The June 2010 issue of Health Affairs is all about health reform–how and why it happened and where we go from here. Rest assured that I’ll be relying on this to provide content for my blog posts for a while. The first article I have to mention was written by the chair of my dissertation committee, Jon Oberlander. You should read the article for yourself, but here’s my synopsis.
Oberlander’s commentary asks and answers the question: “Given the long history of failed health reforms in the United States, why did health reform finally pass this time?” Sure, Obama enjoyed majorities in both the House and the Senate, but those majorities were not novel–in fact, as Oberlander points out, both FDR and Lyndon Johnson enjoyed much larger majorities when Social Security and Medicare were enacted. As a result, Obama–along with Speaker Pelosi and Majority Leader Reid–had to walk a very fine line, negotiating with moderates, but not going so far as to alienate progressives, lest the coalition of votes needed to pass the legislation should disband.
There was the usual problem: People dislike the notion of government involvement in their lives, especially in something as personal as health care, where people tend to embrace the status quo and reject “socialized medicine.” There was also a new contextual problem: The U.S. economy was experiencing the worst recession since the Great Depression. An expansion of “non-essential” government spending could be targeted by opponents as unwise during such a time. And then Sen. Kennedy passed away and Scott Brown won the election in Massachusetts, and it looked like the whole effort was unraveling. So, again, why, with the deck seemingly stacked so high against it, did health reform pass?
Oberlander gives several explanations. First, he says, it has to do with Obama’s decision to prioritize health reform from the start and to remain committed to that priority even when its outcome appeared uncertain or even in doubt. He also acknowledges the commitment of Pelosi and Reid in securing the votes in their respective bodies. Second, Oberlander suggests, the Obama administration learned from the failures of the Clinton administration’s attempt at health reform. Clinton’s White House designed the reform bill in great detail and would have fundamentally changed the structure for purchasing health insurance in this country. By contrast, Obama let Congress draft the legislation, and emphasized the need to build on what works–keeping employer based coverage at the core of the system. Third, the committees in Congress worked together to draft the reform legislation, which helped to avoid early dissension between the various committees which could have prevented a bill from ever reaching the floor. Fourth, the Obama administration engaged and negotiated with a variety of health care stakeholders. As Oberlander puts it “If You Can’t Beat Interest Groups, Co-Opt Them.” Since the health care industry has the most to gain or lose in health reform, getting them involved and neutralizing their opposition was perhaps the biggest factor in the success of reform.
In the end, the effort was successful, although the reform legislation was–and is–seen by many as less than ideal. Oberlander himself suggests that “For health reform in the United States, this is….probably as good as it gets.”