Lessons of 93

POLITICS: Sometimes Health Reform Bills Do Pass...

Joanne Kenen — Tue, 13 May 2008 13:51:00 -0400

We've all done a lot of looking back to the lessons of 1993-94, and the long list of reasons the highly complex, ill-timed and politically-polarizing Clinton health care plan failed. But today the journal Health Affairs published an essay looking back not just at the failures of the Clinton plan but at the successful passage of two major health reform initiatives--the truly bipartisan State Children's Health Insurance Program (SCHIP) and the Medicare Modernization Act, which added prescription drug coverage for seniors.

The article, written by New America's Len Nichols, and Hill veterans Elizabeth Fowler and Christine Ferguson, acknowledges that the drug law remains controversial--a lot of Democrats don't like the basic structure of the drug benefit, and parties are still fighting about payments and changes the law makes to the overall Medicare program. But enough Democrats did back the legislation to see it enacted (barely), and some of them today acknowledge that even if it isn't the bill they would have written, even if they want to change some of it, it is helping seniors get their medication. The authors cite several reasons for its passage. Among them: President Bush took a hands-off approach to the details, letting Congress do its job of legislating. Republican Congressional leaders enforced party discipline so they held together to pass legislation that would help them politically. And, in the several years that lawmakers worked on the issue the two parties' models for delivering the drug benefit evolved to have at least some common ground.

The children's health program has been widely perceived as a bipartisan success from the outset. Clinton backed it, but Congress led the initiatve from the start. "The episode illustrates exemplary congressional leadership, a lack of partisanship, and a president leaving details to Congress while championing the basic goal and message of expanding coverage for low-income children."

Not so, however, for the second chapter of SCHIP, last year's reauthorization battle and Bush's veto. In that case, Bush rejected a bipartisan Congressional initiative and Republicans split among themselves, with the more conservative ones winning the day.

The authors conclude with three lessons (or wishes?) for next year.

Make health reform the top priority.
Be leaders, not partisans.
Develop a broad consensus, but leave the details to Congress.

Hope the folks on both ends of Pennsylvania Avenue next year, whoever they may be, are listening.

POLITICS: But Will Voters Still Love Health Policy Reform in the Morning?

Joanne Kenen — Mon, 12 May 2008 19:24:00 -0400

We hear lots of talk about health care reform and the presidential campaign, and certainly it registers in the polls. But is it resonating enough to make a difference in November—and will the next president, whoever that is, put the issue front and center if voters don't demand it?

As John Whitesides of Reuters wrote the other day:

"The sharply contrasting health care visions of Republican John McCain and his Democratic presidential rivals offer the promise of a grand campaign debate—if the candidates find room on a crowded agenda.

While health care reform ranks as the second-biggest domestic issue after the economy in most national opinion polls, it will compete with the Iraq war, taxes, high gas prices, and other topics for a prime-time spot in the campaign."

The history of public opinion and health care reform is worth recalling. It's only a slight oversimplification to say that "the public" identifies problems in the health system and demands change in the abstract. But then after hearing politicians argue about reform proposals for months, and being bombarded with critiques from interest groups, the public can end up quite change-averse. That support for abstract ideas about change becomes fear or opposition to concrete proposals. And the public tends to worry more about what health insurance means to them—can they afford it, can they count on it—than what it means to society as a whole and the uninsured. As Mollyann Brodie, the Kaiser Family Foundation's public opinion expert, told a gathering of health policy veterans recently (a few slides from her presentation below):

Goals are easy to agree upon
Solutions are hard
Change is scary

Health care is further complicated because people hold rather contradictory views—they don't trust government meddling in their heath care, but they want government to fix it. With a free lunch on the side. As Larry Jacobsen, a political scientist who studies health politics at the University of Minnesota and its Humphrey Institute of Public Affairs wrote recently in the New England Journal of Medicine:

"Health care reform efforts have been undermined not only by Americans' ambivalence toward government but also by the split between public dissatisfaction with the overall system's performance and patients' satisfaction with personal health care. Whereas more than 70% of Americans are quite negative about the country's coverage and costs, less than 40% are disappointed with their own circumstances. A mere 15% complain about the quality of care they receive."

All this suggests that public is more likely to follow if leaders have some kind of consensus among themselves on where to lead. Heated, divisive, partisan debates about complex topics tend to push voters back into a cocoon of the status quo. Only the status quo doesn't really exist anymore. Our system is hurt, and inaction will only make it worse.

Of course heated presidential campaigns aren't the best venue for working out consensus on complex social and economic policy. But on the morning after November 4th, we'd like to see the next president, whover that may be, articulating a vision and starting to build the coalitions that will give Americans the health care they need and deserve.

POLITICS: Daschle Promotes "Health Board" for Saner System

Joanne Kenen — Wed, 05 Mar 2008 19:40:00 -0500

We caught Tom Daschle, the former Senate Majority Leader and newly-minted health wonk, discussing his new book "Critical" today. We were delighted to hear him take issue with the too-common refrain that "America has the best health care in the world." Politicians in both parties say that, and it was an effective slogan against the Clinton health care reform in the early 1990s. It drives us nuts. Yes, we have great doctors and great research and great medical schools and great technology but no, we don't have the best health care in the world available on a consistent basis to all Americans. Daschle's phrase was that we have "islands of excellence in a sea of mediocrity." Like Daschle, we believe that any initiative to expand coverage also requires us to acknowledge our quality gaps and address spending that doesn't buy value.

Daschle, as you may have heard, favors creation of a Federal Health Board, which is loosely to the medical world what the Federal Reserve Board is to the monetary world. It would not "ration" care but it would make rational decisions about care. Daschle recalled that when he was in the Senate, he would get lobbied about things like the cost of oxygen tanks or reimbursement rates for various medical procedures. He concluded that Congress should set overall health policy but not make those technical decisions, which don't belong in the political realm. "Congress doesn't have the institutional capacity" to make those decisions, he told a jam-packed audience at the Center for American Progress. His ideas have been attacked by some on the right already as a Big Brotherly bureaucracy, but Daschle said a "Fed Health" could provide some rational framework for what we should cover and how we pay for it -- even in a McCainiac market-oriented health policy.

Daschle, who is close to the Obama campaign, didn't utter the "M" word (mandates). Obama of course opposes the individual mandate; Clinton endorses it (as do some Republicans). We worry that the mandate fight can be unnecessarily divisive. Daschle's book doesn't dwell extensively on mandates but he doesn't mince words either: Page 166: "The only way we can achieve universal coverage is to require everybody to either purchase private insurance or enroll in a public program. As long as we can make health insurance affordable and accessible for everyone, this is a reasonable requirement."

Like everyone else who survived the health care wars of the early 90s, Daschle came away with a hefty list of Things Not to Do Again Next Time. Being more inclusive, more open to "a vital center" was part of his message. Trying not to squeeze thousands of complex, technical decisions in draft legislation is another. Maybe a Federal Health Board could let Congress hash out a national health policy, without having to worry so much about doctor's fee scales or the how the cost of oxygen will play in Peoria.