Why health care reform could fail again.

Nothing brings on a headache quite like health care reform. My head has throbbed lately, as Congress has begun to consider a serious overhaul--a debate that forces me to recall the painful last time we embarked on a similar effort some 16 years ago. At the time, I was conducting polls for Bill Clinton and, on the eve of his address to a joint session of Congress in 1993--the prologue to the White House's big push on the issue--I went into the field to gauge the national mood. I returned filled with a great sense of hope about the prospects for reform.

Our failure to enact health care reform was tragic for the country, and it played no small part in my exodus from the Clinton White House. But the coming debate over reform is an opportunity that can't be squandered, and it has prodded me to reconsider this chapter. I've been immersing myself in my old surveys and focus groups and memos to the president. It's even led me to return to the field, posing the same questions to the public, to determine how the mood has shifted and how the forces that oppose reform can best be countered.

Perhaps I should know better than to have sensed any profound changes in the country. And, when I got the results for the new survey, I looked at each question warily, remembering how it all went badly wrong. As I reached the last of the questions, I exclaimed: "Oh no. It can't be. Nothing's changed."

Then and now, the country proclaimed its readiness for bold reform. In both instances, one-quarter say that the health care system "has so many problems that we need to completely rebuild it"; half the country sees "good things" in the current system but believes "some major changes are needed." Then and now, about 60 percent of the public feel dissatisfied with the current health insurance system. Yet three-quarters are satisfied with their own health insurance--once again eerily parallel numbers. The same holds when the public is asked to focus on reform. Yes, we're no longer living in the shadow of Ronald Reagan. But the country has maintained the same anxieties about government's ability to improve the system. The country divides evenly on whether the greater risk is an unchanged status quo or government reforms that "create new problems." And, finally, Obama might want to pay attention to how closely his situation echoes Clinton's. Then and now, more people favor the president's health care plan than oppose it, but the supporters make up less than a majority.

If anything, I found on most of these questions that the desire for change and support for reform was slightly stronger 16 years ago, underscoring the importance of learning some lessons from that history.


When President Clinton delivered his much-heralded primetime address to Congress, during which he held up a health-security card, 48 million Americans tuned in. We fully expected a spike in support for our efforts. Alas, it did not happen. Actually, the number of enthusiastic supporters dropped, while one- third of the country remained opposed. We took that response seriously, but it did not stop us in our tracks. It should have.

The health-security card tipped our strategic calculus. We wanted to spotlight the notion of "security"--as Clinton put it, "giving every American health security, health care that can never be taken away." With the recession of 1991 fresh in everyone's mind, our polling showed that "knowing I will be covered" was the sentiment that generated intense emotional support and best withstood attacks.

We knew cost was the voter's biggest worry, as it is now, but the plan championed by the White House made it very difficult for us to win an argument on cost. Having just passed a budget with dramatic tax increases, Clinton could not propose a new round of taxes for health care, yet our polls showed that half the country (quite understandably) thought reform would require new taxes. They just thought we would find a backdoor way to raise them. Meanwhile, our main tool for restraining health care costs was the introduction of "managed competition" and regional "health alliances," something barely understood at the time and, to the extent that it was understood, deeply unpopular. The other tools were premium caps and a national health care budget, barred from rising above inflation and population growth, but those devices merely served to underscore government's large and complex role.

When confronted with these questions of cost, the political advisers in the White House would mumble, look down at our shoes, or defer to the technocrats. But President Clinton didn't have that option. He claimed to be reforming the system precisely because of the impact of costs on businesses and entitlements spending. Our inability to talk credibly about how we would reduce health care spending or costs for individuals and the country built a contradiction into all our efforts--the more we talked about the comprehensiveness of our plans, the more voters worried this would yield higher premiums or higher taxes. Very quickly, voters came to conclude that their families would face higher costs.

And those dynamics are still in play. In my recent polling, I found that voters are skeptical about claims that reform will reduce costs and personal health outlays. Claims about simplicity, information-technology modernization, and best practices don't seem to be enough to persuade them otherwise.

But these misgivings can be trumped.

