Book Review

What Went Wrong with the Clinton Health Plan

Boomerang: Clinton's health security effort and the turn against government in U.S. politics

N Engl J Med 1996; 335:601-602August 22, 1996

Article

Boomerang: Clinton's health security effort and the turn against government in U.S. politics
By Theda Skocpol. 230 pp., illustrated. New York, W.W. Norton, 1995. $27.50. ISBN: 0-393-039-706 B

Bill Clinton was elected President on November 3, 1992, after promising to introduce a legislative proposal for comprehensive health care reform within 100 days after his inauguration. It was a popular message, and many observers believed that George Bush's failure to offer a program of his own was a major factor in the election. Shortly after taking office, Mr. Clinton announced the formation of a task force, headed by his wife, Hillary Rodham Clinton, and managed by his friend and political advisor Ira C. Magaziner, to develop a plan for health care reform. It was an auspicious start, and expectations were high.

The President had already stated his ambitious goals: universal coverage, cost control, accountability for quality, and the maximal possible freedom of choice of doctor and insurance plan. He had also decided that the proposed plan would be based on “managed competition,” which meant regulated price competition among certified managed-care plans. The program was to be funded by mandatory tax-deductible contributions from employers, and the competing plans were to be regulated by regional purchasing alliances. New federal revenues, from unspecified sources, would finance insurance for those not covered through employers or existing government programs.

The task force's assignment was to draw up the detailed organizational and regulatory structure needed to carry out this grand strategy and, where necessary, to prepare tactical options for the President's decision. For about five months, from February to June 1993, more than 500 experts toiled feverishly on the plan under Magaziner's direction, secluded in the Old Executive Office Building adjacent to the White House. The secrecy and intensity with which they worked were reminiscent of war time. However, nearly nine months elapsed before the plan received final presidential approval. It was unveiled on September 22, 1993, at a dramatic and highly publicized joint session of Congress.

The plan — 1342 pages of dense legislative language — was initially received with widespread bipartisan enthusiasm, but in one of the most stunning reversals in recent political history, its prospects soon began to fade. By early 1994, it was in serious trouble in Congress and in the opinion polls. By summer, the Clinton plan, together with a spate of alternative legislative proposals, was hopelessly bogged down in committees. On September 26, Senate Majority Leader George Mitchell announced the obvious — that comprehensive health care reform was dead for that session of Congress. The subsequent Republican sweep in the November elections ensured that it would not soon be resurrected.

The demise of the Clinton plan for health care reform is a fascinating story, with important political implications. In Boomerang, Theda Skocpol, professor of government and sociology at Harvard University, tells the story with admirable insight and clarity. The book should be required reading for anyone interested in understanding the politics of health care reform, but it also has much to say about the inability of Congress to deal with a wide range of major domestic problems. Skocpol discusses many of the reasons offered for the defeat of the Clinton plan. All have some merit, but in her view, the most important factor was the Reagan legacy of an antigovernment and antitax bias.

Attempting to avoid new taxes and reduce the deficit, Clinton's team devised a plan so loaded with elaborate regulations to control costs that it inevitably aroused the ire of the foes of “big government.” Intense lobbying by coalitions of small businesses objecting to mandatory participation of all employers and resistance by private health insurance companies worried about restrictions on their access to the huge and lucrative managed-care market also played a central part, according to Skocpol. She criticizes Clinton himself for not taking a more active role in explaining and selling his plan to the public, before the opposition had geared up its antireform campaign. If the President really believed in the proposal, she says, he should have fought much harder for it in public.

I think Skocpol's analysis is correct but too narrowly framed. She is a student of government, so naturally, she sees health care reform largely in terms of political strategy and economics — of funding and insurance. These matters are important, of course, but they are only half the story. Her book omits the other half — that is, reform of the medical care delivery system itself. Most health care professionals and, I venture to guess, most patients, are as concerned about how medical care is provided as they are about how it is insured and paid for. Indeed, since the delivery system (and the behavior of physicians) has a central role in determining medical expenditures, no discussion of health care reform can ignore how a new system should help physicians control costs and ensure quality.

This, as I see it, is the only serious flaw in Skocpol's invaluable contribution to the public understanding of health policy reform: she does not adequately discuss how the plan would have affected the practice of medicine and what part physicians might have played in getting the plan accepted, had their support been enlisted. It is uncharitable to criticize Skocpol's illuminating work simply because it deals with health care reform purely from a political perspective, but one of the main reasons the reform plan failed was that it did not enlist the cooperation of the medical profession. A book about the plan and its demise, to be complete, should pay attention to the delivery side.

In their zeal to design a politically acceptable proposal to control costs and provide universal coverage, the architects of the Clinton plan neglected the delivery system. They forgot that medical care is what physicians do, and you cannot successfully reform the system without ensuring that physicians take responsibility for using available resources as efficiently and humanely as they can. Magaziner and company largely ignored the medical profession in the critical early stages of their planning, and they assumed that properly regulated “market forces” would bring physicians into the system in appropriate configurations. Moreover, they did not understand that they would need the medical profession's help to counteract the potent lobbying and advertising campaign of a greedy, well-funded private-insurance industry and to reassure a public that was suspicious of “government medicine.”

So medical support and medical cooperation in the design of the plan were never seriously or systematically solicited by the leaders of the task force. Not surprisingly, the American Medical Association's tentative early support of Clinton's goals for health care reform soon gave way before the conservative campaign against “government medicine.” And the half-hearted support of many other professional organizations never coalesced into an effective force. Ironically, the relatively unregulated, business-dominated market that has taken control of health care since the defeat of the Clinton plan is proving to be a far greater threat to the autonomy of the medical profession than the elaborate apparatus of the plan could ever have been. I do not suggest that the Clinton team would necessarily have been successful in enlisting the support of the medical profession for their plan. But they certainly should have tried.

None of my comments should obscure the fact that Skocpol has written an important book that will be a lasting contribution to the history of the politics of health care reform in America. It is a scholarly chronicle of what happened during the great, ill-fated health policy debate of 1993–1994 and an insightful explanation of why reform has been so difficult to achieve. When and if we ever have another opportunity to debate this issue, the lessons explicated in Boomerang should not be forgotten.

Arnold S. Relman, M.D.
Brigham and Women's Hospital, Boston, MA 02115