The raucous, once-consuming quest to reform the nation's health care system ended on Sept. 22 in a subdued conversation between two understated northeastern senators.

Rhode Island Republican John H. Chafee, drenched from a rainstorm and behind schedule for a dinner on Capitol Hill, was dashing into his McLean home when his wife, Virginia, told him Senate Majority Leader George J. Mitchell (D-Maine) had called. When Chafee called back, the conversation was short. Mitchell said the votes weren't there for the last-ditch deal the two had worked out to try to salvage the mess the White House and its opponents had made of health care reform.

"I guess that ends health care for this year," Chafee told his wife.

It was an anticlimactic finale to 21 months of national debate over whether Americans should exchange the present health care system with all its flaws for a new, unpredictable one that President Clinton and First Lady Hillary Rodham Clinton promised would be better.

After hundreds of town hall meetings, months of congressional hearings and markups by five committees, days of Senate consideration and an unprecedented lobbying campaign by special interest groups, neither the House nor Senate ever did vote on a health care bill. As the 103rd Congress adjourned, its unwillingness to act on what President Clinton described as his most important domestic priority stood as the most conspicuous symbol of Clinton's failure to implement the ambitious reform agenda.

It is hard to isolate a single reason for the demise of health care reform; it died from a thousand cuts. But the forces at work can be understood through a series of snapshots along the road that ultimately ended at John Chafee's home.

They focus for the most part on the Clinton White House, first on what in retrospect was the fatal miscalculation that the president brought into the health care campaign -- a vision about government's role that does not fit with the high degree of skepticism with which the American public now views government solutions.

The White House turned out to be absolutely correct in its prediction that the health care industry and its allies would unleash an unprecedented attack on reform. But neither the administration nor its allies responded swiftly or effectively when it came. The attacks and the design of the bill undermined the support of a crucial ally, big business, and so weakened the bill that by the time it got to Congress even such politically adroit allies as House Energy and Commerce Committee Chairman John D. Dingell (D-Mich.) could do nothing to save it.

By then Clinton's presidency was on such shaky ground that he was advised to become invisible on the health care front instead of being the leader many in Congress knew they would need to carry such major legislation through. The whole notion of universal coverage was unceremoniously dropped for modest insurance market changes. Even that was torpedoed by the partisan stalemate that consumed the final days of the 103rd Congress.

A Cumbersome Process and Plan

When President Clinton announced the formation of the National Health Care Reform Task Force on Jan. 25, 1993, with Hillary Rodham Clinton as the head and Ira Magaziner, the bookish business consultant and Rhodes scholar from Rhode Island, to direct its operations, he set up a process that was as cumbersome and unsuited to the Washington political world as the final bill turned out to be.

The task force was stacked with Capitol Hill technical staff, academics, medical practitioners and a couple of insurance industry figures. They did not think politically and even those who tried to apply their real-world experience were often rebuffed for doing so.

Task force members were divided into 34 groups and their work had to pass the oral exams of seven "tollgates" -- an exercise Magaziner imported from his consulting life. He once wrote Hillary Clinton outlining the 1,100 decisions that would have to be made.

The task force was a public relations disaster. White House officials refused to discuss the group's work or to release the names of participants until several publications had published them. Opponents of Clinton-style reform used the secrecy issue to cast the first real doubts on the effort.

They had plenty of targets. The evolving plan was full of newfangled mechanisms that became the grist for a huge new Washington health care press corps. One day it was purchasing alliances, the next a standard benefit package or price controls.

The task force was somewhat of a rogue operation at the White House, causing infighting and weakening the allegiance of key aides and Cabinet members. Magaziner's close relationship with the Clintons, especially Hillary, worked to the exclusion of other advisers with important political skills.

As the task force proceeded, lawmakers and others warned that the plan was becoming too big and complex. So did the task force's own legal review team. "There appears to be no precedent for the enactment and implementation of a national reform that alters so many existing statutory, administrative, contractual, private and moral arrangements as this reform would propose to do," the team wrote Magaziner.

But there is no indication that the Clintons ever seriously considered anything less.

