What Hillary Has Learned from '93

Thursday, Sep. 20, 2007 By JOE KLEIN

Democratic presidential hopeful, Sen. Hillary Rodham Clinton speaks about her health care policy at Broadlawns Medical Center in Des Moines, Iowa.

Charlie Neibergall / AP Photo

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Back in 1993, when Hillary Clinton first tried to reform the nation's health-insurance system, Senator Daniel Patrick Moynihan warned about the difficulty of getting such a gargantuan bill passed: "The Senate has its own peculiar ecology," he told me. "Something like this passes with 75 votes or not at all." Moynihan was then chairman of the Finance Committee, the Senate's natural choke point for big social-engineering schemes. He was worried that the Clintons, especially the First Lady, were being stubborn, trying to jam their bill through with a bare majority rather than build a bipartisan consensus. At the end of his presidency, I asked Bill Clinton what would have happened if he and Hillary had discarded their 1,300-page brontosaurus of a bill and built a bipartisan consensus around the simpler, sketchier — but also universal — Republican plan proposed by Senator John Chafee of Rhode Island. "Maybe that would have worked," Clinton acknowledged. Well, Hillary Clinton has now introduced Health Care 2.0, and — lo and behold! — it is a direct descendant of the plan she chose not to support in 1993. And with some clever consensus building, it is just the sort of bill that may have a chance to work.

Flashback: Hillary's First Health Care Plan

As critics take aim, the President ducks and weaves to defend his health-care reforms

Warning: any discussion of the American health-insurance system is doomed to density. For many, the very concept of insurance is a natural snooze button. But we do have a problem. Our bizarre, disorganized crazy quilt of a health-care system is clattering toward a fall. It is inefficient in the extreme and therefore foolishly expensive. It leaves 47 million people uncovered — and millions of others worrying about how much coverage they have and how much they'll have to pay for it next year and how long their employers will continue to provide it. The sheer anxiety inherent in all this is an incalculable drag on the economy. The question is, How do you reform the system without making it worse and without scaring the majority of people who are happy with their current doctors and health plans? If you're Hillary Clinton, you start by calling your proposal the American Health Choices Plan — to emphasize how different it is from the 1993 one-size-fits-all rendition — and keep on repeating the market-tested word choice throughout your speech. You say things like, "Here's how my plan will work: If you have private insurance you like, nothing changes ... You like the doctor you have, you can keep that doctor."

But two important things would change. Clinton's "choices" come with two national mandates — for individuals and for insurance companies. Individuals will have to buy health insurance, just as car owners have to buy auto insurance. Those who can't afford it will be subsidized by the government, which is why universal plans are so expensive; Clinton's plan has a $110 billion annual budget. But an estimated one-third of the 47 million who don't have health insurance are people who can afford it, mostly healthy young people who don't think they need it. They do, of course; the rest of us subsidize their care when they show up at the emergency room after a skateboarding accident. Their presence in the system will make health insurance less expensive for everyone else. This is a bold move on Clinton's part. Of the major candidates, only John Edwards has presented a plan with a similar requirement. It is a detail that Barack Obama, with his army of youthful supporters and his claim to audacity, avoids.

The other mandate will be far more difficult to impose, however: it requires insurance companies to cover all comers, regardless of age or existing medical conditions. In the trade, this is called community rating, and it will be fought hammer and tongs by the insurance industry. Clinton, Obama and Edwards all require it in their plans; none of the Republicans do. This is where politics intrudes, in the form of a legion of insurance- and medical-industry lobbyists. No universal-health-care plan will pass unless it has enough support from the business community, especially small business, to overcome the opposition of insurers, doctors and the pharmaceutical industry. And this is where Clinton's plan has a subtle advantage.