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The American Political System and Fundamental Health Care Reform

Every single democratic industrialized nation has found away to guarantee health care for all its citizens - except the United States. A chronology of when they did it, reveals how badly the United States is out of step. Politicians who are reluctant to step forward on this issue cite the Clinton failure as their excuse. Excerpts of thoughtful analyses of that misstep follow. Finally, any politically realistic plan will have to account for the power of money in politics.

Health Care for All: An International Timeline

Year in which elected representatives enacted health care coverage for everyone:

Germany	1883
Switzerland	1911
New Zealand	1938
Belgium	1945
United Kingdom	1946
Sweden	1947
Greece	1961
Japan	1961
Canada	1966
Denmark	1973
Australia	1974
Italy	1978
Portugal	1979
Spain	1986
South Africa	1996

Commentaries on the failure of national health reform - 1993-94:

Paul Starr, Pulitzer Prize winning author of "The Social Transformation of American Medicine" and high Clinton health care advisor.

"To say these judgements about strategy were mistaken is an understatement; they proved to be a disaster. Despite the comprehensive benefit package and the extras such as prescription drug coverage for the elderly, we did not receive passionate support from the groups we were counting on. We did succeed, however, in mobilizing the opposition. The scale of the program and its regulatory features caused sympathetic groups in the business community and opinion leaders in the media to think twice about support for reform. Because we had failed to edit the plan down to its essentials and find familiar ways to convey it, many people couldn't understand what we were proposing. There were too many parts, too many new ideas, even for many policy experts to keep straight."

From: "What Happened to Health Care Reform?" in The American Prospect, Winter 1995, p. 25

Theda Skocpol, Professor of Government, Harvard University

"Explanations for the 1993-94 health reform debacle that stress leaders' character flaws or public fecklessness are glib and unsatisfying. The "gridlock is us" view implies that President Clinton was rash to take on health care reform at a time when Americans were not yet ready to make the necessary sacrifices and trade-offs....More than setting the agenda for policymakers can hardly be expected from the citizenry as a whole. Public opinion in general never chooses among exact policy options; nor does it work out the details of policy innovations. These tasks are the responsibility of societal leaders and elected officials, ideally working within a general mandate given by voters and the public....All too conveniently, the "gridlock is us" argument excuses America's politicians, policy intellectuals, and private sector elites from responsibility for the failure of comprehensive and democratically inclusive reform of the nation's system for financing health care."

From: "Boomerang: Clinton's Health Security Effort and the Turn against Government in U.S. Politics," W.W. Norton and Co, 1996, pp.12-14.

Daniel Yankelovich, prominent polling expert

"The nation's leadership and the public are carrying out a bizarre dialogue of the deaf. The nation's elites have little trouble conversing with one another, but when it comes to engaging the public, there is an astonishing lack of dialogue. Public relations, punditry, advertising, speechifying, spin-doctoring, and so-called public education – these mechanisms of top-down communication abound. The absence of plain give-and-take between leaders and the public is striking."

"President Clinton's reform plan was not shaped by discussion with citizens about rising health care costs and what to do about them; a process whereby reform proposals are continuously adapted to the rhythm of public understanding. The plan was the product of experts and experts alone. Technical experts designed it, special interests argued it, political leaders sold it, journalists more interested in its political ramifications than its content kibitzed it, advertising attacked it. There was no way for average Americans to understand what it meant for them."

From: "The debate that wasn't: the public and the Clinton plan," Health Affairs, Spring 1995 , pps 8-9

Haynes Johnson and David Broder, Pulitzer Prize winning journalists

"For many decades, we have known that the schoolbook model of representative democracy obscures the reality....One lesson is that the majority does not always - or automatically - prevail. Our system of government is littered with constitutional and political roadblocks that make it hard for huge policy changes like health care reform to be enacted quickly. We agree, up to a point with those who point this out and conclude that The System operated exactly as it is supposed to in the health care battle: Where no strong consensus exists, major change should wait."

