Also In This Issue Related stories are available to subscribers only: National Journal: Hillary's New Vehicle Related Resources On NationalJournal.com Poll Track: National Polling On Health Care (3/2/07) · Ad Spotlight: Little Voice (4/10/07) · National Journal Cover Story: "The States Step Up" (3/16/07) · National Journal Cover Story: "The Mass.-ter Plan" (6/9/06) · National Journal: "An Opening on Health Care" (12/9/06) · Wealth Of Nations: "A Glimmer Of Purpose In The Pantomime" (1/26/07) · Wealth Of Nations: "The Massachusetts Experiment" (6/23/06) · Insider Interview: Cures For The Nation's Ailing Health Care System? (8/3/05) [an error occurred while processing this directive] Additional Resources On The Web FOX News: "Hillary Clinton Vows Universal Health Care Will Be Her Goal as President" (3/26/07) · Washington Post: "How to Heal Health Care" by Hillary Clinton and Bill Frist (8/25/04) · National Public Radio: "Hillary Clinton Takes on Health Care Again" (4/17/04)

By Marilyn Werber Serafini, National Journal
© National Journal Group Inc.
Friday, May 4, 2007

Democratic presidential hopeful John Edwards eagerly detailed his bold health care plan at the March 24 candidates' forum in Las Vegas. Without hesitation, Edwards, the first 2008 Democratic candidate to unveil a comprehensive health care proposal, declared that making good on his promise to insure all Americans would cost $90 billion to $120 billion a year and necessitate raising taxes.

Ironically, Hillary Rodham Clinton, the 2008 presidential candidate with the most expertise in both the nitty-gritty of federal health care policy and the difficulty of enacting major changes to it, is in no rush to pull her ideas into one tidy package. Ever since her futile 1993 attempt to push through the universal health insurance plan that critics derided as "Hillarycare," she has had the battle scars to prove that a comprehensive plan and its author can become handy targets. Clinton says she has come to believe that having a plan isn't enough -- and isn't even the proper first step, at least for her.

"What I'm doing in my campaign is talking about health care every chance I get, asking people for your ideas, your suggestions," Clinton said at the Las Vegas debate. "I was listening to some of the questions that were asked. Great questions. Deserve answers. We're going to have to deal with every single one of them. But if we don't have the support to get a bill through the Congress, we can keep talking about universal health care coverage, and the number of the uninsured and the underinsured will keep going up, and we'll keep spending more money and we won't have very much to show for it. So we don't only need candidates to talk about it, and we don't just need candidates to have a plan."

Four years ago, as the 2004 presidential campaign ramped up, then-Rep. Dick Gephardt of Missouri presented a major health care plan, and all of the other Democratic candidates felt compelled to quickly follow suit. Polls showed that voters were upset about health care costs and the growing ranks of the uninsured.

Today, voter angst about health care is, if anything, even greater. But don't expect Clinton, the Democratic front-runner, to rush in with a comprehensive blueprint. To be sure, the Democratic senator and former first lady is passionate about the subject. She reads a multitude of wonky policy journals, works tirelessly on health care legislation, and has stacked her staff with health care experts. Nevertheless, the New York senator has decided to take her time. Indeed, when she talks on the stump about health care, she speaks of the broad principles that guide her thinking: Yes, she wants universal health insurance coverage. Yes, she wants to improve the quality of care. And yes, she wants to lower the cost of health care.

At some point, Clinton says, she may get more specific. But when she reaches that point, she would want the American public to feel included in a partnership to improve the nation's health care. "I don't think the challenge is having a plan," Clinton told National Journal in an April 24 interview. "Most people who have studied this issue and share my goal of achieving quality, affordable health care coverage for every American know there's a menu of certain choices you have to make. The real challenge is whether you can engage the country in a movement for change that will guarantee quality, affordable health care."

