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ICM APSA Drafts 8/94 & Final
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August 30, 1994
MEMORANDUM FOR HAROLD ICKES
MAGGIE WILLIAMS
MELANNE VERVEER
LISA CAPUTO
LORRIE McHUGH
CHRIS JENNINGS
JACK LEW /
FROM:
IRA C. MAGAZINER
SUBJ:
POLITICAL SCIENCE ASSOCIATION SPEECH
Enclosed is a draft of the document I propose to hand out at the American Political Science
Association on Thursday evening in New York. The actual speech will be a 30-minute
shortened version of this document.
While I believe we have to make a speech like this now because of all the misunderstanding
that exists, I am concerned that it has the feel of a restrospective, more appropriate after the
process is over. I'm also concerned that it may appear unavoidably defensive.
Any suggestions are welcome. We will prepare a final draft tonight. Thanks for your
prompt attention.
�On any given day, almost 39 million Americans, most of them working people and their
children, have no health insurance. Every month, 100,000 Americans join the rolls of the
uninsured. Millions more stay locked into jobs they want to leave because they can't risk
losing their insurance. Families find they can't get coverage for the very problems they need
care for, because those illnesses have been stamped "preexisting conditions." Small
businesses face health care premiums that are 35 percent higher than those of large
corporations and are projected to continue to grow at double-digit rates. A full third of these
small businesses that now cover their employees say they, will be forced to drop their
workers' insurance.
In spite of the tens of millions of Americans without insurance and the millions of others
with inadequate insurance, our medical bills are growing at over twice the rate of inflation.
In 1993, we spent over 14 percent of our income on health care. By the year 2000, if we do
nothing, that figure will jump to close to 20 percent. We spend over a third more of our
income oh health care than any other country. And the gap is growing, putting our
companies at a competitive disadvantage in the global economy.
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This is the picture candidate Clinton faced: rising health care costs swallowing up growth in
workers' wages, ballooning the federal deficit and stifling the competitiveness of American
industry . Economic downsizing and. a sluggish economy add millions to the ranks of the .
uninsured, and fueled fears about losing it for those who did had cbyerage. He saw the
" health care issue, as inextricably linked to his ihairi campaign thrust of economic recovery,
promised to. submit.'a health care plan within^
Senator; Harkiniadyocafed a:pay-pr-playi m o d e l , ^ h i c h ^ M e ^
requiririg companies that did not cover their;workers ^
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federal goyemnientr
" Candidate Clinton embraced a relatively. new; more moderate fr^ewprk^
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"managed' cbmpetitibh.-. '- V ^rebmbinkidh'b
•universal coyerage'and new government ground n i l e s i f ^ ^ i d ^
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competition and efficiency -- thus holding down healtliicar^ co^^^
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Democrats, including the; Democratic'. Leadership Council--aiid'former ^nator TsorigasJ
favored this approach.
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�Clinton's campaign plan, with private sector health care and increased competition as its
centerpiece, would achieve four main goals:
Provide universal health care coverage to all Americans
Make health care more affordable by controlling the rate of growth of health care
costs so that they did not exceed the rate of growth in personal income.
End discrimination in the health insurance market by outlawing insurance industry
practices of excluding or dropping sick people and charging prohibitive rates to
certain groups.
Provide a prescription drug benefit and better home and community-based long-term
care services to the elderly and.disabled.
These goals were and still are popular with the American people. Yet meeting them has not
, come easily.
We were warned that we faced a serious challenge - - health reform had been attempted by,
seven Presidents. Seven Presidents had failed.. Health reform was ,to6 big, with too many
powerful vested interests. Those who profit from the status quo are tenacious, well-financed,.
: .and wellTorgamzed. Health reform was not afirst-termissue.
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. And as one.old Washington hand wryly noted,- health reform was a good campaign issue .-^ everyone's for health reform.. .But getting something through once m office would be.a A
;-^dif ferent s t o ^
•^v,refomr.^suppo]led ve]y:different<thingSv'and'umtmg;these^
could prove next to impossible
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A yearvago jast month, the President's.economic program,barely, passed a/reluctant .Congress:
-v. ^ As-- avresult- of its -passage?- we are experiencing steady economic growth •OveRvfour-milhon *
.- jobs^ have' been, created smce the.President took office. > The'deficit has: been?slashed,-:andv for
^ the first time.since Harry Truman was President, we'll have three,years of declining deficits
: in a row. , Yet, the President's popularity rating is low and major health reform is now
viewed as an uphill struggle
What happened? - Conventional -wisdom is that .the Presiderit'and his, Admimstration H T v•
^. overreached proposing a radical, big-government, grandiose plan hatched by policy Avonks
with political tm ears.
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In fact,, the President's health care plan - true to the candidate's.promise --. was
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comprehensive, but hardly radical. It built upon the system 90% of Americans now use: :••
;ypnvk]ttfy^dHhOTramce' delivered through the workplace.: Its main provisions mirrpred| those.,
vpioposed by. the likes of Richard Nixon and Bob Packwood ahd cprisehrative 'Pem6c^tsVJiin-;
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�Cooper and Dave McCurdy.
Why, then, was it perceived as so grandiose or over-reaching? What about these now
controversial ideas like employer mandates, premium caps or large mandatory alliances?
What has become conventional wisdom over the course of this debate — that these elements
were some "big government" creatures of the First Lady's Health Care Task Force is simply
not true. It is not the plan itself that was overly ambitious. Rather, it was how it was
portrayed to the American people by opponents of reform.
Employer Mandates
. Virtually all Democrats and moderate Republicans supported the goal of universal coverage
in 1993 when the President's plan was written and presented. In fact, Senator Dole and 23
other Republican senators initially cosponsored the Chafee bill which achieved universal
coverage through a mandate that individuals buy insurance.
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Over the past two years of debate on health care in fact, over the past few decades of
debate -- only a handful of ideas have been proposed that would pay for universal coverage:
1) The raising of broad-based taxes -- the single payer approach; 2) Requiring individuals to
purchase insurance - an " individual mandate"; 3) Requiring individuals and employers, to
share the cost of purchasing insurance - an "employer mandate. "
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The single payer approach would replace today's employer-based system with broad-basied
. income, payroll or value-added taxes,, requiring;at/leaist three to foiir hundred.billioh-''d6ll.'ars..-r-::';_.• .L
. in new federal taxes per year. The government would t^e oyer p'a^
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;A. :-.much in hew taxes ai^-calledforthe goyerhment
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.. ; , A:Secorid.'approach was to mandate that all individuals buy. healili'i^^
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'.' ."";.';•"states now mandate ttiatall individuals buy auto' iiiMart&VA^e^
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• .? Force, chaired by Senator Chafee; had an^individual mandate^s its^vdhicle'-tb achieVe; ''o--;'^ / h % ^ ';.'•
• universal coverage. Many economists favor this approach --.believing that virtually allA '. • './'• ]
" ., health care spending by employers comes directly out of employer wages anyway.{^Biit ; . ; A
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polling data showed .that the public and many, organized groups opposed this approach birthe/- : •; •: ..,
. . ^ .v grounds that workers 'bad negotiated'employer-paid insuranpe; andhad foregbne^age; L i ^ y . y'r. •
;:r.O . increases
to-'get: empibybr-p^^
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many people losing benefits they currently have. In addition,, if individuals ^re>mandated;;''
to buy insurance, it would have to be affordable.. Because health insurance.premiu^
" A expensive, the federal government would have to ensure, adequate subsidies to. Help|lefray -A/- ;.
'"\ :. 'i • vsbme ofthe cost for famliesV Paying for these subsidies meians'i'raismg iignificaht'new--takes> j
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�And, well over half of the population would then be receiving subsidies, requiring a huge
new administrative bureaucracy.
The third approach, a so-called employer mandate, was the approach embraced by the
President during the campaign and later by his Administration. It had the advantage of
building on the current system of joint employer and individual contributions. Almost 90
percent of those with private insurance today get it through their employer, with employers
paying, oh average, 80 percent of the cost of the premium. Spreading that responsibility
across all employers and individuals - not allowing "free riders" - would eliminate "cost
shifting" -- the extra cost families and employers with insurance today pay for those who use
health care services but can't pay for their care. To ensure that this requirement was
affordable, the government would subsidize insurance for low-income families and small and
low-wage businesses.
This was the most conservative route to universal coverage, and enjoyed the broadest
support. The American Medical Association (AMA), the American Hospital Association
(AHA), the Health Insurance Industry Association of America (HIAA), the Catholic Health
Association (CHA), many Labor Unions, the Jackson Hole Group, the National Leadership
Coalition for Health Care Reform (co-chaired by former Presidents Carter and Ford), and
many business groups including the Chamber of Commerce all publicly supported this
approach.
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Hawaii, the state that had come closest to universal coverage, had had an employer mandate
on the books for more than 20 years, and business growth had outpaced the .national average.
Washington,^Oregon; and. other states were follo\ying'Hawaii's lead/
In fact, the Cliiitpri
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similar to .a proposal
made by: the U:S.; Chamber-of Cbihmerce and. to Presiderit^kbn's 1972' health care,
proposai^intr6duced ;by Senator Packwood;; today 's ranlmg ; Repubiican member of the Senate
Finance Committee; ^ ,
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Premium Caps
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JThe biggest .cpncern' the American people Had about health insurance was losing it; the
second was its; cost:'; Cost containment was' critical to insw
care was, affordable
.for'businesses4nd families, and was essential^fbr controliing federal spen^
comprehensive Kealth care bills submitted .by Dek^
cost containment. • •
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But as with universal coverage, there; \yere & limited set of options for meeting this ,Objective.
One option was price controls - directly setting the price for goods and services delivered in
the health care sector, or setting annuaf ceilings' on. the total ^aiiiount the nation would spend
on health. Liberal bills included either global national budgets, or nationally-set rates for
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�each specific health care test and procedure. These measures had the support of some
business and many labor groups. The National Leadership Coalition, co-chaired by former
Presidents Carter and Ford, and including companies like Xerox and Chrysler, supported this
approach.
Managed competition advocates like Senators Breaux and Boren and Representatives Cooper
and Andrews proposed "tax caps", to contain health care spending limits on the tax
deductibility of health spending by companies. By tying the amount of deductibility to the
cost of the lowest-cost health plan in an area, managed competition theory went, families and
businesses would become smarter shoppers and choose lower cost health plans. Families
that chose more expensive plans would be penalized by paying more, dollar-for-dollar, out of
their own pockets. This new cost conscious behavior, combined with other market reforms
like a standard benefits package, would constrain health care expenditures.
We did hot adopt the tax.cap because it raised taxes on middle-class families. But we did
encourage consumer cost consciousness through other measures. Employer contributions
would be tied to the average cost plan in a region. Employees that chose a higher-cost plan
would pay more out-of-pocket, those who chose a plan that .cost less than the average would
: pay less. Like the managed competition approach, cost conscious-behavior, combined with
increased competition due to market reforms would achieve efficiencies and contain costs.
• A third method of cost control was premium caps - limiting the amount insurance premiums
• could be raised year after year. Bills submitted by moderate Democrats and Republicans
,. such as Senators Danfbrth;'and Kassebaum, and; moderate Democrats such as Senator
Bingaman and.. Baucus ,and Representatives ;McCurdy and Glickman included premium caps
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other forms of cost.
^ ; > . ' >.contaihment because j unlike rate setting;^
caps , coyer only, pre-tax .
