Book Review

What Went Wrong with the Clinton Health Plan

The System: The American way of politics at the breaking point

N Engl J Med 1996; 335:602-604August 22, 1996

Article

The System: The American way of politics at the breaking point
By Haynes Johnson and David S. Broder. 668 pp. Boston, Little, Brown, 1996. $25.95. ISBN: 0-316-46969-6 A

A quarter of a century ago, a recent Rhodes scholar on his way to law school wrote a book described as an “exuberant account of the workings of the United States Senate.” The book recounted how, while working as an aide to Senator Warren Magnuson in 1970, the young man shepherded a bill through Congress that established the National Health Service Corps. The title of Eric Redman's book, The Dance of Legislation (New York: Simon and Schuster, 1973), was drawn from an 1885 treatise on congressional government by political-science professor Woodrow Wilson: “Once you begin the dance of legislation, you must struggle through its mazes as best you can to the breathless end — if any end there be.” Wilson — with prescience of his inability to gain senatorial support for the League of Nations — believed that the failure of leadership in American politics was the isolation of the executive branch from legislative responsibility and leadership.

Also in 1970, another recent Rhodes scholar was heading for law school. Like Redman and many of his generation, Bill Clinton believed that “the system” could work, that government could be a positive force in the lives of Americans, and that individual people could shape history by shaping public policy.

Haynes Johnson and David Broder fast-forward this story to the first two years of Clinton's presidency, and in The System, they tell what became of the dance of legislation in a more recent instance. For those who believe that health care reform is the final and essential missing piece of the social safety net first woven by Franklin Roosevelt, the system failed Americans by derailing President Clinton's commitment to affordable care for all. For those who believe that the Clinton plan would have destroyed the world's best health care system, the political system worked just as the founding fathers had planned when they designed a government that would make rapid, radical change very difficult.

The story of The System, then, is the story of the American political system, particularly its federal legislative process. It is a story told well, in journalistic style, rich with quotations from interviews with key players in the debate over health care reform, to whom Johnson and Broder had access because of their stature in the world of political reporting (including the President and the First Lady). The authors tell the story well enough to keep their readers interested, despite the book's 668 pages and the fact that readers already know how the saga ends.

Johnson and Broder criticize the press for being “desultory, inconsistent or focused on the political points being scored by opposing sides.” It is ironic that they lambast the press for ignoring “such important topics as portability of coverage, long-term care, mental health services and rural health facilities,” since they themselves mention these issues only in this passage. The System succeeds in describing the politics of health care reform as much as it fails to explain the issues underlying the debate. But this book is not intended to be a serious exploration of the options for health care policy available in 1992. It is intended to be a book about politics, and in that it succeeds.

There are no villains in this tale, although Johnson and Broder are hardest on Ira Magaziner, the President's friend who was recruited to work with Hillary Rodham Clinton in designing the administration's plan. Johnson and Broder portray Magaziner as a brilliant, if arrogant, management consultant who approached the health care system as he did his consulting. They present Magaziner as a quick study of the health care system but obtuse about the workings of the political system, especially in his unwillingness to show Congress and its powerful staff the deference they expected.

Mrs. Clinton's role receives balanced treatment. Johnson and Broder praise her ability to serve as an effective spokesperson for the President's plan and credit her with shaping the plan itself. However, they assert that her success became a problem when opponents attacked her and when the President's own role in the reform process needed to be more visible.

Mrs. Clinton, like the President, Magaziner, Redman, and others who came of age in the 1960s, believed that a primary responsibility of government and of public leadership should be to mobilize the nation to address its social problems — that is, to change the system. If Hillary Clinton and Ira Magaziner were naive or arrogant, theirs was the exuberance of a generation that celebrated the election of one of their own, who could lead the “revolution” about which their more radical peers had shouted in the 1960s. Bill Clinton's presidency would be the culmination of their generation's hope to change the system by staying within it.

What was it about the system that frustrated the exuberance that accompanied Clinton to the White House? One of the answers from Johnson and Broder is that much of modern American politics is the politics of special-interest groups. By the 1990s, they argue, “The collective power of the lobbies had increased to such an extent that it seemed to drive and dominate The System.” Beginning in the early days of the debate over the Clinton plan for health care reform, more than 30 organizations met secretly as the “No Name Coalition” to plan their opposition to the President's proposal. Some, such as small employers and health insurers, had vested interests to preserve. Others were conservative groups whose motivations were grounded in philosophy.