Clinton has been conducting what she calls a "conversation with America," through town hall meetings and smaller gatherings across the country, to hear voters' ideas about health care and other concerns. Her go-slow approach doesn't surprise political strategists, given the pounding she took in 1993 over her gargantuan health care package. As Clinton remarked in Las Vegas, "I know probably better than anybody how hard [health care reform] will be. Yeah, I know. I've got the scars to show for it."

Initially, conditions seemed ideal for overhauling the nation's health care system when Bill Clinton became president. Shortly after being sworn in, he put controlling health care costs and reducing the number of uninsured at the top of his domestic agenda. He asked his wife to lead the reform drive. Democrats controlled both chambers of Congress, party leaders were eager to proceed, and polls showed that Americans wanted action.

But things did not go well. New to Washington, the Clintons ignored protocol. Instead of announcing broad goals and leaving the how-to to Capitol Hill allies, the president allowed Hillary Clinton and her gigantic crew -- a task force of about 500 health policy experts -- to work behind closed doors for more than six months. Key lawmakers and interest groups seethed about being shut out. In early June 1993, Hillary Clinton set up a "war room" at the White House to respond to attacks. By the time the Clintons presented their 1,300-page Health Security Act to Congress that September, it was doomed.

The measure would have required all but the smallest of employers to provide employee health insurance and to pick up most of the tab. Insurance costs were supposed to decline as a result of increased competition between health plans. The proposal would have capped insurance premium increases and would have made it easier for businesses and individuals to join together to qualify for better rates. The Congressional Budget Office differed radically from the Clintons on their plan's cost: The Clintons estimated it would slash the federal deficit by $58 billion over six years; CBO said it would increase the deficit $74 billion. The budget office agreed, though, that the plan would produce near-universal coverage and would eventually reduce national health care spending.

Details of the Clinton plan began leaking long before it was formally presented. Businesses and insurers were bitterly opposed. The National Federation of Independent Businesses, unhappy with the employer requirements, embarked on a major grassroots campaign to pressure legislators to reject the entire package. The Health Insurance Association of America, which has since merged with another group to become America's Health Insurance Plans, fired pre-emptive shots with the "Harry and Louise" ads that cast Clinton's proposal as a complicated, big-government plan that would force those who were happy with their insurance into something different.

Hill Republicans decided that they would not even negotiate with Clinton or their Democratic colleagues. At a hearing of the House Education and Labor Committee, then-Rep. Dick Armey of Texas, a member of the Republican leadership, told Clinton he would do his best "to make the debate, the legislative process, as exciting as possible," according to a New York Times account. "You and Dr. Kevorkian," Clinton replied, to which Armey said, "The reports of your charm are overstated, and the reports of your wit are understated." Although less vocal, Democrats, too, including then-Senate Finance Committee Chairman Daniel Patrick Moynihan, D-N.Y., were critical of the plan.

"The old adage is, the president proposes and Congress disposes," said Rep. Jim McDermott, D-Wash., who serves on the House Ways and Means Committee, as he did then. "They were new in office, in the first year of their presidency. They hadn't really grasped this." McDermott recalls that then-Ways and Means Committee Chairman Dan Rostenkowski, D-Ill., an old-fashioned master negotiator, advised Hillary Clinton to give him an outline of what she wanted and told her, "I'll work on it, and when we're done, you throw your arms around it and say, 'It's just what I wanted.' " But that's not the way Clinton operated at the time.

She personally briefed Ways and Means members before unveiling the White House plan, "but members left there thinking, 'They don't really want congressional input. They [are] going to do their own thing,' " says someone who was then on the committee's staff.

Rep. Pete Stark, D-Calif., who was chairman of the Ways and Means Health Subcommittee (as he is now), contends that others were more to blame than Hillary Clinton. Still, he concedes that her health package was crafted "as if they were off on Mars, without any thought to political relevancy and problems they were going to have to deal with, like the American Medical Association, the American Hospital Association, Blue Cross Blue Shield, the AFL-CIO. They went ahead and dreamed up a plan that was screwy."

