Since March 30, 1992, when American Health Line
first launched, there have been two major efforts to reform the country's health care system.
In the early 1990s, President Clinton called on first lady Hillary Rodham Clinton to lead an effort to enact major health reform legislation. That effort famously (or infamously) failed.
It wasn't again until 2009, when President Obama took office, that lawmakers attempted such a large-scale effort to overhaul the U.S. health care system. Obama and congressional Democrats overcame decades of failed efforts to enact the Patient Protection and Affordable Care Act, now known as the federal health reform law, the ACA or "ObamaCare."
We looked back at past coverage in American Health Line to examine the difference between the two efforts and why one was successful, and the other was not. Here are a number of key moments from each reform effort that helped determine their failure or success.
Jan. 22, 1993: President Clinton chooses wife, Hillary Rodham Clinton, to lead health reform effort.
Even before President Clinton selected his wife to head up the health reform effort, there was overwhelming public skepticism of her role in the administration. Soon after her selection, an ABC News poll found that 44% of respondents thought that there were more qualified candidates to head up the effort. An editorial in the Boston Globe captured the sentiment of the times: "Here we go! Hillary Rodham Clinton and Ira Magaziner have elbowed aside some of the most experienced health care economists in the world to form a little task force at the pinnacle of the administration to fix the American health care system themselves."
April 5, 1993: 'Sketch'y reform plans
In a speech at a Families USA forum, White House adviser Ira Magaziner "sketch[ed] an early blueprint of the overall plan" the White House health reform health task force was developing. Magaziner "[told the group] that the ... plan probably will mandate a minimum benefits package and care guidelines for all Americans, but will leave it to the states to decide how to meet those national standards." The speech was indicative of the secrecy in which the elements of the overhaul plan came together.
May 3, 1993: Telling it to Republicans
Hillary Clinton hosts a two-and-a-half-hour meeting with about 52 senators from both parties, hoping to convey that the administration was willing to consult with Republicans on a reform plan. However, during the meeting, Clinton and White House advisers Magaziner and Judy Feder again "sketched out" the administration's proposals, compromising both transparency and their efforts to include the GOP. Almost a month after Magaziner offered few details on the administration's plan, Clinton and Magaziner could offer no more details.
June 11, 1993: A spoonful of sugar
Hillary Clinton attends the centennial celebration of Johns Hopkins University School of Medicine, during which she discusses the administration's health reform plans with nearly 600 doctors. Many observers say that the speech was a smart move by President Clinton, in that the situation needed a softer hand.
Sept. 21, 1993: Prof. Hillary Teaches at Health Care U.
Hillary Clinton holds an "unusual" bipartisan briefing to discuss reform, inviting more than 300 lawmakers from both chambers. It is an early misstep for Hillary Clinton -- who was seen by many as having little to no experience with health policy -- because in attendance are many lawmakers who have spent their entire careers attempting to reform the health care system.
Oct. 14, 1993: 'Harry & Louise' versus Hillary
The now famous television advertisements featuring a man and a woman discussing the Clintons' health reform plan are widely credited with doing major damage to the administration's health reform efforts.
Sept. 27, 1994: Failure to coalesce
Many observers noted that instead of coming together around the plan developed by Hillary Clinton and White House staffers, Democrats instead offered up a number of alternative proposals. Senate Majority Leader George Mitchell (D-Maine) declared the last of such plans dead -- and along with it, the Clintons' reform efforts -- in September 1994.
Jan. 20, 2009: President Obama, cheerleader in chief
Literally from his first moment in office, President Obama set the tone for his entire reform effort. In his inaugural address, Obama said that "there is work to be done" on health care. Soon after, administration officials said they "plan to move fast" on efforts to "overhaul the health care system."
March 11, 2009: Obama stays hands off
President Obama makes it clear that he wants reform but will not be leading the effort, instead leaving it up to lawmakers to develop the plan. This frees him to put out fires along the way, instead of being the architect of the plan.
April 30, 2009: Congress passes resolution that includes reconciliation
Although passing a budget with a reconciliation provision didn't seem momentous at the time, it ultimately was the key to passage of the reform law after Senate Democrats lost their 60-vote, filibuster-proof supermajority when Scott Brown (R) won the seat left open by the death of Sen. Edward Kennedy (D-Mass.)
May 6, 2009: Insurers buy in
America's Health Insurance Plans President and CEO Karen Ignagni said members would concede to greater government regulation, as the industry works to prevent the creation of a government-run health plan that could threaten their business. The insurance industry is the first of many groups to offer their support to the overhaul, including health care industry groups, drugmakers (and their lobbying group), Wal-Mart and hospitals.
May 28, 2009: Mandate is not a tax, CBO says
A mandate requiring all U.S. residents to purchase health coverage would not be considered a new form of federal taxation as long as people could choose from a wide variety of private plans and no government entity was responsible for collecting their premiums, according to a Congressional Budget Office report. CBO in 1994, when lawmakers were considering the Clinton administration's health reform proposal, concluded that a proposed requirement that employers and employees make payments into government-run insurance pools would constitute a form of taxation and a major expansion of the federal government.