"But that argument ignores a deeper truth about the critical role that public opinion plays in The System. In many respects, the story of the life and death of health care reform is the story of how to manufacture and manipulate public opinion. A fundamental question that emerges from this story is, Why did the anticipated, and needed, great public debate about what kind of health care Americans want never occur?"

"The answer is that "public opinion" was largely an artifact of the groups that mobilized to defeat reform. They created opinion with their grassroots and media efforts. Then they invoked that public opinion to convince, or provide a rationale for, the members of Congress who for reasons of self-interest wanted to vote no."

From: The System: The American Way of Politics at the Breaking Point, Little, Brown and Company, 1996, pp. 628-9

The Power of Money in Health Care Politics

"Unfortunately, those without health insurance - who disproportionately include working women and children - are not only marginalized from the health care delivery system, they are marginalized from the political process." Father Michael Place, CEO, Catholic Health Association, April 1999

The Big Picture: Money in Politics

Campaign Contributions

Congressional candidates	$781.3 million
Contributions to National Party Committees - hard money	$445 million
Contributions to National Party Committees - soft money	$224.4 million
Issue advertising (estimate - Annenburg Public Policy Center)	$100 million
Independent expenditures	$ 11.7 million
Grand Total	1.56 BILLION DOLLARS

Over the last several election cycles, contributions from businesses and professionals have exceeded contributions from labor by a ratio of 7 to 1, and contributions from single issue groups by a ratio of 13 to 1.

Lobbying

Following are the 1997-98 lobbying expenditures of the top thirty lobbies. Together they account for $2.045 billion in lobbying expenditures, 76% of the total. Six of these thirty have a significant interest in health policy issues. The campaign contributions of these six are also given.

	Lobbying	Campaign contributions
Pharmaceuticals/health products	$148.6 million	$13 million
Insurance	$141.3 million	$31.2 million
Telephone utilities	$130.2 million
Oil & Gas	$120 million
Electric utilities	$118.4 million
Tobacco	$105.6 million
Health professionals	$ 89 million	$31.5 million
Business Associations	$ 82.6 million	$ 2.5 million
Miscellaneous issues	$ 77.1 million
Automotive	$ 76.9 million
Misc. manufacturing & distributing	$ 73.7 million
Air transport	$ 72.4 million
Government agencies	$ 64 million
Computer equipment & services	$ 63.9 million
Commercial banks	$ 62.9 million
Securities & investment	$ 59.1 million
TV/music/movies	$ 57.3 million
Defense aerospace	$ 56.1 million
Education	$ 55.4 million
Chemical & related manufacturing	$ 51.7 million
Hospitals/nursing homes	$ 49.6 million	$ 7.8 million
Real estate	$ 48.9 million
Telecom services & equipment	$ 43.7 million
Railroads	$ 34.5 million
Agricultural services/products	$ 33.2 million
Finance/credit companies	$ 31.1 million
Health services	$ 30.1 million	$ 5.5 million
Lawyers/law firms	$ 25.1 million
Printing & publishing	$ 22 million
Casinos/gambling	$ 20.4 million

Total lobbying expenses for unions were $44.4 million; for clergy and religious organizations, $2 million.

How money affects politics

Despite the billions of dollars invested to influence the political system, it is not always easy to see its impact, because most of its impact is behind the scenes. Sometimes it is possible to predict which way politicians will vote on the floor based on the sources of their contributions and the intensity of a lobbying campaign. More commonly, the money affects which bills politicians will sponsor, which bills will be given hearings in committees, which bills will be voted out of committee, which amendments will be bundled together on the floor, etc. Most importantly, the money influences which bills will not go forward in Congress.

Money sometimes gets what it wants. More frequently it makes sure it doesn't get what it doesn't want. There is no more convincing evidence of this than in the arena of universal health care. Over the past fifty years, a half century in which the vast majority of the democracies of the world enacted coverage for all, there has not been a single vote on the floor of the House or Senate on this issue.