Stanley B. Greenberg: Why health care reform could fail again

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[Stanley B. Greenberg is the author of Dispatches from the War Room: In the Trenches with Five Extraordinary Leaders. ]

Nothing brings on a headache quite like health care reform. My head has throbbed lately, as Congress has begun to consider a serious overhaul--a debate that forces me to recall the painful last time we embarked on a similar effort some 16 years ago. At the time, I was conducting polls for Bill Clinton and, on the eve of his address to a joint session of Congress in 1993--the prologue to the White House's big push on the issue--I went into the field to gauge the national mood. I returned filled with a great sense of hope about the prospects for reform.

Our failure to enact health care reform was tragic for the country, and it played no small part in my exodus from the Clinton White House. But the coming debate over reform is an opportunity that can't be squandered, and it has prodded me to reconsider this chapter. I've been immersing myself in my old surveys and focus groups and memos to the president. It's even led me to return to the field, posing the same questions to the public, to determine how the mood has shifted and how the forces that oppose reform can best be countered.

Perhaps I should know better than to have sensed any profound changes in the country. And, when I got the results for the new survey, I looked at each question warily, remembering how it all went badly wrong. As I reached the last of the questions, I exclaimed: "Oh no. It can't be. Nothing's changed."

Then and now, the country proclaimed its readiness for bold reform. In both instances, one-quarter say that the health care system "has so many problems that we need to completely rebuild it"; half the country sees "good things" in the current system but believes "some major changes are needed." Then and now, about 60 percent of the public feel dissatisfied with the current health insurance system. Yet three-quarters are satisfied with their own health insurance--once again eerily parallel numbers. The same holds when the public is asked to focus on reform. Yes, we're no longer living in the shadow of Ronald Reagan. But the country has maintained the same anxieties about government's ability to improve the system. The country divides evenly on whether the greater risk is an unchanged status quo or government reforms that "create new problems." And, finally, Obama might want to pay attention to how closely his situation echoes Clinton's. Then and now, more people favor the president's health care plan than oppose it, but the supporters make up less than a majority.

If anything, I found on most of these questions that the desire for change and support for reform was slightly stronger 16 years ago, underscoring the importance of learning some lessons from that history.

When President Clinton delivered his much-heralded primetime address to Congress, during which he held up a health-security card, 48 million Americans tuned in. We fully expected a spike in support for our efforts. Alas, it did not happen. Actually, the number of enthusiastic supporters dropped, while one- third of the country remained opposed. We took that response seriously, but it did not stop us in our tracks. It should have.

The health-security card tipped our strategic calculus. We wanted to spotlight the notion of "security"--as Clinton put it, "giving every American health security, health care that can never be taken away." With the recession of 1991 fresh in everyone's mind, our polling showed that "knowing I will be covered" was the sentiment that generated intense emotional support and best withstood attacks.

We knew cost was the voter's biggest worry, as it is now, but the plan championed by the White House made it very difficult for us to win an argument on cost. Having just passed a budget with dramatic tax increases, Clinton could not propose a new round of taxes for health care, yet our polls showed that half the country (quite understandably) thought reform would require new taxes. They just thought we would find a backdoor way to raise them. Meanwhile, our main tool for restraining health care costs was the introduction of "managed competition" and regional "health alliances," something barely understood at the time and, to the extent that it was understood, deeply unpopular. The other tools were premium caps and a national health care budget, barred from rising above inflation and population growth, but those devices merely served to underscore government's large and complex role.

When confronted with these questions of cost, the political advisers in the White House would mumble, look down at our shoes, or defer to the technocrats. But President Clinton didn't have that option. He claimed to be reforming the system precisely because of the impact of costs on businesses and entitlements spending. Our inability to talk credibly about how we would reduce health care spending or costs for individuals and the country built a contradiction into all our efforts--the more we talked about the comprehensiveness of our plans, the more voters worried this would yield higher premiums or higher taxes. Very quickly, voters came to conclude that their families would face higher costs.

And those dynamics are still in play. In my recent polling, I found that voters are skeptical about claims that reform will reduce costs and personal health outlays. Claims about simplicity, information-technology modernization, and best practices don't seem to be enough to persuade them otherwise....
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