,.- 'health;.care' spending;- The American
with aftertax
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cbhtrbls, premium cips do/not try-,to regulate every transaction in th6 market. '
C ••-vlnstead';- they give flexibUity to health plans tb;^
premium. •
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and other services,
hot goyernment bureiiaucrats; Prernium'c
law in Minnesota and
Washington state,, and had been p ^
the state of Califorhia:by the, state insurance
'}•":xohimissioner;. They also were supported'by diverse:grdups.jnciudm^
; "'•'•Of "Physicians (AGPyj' the American A^
Catholic
' f e l t h Association .(CHA). arid •were sup^prtoi..by' prominent physieuihs-ahd health, reform ,
' • .' ' • advockes such as C. Everett Koop; and Jack Wennberg/ '
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�We borrowed this method of cost control directly from the Danforth/Kassebaum bill as an
insurance policy on competition, both as a safeguard for family and employer affordability,
as well for Congressional scoring purposes. If competition worked as predicted, insurance
premiums would never reach the pre-set caps. As with employer mandates, premium caps,
particularly as backstops to competition, were neither a new nor radical idea.
Large Mandatory Alliances
Perhaps no idea occasioned as much controversy as the proposal to establish large mandatory
health alliances in regions around the country. ' These alliances pooled the purchasing of
workers in firms with fewer than 5,000 employees, government employees, Medicaid
beneficiaries, nonworkers and retirees. Through these pools, community rating could easily
be enforced, families would have a wide array of plans to choose from, and families and
businesses would have the maximum bargaining leverage to get affordable prices.
The idea for these entities, originally called purchasing cooperatives, came from the managed
competition advocates at the Jackson Hole Group and the Managed Competition Act
sponsored in 1992 by Representatives Cooper and Andrews and Senators Boren and Breaux.
In this legislation, all firms with fewer than 1;000 employees, all government employees, all
Medicaid recipients and all nonworkers were required-to join purchasing cooperatives. States
had the option to fold in firms with up to 10,000 employees. The rationale for mandatory
purchasing cooperatives was. to prevent firms.withryoung healthy people from opting out and
leaving only sicker, older people in the pools. Haying the podl dominated by costly,
populations would defeat the purpose by making the^
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rating
for^fims^
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allowed them too joih'exclusive purchasing:alliances.^ !^ U'-^W^^:'''J
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Though less in the limelight, the Health'Security 'Act cpii&i)^>a;|^^W.of other significant..; •
provisions ~ these, too, were well within the mainstream
The long- , . ;
, term care benefit, prescription drugs for,iyiedicare^dpient$, 'i:fo
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. quality improvement, the creation of a hWth^ii^^
for academic r'^f]
health centers' mral and urban infrasfrue'mre impro
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bf the bill were all developed from recon^endatiqns.'m
legislation;: from state :
experience, from company: experience or! fforh wel.llesitablished 'acsdemic. analysis.; In fact,
many of these lesser provisions are also included in Republican health reform proposals. .
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�Complexity
While the bill's actual provisions were in the mainstream, size and complexity made it easy
for critics to brand it as bureaucratic social engineering and "big government". The bill is
complex - all 1,342 pages of it. But, as the Congressional Budget Office stated:
"The Health Security Act is unique among proposals to restructure the health care
system both because of its scope and its attention to detail. Some critics of the
proposal maintain that it is too complex. A major reason for its complexity,
however, is that the proposal outlines in legislation the steps that would actually have
to be taken to accomplish its goals. No other proposal has come close to attempting
this. Other health care proposals might appear equally complex if they provided the
same level of detail as the Administrations on the implementation requirements. "
Did the bill really have to be l ,342.pages? Only if we wanted it to work, which we did.
Couldn't we have written a shorter skeleton bill? Only if we were willing to leave the actual
details of the plan to government regulators, which we weren't.
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Health care is a very complex subject, and, like most major pieces of legislation, a bill tp
reform the health care; system is never going to make for beach reading. . The Congressional
leadership requested a fullyfleshedout bill that would be the. basis for committee
deliberations. When you begin to spiell out whatbenefits are covered, how the money flows,
what happens to existing goyehiment-health plans.^ike ;Medicare; and Medicaid, yoU find '
yourself with a long bill. Senator Mitchen's .biir^
'The Senate
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complexity people would supposedly face under; a;refbmed;syste^
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became a symbol'iof the iamount of govemmeht mVplyimentpeo^
in their, health , .,
• care .: Attacking the substance of health" plans; by • attacking their length played to the" cameras'.., ; •;•
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Bob Dole's antics: in weighing' k on .a scale did
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re^latoiy", "big gOvei^ent".; ;We weren't d
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�But, we believed that introducing a skeleton bill that did not give the public and the experts
an explanation of how these reforms would work would be irresponsible. In any event, if we
had laid out a skeleton bill, we would undoubtedly have been attacked for being too
superficial and not well-grounded.
Where are the Radical Social Engineers?
Critics of the President's initiative painted his bill as a radical document. In fact, its
employer mandates were borrowed from Richard Nixon and a host of mainstream groups; its
premium caps came from a bill sponsored by moderates such as Senators Danforth and
Kassebaum and Congressmen such as Representatives McCurdy and Glickman and its large
mandatory alliances came from the bill sponsored in 1992 by Senators Breaux and Boren and
Representatives Cooper and Andrews.
Those elements and the central focus of universal coverage remain popular with the public to
this day. In a recent Washington Post/ABC poll, universal coverage is favored by 77 percent
of people and employer mandates by 72 percent. Government cost, controls are favored by
75 percent of the public.
So. why then, did Members "who had themselves introduced these proposals later come to denounce them and press for different solutions? Why did a plan with moderate foundations
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Several reasons..;, some of them within our control, many: of them outside;6
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events led to,; missed opportunities and a hardened political j-v'-vv
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V ;: eriyirohmerit; The length of the:bili;and mispercept^ns ^
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fears abolit government intnisiveness and complexity: And perhaps most importantly, deep" / v pocketed'opponents and^ their/ endless iiegative;ads,, heaped upon^a President , beleaguered by .. ;
;". orchestrated personal.atta
other diyisive le^slatiye*
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ambivallentlpublie: Though i ^ p p o r t ; ^
: ^.. plan remained high,! the public came to distrust any reform with the:label ."Clihtori plan". p
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DELAt AND THE LOSS OF MOMENTUM
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, : The first problem we encountered was the loss of momentum occasioned by the need to delay
^ A A t h e rfeleiaseVbf the!Pfesideht's"hdahh plaint; When the PresidenttookoffiCe^-hc^
^^'^^'hi^lth^careWk-.forcfe with a 100-day deadline to produced health" plari which the President
,; : could take to Congres? by the end of May. Initially, the President,, with advice from ,
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;!;.!.•'• Cohgressional leJaders 'contemplated including the health plan in his first budget along with;' ,
\ ' i.;;.' his\'ecbripmic:plan.. This had a number, of advantages. It would not be subject to a filibuster .;
' in the'Senate, thus requiring only 51 votes to pass. ;Tying it to his economic plan would
. r p ' ; aiipw'the;P'resideht 'to;;ask-fpr justbhe vpte,;aibeit a:big •and''difficult.one^frbm' allied-'.
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�interest group opposition.
This strategy proved to be impossible when as a parliamentary matter, Senator Byrd and
others felt that it would not be appropriate.
We then intended to introduce our plan by the end of May and push for passage by the end
of the year. We knew that delaying into 1994 raised the risk of having health reform
politicized by the midterm elections.
During April and May, the Health Care Task Force met 21 times to finalize decisions on the
plan with the President in attendance at numerous meetings to make the key decisions.
However, after the defeat of the President's stimulus package and with mounting opposition
to his economic and budget package, Congressional leaders asked that the introduction of
health care be delayed until after passage of the economic package was assured. They feared
that members might trade off their vote on the economic package for concessions in the
health package. For example, when a Department of Treasury analysis listed a tax on wine
and beer, (a tax which was never seriously considered) as a potential source of health reform
financing, the whole California delegation sent a letter of complaint, and some privately
threatened to withhqkf support for the economic package.
As the economic package stalled, the introduction of health care was delayed from early-June;
lo later June to mid-July to late-July and finally to late-September. Theb^
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iehuous. as it was the collective view -.was, that leaked accounts of health care meetings could •
' only disrupt the delicate balance being sought to pass the budget'A
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;did not get made until juscifter Labor! Day: The-speech tp the Joint Session of.Congress':A^
;iritroduCmg!i'the health care plan occurred on September '22vimte^of^
May^and ^ A 5 %P .
legislation Avas^nbi submitted until l a t e ' O c t o b e r . A p p ' / p p p ' p p p A
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This delay gave time for the opposition tO'organize;.arid.caused doubt'.among:' supporters .abbutf6^I^'resblye/^While those of-us. working'on'the heaito'c^-mtiative::were •dispintedp--:
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�SECRECY OF THE TASK FORCE
Though the delay was inevitable, the reputation of secrecy that surrounded the health care
task force was not. The formation of the President's health policy was among the most open
processes ever conducted to form policy in an Administration, yet it is still widely believed,
in the court of public opinion, that the President's health plan was drafted in secret, behind
closed doors and without the benefit of real-world views.
To meet the aggressive timetable, we established a process for making policy that was
unconventional for Washington, borrowed from private sector models for conducting big
projects in a short time frame. To help us flesh out the campaign framework in a way that
would work effectively, we cast a wide net for participants. To establish an atmosphere of
equal footing among departments and agencies and to foster interdepartmental cooperation,
the decision was made to run health care but of the White House.
The health care working groups included an extraordinary-group of people,; many of whom
had extensive careers on thb front lines ofthe health care system. Serious consultations and
reviews included hundreds, of others from'all walks of life. Practicing physicians, nurses,
social workers, hosjpital administrators, benefits consultants and managers,; consumers,
businessmen^ actuaries and accountants • health; lawyers and others were involved in extensive
work associated with the task force.
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Most people took unpaid; leaves from the.ir jobs, left their, homes, and families for three.
. months, and .worked literally around, the clock- to meet the^deadline;; That would have been
trying under any.circumstances. ^
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/ • flowing;iri the door saying:.. "Pm.here for a meetihg ori hCalth care.'W : / ; •; . • - :;;
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and fifficiais from^associations'of state legislatures^-Co^
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groups
included as well.
Between February .20V. 1993 and ^ p r i l 18, 1994; t^;;Ei^t;Lady :held a series^qf 23 public
hearings rand^town meetings'iacross
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�Also by May, review groups composed of health care providers, consumers, auditors,
actuaries, hospital and insurance administrators and lawyers reviewed and responded to ideas
presented by the working groups. The working groups incorporated their comments and met
their deadlines. The whole process resulted in an amazing amount Of work being completed
in a very short time period.
Yet despite this unprecedented level of consultation and involvement, the widely held
perception is one of secrecy. The main reason, I think, has to do with the way we dealt with
the press -- or in this Case, didn't deal with the press. While a few cursory briefings were
held, the press was by and large excluded from the deliberations of the task force and the
ongoing efforts of the working groups. This caused three serious problems from which we
never recovered:
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Many members of the press rightly resented their exclusion from the process. Many
of the reporters covering health care had waited 12 years to cover this story, and now
that moment in history had arrived, they were being kept out.
2.
Reporters meeting daily deadlines for healthcare stories were forced to rely on leaked
iriformation, often provided by people v/ho were not directly involved or wanted to
influence the outcome of policy deliberations. This led to negative and distorted
coverage.
3.
