Major legislative change is hard, so it should come as no surprise that Barack Obama’s drive to comprehensively reform the American health-care system is running into some problems. By contrast, Monday-morning quarterbacking is easy, so it also should come as no surprise that these problems are inspiring a massive wave of second-guessing.
Perhaps the most exhaustive version of the “Obama making mistakes” narrative was unleashed this weekend at Politico by the potent team of Mike Allen and Jim VandeHei, who accuse the president of trying to do too much too soon. In their telling, the administration has relied on a fallacious “big bang” theory of political change, in which economic crisis and an electoral mandate create a good moment for sudden and massive reform of domestic policy. There’s some truth to this. Chief of Staff Rahm Emanuel talked during the transition about how it would be a shame to let a crisis go to waste, and liberals have developed a narrative about sudden bursts of political change under Franklin Roosevelt and Lyndon Johnson that are a bit at odds with the facts.
It’s not only Clinton who failed to accomplish comprehensive health-care reform—his effort joined reform charges by FDR, Harry Truman, Richard Nixon, and Jimmy Carter on the ash heap of history.
At the same time, critics of the Obama administration’s alleged tactical errors should consider that their decision-making has been heavily shaped by the perception that Bill Clinton’s drive for health reform was brought down by poor White House decision-making. Thus, while Clinton had the White House develop a detailed plan that was then presented to Congress, Obama outlined broad principles and deliberately left hugely important decisions to the Hill. While Clinton opened with centrist gestures on NAFTA and budgetary balance, only turning to health care seriously in his second year, Obama leapt out of the gate with an effort to tackle health. Clinton proposed large, systematic change in the way health care would work for everyone, hoping to achieve broad-based support for a better system; Obama has promised a risk-averse population that most people’s insurance will stay the same.
What Clinton tried didn’t work, in other words, so Obama’s trying it another way. Now the United States Senate looks reluctant to pass a comprehensive plan, so people think Obama is making mistakes. But looking back at American history, it’s not only Clinton who failed to accomplish comprehensive health-care reform—his effort joined reform charges by FDR, Harry Truman, Richard Nixon, and Jimmy Carter on the ash heap of history. Johnson, arguably the most accomplished legislator in American history, was too scared to try and brought us Medicare and Medicaid instead. It defies plausibility to suggest that president after president after president is blundering or inept. Rather, we should just admit the obvious—people keep trying and failing to reform the health-care system because reform is hard to do.
It’s hard because most people already have health insurance. It’s hard because the segment of the population most likely to worry about health care—senior citizens—already benefits from a generous Canadian-style system. It’s hard because the people worst-served by the status quo are also the people least likely to vote. It’s hard because the interest-group pressures—not just from insurance companies but also doctors, hospitals, pharmaceutical companies, vendors of medical equipment, and labor unions who’ve already secured generous benefits for their workers—are intense. It’s hard because the issue is complicated and it’s hard because we don’t have one “health-care system” that can be reformed; instead, the population is segmented into a series of very different situations.
And none of it is made any easier by the fact that the U.S. political system is very resistant to change. In most countries, laws are passed by a unicameral legislature elected to express, more or less, the will of a majority of the population. Under Obama, the House of Representatives—which basically fits the bill—has already passed what would, if it were to become law, be the single most important piece of environmental legislation in the history of the world. They’re also poised to pass a universal health-care bill that’s already cleared all three relevant committees and almost certainly has majority support. But the House leadership, sensibly, doesn’t want to ask potentially vulnerable members to cast another tough vote unless the Senate is prepared to act.
And the Senate, simply put, is rarely prepared to act—60 votes is a very high bar to cross.
It’s possible that despite the formidable obstacles, Obama will prevail in the end. Already he’s come closer than any of his predecessors. But it’s also possible that he’ll fail, and if so, there won’t be anything unusual about it. Not only has comprehensive health legislation failed many times over the years, but many presidents have failed at many things. George W. Bush couldn’t privatize Social Security and his tax-reform legislation sank like a stone. Bill Clinton left office popular and successful, but with few enduring major policy accomplishments. Ronald Reagan cut taxes (using the budget reconciliation process that only required 50 votes) but didn’t seriously pare back the welfare state.
Time and again presidents and their supporters learn the main lesson of American policymaking—that for better or for worse, our system makes big changes difficult to implement.
Matthew Yglesias is a fellow at the Center for American Progress Action Fund. He is the author of Heads in the Sand: How the Republicans Screw Up Foreign Policy and Foreign Policy Screws Up the Democrats.