Boomerang: Health Care Reform and the Turn against Government

by Theda Skocpol

How did the debate on health reform turn into the most concerted attack on government in recent American history? In this incisive account, a prize-winning social scientist offers deep insights into the changing terrain of U.S. politics and public policy. Because of far-reaching changes in the Reagan era, Theda Skocpol shows, the Clinton Health Security bill became a perfect foil for antigovernment mobilization. Thus its defeat provides a unique window into the new political landscape.

Genres: Nonfiction, Health Care, Politics, History

240 pages, Paperback

First published April 17, 1996

About the author

Theda Skocpol is the Victor S. Thomas Professor of Government and Sociology at Harvard University and the Director of the Scholars Strategy Network. She is a past president of the American Political Science Association.

Reviews

[Lobstergirl · Rating 4 out of 5]

I have a better grasp now of why President Clinton's health reform plan failed.

Bill Clinton himself. Clinton could not maintain a consistent focus on health reform over the many months from his announcement of the plan in 1993, to its failure in 1994. Some of his attention and political capital was diverted by a budget battle, the passage of NAFTA, and crises in Somalia and Haiti. His and the public's attention was diverted by the Whitewater scandal. But more important, Clinton failed to consistently promote and especially explain reform.

Failures in messaging. Clinton's pollsters had decided that things needed to be kept simple, that people wanted easily understood talking points and that detailed explanations would confuse and repulse them. This may have been true up to a point, but this allowed Clinton's opponents to define the plan for him, which was a huge mistake. Americans remained massively confused about the plan. It turned out that most Americans did want what was in Clinton's plan, but they didn't know that what they wanted was Clinton's plan. Skocpol also found that the pollsters' messaging treated Americans like mere consumers looking out for their personal bottom line, rather than engaged citizens deciding how something as enormously consequential as health care ought to be shaped. Politicians and pollsters often assume that Americans don't like being asked to do things, to take on challenges, beyond consuming and buying (think of George W. Bush in the days after 9/11). It turns out that we do, actually. We want to contribute to society, to engage in public action. John F. Kennedy knew this. Barack Obama knows this. Why don't more leaders?

Democrats in disarray: Democrats could not unite behind one plan, Clinton's plan. There were basically three plans: (a) Clinton's plan, the middle-of-the-road plan, which aimed for universal coverage and mandated that employers contribute to employees' healthcare costs; (b) a plan sponsored by Jim McDermott and Paul Wellstone, a single payer, (more liberal) plan, and (c) one sponsored by Jim Cooper which contained no employer mandate, did not aim for universal coverage, relied on market competition to contain costs, and dismantled Medicaid. Cooper's plan should have been dismissed out of hand by all reasonable people, since it could not even pass the CBO's (Congressional Budget Office) scoring. Yet such an influential publication as The New Republic backed the Cooper plan and pushed it repeatedly, even to the point of publishing false information about the Clinton plan. Such influential Democrats as Daniel Patrick Moynihan and Senator Bob Kerrey didn't help. Moynihan, whom Skocpol calls "one of the least disciplined of Democrats," repeatedly told reporters he wished Clinton had proposed welfare reform before health care reform. As chairman of the crucial Senate Finance Committee, his off-message dithering meant that no one was even sure the committee would act on the legislation. And astonishingly, Kerrey went from supporting a single-payer plan (i.e., a Canadian style system) during 1991-92 when he was a candidate for the Democratic nomination for President, to "refusing to accept any kind of employer mandate or any version of universal health reform during 1994."* Senator Bill Bradley also switched on supporting the employer mandate. With friends like these...

The right-wing noise machine, Republican opposition, and interest group opposition. Rush Limbaugh, Newt Gingrich, Bill Kristol and others repeatedly demonized the plan as socialism, and Hillary Clinton as a power-grabbing wife. Republican interest groups mischaracterized the plan. This kind of scorched earth opposition comes with the territory, and the Clinton administration should have been better prepared for it. The way you counterattack is with better messaging, a president's political capital, and leadership.

What Skocpol's book doesn't do is explain the nitty gritty of how it failed. We're only told that Senate Majority Leader George Mitchell declared it dead in 1994. This is not a blow-by-blow examination of which members of Congress did and said what, when, resulting in the plan's failure. For a good timeline of the development and failure of Clinton's health plan, I highly recommend this at the PBS Newshour website (click through all four pages):
http://www.pbs.org/newshour/forum/may...

The sad truth is that when Clinton came into office, he did essentially have a mandate to reform health care. 59% of Americans were in favor of Clinton's plan in September 1993. (That had declined to 44% by June 1994.) In late 1994, 72% of the public thought that major health reform was needed. Large majorities wanted the uninsured to gain coverage, particularly children and low-income people. In 1996, polls showed a majority would have liked to see Clinton's plan become law. But a political mandate to reform something isn't a guarantee it will happen. For all kinds of reasons, and given all sorts of obstacles, some things just aren't possible at that point in time.

* Sigh, I love the internet. You cannot find a full text copy of the article Skocpol cites here on Bob Kerrey's waffling, except in the archives of the Clinton Library:

http://www.clintonlibrary.gov/assets/... p. 15.

[Dylan Matthews · Rating 4 out of 5]

Why did the Clinton health reform effort fail?

