Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.” The recent words of President Bill Clinton? No, the words of President Harry S. Truman.
As early as 1944, President Franklin D. Roosevelt, in his State of the Union Message, advocated “the right to adequate medical care and the opportunity to achieve and enjoy good health.” That same year, Senators Robert Wagner (D-NY) and James Murray (D-MT) and Representative John Dingell, Sr (D-MI) introduced the “Wagner/Murray/Dingell” bill, which proposed broadening Social Security to include a national health insurance system financed by a payroll tax.
Fast forward to 1994. After a long and contentious 2-year battle to pass comprehensive healthcare reform, the Congress, President Clinton, and the American public find themselves no farther along in the process than their counterparts during the Roosevelt Administration. According to Donna Shalala, Secretary of Health and Human Services, “the public clearly told us that the idea of taking on the whole system, every aspect of it,” was unacceptable. The American public finds itself left in the wake of a reported record $46.1 million spent by health and business interests lobbying on healthcare reform, according to the group Citizen Action.
Although healthcare reform was dead for the 103rd Congress, Americans still retained a whole new set of additions to the American lexicon—or at least those Americans living within the confines of the Washington Beltway. Hard, soft, and fast-track triggers, managed care, premium caps, purchasing cooperatives, community rating, single payer, and incremental reform were spread throughout the pages of daily newspapers and discussed on endless radio talk shows. Healthcare reform in 1995 will doubtless add a few more terms to Webster’s Dictionary.
As we turn our sights on a new Congress that will again have to tackle issues of healthcare reform, it is important to take a hard look at where we’ve been and sort out the real issues of debate from what obviously became the politics of the debate. We now highlight some key events in the recent timeline of reform. Our abridged chronology of healthcare reform begins November 3, 1992. Bill Clinton is elected 41st President of the United States, running on a platform highlighted by a commitment to address the “healthcare crisis” in the United States. Public support appeared to be strong for the new president and Congress to quickly address the issue by passing comprehensive healthcare reform legislation. The President-elect promised the American public that a plan would be announced during the first 100 days of his presidency.
On January 25, 1993, President Clinton announced the formation of the National Healthcare Reform Task Force, headed by First Lady Hillary Rodham Clinton and presidential advisor Ira Magaziner. A complex system of groups was formed to pass recommendations through a series of “tollgates.” Task force membership would soon total more than 500, including 133 Capitol Hill staffers, all Democrats, a precursor of problems to come. Names of members were not released until March, after a lengthy public outcry over the secrecy of the meetings. On March 10, a federal judge ruled that the White House was violating federal open-meeting laws. Many also decried the excessive numbers of academic theorists and economists and the lack of participation of members from the medical and business communities. It was not until late April that the President succumbed to public pressure and announced the formation of a panel of doctors, nurses, and other medical experts to assess the work in progress. Even then, many in the medical community complained that this group would simply be predisposed to rubber-stamp the task force’s recommendations. All of this seemed to divert attention and momentum from the healthcare debate, inexorably slowing the process.
Deadlines for announcement of the plan began to come and go. Deadlines in May and June soon passed. By this time, debate over Clinton’s controversial deficit reduction package was well under way, with health care taking a back seat. Finally, on September 22, 1993, a full 8 months after formation of the task force, President Bill Clinton announced his plans for healthcare reform during a joint session of Congress. The far-reaching legislation was now ready for dissection by five committees in Congress as well as numerous other Congressional panels addressing peripheral issues. An almost unprecedented series of congressional hearings, public forums, and symposiums was to mark the subsequent 9-month period. The subjects open to discussion ran the full gamut of issues. A September 1993 Congressional Quarterly analysis detailed the many areas impacted by the plan, including antitrust laws, workers’ compensation, physician choice, health insurance, malpractice, Medicaid, Medicare, prescription drugs, the self-employed, the uninsured, and tax deductibility. Coverage under the plan would include hospital and emergency services, clinical preventive services, hospice care, mental health care, home health care, ambulance services, dental services, health education, vision and hearing care, prosthetic devices—and the list goes on. The plan’s comprehensiveness was unprecedented. Far less expansive plans had gone to defeat during previous administrations. The bill totalled 1342 pages.
When all was said and done, four of the five committees had passed some form of healthcare reform legislation. Subsequently, plans were introduced by House Majority Leader Richard Gephardt and Senate Majority Leader George Mitchell that melded aspects of the various committee-approved proposals. Even in the waning days of the 103rd Congress, as hope for passage of the leadership plans subsided, additional plans were introduced by a host of legislators, including Representatives Rowland and Bilirakis, Senate Minority Leader Dole, and Senators Tom Harkin and Bob Graham.