When the White House plan finally arrived on Capitol Hill, Democrats gave it a swift burial. They went on to lose control of both the House and Senate in the 1994 midterm election, and many observers blamed Hillarycare -- along with President Clinton's gun control successes and his efforts to allow gays to serve openly in the military.

"The failure at that time marked the administration, and it marked her," says Tony Coelho, a Democratic political strategist and former member of the House. "She had a very detailed plan, and she went after it. And to a great extent it failed [because] it was probably too dogmatic and had to be X, Y, and Z, and people were advocating that there had to be some compromises.... She probably is going in at this point knowing that she needs to be more flexible to succeed."

Clinton's Second Chance
Right now, Clinton's best approach to health care, in the view of many political strategists, is to go slowly to keep the bad feelings of the past, well, in the past. She has to show the public that she still cares deeply about the country's health care problems and that she's learned a few lessons about not micromanaging from the White House.

What Clinton has said as a presidential candidate about health care generally tracks -- at least in principle -- with what she was pushing in 1993:

• The federal government should consider requiring individuals to have health insurance.
• Insurance companies should be required to take all comers and be prohibited from refusing to cover pre-existing medical problems.
• Employers should be required to provide employee health insurance or to otherwise help subsidize their workers' coverage.
• The government should consider allowing people who aren't covered through an employer to enroll in Medicare or the health care system for federal workers.
• Government should encourage investment in health information technology as a way to improve the quality of health care and to lower costs.
• The government should crack down on waste.
• Washington should make the rich help pay for the added cost to the federal government.

Despite the Hillarycare fiasco and the fact that Clinton hasn't spelled out how she would achieve these goals, early polls show that on health care, voters trust her more than other presidential candidates. In a March poll of early-state voters -- those in Iowa, New Hampshire, Nevada, and South Carolina -- 35 percent of respondents said that Clinton would be the best president on health care, double the 17 percent who named Edwards. Eleven percent picked Sen. Barack Obama, D-Ill.; the remaining Democratic candidates garnered only single-digit support. Democratic pollster Celinda Lake oversaw the poll.

A Kaiser Family Foundation poll, also conducted in March, produced similar results. When Democrats were asked which candidate in either major party best represented their own views on health care, 27 percent chose Clinton. Obama came in second with 8 percent. Among Republican respondents, Clinton shared top billing with former New York Mayor Rudy Giuliani. Each received 7 percent.

"What voters want to know is that you're serious, and what matters most is not specifics of a plan but that you're committed to moving forward after the election," said John Rother, policy director for AARP, the seniors group that is pushing candidates to talk more about health care.

Has amnesia set in? Does the American public remember how badly Hillary Clinton's plan to transform the nation's health care system flopped?

It's not that people have forgotten, says Robert Blendon, director of Harvard University's program on public opinion and health and social policy. It's that the public doesn't blame her. "People remember that she cared a lot about health care. They don't remember a political disaster, that things collapsed, that the House changed, people demonstrating.... People remember it was her big issue. She was very active and committed. They say she really cares about this."

Clinton, who this year began her second term in the Senate, has more experience grappling with health care issues than any of her rivals for the Democratic presidential nomination. When it comes to health care, the words "smart," "wonk," "geek," "homework," and "photographic memory" seem to follow her. She not only thoroughly reads staff memos and newspaper clippings given to her, she also gives articles to aides that she has spotted. "She can talk circles around Obama on Medicaid [and other health programs] because she's done all of this before," said a former Democratic congressional aide. On health care issues, the track records of Obama, who has been in the Senate only since 2005, and Edwards, who left the Senate in 2005 after just one term, are slim, leaving them with little choice but to put out detailed plans, political strategists say. Obama has promised to release one within a few months.

