Talk of Power, Power of Talk: The 1994 Health Care Reform Debate and Beyond (review)

Michael W. Shelton. Talk of Power, Power of Talk: The 1994 Health Care Reform Debate and Beyond. Westport, CT: Praeger, 2000. 200 pp. $62.50 cloth.

The early 1990s looked like a propitious time for health care reform. Working Americans were losing coverage that they had taken for granted as an entitlement. Even business interests recognized that soaring health care costs cut into their bottom line. Senator Harris Wofford and President Bill Clinton mustered this crisis into upset political victories. Given the momentum, how could the Democrats have bungled reform?

By setting the health care question in context, Michael W. Shelton shows in Talk of Power, Power of Talk that this is the wrong one to ask. He pointedly observes that in this decentralized, fee-for-service health care system, the very term system is something of a misnomer: "the organization of health care [in] the United States might be thought of most accurately as a patchwork of governmental and nongovernmental elements largely directed by the private, entrepreneurial sector" (17). This is a context that favors incremental reform—if it favors reform at all. Indeed, Shelton notes, "each and every comprehensive national attempt at reform has met with failure" (21). Appropriately, Shelton prompts us to wonder not how Clinton's comprehensive reform effort could have failed but what possessed anyone to think that it would succeed?

There have been many analyses of the failure of health care reform, many from an institutionalist perspective that has emphasized the weaknesses of the Clinton presidency and the Democrats' tenuous hold on power in Congress. Shelton offers something new by bringing a "discursive perspective" to these studies, undertaking a textual, rhetorical analysis of the arguments that defeated the health care initiative (126). Specifically, he focuses on the congressional debate, pinpointing the floor arguments in the Senate over the Health Security Act, which majority leader George Mitchell introduced in August 1994. Using the Congressional Record as his primary textual source, Shelton analyzes five discursive features of the exchange: (1) "crisis" discourse, (2) categories of evidence, (3) "narratives," (4) "language strategies," and (5) "medical metaphors" (61). His central contention is that proponents of health care reform were defeated not by a counterargument that opposed their proposal point by point and on the merits; instead, they were defeated by a counternarrative: "The opponents of comprehensive health care reform
. . . successfully crafted a crisis of big government and defined the Mitchell bill as a symptom of that crisis" (118). And what is remarkable is that the anti-health care reformers did so by managing to displace an "objective" crisis in health care in favor of a "rhetorically crafted virtual crisis of big government" (106). This remarkable outcome raises the following question: "How could the rhetorically constructed virtual crisis of big government outweigh the actual health care crisis?" (106).

The core of this book is devoted to answering that question in a way that illustrates the broader theoretical claim of this study, that "talk is power" (1). In the Senate floor debate, opponents of health care reform harnessed the power of talk in four different ways. First, they managed to push "the right buttons," finding "something for everyone to hate [about health care reform], or at least to fear" (107-108). Second, they told a compelling story about the grave consequences of big government. Third, they played on the "inherent and enduring tension between reassurance and threat" (113). Whereas proponents of the Mitchell bill presented the health care crisis as a threat and the Health Security Act as reassurance, opponents managed to recast that reassurance as a threat in itself: "taxes would increase, individual choice would decline, freedom and liberty would be lost, and our health care system would be modeled on the Postal Service" (113). Finally, whereas proponents of reform detailed the crisis in...