Following my piece on Hlillarycare and why it failed, Martin Goldsmith wrote to me with a slightly more comprehensive review of everything that happened. This is from a article submitted for the forthcoming 11th Presidential Conference — William Jefferson Clinton @ Hofstra University. Martin is a Philadelphia hospital system veteran who was President of National Association of Urban Hospitals during the time in question.

The climate never looked more ripe for reform than it did in 1993.

Relatively unknown Democratic candidate Harris Wofford beat popular former Governor Dick Thornburgh in the 1990 Senate race in Republican-leaning Pennsylvania on healthcare reform platform – not a lot of specifics but  “everyone deserves a doctor” got the job done .The recession of the late 80’s/very early 1990’s caused middle class suburbanites to fear the loss of health care coverage. This anxiety soon was evident throughout much of the country.

With the election of Clinton, in part, on a health reform platform, there was an air of inevitability. In, fact, it was near impossible for any group to oppose broad-based health reform and few did.

For the first time, The American Medical Association, U.S. Chamber of Commerce, Republican Senate leadership – i.e. Bob Dole, supported universal coverage and employer mandates.

While my paper focused on the Clinton healthcare legacy, it was impossible to explore that legacy without substantial exposure to the views of assorted scholars, pundit/journalists and former administration insiders as to the reasons the Clinton Administration failed:

The content is borrowed – the categories are mine

• There really was a right wing conspiracy – immediately after the Wofford victory, Newt Gingrich began organizing to stop the Democrats (this predated Clinton’s nomination) from successfully sponsoring health reform. He feared if they owned it, the political boost would rival the decades long benefit they enjoyed from the New Deal
• The Task Force was a huge bust
  • The anti- feminist reaction to Hilary’s appointment to lead the Task Force
  • Ira Magaziner was a kook, there was too much secrecy, the endeavor was too academic and theoretical and it took far too long
  • The Reform Task Force excluded and demonized key stakeholders – Republicans, drug companies and others almost insuring their opposition
• In the end there was insufficient popular support
  • The economy improved – the middle-class’s fear dissipated
  • The middle class, with the help of the Clinton’s opponents, feared increased taxes to pay for the health care of the uninsured.
  • The fear of government involvement – the old socialized medical argument – the risk of the loss of privacy
  • The scandals – Whitewater, Troopergate, …caused the President to lose influence with Congress and the public
• What did you expect, health reform was the 3^rd most important domestic priority for the American people?
• The packaging of health care as an inalienable right didn’t resonate with the public

• The Practical Realities
  • The health care system may simply be too large & complex to really achieve a complete overall. For sure, the solution was too complex.
  • The passage of the deficit reducing/tax increasing first Clinton budget consumed too much political capital
  • The whole thing took too long. There were too many obstacles…from the illness and subsequent death of Hilary’s father to Somalia, Haiti, NAFTA…..
  • The power of the special interest groups on the Hill was too great.

• Political Missteps
  • The Administration didn’t work with Congress soon enough. A little party unity would have gone a long way.
  • The timing was terrible; welfare reform should have gone first
  • The opponents ran a better campaign – Harry and Louise resonated with the American people. The Administration’s proposal had supporters but no real champions

“Medicare” expansion — the simpler, most obvious approach — was largely ignored!

This is the continuation of an article I’ve threatened THCB readers with for some time about what in my view really happened the last time we got serious about health care reform.  And in it there are lessons for what we should do when the opportunity next comes up. (It’s also really long, so for the first time over here I’ve continued it “below the fold”)

There are lots of versions about what killed the 1993-4 health care reform effort.  Hillary Clinton has now decided that the problem was the lack of incrementalism in her plan.  Last week the New York Times said that since becoming a Senator:

She has deliberately avoided the major mistake she made as first lady, namely trying to sell an ambitious plan to a public with no appetite for radical change. <SNIP>. She summed up her approach in the first floor speech she delivered in the Senate about four years ago, when she unveiled a series of relatively modest health care initiatives. “I learned some valuable lessons about the legislative process, the importance of bipartisan cooperation and the wisdom of taking small steps to get a big job done,” she said, referring to the 1994 defeat of her health care plan.

On the other hand, some people are still claiming victory for the plan’s defeat even if they were at most modest bit players.  Here’s what one fawning bio says about former New York Lt Governor Betsy McCaughey

A 35-year-old senior fellow named Elizabeth McCaughey…wrote an article for The New Republic on what she discovered in a close reading of the 1,431-page document containing the Clinton Health Care Plan: Namely, that it would put every citizen in a single government-operated HMO. That one article shot down the entire blimp, and Betsy McCaughey became a 35-year-old Cinderella. One of the richest men in America chose her as his wife, and George Pataki made her lieutenant governor of New York.

Ignoring the fact that McCaughey spent her time thereafter putting poor New Yorkers into those HMOs she so despised, and then went off the deep end en route to divorce from Pataki, the rich guy, and reality (not necessarily in that order), it’s not really true that one article in The New Republic can be quite that influential. (Sorry Jon!).  Even if the overly geeky Clintonistas in the White House did feel that they had to come out with a point by point rebuttal. And anyway, the article only came out in January 1994 by which time the die was more or less cast the other way. Again we have to look elsewhere for the explanation.

If you want to go back and spend a few minutes wallowing in the era of trial balloons and secret task forces, there’s a very interesting time line of the whole process on the NPR website, as well as a briefer information over at the Clinton Health Plan Wikipedia site. It seems like there was a moment when it could have succeeded, and indeed there may well have been. What has been missing from the whole discussion over multiple blogs over the last couple of months has been the understanding that there’s a real world outside Washington and that sometimes (but not too often) what’s going on there has an impact inside the beltway.