Democratic strategist Bill Carrick praises Clinton's cautious approach. Carrick, who worked for the Gephardt campaign in 2004, recalls what happened after the representative from Missouri was the first out of the box with a major health care plan: "After the applause dies down -- that lasts for about two to three days -- then the rest of the world starts picking it apart.... The more details, the more spitballs come your way."

In the 2000 primary campaign, when Vice President Gore and former Sen. Bill Bradley of New Jersey were duking it out for the Democratic presidential nod, Bradley unveiled a bold, detailed health care plan that Coelho, who chaired Gore's presidential campaign, called the Bradley campaign's undoing. "We were able to take Bill Bradley's specifics and turn on him and make a real negative issue. [Unveiling] his detailed plan too early really hurt him. Gore was behind in the polls and going down, and he took this on and it was one of the last things for Bradley. It made him into a dreamer instead of someone who could get things done."

Bradley had proposed making health insurance available to nearly all Americans by killing Medicaid and instead providing federal subsidies and tax credits to help low-income people buy private insurance. Gore argued that the plan would not come close to providing universal coverage, that it would cost more than Bradley projected, and that it wouldn't lessen Medicare's financial difficulties.

In Coelho's view, Clinton "has a different bridge to cross than most politicians.... With most politicians, people wonder whether they mean it, getting a health plan. The doubts that people have with her are about whether she will listen to others to get done what is do-able."

The Quick Study
Three lessons that Clinton learned the hard way have informed her Senate career: take incremental steps toward major change, include colleagues and interest groups from the start, and partner with Republicans. Following these guidelines, she has amassed an impressive set of health care successes and made allies on both sides of the aisle.

Clinton, a quick study, adjusted her tactics long before she got to the Senate. After Ways and Means Democrats made it clear that her 1993 bill was going nowhere because they didn't like its content and complexity, and because they resented being left out of its development, she backed the committee's ultimately futile 1994 efforts to push its own universal health care bill. Later, while her husband was still in the White House, she was instrumental in getting Congress to create the State Children's Health Insurance Program, which provides health care coverage to more than 4 million kids.

Clinton remained focused on health care after being elected to the Senate. Her first floor speech was on that topic -- she promised to be both energetic and pragmatic. She understood that the time wasn't right to push for comprehensive reform. She focused instead on smaller, do-able bills. Securing a seat on the Senate Health, Education, Labor, and Pensions Committee, she modeled herself after its ranking Democrat, Edward Kennedy of Massachusetts, who boosts his effectiveness by working with Republicans whenever he can do so without abandoning his Democratic ideals. And Kennedy is a master of heading off problems by seeking outside advice while legislation is still being crafted.

Clinton has invested a great deal of time in courting stakeholders, working closely with business, physician, and hospital groups that typically deal more with Republicans. Health care professionals have contributed more to her presidential campaign than to any other candidate's. The Center for Responsive Politics reports that Clinton has gotten $493,496. Next is former Massachusetts Gov. Mitt Romney, a Republican, with $434,050. Obama is third, with $366,698. When it comes to contributions from the pharmaceutical and health products industries, Clinton is again first, with $115,750; Romney is second, with $108,185; and Obama is third, with $50,795.

Clinton worked successfully last year with Sen. John Warner, R-Va., to authorize spending $30 million in fiscal 2008 to help states provide for respites for long-term caregivers of chronically ill people. Clinton and Warner have teamed up once more to try to get those funds appropriated.

Clinton has consulted closely with groups, such as the March of Dimes, and with pediatricians on legislation to ensure that newborns are screened for certain genetic disorders. Sen. George Allen, R-Va., co-sponsored the legislation before losing his re-election bid last year. Clinton partnered recently with House Energy and Commerce Committee Chairman John Dingell, D-Mich., a longtime friend, to introduce legislation to expand SCHIP to include more children. She has been a leader in the fight against Republican proposals to rein in federal expenditures for Medicaid and in the campaign to push the Food and Drug Administration to speed up approval of generic biologic drugs.

