Lessons Learned from Health Reform: Then and Now

The Clinton Administration failed to pass health reform legislation in the 1990s, but the process provided lessons that helped the Obama Administration craft a successful game plan for passage of the Affordable Care Act.

Now that the U.S. Supreme Court has declared the Affordable Care Act constitutional, it may be time tocompare the "now" of the Obama Administration's health reform with the "then" of the effort during the Clinton Administration in 1994.

The latter failed while the former finally succeeded. But it's not really that simple.

What the Clinton Administration ��of which I was a part���tried to do with health reform may not have succeeded legislatively, but it taught us a lot of lessons that informed the Obama Administration's efforts 25 years later.

Lesson #1 � How you do it is as important as what you do

The Clinton Health Care Reform Task Force was primarily a closed process, although there were more than 600 people who participated on a daily basis in the Old Executive Office building, and ultimately we met with all the key interest groups. However, the Clinton White House controlled the process, leaving Republicans and even some of their Democratic Congressional supporters completely out of the loop.

In contrast, the Obama White House delegated the process of developing legislation to Congress from the beginning. Obama was determined not to make the Clinton mistake of cutting Congress out of the development of a bill. He was criticized heavily at times for not pushing harder on Congress, but the success of the bill came mainly because it belonged to the Democrats in Congress.

Lesson #2 � Get support from your key opponents early in the game

The Clinton White House met with hundreds of interest groups, but there were very few formal "bargains" struck with key potential opponents in advance of the release of the bill language to Congress.

The Obama team focused on getting buy-in from key interest groups early on, such as hospitals, doctors, pharmaceutical companies, patient advocacy groups, seniors, labor, nurses, etc. For example, the pharmaceutical companies did not want the government to be able to negotiate for drug prices or allow importation of drugs from Canada and Europe at cheaper rates. Other interest groups had similar interactions in exchange for their support.

Lesson #3 � Piecemeal reform won't work. It must be comprehensive.

Early on, the Clinton Task Force considered just covering children as a starting point, but arguments in favor of a comprehensive approach won out. The policy people believed strongly that doing health reform in pieces could not solve the complex problems of one-seventh of the economy.

Some of Obama's staff also counseled against pushing for comprehensive reform, but those who had worked on the Clinton effort knew how hard it would be to get anything through Congress in pieces.

Lesson #4� Be careful how much change you introduce

As for the two plans, how much health system change did they assume? The Clinton plan was much more centrally and federally controlled, and it relied heavily on managed care.

"We got managed care," says Chris Jennings, who was one of Clinton's top health-care staffers. "But we didn't get the things that would protect us from managed care. We got the Wild West version of it."

The Obama plan delegated many powers to the states, too many some felt (e.g. the essential benefits). But the Obama plan relied heavily on the insurance industry, which displeased his many single-payer and progressive supporters who really wanted a "Medicare for All" approach.

Ironically, even though the Obama plan delegated more to the states and kept the status quo of the insurance industry, it was still called a "government takeover."

Lesson #5 � Talk about health reform early and often. Sophisticated communication is critical.

Here is where both the Clintons and Obama made the same mistake. They both assumed that people were paying attention, cared about the issue, and that they didn't need a big budget to communicate the results. And they were wrong.

We tried to bring communication experts into the White House in 1994 to help devise a savvy strategy for communicating the Clinton plan. But there was suspicion about using any slick communication/marketing consultants and the effort failed. By the time the Clinton bill got to Congress it was widely misunderstood and opposed.

Even though the media and the Obama Administration talked and wrote pretty constantly about the Affordable Care Act throughout 2009 and 2010, the main points never seemed to sink in. The opposition to the ACA from the right wing was loud and simplistic � it built on and surpassed the Harry and Louise message. The ACA became "Obamacare" and hatred for Obama sucked the life out of any positive messages. Lies and distortions circulated on the internet in a constant stream of emails and Facebook postings. Social media made it much easier to communicate an anti-health reform message than was possible in the 1990s.

Although we have made a significant progress toward universal coverage in the U.S., there is still a lot to do to protect the ACA from its attackers. I hope what we have learned this time is that we must constantly reinforce the messages of health reform. There will be no rest for weary health reformers now!