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We had undertaken an enormous task and were using an unconventional process to
, complete it.- Both the importance'of the task,. how it was being worked on, and who
were involved should have beenbetter commumcated arid explained. In short, we
and about
die health care issues which could proyide^^'a
reporting later. :
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;''Hmdsigh|vis'.-always.26/20; -but•far&.was really nojgood reason for.doing this. The rationale
, .of^o^.eonmunicatiom
was '^at W .Wefe simply forming an administration position
;p"preparat^
scale ppennatidMl discussion
But
'vthis,reaspriing;was. flawed. Health care was^different; Decisions like filtering all press
, inquifies through; one person and. failing to give the press the names of people working on
•[,. refbrm led to a perception of secrecy'.and, engendered a sense of hostility which has been
' hard to recover from, v
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�THE COMMUNICATIONS CHALLENGE
We always knew that communication would be essential to the success of the health care
initiative. A special operation called the delivery room was established in late-May to
prepare the groundwork for introducing health care to the nation. The operation was
diverted at the end of June until mid-August toward fighting for passage of the economic
program. It resumed operations again in late-August.
.
We also knew that the first six weeks would be crucial in defining the debate, We had to
educate the American public on what was in our plan before opponents mis-characterized it.
During the summer of 1993 there were intensive discussions in the White House about
scheduling the President's three major initiatives for the fall: health care reform, NAFTA
and reinventing government. A decision was made to introduce reinventing government for
a week just after Labor Day. The President^ would spend a day in'September to introduce .
NAFTA. NAFTA would quietly proceed through Congress until a major public offensive
would be launched in November, a few weeks before the vote. Five solid weeks of the
President's time would be devoted to health care,.beginning jiist before the President's Joint
Session health care speech on September 22.
Open to all Members! of Congress, a "Health Care University "/took place on September 20
and 21. Oyer 40 experts, including the First Lady, briefed Members of Congress on health
reform and the President's plan.! Attended by. both Democrat
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university garnered Republican praiise. • House Minority;Leader Bob. Michel called it "very; , .
very productive and unique...on this issue;; we can defimtely-W
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The following day / . September, 22 . President GHntopldelivfe^
reform speech to the Joint Sessipm of Congress. ^ 1 ^
goals for health reform, themes that had become so f i i m l m r ^ ^
simplicity, choice, and responsibility.. These! pririeiples
but the President invited die American people anditiie/.Cb^
'arid critique the:details.
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His speech was a hit. According to USA Today; ."Lawmakers:of both parties praised'Clinton' ;'
for tackling the issue and his persuasive, determined' tone^M drhe;B6ston Globe reported that
"Clinton went out of his way to frnd Cphimdn gr6rind -wiffi
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both former President Richard M. Nixoft and Reagan-era srirgebn general C..Everett^
as ;
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Inspiration for ekments of his' planl p p ' ' ' . ^ ^ m ^ t ^ y ^ ; y r y ' ^ '
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During the week following the speech. White ''House'''of^fici^Siand; Cabinet Secretaries fanned but across the country in a series of ;meetirigs, 'speeches ; a ^
•
had started off successfully . In ai Washington Post- ABO News poll taken bri September; 23;;
56 percent of Americans said they approved of^Clinton's health plan: ;
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�According to the New York Times the President's plan was "alive on arrival". That
universal coverage would be achieved - - that all Americans would have health care that was
always there - - was a given. Democrats and Republicans alike realized early on that they
had better jump on the universal coverage bandwagon. It was widely believed that any bill
the Congress passed would have to get to universal coverage.
The Clinton plan would serve as the foundation for Congress' efforts - - the Committees
would work through the details - - how large the alliances would be, how generous the
benefits package, when universal coverage would be achieved, the exact mix of taxes and
spending cuts. Universal coverage was hot in question.
Opponents of reform - - insurers, the NFIB, restaurants, for-profit hospitals stepped up their
attacks, mounted their advertising campaigns, began coordinated grass roots lobbying efforts
- - all aimed at bringing down the Clinton plan! Supporters of reform - - the AARP, the
AFL-CIO, many provider groups and businesses and others - - also shared the view that
universal coverage was inevitable. The inevitability motivated opponents to focus their
attacks; it had the opposite impact on our supporters. Believing that universal coverage was ~
a foregone conclusion, our supporters spent their.time, trying to improve the bill in small
ways important to their constituencies.
Even those with different approaches used the Clinton plan as the basis for comparison
Representative Cooper termed.his own plan "Clinton Lite"; a "second cousin" of the Clinton'
plan. Senator Chafee spoke on Sunday talk shows of the "simiiarities in.our approaches",
and his optimism about achieving consensus. The! Wall Street Journal aiiid the New York
Times ran articles about possible minor modifications to the President's plan to get to a final
deal.
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The President's appearances;were followed by ia sucee^
Congress by
the First Lady...\- Hillary Clinton spent the week testifying ! before, the. I louse Ways; and Means•
Committee, the House Eriergy arid Commerce Committee, the Senate Firiance Committee, .;
and the Senate Educ^ibri arid !^b6r ;Cbri
often antagonistic (questions, the Fhst I^dy impressed!.legis^ with.her savvy, arid,. ! ; ; ;
expertise. Representative Dan Rostenkowski, then^chair of^ the Ways and Means Comriiittee,'
told his fellow committee members that "if there was any doubt about whether the President
should have appointed her, there's no doubt about it^ariy: lohger.;p-:'; !!
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Her mere appeariance on Capitol Hill!was unusual: -she is the ihifcliFirst liady,""preceded by ;
Eleanor Roosevelt and Rbsalyn Carter;! to eyesr. testify !bCfbre. a corigressioria;! comrriittee . The
uniqueness of .her testimony especiaUy^intrigueddie niedia: The Washington Post proclaiiried
that "overnight, Hiilary Clinton's activism updated the! First Lady's ;role;to one that •many-.;.'
women believe more accurately' reflects-"the: status' pfrWQmehCin''-.>^en(£.'todky. "•.'' ThefNew.- s'
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�York Times announced "the end of the era in which Presidential wives pretended to know
less than they did and to be advising less than they were."
The New York Times described the Clinton's "elegant tango pn health care, keeping control
of the debate defining the details before opponents can."
Meetings with doctors, including a supportive C. Everett Koop, the Health Care University,
the President's September 22 speech, his town hall meeting in Tampa, and the First Lady's
testimony before the. Congress were all met positively by the Congress and across the ,
country. At last, the White House was coasting on the previously elusive momentum that
was so vital to the success of health care reform.
However, such clear sailing was short-lived. A series of foreign policy crises commanded
the attention of the President and the media, and prevented the President from concentrating,
on health policy until mid-December. On October 3rd, twelve American soldiers were killed
and fifteen wounded in skirmishes with supporters of General Aidid in Somalia. The
President learned of this on the plane to California, where he was scheduled to kick off a
month of health care events. This foreign policy crisis curtailed the California trip and led to
the cancellation of subsequent Presidential health events.
Four days later, the President announced that he would sent 1,700 reinforcement troops to .
Somalia. The international crises continued: on October 11th, Haitian demonstrators
. prevented American ind Canadian peacekeeping troops from landing in Port-au^Prihce, and
V / on October 19th, the United Nations.resumed it soil and arms embargo against Haiti^
'. '"• \.
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, : care.was w h i ^
one day -Vthe event in l a t e - O c t o b e r ^ v
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'. :;''I'vi • A storiCS Critical of theliealth plan gerieriated by one interest'gfpupi'or'another;" The HIAA" ,;'' ' •;•[',
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-, ;. ; funnelled $10 million: in a negative television advertising campaign, and their ^unanswered *!
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attacks proliferated'arid filled the airwaves. Other pppositipn grPupsimitiated'a
•:...
•:' ;.v.:vd^
of thousarids pf.i^encans warning:them of
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.: . the evils;of ^sCl.intdri;health care plan..
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legislatiyeV;; V;••'} o. :
. v? battle,; including every'previous attemptrat.health reform, has met with.opposition, :nowhere :; -• •
, r.';- t ' i n the histpry•.•6f this'Country, is there X precederit'for the level pf^'misihfomation spread, -, ' ..'!,.'
/ -••:<;pduririg:the health; debate,'nor fot.thela^
it. The Arineriberg
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studies ori thisfphenpmena, and their
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a follows: • The Health care debate;has generated "the largest;.... '.:
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•most sustained .advertising campaign-to shapea public polipyi decision 'inthe/hist6tyof'l.he :
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Public Policy Center. 7/25/94]
The first of three studies conducted by Annenberg concluded that "an unprecedented amount
of money ($50 million) had been committed to produce, air and print an unprecedented
amount of ads whose prime purpose was influencing reporters and legislators rather than the
public as a whole. (This conclusion was deduced from the fact that the ads were
concentrated in New York and D.C.) Focusing on the lawmaker and pundit audiences paid
Off, as those who make the laws, those who report on it, and those who offer commentary all
began to fear that they would no longer be able to see their own doctor. I personally was
called aside by worried television anchors, newspaper editors and others who asked if their
brother the specialist was really going to have to go out of business, if they were going to
have to wait in line at a clinic called the DC alliance, ...
And according to Annenberg, the press did not help to clarify fact from fiction: the press
coverage of the ads had focused not on their fairness or accuracy but on "describing them
and mapping their strategies." [The Role of Advertising in the Health Care Reform Debate,
The Annenberg Public Policy Center. 7/25/941
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The study also , indicated that the majority of the ads had opposed rather than favored some
facet of reform with more ads explicitly objecting to the Clinton plan than supporting it.
This study analyzed 198 ads - 125. print and 73 broadcast and. found 28% and 59%,
respectively, to be misleading. Moreover, these ads were found to reflect the claims made
by their sponsors and/or to invite negative inferences rather than just misstate facts; A large
percentage of the ads were also found to "impugn the good will and integrity of those on the
other side of the issue." Arid finally it was found that the "most histribnic arid demonstrably -:
false assertions occur...in direct mail addressed to older Americans.", '
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Not only were the ads' negative, they were scary. • • Health care-is air •extremely; Iperepnal^lssuevfc
one. people Conriect with more deeply and directly -than soriiethirig like trade policy\br
^deficitp.;.,
reduction^ Eyeri thb'se . supportive of a major overhaul were also ''aiiixious •abp'ut'losmg(wiiai' -! . X'. •->'/.
, they themselves;had, so ad campaigns took directNairn' at exploiting/the• seris'e .diiat 'pboipie'v. y; 7 ,/v'.
\ would lose everything they now knew and liked about^ their health/insurance. "The hds.dre
more likely, to provoke anxiety than to provide reassurance.: Fear is ihe primary motivator in
• ads oh all sides.". [The Role of Advertising in the Health Care Refonri Debate^ The ; p . : .
f Annenberg Public Policy Ceriter.. 7/25/941
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�In late-December, the Administration made an effort to reinvigorate the political and
communications effort. But no sooner did this effort kick off than the Whitewater and
Arkansas trooper allegations sprung up. The attacks were venomous and personal, and they
took aim at the core ingredient needed for public support of reform, trust in the President
and First Lady. To diminish public trust in the reformers was to effectively raise fears about
reform - as Rush Limbaugh so boldly put it in his appearance on Nightline: "Whitewater is
about health care."
!
The Administration had formally passed the health care baton to the Congress, but
unforeseen events in both bodies also changed the dynamic on the Hill. Senate Majority
Leader George Mitchell unexpectedly announced his plan to retire after this term. The
powerful chairman of the House Ways and Means Committee, Dan Rbstenkowski, was
charged with criminal misconduct, and forced to resign his chairmanship. If someone had
asked our strongest opponents to make a "wish list" -for helping them defeat health reform, it
could have read: "Undermine the trust and credibility of the President and First Lady, and
knock out the two most powerful consensus builders in both houses of Congress.
