What the death of health reform teaches us about the press.

• Author: Hamburger, Tom
• Position: Includes related article

On a November day in 1991, the nascent Clinton presidential campaign summoned Ted Marmor, one of the authors of this article, to a private meeting with the Arkansas governor at the Washington Court Hotel on Capitol Hill. At the time, the politics of health care reform were gathering force. Harris Wofford had just championed the issue in his landmark Senate victory in Pennsylvania, and Clinton was in search of a health care policy. Debating Marmor--an advocate of Canada's single-payer system--was Ron Pollack, the head of FamiliesUSA, which was then supporting a plan called "play-or-pay."

For about two hours, Clinton and a collection of his advisors listened as Marmor and Pollack squared off. Single payer, Marmor argued, could save billions by cutting out redundant insurance bureaucracies, would achieve universal coverage, better control costs, and guarantee doctor choice. Pollack, once an advocate of single payer himself, made the case that play-or-pay, not single payer, was politically feasible. It built on the existing system by requiring all employers to provide insurance for their workers (play) or contribute to a pool that would cover them (pay). By doing so, play-or-pay avoided direct taxation and the political hazards of calling for the government to become the nation's insurer.

After the two advocates finished, Clinton looked thoughtful, pointed to Marmor and said, "Ted, you win the argument." But gesturing to Pollack, Marmor recalls, the governor quickly added, "But we're going to do what he says." Even considering the Canadian system, everyone in the room agreed, would prompt GOP cries of "socialized medicine"--cries that the press would faithfully report.

But the price of this pre-emptive concession was large. In all the recent obituaries of health care reform, no one has yet noted this first, fateful Clinton concession. On that November day, Clinton decided not to pursue reforms that had been proven in practice. This retreat from considering the pros and cons of foreign experience, combined with a press that also largely failed to explain how those lessons could be applied here, doomed constructive debate on the most important social issue of our time.

Once Clinton's political strategy was set, he became open to proposals celebrating market competition--a clear way, this New Democrat hoped, to avoid the Old Democrat label. So by early February 1992, around the time of the New Hampshire primary, Clinton was privately talking about California Insurance Commissioner John Garamendi's proposal for managed competition. By Labor Day, the seduction was complete, and Clinton had made his second fateful concession to what appeared politically feasible. He committed himself to a plan that advertised market competition as a cost-control device and used employment-based premiums instead of national taxes--things the press said might pass while more straightforward reform could not. What Canada, Germany, Australia, and France had learned in achieving universal coverage with cost control--while still spending less, with higher levels of public satisfaction--was thus off the table.

Clinton did not need to endorse a foreign system outright. But the lessons they provide could have been used to develop a coherent reform plan. And the president could have cited American experience with military medicine, especially during World War II and Vietnam, when very good doctors were drafted and worked under the broad authority of a democratic government. (In fact, the Vietnam work was so good it revolutionized civilian emergency medicine.) Clinton could have marshalled all of this evidence to pre-empt the insurance industry's line (made famous in the $16 million "Harry and Louise" ads) that "government-controlled" health care doesn't work. He is, after all, a president with enormous potential to educate. Remember his splendid Little Rock economic summit? The first budget address? The warmly received initial health care speech to Congress? The fight to pass NAFTA? Clinton knows how to run big teach-ins.

To cover the uninsured (whose expensive emergency care helps drive up costs for everyone), Clinton could have argued, we could target the most obvious source of waste in our system: private-sector bureaucratic overhead from 1,500 private insurers. This way, Clinton could have told the American people that despite what they hear about "big government" from Phil Gramm and Newt Gingrich, administrative costs in Canada's government-centered system are less than half the U.S.'s. Then the Clintons could have made the point that the real tangle in American health care has less to do with governmental than with private bureaucracies. But by sticking with the existing insurance system, and constructing a Rube Goldberg-like plan, the Clintons could not make that anti-bureaucratic case and were hobbled in fighting back when charges of government bureaucracy were thrown at them.

Whatever the Clintons did, they were sure to encounter opposition from interests like the House Republican Conference and the Health Insurance Association of America--opposition whose commercials could distort debate and whose soundbites would be automatically passed along by the media.

That's why the blame for the death of health reform this year does not lie completely with the Clintons. It wasn't tht they crafted a flawed plan and made crucial concessions because they didn't know any better. Instead, they did it because they understood that the American press, by and large, is culturally incapable of confronting an issue, explaining it, exploring possible solutions, and sorting fact from fiction.

To understand how the press' failure to explain the implications of health reform affected what the Clintons did, consider the example of costs. The Clintons were very reluctant to acknowledge that health insurance is something society has to pay for somehow, whether by taxes or premiums or contributions. They never came clean and said, "To pay for the reform we all agree we want, we are going to have to pay a tax of some kind. So let's be honest and debate which kind of tax is best...