Some call 1994 the year of missed opportunity for national healthcare reform.
After all, no reform plan passed Congress. Not even a hint of a down payment. Nothing.
The once-in-a-decade momentum that was built up for reform was squandered, leaving the reform movement significantly behind where it was when the year began.
Not everyone agrees with that assessment, however. A more optimistic take on 1994 was that it was a step toward creation of an improved healthcare financing and delivery system. Sure, there were lost opportunities and missteps, but no more than there were along the path to other major social legislation. Americans were bound to get scared at such sweeping change, but politicians, the public and healthcare providers learned that lesson; and everyone will be better off for the experience.
Or so some say. The truth probably lies between the two extremes.
The real question is what legacy 1994 will leave. Did the rancorous debate poison the waters, making healthcare reform impossible for years to come? Or was it a defining year-one in which we learned what was possible and what wasn't?
Undeniably, in 1994 healthcare reform moved from the domain of egghead debate to Main Street, U.S.A.
But seriously, folks.When "Tonight Show" host Jay Leno made jokes about White House healthcare czar Ira Magaziner in his monologue, it was apparent reform had become the dominant social issue, infiltrating popular culture as few issues have.
Looking back, it seems clear that the explosion of healthcare reform as a topic on the American scene was one of the very things that worked against the passage of comprehensive reform.
What was needed to overcome the inevitable clashes of interests was a process of delicate negotiations. Instead, in 1994 we got a debate about the merits of Harry and Louise, the fictional characters who appeared in trade association advertisements.
The groundwork for 1994's successes and failures was laid in September 1993 when President Clinton-who at that time still thought he had a mandate to pass comprehensive healthcare reform-introduced his nearly 1,400-page plan.
By January 1994 it was already apparent that the president's plan was more than most people wanted. Business led the charge against it. In February, the Business Roundtable, the U.S. Chamber of Commerce and the National Association of Manufacturers joined the National Federation of Independent Business to reject the Clinton package.
The defection of the business groups emboldened opponents of the plan in Congress. By spring of 1994, the administration was in full retreat. It tried to stick to a central principle of universal coverage, but even wavered on that as the debate wore on.
In the summer, as the public's approval ratings for the Clinton plan were plummeting, Congress came to the rescue by modifying the plan. Several committees passed versions of it.
But an ominous note was sounded when the House Energy and Commerce Committee, which was considered to be one of the most representative committees in Congress, was unable to agree on anything.
Ominous note, part two.Then, the
Senate Finance Committee passed, by an 11-9 vote, a plan that did not include an employer mandate, but it was no more popular with special-interest groups than the Clinton plan had been.
As summer turned to fall, it became apparent that the bill with the largest block of support in Congress was still a single-payer plan. Meanwhile, other members of Congress renamed their plans to sound as if they were at the center of the political spectrum: mainstream coalition, bipartisan plan, mainstream bipartisan, etc. In fact, little middle ground existed.
In the end, Senate Majority Leader George Mitchell's announcement that reform was dead came more as a relief than a shock.
While the announcement marked the end of the road for reform in 1994, the issue had consequences in the mid-term elections in November. According to several exit polls done the day of the election, healthcare reform, which was supposed to be the bedrock on which the Clinton administration was built, hung like a millstone around the necks of Democratic candidates.
The events of the last year contain several lessons:
American voters had no idea what they meant when they said they wanted universal coverage. Voters thought it sounded like a good idea, but when the cost of bringing 35 million people into the healthcare system was calculated, the status quo suddenly didn't seem so bad.
"It was useful to have this debate," said Princeton University economist Uwe Reinhardt. "We now know what people want. They want (a modified version of the current) three-tier system (Medicare, Medicaid and private insurance). That tells us that we should build on the current system next year."
Healthcare reform, good. Clinton plan, bad. According to a poll done by the Kaiser Family Foundation and the Harvard University School of Public Health, healthcare reform is the top priority among voters for the next Congress. However, only 18% of voters said the Clinton administration should take the lead on the issue.
"Voters did not feel that the government could do it right and they had no intention of giving them a try," said Robert Blendon, chairman of the Department of Health Policy and Management at the Harvard University School of Public Health.
"Voters wanted healthcare reform, but it literally came down to the fact that people got more scared of government taking over healthcare than they were of losing their insurance."
Lawmakers can't wait for voters to understand the healthcare issue before they act, or nothing will ever get done. Matt James, vice president of communications for the Kaiser Family Foundation, said despite intense media coverage, their polls detected no increase in the level of knowledge about healthcare issues among voters from May 1993 to November 1994.
Americans "want something, but they don't know what that something is," said Robert Doherty, vice president of governmental affairs at the American Society of Internal Medicine.
Armed with this knowledge, both the new Republican-led Congress and the revamped Clinton healthcare team have pledged to revisit healthcare reform next year, albeit on a much scaled-back level. If they have, as they claim, learned from this year, then the hundreds of hearings, millions of pages of healthcare plans, endless debate and untold millions in lobbying expenses will not have been in vain.
Mr. Weissenstein is a Washington correspondent for Modern Healthcare