Misconceptions about the President's plan had by,this point become widely accepted and
many ordinary Americans reacted with a mixture of fear arid .anger oyer what they were sure
we proposed to do to their health care. At town hall meetings I attended, angry, people
would state their vociferous opposition to the Clinton plan.; I would ask why they were
against it. They would respond that the plan would have, the government taking over arid
running all the hospitals in the country. I would reply:that this was nbt what the plari said.
The questioner would shout back that I was lying arid-;waye a mailing he had received; from
some group • asserting it. • • Another favorite' mi^^ra^erizaiionl was'ithai people - would not be
permitted to see their own doctor outside the health plan ap^rdyedjby-the^gdvernm^ and that if they did so, they and their doctors Could:gq;to;^
ridicuibus// . .
The Wall Street Jourrial article detailing the false ^dyertis^
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if you buy extra health care", as; the
direct-mailpackage it has sent;^
an anti-bribery jprpvision in the Glintpn proposal; the bill-explicitly says that people
are free to purchase "any health care services" they want out of their own pockets. " I ••••;,
don't see anybody going to jaiFpri>a Hyer,tram^
president -.at'lieaith- consulting *firmLewin-VHI; ;Inc. • "fhey'retryirig to scare litae.jC)id.:.v..C'.--i'• • ';- ;
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;d by Washirijgton-pundits,;magazine and newspaper
columnists and at almost every town hall riiceting Lattended. •;•'::; p p . •;.
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�Public Support
The opponents were successful. Despite high and consistent support for all the major
elements of the Administration's proposal, support for anything labelled the Clinton Plan
declined dramatically since September of 1993. This was best captured in a Waif Street
Journal ;article that was title "Many Don't Realize It's the Clinton Plan They Like". The
Clinton plan, when described without the label was viewed favorable by 76 percent of those
surveyed, versus 48 percent for the original Chafee plan, 42 percent for the Gramm plan, 34
, percent for the Cooper bill and 30 percent for the McDermott bill.
Consistently, when labels are removed from plans and their essence is described to the public
in polls or focus groups, the Clinton plan wins far and away the most support as delivering
what Americans want in the way they want.
PARTISAN GRIDLOCK
Finally, the decline in presidential popularity and the battering, taken by the plan itself led
Republican leaders to conclude that they could effectively stonewall on health care and hand
the President a major political defeat.
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While minority-leader-in waiting Gingrich had been urging and enforcing an obstructionist .
path in the House from the beginning. Senator Dole went back and forth, alternatively
. " speaking constructively abcnit achieving Universal cbVerage,:the President's bottom'line, and
at other times declaring that there was no health care; crisis and that we should do nothing..
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. '. "A for;itthey did not, they could potentiaily gaiii sighificaftdy-at the m
In aV
; June '7;i^mCmb,; Republican strategist Bill Kristol.urged republicans)to reje
a; ;"•'• \
; watered down billrthat would allow the President to honor- his veto-pledge, since it would v .
• . '' ^'protect. ^•'Pxesidgnt's 'read- my lips', pledge on health cafe." ' By I July,, Kristol's advice was :
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health (toe heg^
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- ;-.'.;;•;, aliernatiye that, pimpcrdts offer and insist on starting over in '95:We should send them to
• . . .. . the voters empty-handed." .
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the crime bill ihythe Spring andvtheii they tried to kili^it in i
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turned very ^partisan. ^ • • - r
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Supported which .moved far in the direction of Republica.n "v j-. . -;
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��LM DRAFT #3 —
9/1/94 Noon
IRA C. MAGAZINER
REMARKS TO THE AMERICAN POLITICAL SCIENCE ASSOCIATION
NEW YORK CITY
SEPTEMBER 1, 1994
Today we f i n d ourselves i n a great — y e t s t i l l u n f i n i s h e d - chapter o f American p o l i t i c a l and s o c i a l h i s t o r y . Great because
for the f i r s t time i n decades we have s e t i n motion a process f o r
d e a l i n g w i t h one of the most i n t r a c t a b l e s o c i a l and economic
problems o f our time — a health care system t h a t i s out o f reach
f o r m i l l i o n s o f Americans and too c o s t l y f o r our n a t i o n .
Unfinished because Congress has not y e t w r i t t e n the f i n a l words
of t h e t e x t .
As you know, the d a i l y accounts we read on issues l i k e
h e a l t h care reform are merely f i r s t d r a f t s of h i s t o r y . Over time,
those i n t e r p r e t a t i o n s are r e v i s i t e d by scholars l i k e you, who
b r i n g t h e i r own t h e o r e t i c a l and h i s t o r i c a l perspectives t o bear.
Analyzing health care reform i s a l l the more d i f f i c u l t r i g h t
now because the process i s f a r from over. So my perspective, l i k e
the perspectives of other i n s i d e r s and j o u r n a l i s t s and p o l i t i c a l
commentators, i s based on current and f l u i d events t h a t can
change from day t o day and month t o month. But h o p e f u l l y I can
o f f e r some u s e f u l i n s i g h t s i n t o the h e a l t h care reform process
t h a t has engaged the C l i n t o n A d m i n i s t r a t i o n and Congres^
much
s
of t h e l a s t year.
7p\
B i l l C l i n t o n remains committed t o reform today f o r t h e same
two reasons he o u t l i n e d when he ran f o r t h e Presidency!: F i r s t ,
because the h e a l t h of tens of m i l l i o n s o f Americans — both
uninsured and insured — was a t r i s k and i s a t r i s k i n t h e
_current_system. And second, because there i s no way toi r e s t o r e ^
-rrcnr-economy without doing something about r i s i n g health care
~
costs.
Every day, the health care p i c t u r e gets worse. On any given
day, close t o 40 m i l l i o n Americans — most of them working people
— lack insurance. M i l l i o n s are locked i n jobs they couldn't
leave f o r f e a r o f losing t h e i r insurance. Families can't get
coverage because of " p r e - e x i s t i n g c o n d i t i o n s " and other forms of
insurance d i s c r i m i n a t i o n . Small businesses face health care
premiums 3 5 percent higher than those o f large corporations —
and p r o j e c t e d t o grow a t d o u b l e - d i g i t r a t e s .
And t h e r e i s l i t t l e hope o f reducing the d e f i c i t when health
care expenditures consumed about 14 percent o f our n a t i o n a l
�income. By the year 2000, the f i g u r e would be c l o s e r t o 20
percent. Month a f t e r month, year a f t e r year, h e a l t h care costs
are f u r t h e r eroding our savings, our investment c a p i t a l , our
a b i l i t y t o c r e a t e new jobs i n the p r i v a t e s e c t o r and the public
t r e a s u r y . And given the immensity of the d e f i c i t , there i s no
hope of r e s t o r i n g economic growth or r e i n i n g i n h e a l t h care costs
simply by chipping away a t Medicare and Medicaid.
So t h e question the new P r e s i d e n t faced upon h i s
inauguration 20 months ago was t h i s : How do you solve a problem
of t h i s magnitude, of t h i s complexity, of t h i s urgency, when no
P r e s i d e n t , Republican or Democrat, has managed t o do i t i n 60
years?
Many people advised President C l i n t o n t h a t i t was too
p o l i t i c a l l y r i s k y to t a c k l e h e a l t h care reform. I t couldn't be
done, they s a i d , because of the a r r a y of s p e c i a l i n t e r e s t s
p o s i t i o n e d to stop i t — s p e c i a l i n t e r e s t s that had spent
m i l l i o n s and m i l l i o n s of d o l l a r s to stymie the e f f o r t s of
P r e s i d e n t s Truman and Kennedy and Nixon and C a r t e r before him.
But t h e American people demanded reform. The economy
demanded i t . And — to use a f o o t b a l l metaphor, s i n c e f o o t b a l l
season i s now upon us — the President was not about t o punt on
such a c r i t i c a l and momentous i s s u e .
Health care reform was simply the r i g h t thing t o do
s o c i a l l y , economically, and morally. That's why the President
took on t h i s mammoth challenge, and s e t i n motion t h i s h i s t o r i c
process, r e g a r d l e s s of the p o l i t i c a l r i s k . That's why he i s
s t i c k i n g t o i t , and why he w i l l keep f i g h t i n g for reform u n t i l i t
i s achieved.
Throughout the process the P r e s i d e n t ' s goal has been
twofold: t o achieve u n i v e r s a l coverage and t o c o n t r o l h e a l t h care
c o s t s w h i l e s t i l l preserving q u a l i t y . U n i v e r s a l coverage and cost
containment sometimes are viewed as c o n t r a d i c t o r y , when i n f a c t
they go hand-in-hand. C o u n t e r - i n t u i t i v e a s i t may seem, you can't
reduce t h e burdens on business and government and i n d i v i d u a l
f a m i l i e s u n t i l there i s no more cost s h i f t i n g t o compensate for
the h e a l t h care of m i l l i o n s who are un- or under-insured.
The r e a l i t y i s t h a t people who don't have insurance s t i l l
get h e a l t h care. They j u s t get i t when i t ' s too l a t e , too
expensive, and often from the most expensive source of a l l , the
emergency room. The r e s u l t i s that the r e s t of us end up footing
the b i l l through higher h o s p i t a l b i l l s and higher insurance
premiums.
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When t h e President's plan was f i r s t presented l a s t year,
v i r t u a l l y a l l Democrats and moderate Republicans supported the
goal of u n i v e r s a l coverage. And v i r t u a l l y a l l the comprehensive
\
�h e a l t h c a r e b i l l s subsequently s u b m i t t e d by Democrats
moderate Republicans i n c l u d e d c o s t c o n t a i n m e n t .
and
There were o n l y t h r e e ways t o go about u n i v e r s a l coverage,
a l l o f which have been debated by p o l i t i c i a n s , economists, and
p o l i c y e x p e r t s f o r y e a r s . One was a s i n g l e payer approach t h a t
would r e p l a c e today's employer-based system w i t h a broad-based
income, p a y r o l l o r value-added t a x . I t would r e q u i r e about t h r e e
t o f o u r hundred b i l l i o n d o l l a r s o f new f e d e r a l t a x e s each y e a r , a
political implausibility.
A second approach was t o r e q u i r e a l l i n d i v i d u a l s t o buy
h e a l t h i n s u r a n c e , t h e same method many s t a t e s use w i t h a u t o
i n s u r a n c e t o d a y . The down s i d e o f t h a t method was t h a t employers
m i g h t be i n c l i n e d t o stop c o v e r i n g t h e i r w o r k e r s , t h a t more and
more i n d i v i d u a l s would need government s u b s i d i e s t o h e l p pay f o r
t h e i r premiums, and new taxes and a new a d m i n i s t r a t i v e
bureaucracy would r e s u l t . More i m p o r t a n t , t h e p u b l i c opposed i t .
The t h i r d o p t i o n — t h e approach t h e P r e s i d e n t chose —
was
t o e x t e n d t h e system t h a t 90 p e r c e n t o f i n s u r e d Americans a l r e a d y
used. The employer mandate seemed t o be t h e l e a s t d i s r u p t i v e ,
most c o n s e r v a t i v e o p t i o n a v a i l a b l e . And, once a g a i n , i t was an
o p t i o n embraced by groups across t h e p o l i t i c a l spectrum — groups
t h a t had s t u d i e d t h e issue more c l o s e l y t h a n anyone e l s e because
t h e y were t h e most d i r e c t l y a f f e c t e d by i t : t h e American M e d i c a l
A s s o c i a t i o n , t h e H e a l t h Insurance I n d u s t r y A s s o c i a t i o n o f
American, many l a b o r u n i o n s , t h e Jackson Hole group, t h e Chamber
o f Commerce and o t h e r business groups, and a n a t i o n a l c o a l i t i o n
on h e a l t h c a r e r e f o r m c o - c h a i r e d by f o r m e r P r e s i d e n t s C a r t e r and
Ford.
