Yes We Can? The New Push for American Health Security

• Author: Jacob S. Hacker
• Published date: 01 March 2009
• Date: 01 March 2009
• DOI: http://doi.org/10.1177/0032329208329752
• Subject Matter: Articles

Yes We Can? The New Push for American

Health Security

JACOB S. HACKER

What are the prospects for meaningful reform of U.S. health care? To answer this

question requires understanding why previous reform efforts (and in particular the

1993 Clinton health plan) failed—the combination of deep structural biases

against large-scale public provision and the inherited constraints posed by the

rise of employment-based insurance. Generally, the context is more favorable

today than it was fifteen years ago. But the prospects for change hinge on learning

the right lesson of history: Politics comes first. Putting politics first means avoid-

ing the overarching mistake of the Clinton reformers: envisioning a grand policy

compromise rather than hammering out a real political compromise. It also means

addressing the inevitable fears of those who believe they are well protected by our

eroding employment-based framework. And it means premising political strategies

on the contemporary realities of hyperpolarized politics, rather than wistfully

recalled images of the bipartisan politics of old.

Keywords: health care reform; welfare state; economic security; American

politics; health policy

3

The author thanks Fred Block, Libby Wood, and the Politics & Society editorial board for

extremely helpful comments.

POLITICS & SOCIETY, Vol. 37 No. 1, March 2009 3-32

DOI: 10.1177/0032329208329752

© 2009 Sage Publications

Americans have been fighting over health care for a very long time. With

pendulum-like regularity, the battle has flared up roughly fifteen years after it

last flamed out. Reform efforts came to a halt in 1920, 1935, 1950, 1965 (when

Medicare and Medicaid were enacted), 1980, and, of course, upon the crashing

failure of the Clinton health plan in 1994.

Each time, well-intentioned reformers brimming with statistics and policy

ideas have argued that change must finally come. And each time reformers have

run headlong into a wall of ideologically charged opposition that has thrown

exorbitant resources and energy into convincing Americans and their leaders

that they will be made worse off by change. Although the predictions have not

always been as dire as Ronald Reagan’s grim forecast in 1965 that Medicare

would usher in “federal programs that will invade every area of freedom as we

have known it in this country,” they have always involved the frightening claim

that government involvement will lower the quality and raise the costs of medi-

cal care, threatening the wellness and financial security of those who are already

insured.1 In a political culture skeptical of egalitarian government efforts and a

political framework designed to make major policy transformation difficult,

reform efforts have again and again collapsed under the weight of public con-

cerns and interest-group opposition, leaving reformers short of their ultimate

goal of universal health security.

So here we are (at the writing of this article), back on schedule to have a

major national debate about health care. In the race to launch the post–George

W. Bush era, the Democratic nominee, Barack Obama—whose optimistic cam-

paign slogan, “Yes We Can,” provides the querulous title for this essay—has

said he will pursue health care for all within the first hundred days of his admin-

istration. The Republican nominee, John McCain, has vowed a very different

but no less path-breaking approach: transforming the tax code to encourage

movement from employment-based health insurance to individually purchased

private coverage—a movement welcomed by many Republicans in Congress

but sure to be fiercely resisted by the Democratic majority. Whatever the out-

come of the presidential election (less than two months away at the time of this

writing), the struggle for health security is certain to return to the center of dis-

cussion. But if Obama inherits the mantle of presidential leadership, we are set

to embark on the seventh great debate over the future of American health care.

This raises the obvious question: Should we expect anything to be different

this time? Is the present moment sufficiently more auspicious than when our

leaders last waged battle on this issue? Has the lineup of contenders or the expe-

riences or views of the public changed in fundamental ways? And what are the

lessons those leaders should take from the past about the most feasible route to

change today—particularly from the high-profile failure of the Clinton health

plan in the early 1990s?

Much of the analysis of health policy in the United States has been domi-

nated by economists, whose methodological tools equip them well to examine

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