Congress: A Good Place for Health Care To Die

While most of the world's attention has been focused on Iran, health care reform has had a rough couple of weeks. First, in a move that was not entirely unexpected, the AMA came out against a public option in the Democrats' health care plan. Secondly, a draft version of the bill from the Senate's Health, Education, Labor, and Pensions Committee -- a very incomplete draft, which didn't include key provisions like the public option -- was scored poorly by the CBO, as was a preliminary version advanced by the Finance Committee on Tuesday. Thirdly, some centrist Democrats have begun to rally around a watered-down bill created by North Dakota's Kent Conrad -- a bill which Conrad said he created because more sweeping versions lacked the votes to pass. And fourthly, the Finance Committee and the HELP Committee increasingly seem to be running along separate, and possibly competing, tracks, as the Finance Committee delayed the markup of its own bill until after the July 4th holiday.

So far, there is no sign of erosion in the public's support for health care reform. And the Administration appears poised to begin doing some more explicit advocacy for the legislation, beginning with a one-hour national forum on June 24th. But it had better be prepared for that town hall meeting to be a start of a trend, because history suggests that leaving a health care bill unattended before Congress is just about the worst place for it to be.

A comparison to the Clintons' failed efforts to pass health care reform in 1993 and 1994 may be instructive. It is somewhat commonly believed that the problem the Clintons had is that they were too hands-on and oversold the bill. Looking back at the polling, however, suggests something else.

The chart below presents Bill Clinton's Gallup approval rating throughout 1993 and 1994, in conjunction with the major events of the health care debate. In the absence of specific polling on health care itself, this is perhaps the best barometer of the bill's political fortunes.


The approval polling suggests that Clinton was benefiting when he was doing the most direct salesmanship of the bill. A joint address to Congress on September 22, 1993 was met with a sudden jump in Clinton's approval rating. Although that bounce was short-lived, his approval rating then continued to improve throughout the balance of 1993 as a health care bill was presented to Congress in November. It was only when the bill was left to linger before Congress in the spring of 1994 that both its fortunes and those of Clinton began to suffer. Clinton's approval rating hit a nadir at 39 percent on August 16, 1994, the lowest it would be for the rest of his Presidency, which is right about when George Mitchell was making it clear that no bill had the votes to pass the Senate.

This is, obviously, a simplified re-telling of a complex time in American politics. But the Congress is never a popular institution, and with Ted Kennedy ailing and Hillary Clinton heading the State Department, the Democrats are notably lacking the sorts of charismatic leaders who know how to pitch legislation to the public. Polling suggests that 58 percent of the public trusts Obama to sell health care, but just 42 percent trust the Congressional Democrats -- a figure that puts them down in the gutter with the pharmaceutical companies, although ahead at least of the Congressional Republicans.

A more recent and perhaps equally relevant precedent is that established during the selling of Obama's most significant achievement to date, that of the economic stimulus package. That bill, initially rather popular, came dangerously close to failing when the White House went dark as it tried to navigate the Tom Daschle mini-crisis and let Congress take the lead; only some last-minute salesmanship efforts by Obama may have resuscitated it. And the stimulus package was simple as compared with health care -- it was really just a matter of agreeing on two numbers, the overall amount of the bill and the proportion devoted to tax cuts.

In contrast, the health care debate is multidimensional, requiring the resolution of a series of disputes ranging from the presence or absence of a public plan, to the best way to pay for it, to the wisdom of an employer mandate. There are an effectively infinite number of possible health care bills based on the way these parameters are resolved, and indeed there seem to be dozens of permutations on health care reform working their way around the Hill: a non-exhaustive list would include the HELP Committee's partially-unformed version, the Finance Committee's largely unformed version, Conrad's version, Max Baucus's version (which might or might not be different from the Finanice Committee version), the Dole-Daschle compromise, the Schumer Plan, the Rockefeller Plan, the House Democratic version (of which there may be several), Wyden-Bennett, AmeriCare, Mike Enzi's quasi-serious Republican alternative, and Olympia Snowe's "trigger". Notably absent seems to be any version from the White House itself, even though Obama campaigned on and won with a health care framework that offered relatively specific proscriptions to many of these questions.

Perhaps the Administration takes a different lesson from Bill Clinton's failure: that it was not so much the public salesmanship of the bill that was the problem, but rather, the the Clintons' inflexibility in the face of the political realities faced by the Congress. But the Doomsday Scenario for the White House is probably not that health care fails a straight up-or-down vote, but rather, that no individual version of the bill has enough votes to pass as legislators convince themselves they can hold out for an alternative more to their liking, while all the while the industry is having time bought for it to lobby against the bill, or to watch any of several political contingencies unfold (another crash in the stock market; the incapacitation of Senator Kennedy, which would deprive Democrats of a vote until a special election were held in Massachusetts) that could weaken the Democrats' position.

This has been an extremely cautious White House to date; they have scrupulously avoided doing anything that might ruffle Congressional or public feathers and they are probably afraid of gambling on a specific plan and losing. But as Neville Chamberlain learned long ago, and Spock learned in the latest version of Star Trek, caution does not always equate with safety. It is time for the White House to take hold of this debate and not let go.