I n f a c t , the President's proposal f o r achieving u n i v e r s a l
coverage t h r o u g h an employer mandate was f i r s t proposed by
P r e s i d e n t Nixon more t h a n two decades ago.
Cost c o n t a i n m e n t was an e q u a l l y i m p o r t a n t p a r t o f t h e
P r e s i d e n t ' s e q u a t i o n . Cost containment i s e s s e n t i a l i f you want
f a m i l i e s and businesses t o be a b l e t o a f f o r d h e a l t h c a r e , and i f
you want t o c o n t r o l f e d e r a l spending.
But as w i t h u n i v e r s a l coverage, t h e r e were o n l y a few ways
t o g e t c o s t s under c o n t r o l .
One o p t i o n was t o have t h e government d i r e c t l y s e t t h e p r i c e
f o r goods and s e r v i c e s d e l i v e r e d i n t h e h e a l t h care s e c t o r , o r
s e t c e i l i n g s on t h e t o t a l amount t h e n a t i o n would spend on h e a l t h
c a r e . But h a v i n g t h e government i n v o l v e d i n e v e r y h e a l t h c a r e
t r a n s a c t i o n seemed way t o o b u r e a u c r a t i c .
Some advocates supported t h e i d e a o f " t a x caps" t o c o n t a i n
h e a l t h c a r e spending — l i m i t s on t h e t a x d e d u c t i b i l i t y o f h e a l t h
�spending by companies. The President r e j e c t e d t h a t approach
because i t would r a i s e taxes on middle-class f a m i l i e s .
The President's plan r e l i e d on c r e a t i n g a more competitive
market and a more cost-conscious consumer t o c o n t r o l c o s t s . As a
back-up, the President proposed premium caps t o l i m i t the amount
insurance premiums could be r a i s e d i f market forces d i d not
succeed i n keeping p r i c e s down. This approach was borrowed
d i r e c t l y from a b i l l put f o r t h by Republican Senators Danforth
and Kassebaum and moderate Democratic Representatives McCurdy and
Glickman.
As you examine the main elements of the President's plan you
w i l l f i n d t h a t the bulk of ideas he proposed were gleaned from
members of both p a r t i e s , from l i b e r a l s and conservatives and
moderates a l i k e . And i n many cases, the proposals already had
been tested s u c c e s s f u l l y a t the state l e v e l .
Perhaps no idea occasioned as much debate i n i t i a l l y as
mandatory a l l i a n c e s . The idea behind a l l i a n c e s was t o pool the
purchasing of workers i n f i r m s w i t h fewer than 5,000 employees,
government employees. Medicaid b e n e f i c i a r i e s , nonworkers and
r e t i r e e s . Through these pools, community r a t i n g could be e a s i l y
enforced, f a m i l i e s would have a wide array of plans t o choose
from, and f a m i l i e s and businesses would have the maximum
bargaining leverage t o get a f f o r d a b l e prices.
The idea f o r these a l l i a n c e s came from the Jackson Hole
group, which advocated managed competition, and from l e g i s l a t i o n
sponsored i n 1992 by Representatives Cooper and Andrews and
Senators Boren and Breaux.
Other provisions such as the long-term care b e n e f i t ,
p r e s c r i p t i o n drugs f o r Medicare r e c i p i e n t s , a focus on primary
care, funding f o r academic h e a l t h centers, improvements i n r u r a l
and urban health care i n f r a s t r u c t u r e s , and some p u b l i c h e a l t h
i n i t i a t i v e s were also included i n Republican h e a l t h reform
proposals.
So i f you compare the President's approach t o some of the
o p t i o n s a t hand, you w i l l see t h a t — i n case a f t e r case — h i s
p l a n was fundamentally reasonable, moderate, and i n l i n e w i t h
what mainstream Americans wanted then and s t i l l want now.
Yet while the b i l l ' s p r o v i s i o n s r e f l e c t e d the p o l i t i c a l
center, the size and d e t a i l of the document generated c r i t i c i s m
from opponents t h a t i t was a bureaucratic form of s o c i a l
engineering and an example of " b i g government."
Health care i s a very complex subject and, l i k e most major
pieces of l e g i s l a t i o n , a b i l l t o reform the h e a l t h care system i s
never going t o make f o r l i g h t beach reading. Our goal was t o
�provide enough d e t a i l and explanation of how the money would
a c t u a l l y flow t o s a t i s f y the Congressional leadership. We f e l t
t h a t i n t r o d u c i n g a skeleton b i l l would be i r r e s p o n s i b l e t o the
p u b l i c and the experts.
I t ' s worth noting t h a t other h e a l t h care b i l l s c i r c u l a t i n g
on t h e H i l l have ranged from 650 pages t o w e l l over 1,000 pages.
The crime b i l l t h a t passed two weeks ago was as long as most of
the h e a l t h care l e g i s l a t i o n and NAFTA was l i t e r a l l y thousands of
pages. Yet only our b i l l was the only one branded as "too
complex" because of i t s d e t a i l .
^
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Another misperception i s t h a t the formation of Jthe
President's health reform p o l i c y was done i n s e c r e t . j l n f a c t , i t
was among the most open processes ever conducted i n an
Administration.
To meet an aggressive timetable, we established a process
f o r making p o l i c y t h a t was unconventional f o r Washington,
borrowed from p r i v a t e sector models f o r conducting b i g projects
i n a s h o r t time frame. We cast a wide net f o r p a r t i c i p a n t s .
There were serious consultations w i t h hundreds of Americans
from a l l walks of l i f e : Physicians, nurses, s o c i a l workers,
h o s p i t a l a d m i n i s t r a t o r s , benefits c o n s u l t a n t s and managers,
consumers, businesspeople, actuaries and accountants, health
lawyers, and many others. .
J
The task force met w i t h more t h
erest groups.^/ V^jCf
±rivoi-ved~~mOre
h e l d d a i l y meeting w i t h members of C
ies i n the workin
than 120 Congressional s t a f f e r s from
groups. During the 14 months between February of 1993 and t h i s
past A p r i l , the F i r s t Lady held 23 p u b l i c hearings and town
meetings across the country.
By May, review groups composed of h e a l t h care providers,
consumers, a u d i t o r s , actuaries, h o s p i t a l and insurance
a d m i n i s t r a t o r s , and lawyers responded t o ideas t h a t had been
proposed by d i f f e r e n t working groups.
The whole process resulted i n an amazing amount of work
completed i n a very short amount of time. We succeeded i n meeting
a very t i g h t deadline.
Has i t been a flawless operation? Of course not. We see t h a t
even more c l e a r l y i n hindsight. While the task force was ready t o
move forward a t the end of May, we encountered some unforeseen
o b s t a c l e s , some avoidable, some not.
We were ready to deliver the b i l l i n the f i r s t 100 days,
j u s t as the President had pledged we would do. But then we found
ourselves captives of a l e g i s l a t i v e calendar that interrupted our
�timetable on reform and cost us momentum.
During A p r i l and May of l a s t year, the task force met 21
times to f i n a l i z e decisions with the President. But after the
defeat of the economic stimulus package, i t became clear to
everyone that the introduction of health care reform should be
delayed u n t i l passage of the economic package-w^s assured. There
was concern that members of Congress might^fcfage^Vetea on the
mire- package__for concessions on health c a ^ j For example,
when word leaked out — erroneously —
aboutaTreasury
Department analysis of health care financing that included a tax
on wine and beer, the California delegation immediately sent a
^letter of complaint to the White House and some members privately
threatened to withhold support for the economic package.
Mth
thft-^frnrronTi r; pa<-.k-agp s r a i i p r i , rhP
i nrrnmir-.r i nn
nf
health care was delayed from early June, to late June, to mid
July, to late July, and f i n a l l y to late September. The
l e g i s l a t i o n f i n a l l y was submitted in late October instead of in
late May. Attention was further diverted from health care because
of the debate over NAFTA and the c r i s i s in Somalia, both of which
dominated the White House and Congress during the weeks after the
President's b i l l was introduced.
There wasn't much we could do about the calendar. But we
could have done things differently in terms of the press. From
the outset, we should have done a better job of informing the
press about the process. That way we could have avoided
perceptions that the deliberations were cloaked in secrecy, and
we could have helped the news media develop a better
understanding of reform as the debate evolved.
These problems notwithstanding, when the plan was introduced
in the f a l l i t was greeted very enthusiastically. The President
was applauded for offering a clear and persuasive enunciation of
his goals to Congress and the nation. Polls showed broad support
for h i s goals. The New York Times went as far as to term the
President's b i l l "alive on a r r i v a l . "
Then the interest groups took over the debate.
That was perhaps the biggest single obstacle we faced then
and s t i l l face today as we try to move forward with reform.
Several recent studies have documented the amount of money spent
on advertising and lobbying to influence the outcome of the
health care debate. Every major l e g i s l a t i v e battle — from the
New Deal to S o ^ i a l S e c u r i t y to C i v i l Rights — has met with
opposition. Bdt nev^r in the history of this country has there
been the same degr&p/ of misinformation spread as has been spread
during t h i s 7Fi&€t4£n<care debate. And never has there been such an
extraordinary a/nount of money spent on disseminating that
misinformation.
�The Annenberg Public Policy Center studied this phenomenon
and concluded that the health care debate has generated "the
largest, most sustained advertising campaign to shape a public
policy decision in the history of the Republic."
Over $100 million has been spent overall to influence the
outcome. One study found that $50 million largely to influence
reporters and l e g i s l a t o r s rather than the public as a whole. And
these figures don't capture direct mail and phone bank efforts
financed by opponents.
Whatever your view of health care reform, i f you've seen the
now famous — or infamous — ads you know that they are not only
negative, they're downright scary.
In fact, they were so distorted that the Wall Street Journal
ran a story about the misinformation campaign under the headline
"Truth Lands In Intensive Care Unit."
The a r t i c l e began:
The baby's scream i s anguished, the mother' voice desperate.
"Please," she pleads into the phone as she seeks help for her
sick c h i l d .
"We're sorry, the government health center i s closed now,"
says the recording on the other end of the l i n e . "However, i f
t h i s i s an emergency, you may c a l l 1-800-GOVERNMENT." Her baby
s t i l l wailing, she t r i e s i t , only to be greeted by another
recording: "We're sorry, a l l health care representatives are busy
now. Please stay on the line and our f i r s t available . . . ."
"Why did they l e t the government take over?" she asks
p l a i n t i v e l y . " I need my family doctor back.
The story goes on to say: The only problem with the radio
spot, produced by a Washington-based group c a l l e d Americans for
Tax Reform, i s that i t i s n ' t true. [WSJ, 4/29/94]
Misconceptions about the President's plan were continually
fueled by t h i s type of fearmongering. At town h a l l meetings I
attended, angry people would shout their opposition to the
Clinton plan. I'd ask why there were against i t . They would talk
about government taking over and running a l l the hospitals. Or
they would t a l k about how people wouldn't be allowed to see their
own doctor outside the health plan approved by the government and
that, i f they did, the doctors could go to j a i l . I'd explain that
these were not elements the plan. But the questioner invariably
would should back that I was lying and wave a mailing he had
received from some group asserting one or another of these points
as f a c t .