In early September 1993, a 238-page draft was leaked to the news media by congressional sources. The premature disclosure forced administration officials, after months of refusing press interviews, to go on the record for the first time -- not to elaborate on their plan, but to explain the unofficial preliminary draft. By then, industry groups, which had been warily watching the process unfold, were preparing to seize the moment.

'Harry and Louise' et al.

As the White House staff was writing the final 1,342-page bill that summer, pollsters hired by the Health Insurance Association of America (HIAA) were in Alexandria and Charlotte, N.C., testing a television commercial whose fictional characters would become more important to the debate than most members of Congress.

Former congressman Willis D. Gradison, president of the group of mid-sized insurance companies, thought health care was the kind of issue people would talk about around the kitchen table, so he hired actors whose real names were Harry and Louise to sit around one and express their fears about what Clinton had wrought.

The 30-second spot was the beginning of a $15 million HIAA ad campaign targeted at legislators, opinion makers and the news media -- and spread far beyond its paid targets by news stories about the campaign and the president's denunciation of it. "Harry and Louise" were just the most visible side of the lobbying onslaught. Insurers paid for and packed forums in key congressional districts, giving the appearance of spontaneous town hall meetings with an anti-reform flavor. Hospitals organized their trustees and candy-stripers to fight Medicare cuts. Tobacco companies set up front groups to mobilize opposition to a cigarette tax hike.

In Washington, industry groups hired "Friends of Bill" to lobby the White House, and then hired every former lawmaker they could find to work the House and Senate floors.

The lobbyists and health and business interests poured a record $46.1 million into the health care fight, according to Federal Election Commission records compiled by Citizen Action, a liberal consumer group.

The administration was supposed to have its own cheerleaders to counter the industry lobbying. But the Democratic National Committee, charged with coordinating a coalition of labor unions, senior citizen advocates, consumer groups and medical professionals, was unable to pull it off.

A National Health Care Awareness Day, scheduled for Sept. 14 to be the kickoff event in a $30 million campaign to push the program, was canceled for lack of planning. Earlier, the DNC had created and then, under criticism, quickly disbanded a nonprofit organization that would have raised money for the campaign.

It would be months before proponents regrouped under the name Health Care Reform Project, only to launch a series of lukewarm ads and news conferences that never began to dominate the opposition.

Big Business's Message

On a cold, crisp evening in February, members of the Business Roundtable, the men who run the country's 100 biggest corporations, met in a ballroom at the Willard Hotel, two blocks from the White House. Their meeting would begin the crucial unification of the business community against Clinton-style reform.

White House officials once gloated about division in the business community, believing it would work to their advantage. Small business opposed the employer mandate -- the proposal that firms provide coverage for employees -- because many of them did not pay for their workers' insurance.

Big business was another matter. They typically paid for coverage for employees and often for their spouses and children. Their payments to hospitals and doctors were inflated to cover the cost of free care to the indigent. Many corporate executives believed reform would cut their health care bills.

The White House, told the Roundtable was likely to endorse a rival plan sponsored by Rep. Jim Cooper (D-Tenn.), had panicked in the days leading up to the meeting. Among other things, Cooper's bill did not guarantee universal coverage -- Clinton's bottom line. The administration swung into action.

Vice President Gore, presidential economic adviser Robert E. Rubin and then-Deputy Treasury Secretary Roger C. Altman called dozens of chief executives. Dingell and House Ways and Means Committee Chairman Dan Rostenkowski (D-Ill.) were enlisted to pressure executives of companies with business before their committees. Hillary Clinton and Magaziner summoned a half-dozen Roundtable allies to the White House.

The decision-making process at the Roundtable had been dominated by the businesses that had the most to lose: insurance companies and fast-food chains that did not insure their employees. But as the Roundtable vote neared, health care turned into a referendum on the new administration.

Big business had backed the administration in its budget fight with Congress on the strength of White House promises of additional cuts in domestic spending. But the cuts never came. Many now believed the health plan would become an open-ended entitlement that would raise taxes and the federal deficit.

"The only things these guys in the White House understand is a sharp stick to the nose," one executive told another as the session broke up.

