A Lost Cause: Bill Clinton's Campaign for National Health Insurance, and: The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security

The authors of these books offer competing interpretations of the failure of President Clinton’s attempt in 1993 and 1994 to reform the financing of health care. They share a refusal to blame the failure, as some scholars and journalists have, on either the American political system or the president and his advisors.

Jacob Hacker and Nicholas Laham describe the events of 1993 and 1994 as the most recent of many failures to enact comprehensive national health insurance in the United States. Each of them, however, is more concerned about recent history, and especially about contemporary congressional politics and policy making, interest-group behavior, and the emergence of a cohort of health-policy experts whose political experience consists entirely of doing business with people like themselves.

The proposed reforms of the Clinton administration were not, however, the latest in a series of failures. The United States has had a national health-care program for more than half a century. This program is remarkably comprehensive, though it is not universal. Leaders of government, business, and labor, who are frequently joined by health professionals and providers, continuously renegotiate the program.

The national health program receives an enormous public subsidy. The largest proportion of this subsidy, which totals about half of all spending for health care in the United States, comes from federal tax policy (the exclusion of the cost of employment-based insurance from personal and corporate income tax) and from social security policy (Medicare). The subsidy also consists of federal and state appropriations for Medicaid, as well as spending, by all levels of government, to maintain and increase the supply of research that affects health care, of facilities (especially hospitals and nursing homes), and of physicians, nurses, dentists, and other health professionals.

This program leaves about 15 percent of the population with universal entitlement to emergency care but not broad insurance coverage. Moreover, its benefits vary geographically and by industry. This variation is a result of differences in state spending, in coverage through employment in different metropolitan regions and rural areas, and in the percentage of wages and salaries allocated for benefits by employers.

From the election campaign of 1992 until the summer of 1994, Bill Clinton and his supporters advocated major changes in this national health program. Initially they tried to build support for policies to cover uninsured persons and to remedy the grievances of many workers and their dependents who had coverage through their employment (for instance, the lack of insurance portability from job to job, and the denial of coverage to people with preexisting conditions). However, President-elect Clinton accepted advice that he should also make major modifications in the policy for subsidizing health care that had grown by accretion since the 1940s. As a result, the administration proposed health-reform measures that were opposed by leaders of politics, business, the insurance industry, and health care, and then by the general public.

Hacker ably documents the history of managed competition, the mechanism of creative destabilization chosen by Clinton and his allies. He describes the ascendancy of economics among the social sciences applied to health care, and he then documents the process by which proposals for reform based on the logic of that discipline seduced persons in government, health care, universities, and think tanks, and even an economist on the editorial board of the New York Times. He concludes that the persons whom the president entrusted with health reform reduced it from a political to a technocratic problem: they made the “task of passing reform a problem of policy analysis rather than one of values, interests, institutions, and strategies” (p. 137).

Hacker discusses aspects of the theory of agenda-setting in government. Though it is a...