�I n another story, the Wall S t r e e t Journal s a i d t h a t "another
of the big canards about the C l i n t o n plan i s that people face '5
y e a r s i n j a i l i f you buy extra h e a l t h c a r e . ' " The story was
r e f e r r i n g to a d i r e c t mail package sent to m i l l i o n s of Americans
by the American Council for Health Reform. The story explained
t h a t t h e r e was an a n t i - b r i b e r y p r o v i s i o n i n the C l i n t o n proposal
but t h a t the b i l l e x p l i c i t l y stated people were free to purchase
any h e a l t h care s e r v i c e s they wanted.
I point out the degree of misinformation because these
a d v e r t i s i n g campaigns d i s t o r t e d the President's plan i n t o some
r a d i c a l , wild-eyed attempt to revamp our health system. I n f a c t ,
as I mentioned e a r l i e r , the main elements he proposed were^etti±et| "
from Republicans and Democrats a l i k e — most of whom could be
rfsyo*-*^
d e s c r i b e d as p o l i t i c a l moderates. U n i v e r s a l coverage, employer
mandates, and premium caps are about as mainstream and
c o n s e r v a t i v e an approach to health care as you can get. And these
p r o v i s i o n s were p r e c i s e l y the ones favored by most Americans even
though, as a Wall S t r e e t Journal headline noted, "Many Don't
R e a l i z e I t ' s the Clinton Plan They L i k e . "
That's why I b e l i e v e that, even though the i n t e r e s t groups
have been s u c c e s s f u l and remain our biggest obstacle as we move
forward, the process i s going to succeed.
The American people have s a i d what they want — and they
have s a i d how they want to pay for i t . And they've been very
c o n s i s t e n t i n t h e i r views.
A r e c e n t Washington Post/ABC p o l l showed that 77 percent
favored u n i v e r s a l coverage, 72 percent favor an employer mandate,
and 75 percent favor government c o s t c o n t r o l s . Even more, 80
p e r c e n t , support a tobacco tax.
With t h a t kind of support, these ideas and proposals are
going to disappear and be forgotten by the p u b l i c .
not
Another thing worth remembering about t h i s process i s t h a t
the P r e s i d e n t never expected h i s plan to be the f i n a l v e r s i o n
adopted by Congress. He has always s t a t e d very c l e a r l y t h a t h i s
bottom l i n e was u n i v e r s a l coverage but he knew h i s plan would be
r e w r i t t e n . I n f a c t , two House and two Senate committees wrote
t h e i r own b i l l s . Was that a f a i l u r e on the part of the President?
Not a t a l l . I t was part of the l e g i s l a t i v e process he envisioned
a l l along.
So where are we today, nearly 20 months a f t e r the process
began?
We are on the path to r e s t o r i n g the economy and f u l f i l l i n g
the P r e s i d e n t ' s broader agenda. And u l t i m a t e l y h i s t o r y w i l l show
t h a t t h i s was a time of great ferment and energy when t h i s
8
�President launched a process t h a t led us t o solve the h e a l t h care
problem once and f o r a l l .
So, w h i l e we s t i l l have f u r t h e r t o go, we w i l l get there.
The business of h e a l t h care reform i s not y e t over.
Thank you very much.
�]
IRA C. MAGAZINER
REMARKS TO THE AMERICAN,POLITICAL SCIENCE ASSOCIATION
NEW YORK CITY
SEPTEMBER 1 , 1994
Today we f i n d ourselves i n a great ~ y e t s t i l l unfinished - chapter of American p o l i t i c a l and s o c i a l h i s t o r y . GreaJ;because
f o r the f i r s t time i n decades we are addressing one. of thejmost
i n t r a c t a b l e s o c i a l and economic problems of our time - r a healtn
care system t h a t i s out of reach f o r m i l l i o n s of Americans, and
too c o s t l y f o r our nation. Unfinished because Congress has not
yet w r i t t e n the f i n a l words of the t e x t .
As you know, the d a i l y accounts, we read on issues l i k e
h e a l t h care reform- are merely f i r s t , d r a f t s of h i s t o r y . Over time,
those i n t e r p r e t a t i o n s are r e v i s i t e d by scholars l i k e you, who
b r i n g t h e i r own t h e o r e t i c a l and h i s t o r i c a l perspectives t o bear.
• Analyzing health care.reform is all the more- difficult right
now because the process is far from over., SO: my perspective,,liHe
the perspectives of other insiders and journalists and. political .;
• commentators, is based: on current and fluid events thjt. can •..
change from day t o day ,and month to.month. But-hopefully 1;can
^
o f f e r some u s e f u l i n s i g h t s i n t o the health,care reform; process ^
•. t h a t has engaged t h e - C l i n t o n A d m i n i s t r a t i o n , a n d , p o n g p s ^ o r ^ u p n - .
•:: .,;6f t h e ^ i a ^ t ; year... •
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' ' Presidency:: F i r s t , because the ; h e a l t h ^ f tens .of m l l l i o n s ^ o f ; • _ '
A m e r i c a n s — both uninsured^ and. insured ---/Was, a t ^ri^lt. a n c l / a t ,
• r i s k i n ^th^ - current/system v f And^ecorid /-/because; .^hf p j ^ n ? ^ay ;. •:
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labk'Insurance. M i l l i o n s , are locked/In 'jobs; they;;couldn^t ; :
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leave/for fear of losing t h e i r insurance, F a m i l i ^
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. • coverage.: because: of-"pre-existing conditions^and o^erv?€orms, of ,.. ^ ,,
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z'':• .-premiums/ 35 percent hie
. and/those premiums are
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�are further eroding our savings, our investment capital, our
public treasury, our.ability to create hew jobs in the private
sector. And we cannot, take full advantage of the progress this
President is making in restoring.the economy if we attempt to
reduce health care costs simply by.-ichipping- away at Medicare and
Medicaid.
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/ So the question President; c i i n t o h . faced upon h i s
inauguration 20 months ago:was t h i s : : How do you solve a problem
of t h i s magnitudey . of .this.complexity , of t h i s urgency , when no
President, Republican or Democrat, .has managed t o do i t i n '60
years?
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•-' Many people advised President C l i n t o n t h a t i t was t o o
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p o l i t i c a l l y r i s k y : t o t a c k l e h e a l t h care r e f o r ^ I t couldn't be
done, they s a i d , because of t h e array b
i n t e r e s t s \;
. p o s i t i o n e d / t o stop i t — : special;, interests, t h a t : had:• spent •
'•; m i l l i o n s and - mi 11 ions o f dol i a r s t b . ^
e f f o r t s o f . _.
•
•
.
v Presidents Truman and. Kennedy:, and,iNixbh /andv.Cart.erv before him.; '•'/;T;
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v.-' took, ori this,. mammoth>;chai;i4ng'e;;:Vand^;s.et .^iri. m o t i b n . / t h i s r h i s t o r i c . : ' ;
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process i ^ r e g a r d l ^ s / p f ^ t l ^
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�hundred b i l l i o n d o l l a r s of new f e d e r a l taxes each year, a
p o l i t i c a l implausibility.
A second approach i s t o r e q u i r e a l l i n d i ^ i f ^ a S S S
uSe The employer mandate i s the l e a s t d i s r u p t i v e , most
cohservJtive,option a v a i l a b l e , i t was an o p t i o n embraced by
Jrross the p o l i t i c a l spectrum: the American Medical
Reform co-chaired by former Presidents Carter and Ford.
:
:
m f a c t 'the President's proposal f o r achieving universal,
- cover^e ?hrcu|h"an employer/.m^ate
f i r s t ; proposed by
? ? e s i d i n t Nixon more than two decades ago in^a b ! . ? ; ^ ^ ^
sShator Packwood, the ranking .Republican member o f the Senate
Finance * Committee • ,
^ i'-CyW'': v;';.^'; ^7,>i,-''LT.
••
Cost containment i s an equally important P j r t o r the
P r e s i d e r i t ' s ^ ^ a t i o r v - ;Cost,cpntai
^
^ff
f a S l i e ^ d ^ b u s i n e s s e s to- be-able t o a f f o r d h e a l t h care, and i f
you, want to; c o n t r o l , f e d e r a l spending.
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S S e : But having the government involved^; in- ;every h e a l t h care
' ; t r a n s a c t i o n . i s way too b u r e a u c r a t i c .
• T v ' ; i s o ^ ^ & e s . > ^ p | | M l i ? e a of ' ' ^ ^ S f b i U t ^ o f ^ a l t h
HO;, n-h care soendinq - - l i m i t s on^the t a x , d e d u c t i b i l i t y ot^neaitn
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ate
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p«mIuB caps i n Washington'and H^nesota.
/ • Perhaps no idea - - i o n e d ^ u c ^ d e ^ i n i t i a l l ^ a s
mandatory,alliances. T h e ^ f i r s t b a r r a g j
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f o r l i g h t : •\
to offers
�changes would work.
I t ' s worth noting t h a t many
vet the length of * e
_
reform measure^
i e g i s l a t i o n
c a r e
a r e
Preset's health^are^^
h e a l t h care.
How
^
we arrive at:the provisions o
:
m
:
> istable
a short tim.
....
and irom around the country.
invo
; grpu.
meetings
:Sl^|^;ke#i:daiM^^
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the -h.11.
«e established a process
h
n i
-one must address dozens
.
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of health
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to
withhold support for the economic package.
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With the economic package stalled^ the ^
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health care was delayed from early June, to^late June, ro mia
0
d
WMmMSmm
President's b i l l was introduced.
There wasn't much we could- do about the calendar. But we
I t t o u l l have helped the news nodia develop a better
understanding of reform as the debate evolved...
"
These problems notwithstanding, when^the - P ^ f
i i i was greeted, very :-enthusiast.icaiay;
^oam5: i b L l l i n f t o other approaches. ^ P ^ f
. ^ ^ J ?
r
P§°P^
o n
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q
. SL Mpw vork Times wdnt as f a r as :ta t e r t f ^ e .President s • b i l l
. " a 1 ive on arr i va 1.'!.
.
^ • •/
v
" " AS the President's plan generated e x c i t ^
reform? in^erel? group, who b L e f i t e d froxn the status. quo
mobilized their attacks.
• . .. . ;: .-;
:;
.
f o r
;
Powerful special interests are perhaps the * i ^ e s t ^ s i n g l e
.'i r -
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1
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;
�about health care reform. And never has there been such an
extraordinary amount of money spent on disseminating t h a t
misinformation.
;
The Annenberg Public Policy Center studied t h i s phenomenon
and concluded-that the health care debate has generated "the
l a r g e s t , most sustained a d v e r t i s i n g campaign t o shape a p u b l i c
p o l i c y d e c i s i o n , i n the h i s t o r y of t h e Republic."
Over $100 m i l l i o n .has been spent o v e r a l l t o influence the
outcome. One study found t h a t $50 m i l l i o n was spent., l a r g e l y t o
influence r e p o r t e r s and l e g i s l a t o r s r a t h e r than.the p u b l i c as a
whole. And these f i g u r e s don't capture d i r e c t mail and phone bank
e f f o r t s financed by opponents.
Whatever your view of health.care reform, i f you've seen or
heard t h e now famous
or infamous —• ads you know t h a t they are
not only negative, they're downright scary.
I n f a c t , they were so d i s t o r t e d t h a t t h e Wall Street Journal
rah a s t o r y about the misinformatipri'..campaign under t h e headline
"Truth Lands I n Intensive Care U n i t . " •
' •. • \
The a r t i c l e , began:.) . •. '
:
The baby's scream is) anguished, j the:mother's voice
, desperate. ? "Please," she pleads' i n t o ; the phohie as she seeks help ,
for.;her s i c k c h i I d .