June 23, 2009: Governors concerned about Medicaid expansion
Some governors attempted to scale back or eliminate provisions in the Senate and the House versions of reform legislation to expand Medicaid to provide health care coverage to the uninsured. Maintaining the provision helped the Obama administration get the law passed -- by bumping up the percentage of U.S. residents who would be insured under the plan.
July 31, 2009: Spreading the message
The congressional recess allowed both sides to spread their message in favor or against the reform proposals. While opponents did it more vociferously, the fact that proponents of the law were still standing after the break gave them the resolve to press on.
Aug. 14, 2009: Death to "death panels"
The Senate Finance Committee eliminated a provision that would reimburse physicians for consultations with Medicare beneficiaries on end-of-life care. The committee is dropping the provision after opponents of health reform cast it as the start of "death panels" that would encourage euthanasia. Democrats' willingness to eliminate the provision demonstrated that, even in the face of misinformation, they were willing to do whatever it took to move reform legislation forward.
Aug. 17, 2009: Another concession
The Obama administration signaled that it was willing to drop a public option from the reform plan. A public plan was hugely popular with liberal voters and lawmakers, but Republicans despised the idea and panned it as an unnecessary expansion of government.
Aug. 26, 2009: Ted Kennedy dies
The death of Ted Kennedy marked a significant blow to Democrats' efforts to pass reform legislation. However, because of their previous work on reconciliation, overhaul supporters were able to overcome the loss of Kennedy's vote. Further, some observers say the death of Kennedy -- who had been a long time supporter of overhauling the U.S. health care system -- spurred on Democrats to "do it for Teddy."
Sept. 17, 2009: Health care is expensive
A report by Business Roundtable -- a group made up of some of the nation's top CEOs -- found that employers could experience a 160% increase in health care costs over the next 10 years if the health care system remains unaltered. The report served to demonstrate the necessity of reforming the system.
Oct. 21, 2009: Leaving things out
Although lawmakers from both sides acknowledged the need to permanently fix the formula that determines Medicare physician reimbursement rates, Democrats decided to leave such a fix out of the final health reform legislation. It was a key decision, in that it allowed Democrats to keep the cost of their proposal below $1 trillion.
Oct. 23, 2009: Stockholm syndrome
Although the health insurance industry must have been tired of being the scapegoat, the lure of millions of additional customers kept it supporting the reform effort.
Nov. 9, 2009: House passes reform bill
Passage of a reform bill in the House set the ball rolling on a process that ultimately ended in Obama signing a final bill.
Dec. 9, 2009: Public option out
Though it was wildly popular among progressives, the public option became too much of a sticking point in negotiations, forcing Democrats to drop it. Once again, Democrats demonstrated that they were willing to do nearly anything to push through health reform. Dropping the public option also paved the way for the health insurance exchanges that eventually were included in the final bill.
Jan. 20, 2010: The end of Dems' supermajority
Massachusetts state Sen. Scott Brown won a special election to fill the U.S. Senate seat once occupied by the late Sen. Edward Kennedy (D), making him the 41st Republican member of the Senate and ending the 60-vote, filibuster-proof majority that Democrats had expected to use to pass health reform legislation through the chamber. However, Brown's win forced Democrats to reconsider reconciliation, which they ultimately used to push a bill through the Senate.
Feb. 9, 2010: The ultimate scapegoat
HHS Secretary Kathleen Sebelius sent a letter to Anthem Blue Cross of California asking the company to explain a proposed premium increase of nearly 40% for many of its approximately 800,000 individual policyholders. Many observers saw Anthem's proposal as the ultimate example of insurers' largesse, justifying the administration's villainization of the industry.
March 24, 2010: Bring out the pens
President Obama signed the Senate's health reform bill (HR 3590), noting that the legislation highlights "the core principle that everybody should have some basic security when it comes to their health care."
What's the Difference?
Looking back through the coverage of both efforts, it is clear that three key factors -- all of which were lacking in the Clinton effort -- helped Obama pass a health reform law:
- Consistent lobbying by the president;
- The presence (or, according to some, the manufacture) of a scapegoat in the form of health insurers; and
- The wisdom gleaned from the Clintons' failed effort.
Early on in the process of developing a health reform proposal, Obama made it clear that his plan would involve open negotiations and complete transparency, hitting on the two major procedural criticisms of the Clintons' 1994 reform failure: that administration staffers did not include insurance industry representatives in meetings to draft the plan, and that the process was confidential until the final plan was released, at which point opponents could only call for its dismissal, rather than seek a compromise.
Many observers saw Obama's mostly hands-off approach to the more contentious issues as an indication that he has learned from the mistakes made by the Clinton administration. Obama spent much of the health care debate on the sidelines, often making his priorities and preferences known for certain proposals but letting health care efforts progress through committee without much public commentary from the White House. As a result, he was able to spend his time lobbying for the law and continually push lawmakers to keep at it in the face of long odds.
However, one thing above all else might have given Obama the advantage over the Clintons. As Sen. Bob Bennett (R-Utah) noted in July 2009, health care costs rose dramatically from 1993 to 2009. As a result, Obama faced a more dire economic situation, higher costs of health care and a growing number of baby boomers facing retirement and Medicare enrollment than Clinton ever did.
by Anthony Wilson, Editor