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Clinton-Era Health Fight Veterans Hold Out Hope for Overhaul

By Jane Norman, CQ HealthBeat Associate Editor

September 11, 2009 -- The environment for major change in the health care system may be even tougher than when President Clinton's attempt failed in the 1990s, but a panel of experts assembled at the American Enterprise Institute on Friday held out hope that the outcome still may be different.

In comparing the period of 1993–94 and now, there are fewer moderate members of Congress equipped to broker a compromise between warring partisans on the left and right, and fewer with detailed knowledge of how the system works, the panel members said. The nation's economic status is more dire and spiraling health costs bog down the federal budget as baby boomers' retirements begin and burden the Medicare program.

The media environment has shifted, with talk radio and the instancy of the Internet supplanting three television networks and newspapers.

Yet William Gradison, a former Republican congressman from Ohio who as the head of the Health Insurance Association of America helped lead a fight against the Clinton plan, said he believes Congress this time will act. So did Dean Rosen, a health consultant who served as a top health adviser to the former Republican leader in the Senate, Bill Frist.

"I think Congress is going to pass a bill—I think for the Democrats to have 60 votes in the Senate and not to pass a bill would probably be legislative malpractice for them, given how much this president has staked politically on reform," said Rosen. "He is way out there. I do not think failure is an option."

The discussion came after a roller coaster week for the health overhaul in which President Obama laid out the outlines of a health proposal in a joint session of Congress, interrupted by a shout of "You lie!" from a South Carolina Republican congressman, and the chairman of the Senate Finance Committee announced his plans to move ahead toward a markup of a bill by the week of Sept. 21.

Obama until now had stayed away from too many specifics, taking a lesson from the Clinton experience, when Hillary Clinton and a group of advisers assembled a health care proposal behind closed doors and presented it to Congress.

But following an August recess filled with loud and sometimes inaccurate attacks on the health care overhaul at town hall meetings, and falling approval ratings, Obama presented an outline that included many of the elements included in the House and Senate bills already approved by committees.

Len Nichols, who was a health adviser at the Office of Management and Budget during the Clinton years, said "Congress did its job" in approving legislation in three House committees and one Senate committee fairly rapidly, but not in time to avoid the town hall troubles.

The atmosphere was similar to the strong negative emotions stirred by the "Harry and Louse" TV ads that helped kill the Clinton proposal, though as Nichols observed "Harry and Louise are now Democrats" and taping ads calling for change.

"So one similarity between now and then is explaining complexity when people are scared is really hard and I'm not sure anybody could do it," Nichols said. "Once you get past the shouting, which indeed with some effort you can, when you talk to people about what it's really about. . . people can be calmed down. There is a broad recognition the system is broken down."

That's different from in the 1990s, when "we were pretty smug" and the American health care system was regarded as expensive but the best in the world, said Robert Reischauer, the former director of the Congressional Budget Office. "A lot of studies have brought that into question now," he said.

Gradison said "the insured do vote" and what polls have found then and now is that they also want to keep the health insurance they have—and pay less for it. He questioned what the reaction will be if Americans can't keep high deductible policies favored by groups such as farmers and ranchers, or if insurers increase premiums to make up for taxes possibly levied on insurance companies to help pay for the overhaul.

Another member of Congress once warned him against voting for legislation that includes "something in there for everybody to hate," said Gradison. "If a bill is rushed through too fast, there may be things in there that once they become public, can cause some real concern among the body politic," said Gradison.

"It has been puzzling to me over the last month or so to hear people arguing for or against the plan, when there isn't a plan to be for or against at this point in time," he added. "Far too much of what has passed for public discourse has been based more on lack of information than it has on misinformation."

One element that's remained consistent and difficult to surmount is that many Americans—and politicians—don't really understand how the health care system works or how care is financed, said Reischauer, now the president of the Urban Institute.

"The American people and many of their leaders remain woefully confused and misinformed about health," he said.

"They don't understand who's footing the bill, the employer or the worker. They don't fully appreciate what the insurance they're receiving from their employer costs. They think the premiums are outrageous even though they're paying a rather small fraction of the total. They're sure they could have the same thing a whole lot cheaper and there must be someone out there screwing them," said Reischauer.

"They don't want to look in the mirror and say, hey, I might be a part of this," he said. "A huge education task lies before us whether we are successful in this round or not."

This year's congressional process may have been smoother had the late Sen. Edward M. Kennedy, D-Mass., not fallen ill and had to step away from negotiations, said Nichols. Kennedy, who died in August, was the chairman of the Senate Health, Education, Labor and Pensions Committee.

"I would say the impact of his illness has already seriously been felt," said Nichols. Two key Republican senators on the committee, Orrin G. Hatch of Utah and Michael B. Enzi of Wyoming, both expected to work with Kennedy on a bipartisan agreement, said Nichols.

"His illness prevented that from being possible," said Nichols. "Unfortunately, that had the spillover effect of taking that frustration and sadness and hurt into the Finance Committee, where it was even harder to deal with."

Both Hatch and Enzi also serve on Finance and Enzi has been a member of the "Gang of Six" bipartisan negotiators, though relations have been very strained at times. Hatch declined to continue with the talks.

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