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.;; says; the :'redording-vohr^^^
"iiAirowor- • A f •'. - '
•- th i s is; ian. /emergency,; - you.; may
stiiT'VwaXiin^^
, r.ecprding: ,.."We' re sorry, a l l health care representatives are busy
V " nbv/; ..Pleasei-V
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The story' goes' on ;to Vsay:; Th'ev or) 1 y., pr obi em-; with • the radio
spot, . produced,, by a Wash ingtprir-basisd group, c a l led;. Amer leans for
Tax Reform, . "is -thati i t i s n ' t true.: [WSJ,: ..^
v; '
:
: ' •/Clihtpn piah>: I 'd : ask/why- the^Cwer^a^'aLiri
; ^^i^ +-v,o- ^r^r-^^**.*\ri„r.
.-W^-
'•.
i Vi;^ fipspitais. '•
to se'ie •,. .
doctor : o\itside the; h e a l t h ;-pIan; apprdyed Viby^^the;;.
. •. .' ; , > ;;;
.goyernmentt and t h a t , i f • t h e y : & i d , ^ ^
: to j a i l i ' "' V.
in; thlat^this;;justvWa^n^trtruev)^
'/ .
;
;
:
;
�i n v a r i a b l y would shout back t h a t I was l y i n g and wave a " a i l i n g
^ had received from some group asserting one or another of these
• p o i n t s as f a c t . .
'
.
^
w n s t r e e t Journal said t h a t "another of t h e b i g
canards a l o u t t h e C l i n t o n plan i s t h a t people face '5 years i n
i a i l i f - you buy e x t r a , h e a l t h c a r e . T h e s t o r y a ^ d e d t o j i
d i r e c t mail package sent t o m i l l i o n s of Americans by t h e American
Council ?or SSalth Reform. The s t o r y explained t h a t this, penalty
r e S r ^ e d ?o an a n t i - b r i b e r y p r o v i s i o n vim the, C l i n t o n P ^ p p s a l
Snd- I n f a c t , : t h e President's b i l l e x p l i c i t l y s t a t e d that.people
were free, t o purchase any. health care services they wanted.
a
:
:
But these ads proved t h a t i t ' s always easier t o jake t h e
negative case r a t h e r than.the p o s i t i v e , more complicated case.
'
I p o i n t out t h e degree of misinformation because these ^
a d v e r t i s i n g campaigns d i s t o r t e d the. President's P l ^
J
^ :
r a d i c a i , - wiid-eyed dttempt t o revamp our h e a l t h system.^In f a c t ^
as I mentiorted e a r l i e r v the, main elements he P J P ° ^ . ^ ^ ^
.
from Republicans sand, Democrats a l i k e - most of whom could be
^described: as: political^moderates.\Universal/poverage employer
mandates, and premium.caps/ while- opposed by powerful i n t e r e s t
S o u p ^ a r e h e a v i T y ^ y o r e d :by^.^^
:-.•iFSSih ^ t r - P e t 'Joiirh^l lheadline/noted//"Many, Don't Realize I t ' s
'the C l i n t o n Plan They Like.". . .. . i n s p i t e of t h e barrage from s p e c i a l i ^ e r e s t s t h e American
,> people have,said; what-they want - and,they have said how they
, • want;tb^pay f o r i t . W
they',ve been ^very .consistent, i n t h e i r ,
views. *
n
t
S
n
0
d
t
a W n
r
;
;
" ' ^ ' r e i e n t Wathi^ngton'pbstM
showed t h a t 77 Percent
J
'
• Another t h i n g worth remembering about,this process i s t h a t
: : the P r ^
™ } ^ i ^ i s
• I d & t e d - b y Congre^^He^has alw^
• • :•; & ,b6?tomUine:Was ^rviversaT'Coverage, but he knew h i s p i an / would .be
• - W r i t t e n < ;irv M c t y VtWb'Hou^e . c6minittees>and .one Senate committee
€
a
:
;
This/^f^^art/^
- .began?A3; V'/. -v.;-.•
• •^•••.^.v, v . • •
• .
-
/>-:
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�We are on the path t o r e s t o r i n g the economy and f u l f i l l i n g
the President's broader agenda. And u l t i m a t e l y h i s t o r y w i l l show
t h a t t h i s was a time of great ferment and energy when a
courageous President d i d n ' t dodge a. d i f f i c u l t issue, but instead
launched a process t o solve the h e a l t h care problem once and f o r
' all.
' , We have made extraordinary progress i n t h e . f i g h t f o r the
h e a l t h s e c u r i t y of the American people and the f i g h t goes on. The
Congressional Leadership has made c e r t a i n t h a t h e a l t h care w i l l
be f i r s t on the agenda when they r e t u r n t o Washington. As was
proven w i t h passage of the Crime B i l l , special i n t e r e s t s do not
always succeed i n undermining the i n t e r e s t s of.the American
people. And we must continue t o make sure t h a t the voices of
reason aire heard over the shouts of fear and confusion. That's
why we w i l l not walk away from the f i g h t t o provide s e c u r i t y f o r
.the American people.
Thank you.
###
�• ..
A RetrospecGive on -Health Care Reform
October 1994
• ,
'
•
,
On September 22, 1993, President Clinton proposed 'a plan to
provide health qoverage to a l l Americans and control'escalating
health care, costs. A l i t t l e over a- year later, after successfully
moving health care l e g i s l a t i o n through four Congressional
committees and to the floor of both Houses , health care reform
failed-.'
What happened?
,
1
President Clinton.--in keeping with-his campaign promise to
provide quality, affordable .health.'care coverage to a l l Americans
- put forth a plan to help solve the nation's health care
problems. Building on what i s good in our current health care
system, he proposed universal coverage, phased i n over several
years, and a p r a c t i c a l approach to rein in health care costs for
American families.
.•'
Opponents of reform, the same i n t e r e s t groups that have
h i s t o r i c a l l y , opposed change, waged an a l l out war t o defeat
h e a l t h care reform. While some paid l i p service t o the goals of
reform, they^spared no e f f o r t .to protect the status quo.
And
they succeeded. ,
Although they f a i l e d to convince the American public that the
fundamental goals of universal coverage,and cost containment were
wrong, they succeeded in scaring and'misleading the public'that
the b i l l s proposed by the President and various Congressional
Committees would threaten what they l i k e about their -own health
care. They scared the public - confusing them about whether they
would be able to see their own doctor and whether the health care
system would turn into a giant government bureaucracy.
I t i s i n t e r e s t i n g t o note t h a t despite the hundreds pf m i l l i o n s .
of d o l l a r s spent t o defeat health care reform,- suppport f o r the
President's goal of universal coyerage remains strong. The
l a t e s t NYT/CBS News p o l l found that an•overwhelmingy m a j o r i t y •close t o 70% - of Americans s t i l l t h i n k that i t is. very important
t h a t every American receives health care coverage.
Why d i d these 'special i n t e r e s t s triumph in- the face of a'united
President and Democratic leadership?- They succeeded i n c l a s s i c
Washington s t y l e - - a combination of massive special, i n t e r e s t
money spent on a d v e r t i s i n g , delay, d i s t o r t i o n , and e x p l o i t a t i o n
of the complexity of the Congressional process. According t o
Newsweek (September 19, 1994), " i n t e r e s t groups spent at l e a s t
$300 m i l l i o n '- more than the Democratic and Republican 1988 and
1992 p r e s i d e n t i a l nominees combined - t o defeat h e a l t h care.
Much of t h i s money ,was spent on b l a t a n t l y untrue advertisements
designed t o scare the public.-,."
The heroic e f f o r t s of countless Members of Congress, l e d by
S.enator M i t c h e l l and Congressman Gephardt, outside groups and,
dedicated i n d i v i d u a l s pushed health care reform f u r t h e r than i t
�has .advanced i n 'sixty years of t r y i n g under seven Presidents.
Because of these e f f o r t s the public understands .the importance of
health reform and strongly supports'efforts to fundamentally
improve 'the • current, system.
Change i s d i f f i c u l t in the current Washington environment. As i s
so.often true, the forces of the status quo have the upper hand.
Were mistakes made? Absolutely. Could the Administration have
done a better job? Certainly. But the President, his
Administration, many Members of Congress, and numerous groups and
individuals fought as hard as they could to pass reform. •
The biggest disappointment in the fight for health care reform i s
that the people who have lost' the most are the tens of millions
of American families who are without insurance or who l i v e in
constant r i s k of losing their insurance. They lost to, the forces
of the status quo, the special interests who have,foiled efforts
to change the current system for years.
'
These special i n t e r e s t s fought f o r t h e i r r i g h t t o continue t o "
make money from the current system, and they d i d a good job.
They won t h i s round. • But t h i s b a t t l e i s ' f a r from over. - The
e f f o r t s made and the lessons' learned w i l l c o n t r i b u t e . u l t i m a t e l y
to reform of our health system. There w i l l be a day - hopefully
i n the not too d i s t a n t f u t u r e - when the p u b l i c i n t e r e s t s are put
ahead of the special i n t e r e s t s and r e a l health s e c u r i t y i s
achieved.
�\ •, , .
M y t h : The- P l a n Was
Grandiose. ,
Doomed From>the B e g i n n i n g - I t
was
Naive
and
R e a l i t y : S p e c i a l I n t e r e s t s s e t out to defeat anything that
challenged the s t a t u s quo.
I n f a c t , the President's plan was
b u i l t on what works i n the current system.
The s p e c i a l i n t e r e s t s linied up t o oppose change, t o prote'ct t h e
s t a t u s quo, as t h e y have f o r s i x t y y e a r s . No m a t t e r what had
been proposed, i f i t was fundamental change, the s p e c i a l
i n t e r e s t s would have o p p o s e d . i t ; I n d i v i d u a l elements o f every
p l a n proposed - whether by the P r e s i d e n t , Congressional
Committees, Democrats o r Republicans - were met w i t h .fervent
o p p o s i t i o n . I h essence any approach which t r i e d t o change t h e
s t a t u s quo r a n d i r e c t l y i n t o the same w a l l o f s p e c i a l i n t e r e s t
opposition.
The A d m i n i s t r a t i o n ' s p l a n .was b u i l t , upon what works i n the
c u r r e n t system, coupled w i t h p r o p o s a l s p u t f o r t h by Democrats and
Republicans.
For example, t h e employer mandate s i m p l y expanded
on today's system where 90% o f people who c u r r e n t l y have p r i v a t e
insurancei r e c e i v e i t . t h r o u g h the workplace.
I t was a l s o the same
. approach t h a t P r e s i d e n t Nixon proposed two decades- ago, and
supported a t the time, by groups l i k e the AMA, t h e Chamber o f
Commerce, t h e A s s o c i a t i o n o f Corporate B e n e f i t s Managers, t h e
American H o s p i t a l A s s o c i a t i o n , the N a t i o n a l C o a l i t i o n on H e a l t h
Care Reform c o - c h a i r e d by former P r e s i d e n t s C a r t e r and Ford,.and
many o t h e r groups.
The recommendation o f premium caps came s t r a i g h t , from a b i l l
proposed by Senators D a n f o r t h and-Kassebaum and R e p r e s e n t a t i v e s
McCurdy and Glickman.
They were supported by many g r o u p s ,
i n c l u d i n g , t h e American College o f P h y s i c i a n s , t h e C a t h o l i c H e a l t h
A s s o c i a t i o n and the League o f Women V o t e r s .