And a sharp stick it was. The Roundtable voted 60 to 20 to support the Cooper plan. In subsequent weeks, two other major business organizations, the National Association of Manufacturers and the U.S. Chamber of Commerce, came out against the Clinton plan.

The five congressional committees conducting hearings on health legislation watched anxiously, nowhere more closely than in Dingell's Energy and Commerce Committee, the House's bellwether on health care reform. Its members are considered most representative of the membership of the full House because of their eclectic philosophies and regional diversity.

"When the president failed to get the {Business Roundtable}, there was a big shift in sentiment inside the committee," Dingell said recently. "That was a defining event."

Dingell's Defeat

The Energy and Commerce Committee, which sets the rules for a large swath of the U.S. economy, has a tradition of working through tough issues with the help of Republicans. But from the start, Dingell said, House Minority Whip Newt Gingrich (R-Ga.) secretly demanded that House Republicans oppose any Democratic bill, making it a test of party loyalty.

Members of Dingell's own party were divided. More than a third of the 27 Democrats came from districts where important constituents were antagonistic to Clinton's plan.

Dingell tried to co-opt industries with promises to work out their special problems. But the job was too big for a single committee chairman, he said. Only the president had the resources to put together a winning coalition and Dingell believed he was hindered by Clinton's fractured attention span.

Nevertheless, Dingell mowed down the sticking points, one by one. He pledged to foster new crops in tobacco country to ease the blow of higher cigarette taxes. He agreed to drop proposed price controls on drugs produced by biotechnology firms. Nearing the 23 votes needed for a majority, Dingell offered his best hand. He exempted family farmers from the employer mandate to win over rural Democrats and agreed to eliminate the mandate for merchants who the National Federation of Independent Business (NFIB) said were most vulnerable -- those with fewer than 10 employees.

When he left town on the spring recess he was confident. But rival forces were at work too. Rep. Jim Slattery (D-Kan.), a Dingell protege, ran into an NFIB "emergency alert" sent to its 8,000 small business owner members in Kansas.

Slattery, who was running in the Democratic primary for governor, was the final vote Dingell needed. But on April 21, the Kansan received a critical four-hour visit from lobbyists for Hallmark Cards and the parent firm of Pizza Hut, two of his state's biggest employers. Both relied on large numbers of part-time, uninsured workers and vehemently opposed any mandated employer payments.

Later in the day, Slattery issued his own health care plan. It rejected any employer mandate. The stalemate was complete.

On the afternoon of June 28, Dingell told more than a dozen of his Democratic loyalists that he couldn't pry loose a single Republican vote or get enough of the committee Democrats to support a strong bill. He preferred to "pull the plug," he said, rather than pass a weak measure that would lower the threshold for reform.

No one dissented, and Dingell put on a positive face. But last week, he owned up to his fears. When Energy and Commerce folded, he said, "it told me the situation was not good from the standpoint of getting a bill" to the floor.

With Dingell out of the picture, health care reform fell to the Ways and Means and the Education and Labor committees -- both more liberal and more loyal to the House Democratic leadership than the House as a whole. The House leadership then took the committee bills and created its own.

But when House Majority Leader Richard A. Gephardt (D-Mo.) finally put forth his proposal, many lawmakers believed it was too far-reaching to pass. Those who know Gephardt believed he must have done so expecting that the Senate's bill would be much more conservative. Eventually he hoped for a compromise in the middle.

But things did not go as planned in the Senate.

Moynihan and the 'Mainstream'

A week later the Senate Finance Committee became the last of five committees to finish work on a health care bill, in the process exacerbating the tense relationship between committee Chairman Daniel Patrick Moynihan (D-N.Y.) and the White House.

Moynihan, renowned for his intellect, seemed to his colleagues to be unengaged in health care. "I don't know about health care," he said on several occasions.

Once, in front of a roomful of senators, he ridiculed Hillary Clinton. "You just don't seem to get it, do you?" he said, according to attendees. He became enraged at White House slights and several times threatened to go public with harsh denunciations of Clinton's health care ideas.