Then and now, the biggest hope for health care reform is "reducing health care premiums and costs for the average family," while the goal of "guaranteeing that no one will lose coverage if they move, get sick or lose their job" is not far behind. And, at the end of the survey, after hearing all the arguments and attacks, it is the prospect of insurance for all that people recall most, not arguments about reduced costs or increased affordability.

The health-security argument lost force during the earlier battle as unemployment dropped steadily, but the opposite is happening now. Almost 40 percent indicate that they or a member of their immediate family has been unemployed in the last year, and these are the voters among the most supportive of Obama's plan.

Still, you cannot expand support for reform unless you can convincingly talk about how you will reduce costs. Even though President Clinton declared that "we come together to write a new chapter in the American story," people responded personally, working to figure out what it all meant for them--the impact on their family, access to their doctors, dollars and cents, and on everything they'd done to become satisfied with their health care. Judging whether the plan would help or hurt one's family suddenly became the dominant predictor in our computer modeling of support for or opposition to the Clinton health care plan. The plan that took Ira Magaziner three days to explain to the political advisers and that George Stephanopoulos described to me as a Rube Goldberg monstrosity was unpacked by real people--months before the special interests and politicians would get to caricature it. In the end, they didn't have to. People will soon engage in the same personal calculus about Obama's plan.


One of the reasons the Clinton health care plan failed was the resistance of key groups. Seniors couldn't see what was in it for them, even though the president reassured them Medicare would be protected, buttressed by a new prescription-drug benefit. They believed that this vast new commitment to health care spending would erode support for their own care.

It may surprise you that Obama has already lost seniors, according to our current survey--only one-third approve of his plan. It doesn't take a rocket scientist to see there isn't much in it for them. There is already talk of carving out major savings from Medicare and, unlike during Clinton's battle, no offer of a new drug benefit. Clearly, they need to see health care gains for themselves too.

One would have expected union households to be among the most enthusiastic supporters of Clinton's health reforms, but they held back. Resentment over NAFTA played a part, for sure. But the reforms also had uncertain benefits for their members, most of whom already had health care--many with the kind of "Cadillac" plans that Clinton's team speculated about taxing. In the end, unions never seriously mobilized their members or financed advertising to defend reform.

Today, the unions are battered and divided and deeply affected by the changes in health care and employment that are propelling the country toward reform. With few illusions about the old system, union households are strong supporters of Obama's proposal. Yet the members will ultimately judge whether the plan is good for their families--and I'm certain that all the talk about taxing insurance contributions has not gone unnoticed.

Ross Perot's bloc of rebellious voters was contemptuous of elites and big government spending and would ultimately turn against the Democratic Congress and Clinton. Improbably, a majority of them initially supported the Clinton plan. But, when they got a good look at its complexity and bureaucracy, they were lost.

President Obama and the Democrats regained power in the last two elections because trust in government again fell to the historic lows reached in 1992. And, while voters have great confidence in Obama and his administration, they are worried about the deficits and spending and the government bailouts of the irresponsible. So, while voters want to see a rebalancing away from greed and toward the public good, almost half the citizenry is worried the government may get it wrong.

Ross Perot is a distant memory, but his more libertarian, blue-collar male voters are very much alive. They are pretty certain government will mess this up--and only about 30 percent support Obama's health care plan right now. With Republicans reciting their mantra about no "government takeover" of health care, the plan's opponents have found a common text.


There's one final number that I have to highlight--the three-quarters that say they are "satisfied" with their own insurance. Most are not at all satisfied with a system that has forced them to trade higher wages for continued health insurance coverage and other compromises. But those personal compromises to get satisfactory coverage will mean people can live a little longer with the status quo and want to make sure the proposed changes really will make things better for their families.

At the moment, the country is tilting toward enacting Obama's reforms, and it will do so more enthusiastically if Obama learns from the Clinton experience and rises to the educative role that he relishes. He must respect the thoughts, feelings and calculations of ordinary citizens who are not easily spun on important issues. People will take out their calculators when he lays out his plan, and he can't avoid speaking candidly about its costs and consequences. And he can't forget that he has a big story to tell about a changed America, one in which health care is but a pile of bricks in the new foundation he is laying.

Stanley B. Greenberg is the author of Dispatches from the War Room: In the Trenches with Five Extraordinary Leaders.

By Stanley B. Greenberg