1
To enhance consumer choice and p r o v i d e f o r community r a t i n g , t h e
A d m i n i s t r a t i o n proposed mandatory a l l i a n c e s , which were c o n t a i n e d
i n the 1992 b i l l . s p o n s o r e d , by R e p r e s e n t a t i v e s Cooper and Andrews
and Senators Boren and Breaux..
,
:In many cases, these p r o p o s a l s have been t r i e d and t e s t e d and are
p e r f o r m i n g s u c c e s s f u l l y a t t h e s t a t e l e v e l . Employer mandates
are w o r k i n g e f f e c t i v e l y i n Hawaii; Washington arid Oregon; premium
caps', in"Washington and Minnesota.
And a l l i a n c e s are w o r k i n g i n
models such as CalPers and the Federal Employees H e a l t h B e n e f i t s
Program.
Myth:
The
Plan
was
developed
in
secrecy.
R e a l i t y : The Plan was developed through one of the most open and
i n c l u s i v e policy-making processes ever conducted.
T h i s was
one of the most open and i n c l u s i v e p o l i c y - m a k i n g
�processes ever conducted b y an A d m i n i s t r a t i o n i n terms o f t h e
f u l l range o f i n d i v i d u a l s who d i r e c t l y p a r t i c i p a t ' e d • i n p r o v i d i n g '
e x p e r t i s e and t h e o p t i o n s c o n s i d e r e d oh h e a l t h care- reform.
The ..
process i n c l u d e d .members o f Congress and. t h e i r - s t a f f s , .state and
l o c a l government o f f i c i a l s , o u t s i d e r e v i e w e r s , h e a l t h care
p r o v i d e r s , consumers e t c . - t o ensure d i v e r s e p o i n t s o f view were
represented.
.
•
Myth:
costly
The Working
delays
Group process was unwieldy
and chaotic,
causing
R e a l i t y : Delay on introducing h e a l t h care was i n l a r g e p a r t a
r e s u l t of other i s s u e s oh the Congressional calendar.
The A d m i n i s t r a t i o n was ready t o move f o r w a r d a t t h e end o f May
1993.
But a f t e r t h e d e f e a t o f t h e economic s t i m u l u s package, i t
became c l e a r t h a t t h e i n t r o d u c t i o n o f h e a l t h care r e f o r m should ,
be d e l a y e d u n t i l passage o f t h e economic p l a n was assured. For.
example, when word l e a k e d o u t about a Treasury Department
a n a l y s i s o f h e a l t h care f i n a n c i n g t h a t i n c l u d e d a t a x on wine and
beer, t h e C a l i f o r n i a d e l e g a t i o n sent a l e t t e r o f c o m p l a i n t t o t h e
White -Hous.e and some members p r i v a t e l y t h r e a t e n e d t o w i t h h o l d '.
support f o r t h e economic package. Without a doubt, t h i s
u n a v o i d a b l e delay.gave more time t o t h e o p p o s i t i o n t o confuse and
mislead the p u b l i c .
Myth:
plan.•
The Administration
was not
united
behind
the
President'a
• ,
F a c t : During the d r a f t i n g process, members of the A d m i n i s t r a t i o n
d i s c u s s e d v a r i o u s options. When the plan was introduced by the .
President, h i s Administration was f u l l y united behind i t .
The A d m i n i s t r a t i o n was u n i t e d behind h e a l t h care r e f o r m .
Members
of t h i s A d m i n i s t r a t i o n worked as.hard as they c o u l d .to pass
h e a l t h - reform:.
L i k e any o t h e r issue o r i n i t i a t i v e o f an A d m i n i s t r a t i o n , there'
were disagreements as t h e _ p o l i c y was b e i n g developed. Everyone
was heard; everyone had t h e o p p o r t u n i t y 'to make t h e case- b e f o r e
the P r e s i d e n t made h i s d e c i s i o n s .
Disagreements and d i s c u s s i o n s
were normal and .productive.
They shaped t h e d e c i s i o n s t h a t l e d
t o t h e P r e s i d e n t ' s piroposal.
"'
Everyone l i k e s t o d i s c o v e r arid r e v e a l d i f f e r e n c e s w i t h i n an •
Administration.
There a r e many o p i n i o n s i n an A d m i n i s t r a t i o n on
any i s s u e , as t h e r e were as h e a l t h care'was being developed and.
as i t was b e i n g d i s c u s s e d . i n Congress. But more i m p o r t a n t was •
-the commitment o f t h e e n t i r e A d m i n i s t r a t i o n t o passing- h e a l t h
care r e f o r m .
Once t h e President made h i s decisions', t h e e n t i r e '
A d m i n i s t r a t i o n u n i t e d behind t h e goal o f g e t t i n g h e a l t h care;
�r e f o r m .passed.
_
,
Myth: Interest
groups
that supported
universal
coverage
the HIAA and AMA - were never brought
into a coalition
the President's
goal of universal
coverage.
• •' ' ' .
- such as
to
support
1
.'
R e a l i t y : Several groups paid l i p s e r v i c e to h e a l t h care reform
and u n i v e r s a l coverage while using every ounce of energy to
maintain the s t a t u s quo and defeat reform.
Judge t h e s p e c i a l , i n t e r e s t s by what t h e y do, riot'what t h e y say. '
I t ' s v e r y easy t o say you a r e f o r u n i v e r s a l coverage, and a t t h e
same t i m e spend'every resource you have t o d e f e a t any' e f f o r t t o
enact fundamental r e f o r m .
L e t ' s n o t be n a i v e . These a r e v e r y s o p h i s t i c a t e d groups t h a t
kriew e x a c t l y what t h e y were doing. They acted i n what t h e y
viewed as t h e i r s e l f - i n t e r e s t and they were n o t g o i n g t o a c t
o t h e r w i s e . A c c o r d i n g t o Newsweek (September•19, 1994), $300
m i l l i o n was spent by. i r i t e r e s t groups t o d e f e a t reform-. This t y p e
o f campaign was unprecedented and e f f e c t i v e .
• D i d we kriow t h a t s p e c i a l i n t e r e s t s were g o i n g t o a t t a c k h e a l t h •
care reform?
Of course we d i d . S p e c i a l i n t e r e s t s h i s t o r i c a l l y
f o u g h t ' a t t e m p t s t o r e f o r m . We knew t h a t i t is' e a s i e r t o make, a
negative'case and t o scare people.
Perhaps we u n d e r e s t i m a t e d t h e
degree t o which opponents would i n t e n t i o n a l l y spread.
m i s i n f o r m a t i o n . The d i s t o r t i o n campaign t o p r o t e c t t h e s t a t u s •
quo was enormous - and i t worked - t o t h e d e t r i m e n t o f t h e h e a l t h
s e c u r i t y o f t h e American people.
1
;
Myth: A compromise
on health
care
attainable,
but the Administration
Republicans'.
reform with Republicans
did not reach out
to
was
R e a l i t y : The A d m i n i s t r a t i o n ' s g o a l was always t o work i i i a
b i p a r t i s a n f a s h i o n . Republicans were c o n s u l t e d t h r o u g h o u t t h e
process.
^
The A d m i n i s t r a t i o n recognized from t h e v e r y b e g i n n i n g t h a t i f w e
were t o answer t h e c a l l o f t h e American, people t o p r o v i d e f o r
u n i v e r s a l coverage and c o n t r o l h e a l t h care c o s t s we needed t o
work t o g e t h e r i n a . b i p a r t i s a n f a s h i o n . From t h e b e g i n n i n g , we
reached o u t t o Republicans.
We had meetings w i t h t h e Senate Republican Task Force, the .House Republicans and t h e i r
leadership.
s
Twenty-three Republican Senators supported u n i v e r s a l coverage
when t h e P r e s i d e n t ' s p l a n was i n t r o d u c e d , ' i n t h e l a t e s p r i n g o f
199.4, t h e Republican l e a d e r s h i p , u n i f i e d i t s membership around a
d e c i s i o n n o t to. g i v e t h e P r e s i d e n t any major v i c t o r i e s . A t
v a r i o u s p o i n t s t h e ' P r e s i d e n t and t h e Congressional l e a d e r s h i p
/••
�o f f e r e d t o move c l o s e r .to moderate Republicans,, b u t t h e y backed
way.
Republican r e s i s t a n c e i n t h e Senate.to t h e crime b i l l , on
Gafet- and on h e a l t h care d u r i n g t h e summer a l l p o i n t t.o' a d e s i r e
by t h e Republicans t o o b s t r u c t l e g i s l a t i o n t h a t wold be counted
as v i c t o r i e s f o r t h e P r e s i d e n t .
Myth: The Administrati
support
and the fact
on failed
to capitalize
that Democrats
controlled
on the wide
Congress.
public
R e a l i t y : Throwing sand i n t o the gears of the l e g i s l a t i v e process
i s easy, making i t work i s hard.
T h i s was never g o i n g t o be easy. Major change i n o u r h e a l t h care
system does n o t come e a s i l y
we have s i x t y years o f experience .
t:o demonstrate t h a t .
• The A d m i n i s t r a t i o n f o u g h t as hard as i t c o u l d . O^f course, we
r e g r e t . w e were unable t o get.major r e f o r m t h i s year. Of course,
we made,some'mistakes, and, i n h i n d s i g h t , we can a l l p o i n t t o
t h i n g s we- s h o u l d have done d i f f e r e n t l y .
The g e n e r a l support o f t h e p u b l i c does n o t . a u t o m a t i c a l l y
t r a n s l a t e i n t o success i n t h e face o f entrenched s p e c i a l ,
interests.
Changing t h e s t a t u s quo i s hard; t h e opponents have
t o accomplish .only one t h i n g , t o s t o p something. They don't have
t o pass an a l t e r n a t i v e . • They can d i s t o r t t h e t r u t h ; t h e y can
d i v e r t a t t e n t i o n from t h e r e a l i s s u e s ; t h e y can m i s l e a d .
;
1
Passing l e g i s l a t i o n t h a t upsets t h e s t a t u s q u o . i s h a r d .
Throwing
sand i n t o t h e gears o f t h e l e g i s l a t i v e process "is easy; making i t
work i s hard. The opponents of: change spent unprecedented .
amounts o f money, $300 m i l l i o n a c c o r d i n g t o Newsweek, t o confuse
the p u b l i c , t o convince t h e p u b l i c t h a t t h e y would l o s e t h e i r
d o c t o r and t h a t t h e h e a l t h care system-would become a g i a n t
government'bureaucracy.
'The s p e c i a l i n t e r e s t s used t h e t a c t i c s t h a t are so f a m i l i a r i n
. Washington t o p r e v e n t change. They" confused t h e p u b l i c ; t h e y
d e l a y e d . t h e Congressional process; t h e y bombarded Members o f
Congress w i t h t h e i r s p e c i a l i n t e r e s t p l e a d i n g s ; t h e y c o n s t r u c t e d
a w a l l o f c o n f u s i o n between Members o f Congress and p u b l i c
o p i n i o n on t h e need t o r e f o r m t h e . h e a l t h system.
They succeeded i n t h e same way t h a t t h e f o r c e s o f t h e s t a t u s quo
have succeeded,in Washington many, times i n t h e p a s t . They won
t h i s round; "but t h i s "is n o t a P r e s i d e n t who g i v e s up. H e a l t h
care' r e f o r m may be delayed, b u t i t w i l l not be d e f e a t e d as l o n g
as t h e r e are m i l l i o n s o f Americans who l i v e .'in d a i l y f e a r t h a t
they w i l l lose t h e i r h e a l t h insurance.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
ICM - APSA [American Political Science Association] Drafts – 8/1994 and Final
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Jack Lew
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 27
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092993" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12092993-20060885F-Seg2-027-001-2015
12092993