Although the Clinton team enjoyed early support from the elderly and certain unions, it lost other allies as the proposal took shape. The complexity of the plan and the time taken in constructing it enabled opposition to be mobilized and frightened off some potential supporters, including big business, which would probably have benefited from the plan's expanded coverage but whose intrinsically conservative leaders became convinced that the plan represented big government and excessive regulation. Similarly, hospitals and physicians — despite the prospect of more paying customers with universal coverage — were worried about the regulatory aspects of the plan and the possibility of decreased prices for their services.

The organization of the special-interest groups that mobilized opposition to the Clinton plan was accompanied by an aggressive response by the Republican party, as depicted by Johnson and Broder. They recount their interview with Newt Gingrich, who told them that as early as 1991, he was convinced that the “next great offensive of the left” would be “socializing health care.” Gingrich designed a plan of “coagulation” that instructed Republicans to “clot everybody away from Clinton.” Gingrich saw the defeat of Clinton's health care plan as the key to Republican control of Congress and, according to Johnson and Broder, his ascension to the position of speaker of the House. Even Republican leaders who had initially advocated compromise with the Democrats soon saw the political advantages of killing any health care reform for which Bill Clinton could take credit.

As leaks emerged from the Clinton task force about a plan that seemed to be complex and threatening to those who opposed government's role in health care, Republicans and the special-interest groups realized that “this battle is not going to be a typical inside-the-Beltway battle. This battle is going to be waged across the country with the American people.” Television advertisements depicting average Americans Harry and Louise expressing their fears about the Clinton proposal won early skirmishes, as well as awards from the advertising industry for their sponsors. The Clinton task force tried to borrow the best from the market and federal involvement in health care, but by early 1994, the public had become convinced that access to high-quality care of one's own choosing was at risk. “Playing on mistrust and fears of government,” write Johnson and Broder, “enabled Gingrich to use the health care battle as a powerful symbol of the failings of the liberal welfare state.”

Republican unity, in concert with well-organized and well-funded interest groups, had outflanked and outmatched the proponents of reform. Although the Democrats held the White House and both houses of Congress, they were unable to agree on an approach to reform. Even the powerful Democratic committee and subcommittee chairmen in Congress were unable to exert enough discipline to achieve party unity. For some Democrats, there were serious policy questions, such as the employer mandate. For others, there was frustration at not having been sufficiently involved by Magaziner and the task force.

As if well-organized special-interest groups and Republicans — insufficiently opposed by reform advocates and Democrats — were not enough, the Clinton task force itself became a problem, according to Johnson and Broder. It grew from a planned group of 98 members to 630 in 8 teams and 34 working groups. The task force “short-circuited The System's conventional policy making process, and The System rebelled.” The task force's secrecy led to leaks and to congressional suspicion and jealousy. Even many senior administration officials felt shut out. A group of moderate Democrats and Republicans tried late in the process to salvage some parts of the reform plan, but even this “mainstream coalition” was unable to offer a compromise that would save health care reform.

In The System, Johnson and Broder offer a case study of American politics in the 1990s and of the barriers to major change. As John Rother of the American Association of Retired Persons told them, “If this comes out with something good at the end, it won't be because of The System. It'll be despite it.” The authors warn against dwelling on the roles of the individual players in the drama and thus minimizing the institutional obstacles and historical forces that were at work.

What they neglect to warn against, however, is the conclusion that nothing was achieved in the debate over health care reform. The health services research of the previous decades on the problems of the uninsured became the centerpiece of a national debate. Legislation for universal health insurance did not pass Congress, but it got farther than ever before. Although Monday-morning quarterbacks may argue that other proposals and other processes would have resulted in universal insurance, the fact remains that Americans debated the future of the nation's health care as never before. With the rejection of government's role, the decision was made to rely on the market. Some will contend that the market is already beginning to work — that health care costs are falling, medical students are entering primary care fields, and integrated systems of care are being developed with private investment. Others will argue that the market has brought, more quickly than government ever would have, just those constraints that opponents predicted the Clinton plan would impose — rationing, limitation of choice, and neglect of threats to the quality of care — while still leaving millions of Americans without access to health care.

The debate over health care reform continues today, and budget cuts in Medicare will probably be an issue in the 1996 presidential election. The final chapter in the story of reforming American health care has not yet been written, as the dance of legislation continues.

John M. Eisenberg, M.D.
Georgetown University Medical Center, Washington, DC 20007