To the dismay of Democrats, Moynihan helped give Republicans a platform in what had by then become a highly partisan fight. He sometimes let ranking minority member Bob Packwood (R-Ore.) chair private committee sessions and he later brought him to the White House to tell Clinton the votes weren't there for a universal coverage bill. Packwood would later gloat at how successful Republicans had been at killing reform.

As the clock ticked down on the committee's markup, Moynihan seemed to turn the process over to a bipartisan rump group of committee moderates who rewrote the bill in three days. That group, led by Chafee and Sen. John Breaux (D-La.), developed into what was called the "mainstream coalition" that worked through September to find common ground with Mitchell, the majority leader.

The mainstream compromise was closer to the minimalist proposal of Senate Minority Leader Robert J. Dole (R-Kan.) than it was to any of the Democratic leadership bills. But by then Republicans had made it clear they would not cooperate on any bill.

Dole and Gingrich told Clinton they would hold up legislation for the General Agreement on Tariffs and Trade (GATT) if the Democrats pushed health care onto the Senate floor. And many moderate and liberal Democrats said the mainstream bill was too incremental to take seriously, anyway.

"We were creating a bill that had no constituency," Breaux said.

On Monday, Sept. 19, Chafee had his final meeting with the mainstream group and at 11 a.m. he briefed Mitchell. By then U.S. troops were going into Haiti and Mitchell was called out frequently to deal with that. But Mitchell, who had given up a possible seat on the Supreme Court to help pass a health bill, was cutting deals up to the last minute.

The next day Chafee polled moderate Republicans. Only four said they would support a move to end debate and vote on the health bill. That evening at a meeting with Chafee and three other senators, Mitchell was pessimistic, especially in light of what he called the "atomic bomb" dropped by Gingrich in the form of a threat to hold up GATT.

It was two more days before Mitchell made his call to Chafee to acknowledge defeat. When he finally made his decision public the following week, he blamed Republicans and the insurance industry. Clinton issued his own statement condemning Republicans and lobbyists.

"We are going to keep up this fight and we will prevail," the statement said.

Staff writer Steven Pearlstein contributed to this report.

Despite enormous efforts by the Clinton administration beginning with its inauguration in January 1993, efforts to reform health care have come to naught.

President Clinton sets goal

Winter 1993

Jan. 25

Clinton names First Lady Hillary Rodham Clinton to head National Health Care Reform Task Force. The group has more than 500 members, including six Cabinet secretaries.

March 8

U.S. Chamber of Commerce endorses managed competition, signals potential endorsement of further provisions of Clinton plan.

Clinton unveils plan


Sept. 8-10

White House shares preliminary plan with congressional staff, who leak it to press. Health Insurance Association of America launches "Harry and Louise" advertisements criticizing Clinton health plan.

Sept. 22

Clinton unveils plan to Congress. Public approval peaks a month later.

Oct. 27

1,342-page Clinton Health Security Act delivered to Congress.

Universal coverage, at what cost?


Jan. 25

In his State of the Union Address, Clinton threatens to veto any health legislation that does not include universal coverage.

Feb. 2

Business Roundtable endorses rival health plan offered by Rep. Jim Cooper (D-Tenn.).

Feb. 8

Congressional Budget Office reports that Clinton plan would increase deficit in first five years of operation and that savings advertised by Clintons would not be realized until year 2000.

Congress weighs rival plans



Five congressional committees wrestle with specifics of health care reform. At end of month, the key House Energy and Commerce Committee chaired by John D. Dingell (D-Mich.) gives up on issuing a bill.

July 20

At National Governors Association meeting, Clinton says employer mandate is negotiable and 95 percent coverage will meet his goal of "universal."

July 28

Democratic leaders send comprehensive health bill sponsored by House Majority Leader Richard A. Gephardt (D-Mo.) to House floor.

Aug. 2

Senate Majority Leader George J. Mitchell (D-Maine) unveils his health plan, which would cover 95 percent of the population and have no employer mandate. On Aug. 15, Mitchell threatens nonstop session on health care unless GOP agrees to vote.

Aug. 21-25

Both houses recess without acting on health care reform, return on Sept. 12.

Plan dies in Congress

Fall 1994

Sept. 26

Congress formally abandons health care reform efforts for 1994.

*Washington Post-ABC News Poll