train together," he told Newsweek. "And I expect to ride it all the way into a signing ceremony."

But both strategies were undermined by fatal delays. Bill and Hillary Clinton waited almost a year to unveil their plan. With the Obama initiative, Congress has been the laggard. Administration lieutenants hoped to get something passed quickly; then they would sell the plan to the public. But the delay frittered away the public's post-election enthusiasm for reform while allowing opponents to mount a counterattack. "By September, polls showed that a majority of people did not support it," said Robert J. Blendon, professor of health policy and political analysis at the Harvard School of Public Health. "The lesson from 1994: The longer you drag it on, the more opposition builds."

Too big, will fail

The Clinton plan touched every corner of health care. Everybody could find something to hate in it. The Obama plan is actually narrower, focusing on health insurance reform, but it seems like a really big and overly complicated plan.

This is due to how the drama has unfolded in Congress. No one seemed in charge of the narrative of why health reform matters, so the public viewed a daily soap opera of squabbling lawmakers. One day, a particular reform was in; another day, out. Public option a must? Or a bust. Deals for whom -- Nebraska? Unions? Big Pharma? What about home care? "Death panels"? Abortion restrictions -- in, out. Cost control -- out, with the special deals. The public became more confused about what was in the plan -- and more disgusted with Washington.

In 1994, three-quarters of Americans believed that if a Clinton health bill were passed, their taxes would go up; they would pay higher premiums for coverage and have fewer choices of doctors and hospitals. This year, that was the campaign message of upstart Republican Scott Brown of Massachusetts, who handily won the special election to the U.S. Senate. His election means the GOP now can filibuster health care, torpedoing Obama's inside-game strategy.

Double-think nation

Polls then and now show that the overwhelming majority of Americans support the idea of health reform -- more than 80 percent, according to a recent analysis in the New England Journal of Medicine. But they don't like the specifics of any plan.

This ambivalence can be explained by the theory of cognitive dissonance, the anxiety and anger that comes from holding two contradictory ideas at once. On one side, we believe in rugged individualism and want Big Brother to stay out of our lives. On the other side, we expect government to rescue us if we get in trouble.

"Americans are like motorcyclists about to take a spill," says Uwe E. Reinhardt, a professor of economics and public affairs at Princeton University. Born free, they don't want the government to tell them to wear a helmet. Then when they get injured, they expect the government to take care of them -- thanks to a 1986 bill (signed by rugged individualist Ronald Reagan) that ambulances and hospitals provide emergency services regardless of a patient's ability to pay. "The motorcyclist is a rugged individualist until he needs to go to the hospital."

This double-think is so pervasive in health care that constituents keep telling Congress: Don't let the government mess with my Medicare!

Unresolved, this cognitive dissonance "drives people nuts," says Reinhardt. Psychologists know that people trapped in double-think can become defensive and angry as they try to justify one side or the other to dispel their uneasy ambivalence.

Over the past year, there has been no grand communicator to help people reconcile these contradictory beliefs into a coherent philosophy of life that embraces personal freedom protected by a social safety net.

The president has remained aloof. As he said in the State of the Union address: "I take my share of the blame for not explaining it more clearly to the American people."

Revolution redux

When Hillary Clinton campaigned to overhaul health care, the medical marketplace was already undergoing a revolution. Managed care was altering the way Americans get care, often limiting their choice of health plans, doctors and hospitals.

This time the revolution is in new media, changing the way people get news and information. Partisan television channels, radio talk shows, free-for-all debate on the Internet, blogs galore, YouTube, Facebook, Twitter now dominate communication and shape what people think and feel.

In different ways, both initiatives failed to take into account these social revolutions and were overtaken by them.

Class clash

In 1994, people followed their pocketbooks. The haves -- individuals and large corporations -- believed that if coverage were extended to everyone, the quality of care would go down and they would be worse off.

With Obamacare, there seems to be a realignment. Now the upper classes generally favor reform, and so do lower classes. The middle class is opposed. Massachusetts polls showed that the defeated Democratic Senate candidate overwhelmingly carried the bottom third of the population as well as upper-income voters. She lost those of middle income.

Rant and rave

In 1994, I covered the Health Security Express, a busload of "reform riders": men, women and children with different illnesses who traveled across the country to spread the word about the need for universal coverage. The riders became a target for attacks against the Clintons. At each stop, small but vocal crowds were organized to protest "BillaryCare" and "socialized medicine." One protester yelled at a woman in a wheelchair: "Go back to Russia!" I was stunned by the vitriol and nastiness of protesters. But these demonstrations occurred far beyond the Beltway, away from the lens of the national media.

Today this rage has morphed into a national movement -- the Tea Party people and their conservative backers, who have galvanized media attention to their attacks on big government, higher taxes and Obamacare. Meanwhile, the administration has failed to put a human face on their plan. The president talks about groups, such as the middle class, but does not name specific individuals who could personify the need for legislation.

And stories are there. The Obama transition team fanned out across the country to tap the public mood and wrote a report filled with examples such as this: "From Fayetteville, North Carolina . . . A single mother of two [who had to choose] between health insurance and food for her family." At Healthreform.gov you can read about Stephen in Florida and Holly in Georgia and Lisa in Colorado. But you don't see their faces or learn how they would be affected by legislation.

There's a danger from overdoing anecdotes, as the Clintons did, but people relate to people. If you can't put yourself in the shoes of a family bankrupted by medical bills or a couple worried about premium hikes, you lose the empathy factor.

Now, noisy rhetoric -- on both sides -- has widened the empathy gap, diminishing the chances of reconciliation.

Cherchez la femme?

Hillary Clinton took the blame for Clintoncare's defeat. It's tempting to point the finger at Martha Coakley, the failed Massachusetts Democratic candidate. But the culprit here is fate and the historic role of the special election in the saga of health-care reform.

Two decades ago, a relative unknown beat an entrenched candidate in a Pennsylvania special election. The victor, Democrat Harris L. Wofford, campaigned on this idea: "If a criminal has a right to a lawyer, I think working Americans should have the right to a doctor." Health-care reform emerged as a popular issue, propelling the Clintons to make it the centerpiece of their agenda.

Now the movement for sweeping health-care legislation has been derailed by another special election. But the lesson in the Wofford victory is double-edged: The general idea of reform is great on the campaign trail, but the details of a plan can be fatal. Cumbersome, controversial, confusing bills seem to get dashed by the cumbersome, controversial, confusing political process.

The Obama plan has come much closer to fruition than the Clinton plan did. The administration is determined to keep trying. As Obama urged Congress: "Don't walk away from reform. Not now. Not when we are so close."

Stay tuned.

Trafford, a former Post editor, writes the My Time column.


© 2010 The Washington Post Company

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