If Americans decide to elect not just a Democratic president but also an overwhelmingly Democratic Senate this year, then universal health insurance will happen. But since the latter remains an unlikely possibility, at least for now, many very smart people assume that the short-term prospects for passing universal coverage are slim to none. One reason (among many) for that skepticism is the experience of 1993 and 1994, when another Democratic president (Bill Clinton) and a closely divided Congress tried to pass universal coverage – and failed pretty miserably.
But it's easy to over-learn the lessons of the Clinton health care fight – or, at least, to learn the wrong ones. That's why I strongly recommend reading Ezra Klein's new article from the American Prospect. In it, Ezra revisits the '93-'94 fight and reminds us, first, that the plan was victimized by bad strategic choices (starting with the decision to have the White House, not the Congress, draw up the detailed blueprint) and bad circumstances (like the fact that a national security crisis happened just days after Clinton formally announced the plan, thereby destroying its political momentum). While reformers can't do anything to avoid similar chance happenings this time, they can be more savvy. And, as Ezra notes, they've already shown signs of doing that.
For one thing, all three of the Democratic presidential candidates have emphasized that people who already have good insurance won't have to switch policies – a promise Bill Clinton couldn't make ten years ago, since his plan would have required the vast majority of people to do precisely that. (The new coverage would have been just as good, if not better, than what people already had. But that was too hard a case to make politically.) In addition, the Democrats have indicated that health care will be priority one in a new administration. Last time, it came after the push for the North American Free Trade Agreement (NAFTA). That squandered political capital and, perhaps more important, it alienated the labor movement, without whose support any reform plan was bound to fail.
Ezra also points out that the health care crisis has simply gotten worse. The number of people without coverage has grown, both as a raw number and as a percentage of the population. (The latter change is incremental, but even an incremental rise amounts to a few million people.) And, quoting economist Len Nichols, he points out that health care expenses have grown as a percentage of family income. Even people with insurance are increasingly worried about the cost of care.
Does any of this make universal coverage a slam dunk? Hardly. The country remains deeply ambivalent about “big government” and the taxes to pay for it -- even though universal coverage, in any form, requires a significant expansion of government and, one way or another, an infusion of new funds. Just like in 1994, the vast majority of Americans still have insurance – insurance, moreover, that they like -- making them easy prey for right-wing demogoguery. Business says it wants reform this time; but, then, it said the same thing last time. And while it's easy to avoid the strategic mistakes of the past, that doesn't mean the next president won't commit new ones. Still, Ezra is right to suggest (for reasons besides the ones I just listed) that universal coverage isn't an impossible dream – particularly if would-be reformers learn from the past.