Ezra Klein: The Ghosts of Clintoncare

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http://www.washingtonpost.com/wp-dyn/content/article/2009/07/24/AR2009072401876.html?hpid=opinionsbox1

The Ghosts of Clintoncare

By Ezra Klein
Sunday, July 26, 2009


Barack Obama's strategy to pass health-care reform seems based on a simple principle: Whatever Bill Clinton did, do the opposite.

Where Clinton and his team crafted their health-care reform plan in the executive branch, Obama has left the details of his effort almost entirely to Congress. Where Clinton pursued an ambitious reconstruction of the entire sector, Obama has sought to preserve existing insurance arrangements and win the support of industry players. Where Clinton spent a year developing his bill before even getting to Congress, Obama lashed his efforts to a tight (and apparently unrealizable) timetable. Even the atmospherics offer contrasts: Clinton's big push for reform came in a soaring 1993 speech before a joint session of Congress, in which he offered painstaking details of his plans; Obama made his argument to the nation at a news conference last week, addressing concerns more than specifying proposals.

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All of this has led to an interesting reversal in this year's health-care debate. In 1994, people feared that Clinton would restrict their choices. In 2009, people want Obama to bring their choices back. On June 2, Obama sent Sens. Ted Kennedy and Max Baucus, key players on reform, a letter laying out his "core belief" on a health overhaul: "that Americans should have better choices for health insurance." He's tapping into something. A Washington Post-ABC News poll last month showed that 62 percent of Americans support the choice of a public insurance option. It's one of the most popular aspects of health-care reform. But if the public option would drive private insurers out of business and reduce consumer choice, the numbers flip, with 58 percent opposing it.

What people support, in other words, is not public or private insurance, but choice in insurance. That, along with protection from escalating costs, is the inviolable principle of health-care reform.

The irony is that some of the health reform proposals on the table this year are a bit of back to the future. The health insurance exchanges that Obama envisions -- regulated markets that the government would set up where insurers would compete for business -- are the successors to the managed competition that Clinton sought. The regulations on insurer behavior and the out-of-pocket caps are direct descendants of the Clinton bill.

There are important ways, however, in which the bills currently working their way through Congress do not go as far as Clinton's plan did 15 years ago. In attempting to ensure that Americans can keep the coverage they like, they do not always ensure that people can leave insurers they do not like. The insurance exchanges, in particular, are limited to the self-employed, the uninsured and small businesses. Someone who works for a larger employer would not have any more choice under these proposals. Indeed, the problem with trying to make sure that everyone can keep what they have is that you can't change very much. This makes it hard for advocates to explain exactly how health-care reform will improve conditions for the insured, at least in the short term.

Many in the White House say this is not a bug in the proposed system; it's a deliberate feature. The lesson of Clintoncare was that even if the American people want reform, they do not necessarily want change. And so Obama's health-care strategy involves a delicate effort to answer the question that doomed Clinton: How do you reform the health-care system without substantially changing it?

But this is not the early 1990s. The indemnity insurance that most Americans enjoyed then is virtually nonexistent today. The mergers and takeovers and consolidations in the insurance market have given people less choice and thus less power. Today, the cost issue is more acute, the president is more popular, the Democrats have more seats in Congress, and the Republicans are more fractured. Obama, in other words, was right to dismiss those who would "dust off that old playbook."

But the ghosts still hover. Republicans are fixated on what worked for them in the last health-care battle, and Democrats are overly concerned with what contributed to their failure. Just as Clinton's plan was weighed down by the impression that it would change too much, history may leave Obama's effort vulnerable to the charge that it is changing too little.