There are a few theories. One, popular on the left, is that the Clinton administration squandered all good will with labor by pushing NAFTA, which left its proposal without champions. Another, popular in Congress, is that Hillary Clinton and especially Ira Magaziner were arrogant defenders of a baroque scheme they concocted together, unwilling to give ground on even small matters. Another, popular on the right, is that the American people do not like or trust government and understandably rejected a heavy-handed government effort to reconfigure health care.

Skocpol strongly rejects the second theory, which makes sense given the extraordinary access Magaziner and Hillary Clinton gave her to their files (remember, this was written before Clinton’s reelection, so it was all very fresh). At times, the bias towards her sources feels a little glaring, as when she argues that Magaziner was not arrogant in his presentation of the plan, but just someone who’d done a lot of hard work who was understandably proud of that (see page 59). I mean, maybe. Or maybe he was also kind of prickly and defensive.

But she picks surprisingly freely from the left and right theories alike. While she doesn’t emphasize it, the NAFTA debacle comes up again and again in her narrative, as in Mike Lux’s memo to Clinton explaining the interest group picture on health care as 1993 came to an end (page 95-96). It’s clearly why labor, which had been a linchpin of the Medicare effort in 1965, backed away. And maybe with assured support from labor, the AARP, the other half of the 1965 coalition, could’ve come aboard too.

The failure to put together an interest group coalition capable of airing ads and doing grassroots work boosting the health security proposal is central to Skocpol’s story, and the labor/NAFTA angle, admittedly, is just one piece of it. The bigger problem, arguably, is one Skocpol has hammered home in her work for decades: the hollowing out of the Democratic Party as an institution directly involved in people’s lives and the proliferation of foundation or direct mail-funded interest groups that for tax and other reasons decline to intervene directly in elections or policy. The descriptions of baffling ads in support of health reform, that could not mention the actual Health Security Act for legal reasons, are especially galling (pages 97-98). The AARP didn’t get on board, which in turn limited what groups funded by them (an important subset) could do.

By contrast, there were fewer limits on the opposition, particularly HIAA, which wasn’t tax-exempt and wasn’t forced to align with a specific proposal. This is where Skocpol’s embrace of the conservative explanation comes in: Americans genuinely did not trust their government to solve problems, and certainly trusted it less than they did when Medicare passed, and obviously it was going to be hard to push through something of this scale with that sentiment just under the surface waiting to be exploited.

Her prescriptive takeaway from that, namely that Clinton should’ve forthrightly made the case for the value and importance of government and tried to change that underlying mistrust, strikes me as foolhardy. These changes aren’t reversible by individual people. Clinton was smart to try to work within the limits of the political world as he saw it. But if he got dealt a bad hand, he also played it poorly.

That’s clearer in retrospect, having seen Barack Obama dealt a very similar hand and play it much, much better. The ACA did not achieve what the Health Security Act would’ve achieved: we have not decoupled insurance from work, we have not ensured all citizens and legal immigrants are covered, and we have not given states the option to do single payer (one of the most intriguing provisions in the bill). But it achieved far more than the nothing that Clinton got for his efforts.

In retrospect, Skocpol’s focus on interest group coalition management was prescient, but the winning strategy was one she didn’t identify: simply buy off the insurers and PhRMA to ensure they won’t kill the bill.

[Leslie · Rating 4 out of 5]

This is an interesting and insightful analysis of the 1993 Clinton Health Security reform, its failure, and the political and social institutions that aided and abetted the failure. It covers the major players, the major selling points of the reform effort as well as the background political issues that helped to frame them (huge budget deficits, low popular trust of government). Unfortunately, there appear to be many, many parallels to the present, and I am afraid Obama's efforts may similarly be quashed. Reactionary voices are easy to hear in a sound-bite culture and inflame popular skepticism, while well-reasoned argument takes attention spans and costly air time. Hopefully, well-intentioned citizens trying to achieve egalitarian ends will be able to unite and rework many of the poorly formulated government groups, policies, and agendas, that perpetuate self-serving, incoherent, and inefficient policies.

[Tyffanie A · Rating 4 out of 5]

As someone who isn't all that interested in politics in general but was assigned this book for a class in my program, I found this book to be quite interesting and very well written. Skocpol writes about the rise & failure of the Clinton health care reform in a way that doesn't overwhelm the reader with details, but thoroughly analyzes the multitude of forces that came together to ultimately kill the bill. It is a great commentary on the 'political games' in play during the 92-96 era, but that can still be seen today. It also helps a non-politically-oriented person a good sense of what each political party believes and even problems within each party. I would love to read a follow-up by Skocpol about Obamacare because she could link it well to any foundation laid 10 yrs ago as well as how the political climate post-9/11 might have affected the eventual passing of this health care reform.

[Scott · Rating 3 out of 5]

I read this (a study on Clinton's attempt at health care reform) during the health care reform process/debate in 2009. It was dry but enlightening reading. A bit depressing, at least for a liberal. Interesting commentary on recent American politics, and yields interesting comparisons with the Obama administration (not that these are in the book itself, it's pre-Obama). If you're interested in both policy and politics, you'll probably appreciate it.

[Kai Palchikoff · Rating 3 out of 5]

W. W. Norton & Company