The lessons of 1994

This is a TIE-U post associated with Jonathan Oberlander’s Political Dynamics and Policy Dilemmas (UNC’s HPM 757, Fall 2011). For other posts in this series, see the course intro.

As I indicated in my brief review of Paul Starr’s Remedy and Reaction, some of the book’s content explains how aspects of Clinton’s failed attempt at health reform influenced and foreshadowed Obama’s successful one. If you’re familiar with the political and legislative story of the ACA, you can draw some of those connections yourself by reading Starr’s 1994 article What Happened to Health Care Reform? [1]

In 1993, 23 Republican senators, including then-Minority Leader Robert Dole, cosponsored a bill introduced by Senator John Chafee that sought to achieve universal coverage through a mandate that is, a mandate on individuals to buy insurance. Nearly every major health care interest group had endorsed substantial reforms–grandiose ones, in fact. The American Medical Association (AMA) and Health Insurance Association of America (HIAA), the two great, historic bastions of opposition to compulsory health insurance, both went on record in support of an employer mandate and universal coverage. Even the U.S. Chamber of Commerce endorsed an employer mandate, as did many large corporations. […]

In citing evidence from the 1990s that some Republicans supported an individual mandate and many interest groups supported an employer mandate, I am not revealing anything policy wonks don’t already know. These facts were not lost on Democrats in the late 2000s, like Senator Max Baucus or then-candidate Hillary Clinton, who built such mandates into their own proposals. Naturally, they preferred a bipartisan solution to the problems of our health care system. Incorporating what they presumed to be Republican preferences–what had once been some Republicans’ preferences–seemed to be a route toward such a solution.

But Starr says there was another lesson in the failure of the Clinton plan.

We wrongly assumed that the leading Republicans and key interest groups that had endorsed substantial reforms would at least maintain their positions and might be pulled closer to ours in a final bargain. But by spring 1994, they had no reason to accept a deal. Republicans were already anticipating big midterm election gains; killing reform in the 103rd Congress was rational (“Sight unseen, oppose it” was Republican strategist Bill Kristol’s advice on Senator Mitchell’s attempt to craft a compromise proposal).

Independent of policy considerations, opposing Democrats’ health reform agenda in 1994 was good politics, leading to the Republican Revolution, a takeover of the House and Senate. Though relatively less successful and dramatic, a similar dynamic played out in 2010. Republicans unanimously opposed the ACA and took control of the House and gained seats in the Senate in the midterm elections.

It begs some questions: If the subsequent congressional election is taken as the metric, is consideration of substantial health reform always politically damaging? Need it be? In considering 1994 and 2010, one has net out typical mid-term losses for the party holding the presidency. Did health reform cause the opposition’s victory to be even greater? That is certainly the prevailing interpretation.

Whatever the answers, the lessons of the 1990s certainly made the experience of 2010 fairly predictable. Some may have been surprised, but certainly not everyone. Starr himself may have been overconfident in 1993-1994, but it’s unlikely he was caught off guard in 2009-2010. He concluded his 1994 article,

Like many others who supported reform, I failed to appreciate the risk of losing everything. We were too confident that reform was inevitable, just as some are now too certain that defeat was inevitable. Strategy and speed matter in politics as in sports. But, in both, new seasons bring new lineups and new opportunities. Health care will remain in the center of our politics for a long time to come.

Notice that he did not write that health care will remain a policy focus. That’s far form certain, as what’s at the top of the policy agenda fluctuates. Given its impact on our economy and government budgets, health care policy is critical to almost any other policy domain. But even if when there’s little chance of substantial policy change, health care is prominent in our politics. We’re seeing that in the current GOP primary campaign, and we’ll see it in the campaign for the general election.


This week, Oberlander also assigned a paper by Alain Enthoven on managed competition [2], a central idea in the 1993-1994 reform effort and also a concept behind the ACA’s exchanges. I’ve already blogged about it. For more on the Clinton health plan see Walter Zelman’s 1994 article in Health Affairs [3].


[1] Paul Starr. 1995. What Happened to Health Care Reform? American Prospect.

[2] Alain Enthoven. 1993. The History and Principles of Managed Competition. Health Affairs 12 (supplement): 24-46.

[3] Walter Zelman. 1994. The Rationale Behind the Clinton Health Care Reform Plan. Health Affairs 13(1): 9-29.

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