In reality, by the time the leadership melded the various proposals together, pressure was already intense for proceeding with far less ambitious plans, particularly those that steered clear of the contentious employer mandate issue. With elections on the horizon and time running out, it soon became clear that the Republican leadership, particularly in the Senate, would support no version of health care. Previously stated problems with the White House strategy aside, the various pieces of legislation ultimately died from old-fashioned congressional politics. For most of the process, bipartisanship was lacking. Bills were approved in committee with little or no attempt by Democrats to garner Republican support. Nor were Republicans forthcoming with support. As President Clinton’s popularity continued to fall, it became clear that House and Senate Republicans sensed that gaining control of either or both houses of Congress was becoming more possible. At that point, key members of the House and Senate, including House Minority Whip Newt Gingrich (R-GA) and Senate Minority Leader Bob Dole, made it crystal clear that they would support almost no form of healthcare reform, sending Democratic candidates to the polls in November with a major campaign promise unfulfilled.
Whoever was to blame, the result was clear. In the House, the Ways and Means Committee plan received no Republican votes. With House Energy and Commerce unable to garner any Republican support, nearly all Democrats on the committee were needed for passage. That support was not forthcoming.
By late summer 1994, it was clear that no legislation would achieve universal coverage. At that point, one of the few examples of bipartisanship prevailed. A group of moderate Republicans and conservative Democrats joined together in a so-called “mainstream coalition” in support of reaching 95% coverage without an employer mandate. This plan actually garnered the support of the National Federation of Independent Business, which had led the fight against the Clinton healthcare plan. The mainstream group was able to incorporate large parts of its proposal into the bill eventually approved by the Senate Finance Committee. The mainstream coalition plan proposed insurance market reform, low-income subsidies, and imposition of a so-called soft trigger, providing that an employer mandate would not take effect unless market competition failed to achieve universal coverage.
As Congress headed toward a more incremental approach, many may have had a feeling of déjà vu. According to a 1993 report from the Democratic Policy Committee of the US Senate, in 1954 President Eisenhower proposed what he considered a “middle ground” approach. According to the March 1955 Congressional Digest, the proposal antagonized opponents on both sides of the issue, who attacked it as dangerous and unnecessary. The Chamber of Commerce claimed it was not needed: “The record shows that private insurance organizations are fulfilling their responsibility to make adequate insurance coverage available on a sound basis.” On the other side of the ledger, organized labor attacked the Eisenhower approach as “inadequate” and “ineffective.”
Later on, introduction of President Kennedy’s legislation met with opposition from the American Medical Association, the Chamber of Commerce, and health insurance associations. Under the administration of Lyndon Johnson, the American Farm Bureau and Blue Cross/Blue Shield were among the harshest critics. Vault ahead to 1993, and President Bill Clinton was to face many of the same opponents of healthcare reform.
There were many reasons for the death of comprehensive healthcare reform. Washington pundits have laid blame on many doorsteps: the overcomprehensiveness of the plan, the secret meetings of the healthcare task force, the ineffective advocacy effort by the Democratic National Committee, the contentious paid television advertisements such as the now famous “Harold and Louise” pieces, the lack of bipartisanship, the lack of presidential coordination with Congress, and the multimillion-dollar effort of special interest groups bent on preserving the status quo. At one point, H. Ross Perot offered the Republican Party at least $1 million to produce a televised program to critique President Clinton’s healthcare reform plan. Internally in the Congress, the indictment of House Ways and Means Committee Chairman Dan Rostenkowski led to the elevation of little-known Sam M. Gibbons (D-FL) to the position of acting chairman of the committee. Gibbons moved quickly to put his own imprint on the soon to be approved Ways and Means version of reform.
Who would have guessed that the House Energy and Commerce Committee chaired by John Dingell, Jr would fail to gain a consensus of its membership on any version of reform, with the employer mandate the final stumbling block? This comes 50 years after his father introduced his healthcare reform proposal. In fact, a Dingell had introduced a healthcare bill during each session of Congress from 1944 to 1994!
In the end, only the House Ways and Means Committee supported true universal coverage. On June 30, 1994, the committee approved legislation providing universal coverage by January 1, 1998. All employers would have been required to pay 80% of the premium for full-time workers. Small business would receive credits for premium costs. A new program, called Medicare part C, would enroll the unemployed, part-time workers, welfare recipients, and employees from participating small companies. Subsidies would be provided to those with low incomes. Some cost controls were also approved, with soft triggers going into effect in 2001 if target levels were not reached. The measure was to be financed by an increase in the cigarette tax and a 2% tax on insurance premiums, among others.
Despite concerns by many over the complexity of many of the healthcare bills, as late as July 1994, a New York Times/CBS News poll found that 8 in 10 polled felt that it was very important that each American receive health insurance coverage.
Public statements from the White House just before the November election now point to the likelihood of a 1995 Congressional strategy for healthcare reform that will concentrate on cost containment, including reductions in entitlements, and will probably be incorporated into the 1996 budget process. The president’s July budget review estimated that without healthcare reform, the deficit will rise from $156 billion to $178 billion in fiscal year 1995.
And the battle for healthcare reform goes on.
- Copyright © 1995 by American Heart Association