Presidential Health Care Plans

by Jonathan Cohn | May 21, 2007

Mark Schmitt humbly begins his essay by confessing that he has worked on just one presidential campaign. Well, I can top that: I haven't worked on any! And while I've certainly covered my share of campaigns as a reporter, I'll confess that my expertise is in policy, not politics. On questions of campaign strategy, I'd typically defer to Mark's wisdom, which I believe to be considerable. That's particularly true on an issue like health care, which experience has shown to be so treacherous politically.

And I suspect we share at least some common ground--more, at least, than he might realize. He's against too much specificity--but, in a sense, so am I. When I said I wanted Hillary Clinton and Barack Obama to give us more specifics on their designs for health care, I didn't mean I expected to see white papers covering every possible detail, right down to precisely calculated financial estimates that would pass muster with the Congressional Budget Office. Like Mark says, it's become a "hazing ritual" conducted by journalists like me--and a highly unproductive one at that. Indeed, as I mentioned in my original essay, it's not like candidates can count on the press to give them credit for the specifics, even when they make sense.

So what do I want candidates to give me (and the rest of the public)? The basics will suffice. When you say universal coverage, do you mean everybody? If so, by when? Roughly what level of benefits do you consider adequate? Do you want to blow up the whole health care system or simply find a way to patch the holes in coverage? If it's the former, do you intend to create a single-payer system or craft a system that relies heavily on private insurance? If it's the latter, how do you intend to pay for your plan, since it probably won't save enough money to cover the extension of coverage?

Just to be clear, you can be specific without being stubborn. There's nothing wrong with declaring a preference for one model of reform while leaving the door open to others. In fact, preserving flexibility makes a lot of sense: Embrace one approach but indicate a willingness to discuss alternatives that achieve the same goals.

 

I gather, however, that Mark thinks even this approach would go too far. After all, he says, the more details you give, the more likely you are to lose in the general election. And if the Democratic candidate loses in November, that will greatly diminish the chances of universal health care anytime soon--all the more so if the candidate has campaigned on the issue. Get the politics right first. Get the policy right second.

But one problem with this approach is that it emphasizes strategy while ignoring substance. As I explained, a big part of the reason I want to hear more is that I genuinely don't know what the two leading candidates think about it. Obama is so inexperienced I have very little sense where he'll come down on the key questions I set out in my essay. And while Clinton has a very clear track record--thanks to her role in the Clinton health care plan of 1993-94--it's not clear whether she'd go in a similar direction, or show similar ambition, if given the chance all over again. In a nutshell, I want to hear some details because I care a lot about health care and want to vote for a candidate whose views on the matter make the most sense to me. How are voters supposed to make informed choices if the candidates remain vague on the issue until after the election, as Mark advises?

And let's ignore substance for a moment. Is it really such bad politics to put out details during the campaign? Yes, you open yourself to attack. But you also gain credibility as a reformer who is serious enough to have thought through the problem. And, yes, you antagonize some interest groups. Then again, beating up on interest groups like insurance companies and the pharmaceutical industry--neither of whom are very popular these days--can also win you some pretty cheap political points.

To this, Mark says, in essence, why rush? See what the political landscape looks like in January 2009 and then make enemies as necessary. But this idea that it's better to wait until after the election before developing a strategy for reform is exactly what's wrong with so much strategic thinking in Washington: the assumption that politicians must always react to political circumstances, rather than shape them. Politics is not so static. Public opinion moves. And, more important, it can be moved--by the right candidate with the right message and ideas.

Consider the example Mark cites: the posture of the business community. I agree that it will play a critical role in determining whether health care reform actually happens. But its position on reform in 2009 will depend a great deal on what happens before then. If, for instance, its members perceive that a candidate has made universal health care inevitable, then they will be far more likely to strike a deal. One big reason so many abandoned the idea of universal coverage in early 1994 was that it was precisely at that moment that it lost the aura of inevitability.

 

Do I have any historical precedents--any examples of a time when outlining a detailed plan for such a sweeping initiative actually led to the passage of that plan? Actually, I do. Sort of. In 1960, John Kennedy made Medicare a staple of his campaign for the presidency. Following up on proposals he and other Democrats had made in Congress, he laid out a pretty detailed proposal, sketching out how the program would be administered and the benefits it would confer. It even specified the size of the payroll tax deduction necessary to finance the plan. As it happens, I own a vintage Democratic Party advertisement from that era. It ends with the slogan: "JFK's way is the American way. Back Medicare/Vote Democratic."

Granted, Medicare wouldn't become law for another five years--it would require Lyndon Johnson and the 1964 Democratic landslide to make that happen. By that time, however, the public was practically demanding it, thanks to Kennedy and Johnson's stumping for it--details and all--on the campaign trail. (LBJ had indicated it'd be his top domestic priority.) The initiative's popular appeal played at least some part in that victory. You could also argue that the momentum Democrats built behind the plan was instrumental in pushing it through Congress, if only by convincing at least some of the special interests (mostly hospitals and some of the insurers) that it was a fait accompli--meaning they were better off trying to help craft a compromise to their liking than trying unsuccessfully to block it.

I know that campaigns have changed a lot since then. You didn't have rapid response teams to make serious policy talk so treacherous. So I agree that a little caution makes sense this time around. Just not too much.

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