Clinton has worked on mental health legislation with Sen. Susan Collins, R-Maine, and on HIV legislation with Sen. Gordon Smith, R-Ore. She has joined Sen. Lindsey Graham, R-S.C., who as a House member was a leader in the drive to impeach her husband, on military health issues. She has been instrumental to the success of legislation to get the FDA to require drug companies to pay closer attention to the effects of pharmaceuticals on children in clinical trials.

Clinton worked with then-Senate Majority Leader Bill Frist, R-Tenn., on bills that would establish compatibility standards for electronic health records systems and would fund demonstration projects to encourage medical providers to adopt electronic systems. She has also collaborated in recent years with former House Speaker Newt Gingrich, R-Ga., despite their many policy differences and Gingrich's role in the 1998 impeachment. The two share a passion for promoting health information technology. "She is very hardworking and very studious. She takes seriously trying to understand problems we're trying to understand in this country," Gingrich says.

The Pressures Ahead
Although many political strategists predict that Clinton's go-slow approach will continue to help her presidential campaign, others question how long she'll be able to avoid presenting a plan if other Democratic candidates market theirs. Lake, the pollster who found that the public trusts Clinton on health care, also reported that in Iowa Edwards and Clinton were in a statistical tie for first place on health care issues after he released his detailed plan. (Thirty percent of Iowans ranked him best; 28 percent put her first.) In the three other states polled, Clinton was alone in first place. Just before Lake polled in Iowa, she said, Edwards mailed 70,000 DVDs about his health care plan to households there.

"When candidates make the issue a centerpiece, voters take note," Lake says. Moreover, she said that in research for the Service Employees International Union, she has found that voters think candidates are talking too much about health care problems and not enough about solutions. "They want their candidates to have a plan. They want real health care reform, and they want to know how you get from principles to the practical," Lake said. Bill McInturff, a partner at the Republican polling group Public Opinion Strategies, predicts that Clinton will feel pressure within the next few months to get more specific. "On the Democratic side," he says, "58 percent of voters are women, and this issue is particularly important to primary voters. It will be difficult for her to be that much on the sidelines without more details."

Regardless of whether she produces a new plan, Clinton will probably have to deal with lingering fallout from Hillarycare if she becomes the Democratic nominee. "If health care is central [in the general election], it will spur TV and radio talk shows to go back and talk about the last time Hillary tried to fix health care," Harvard's Blendon said. "If she is the Democratic candidate, the Republican candidate will try to talk about her executive leadership experience. They'll say this is the one chance when she was in a role delegated by the president to make national policy," he continued. "The worst case from her perspective is questioning her executive ability. The Senate role is not an executive role. It's a policy role. The executive role is what the president does."

Much will depend on the identity of the Republican nominee, said Carrick, the Democratic strategist. For example, Romney might not want to draw attention to health care. As governor of Massachusetts, he ushered through the Legislature a universal coverage health care bill that requires individuals to buy insurance and employers to cover workers or pay a fee. Initially hailed as a model for other states, the Massachusetts plan is running into complications as insurance companies weigh in with higher-than-expected prices, and as critics pose legal challenges to the requirements for employers. "Romney isn't talking about his own plan on the stump, because there are a lot of Republicans who don't like what he did in Massachusetts," Carrick said.

Coelho, though, speculates that if Romney wins the GOP nomination, he will "talk about [Clinton's] inability to get something through a Democratic Congress and his ability to get something through a Democratic Legislature. Republicans are going to say she can't do the executive thing."

Clinton herself says that a Republican attack on her health care past would "backfire. They may very well try it, which I would welcome, because I want an election about health care. Give me credit for having tried something really hard."

On Capitol Hill, Republicans say that no matter how collegial Clinton tries to be, they're willing to cooperate only up to a point. As Sen. Orrin Hatch, R-Utah, puts it, "She's a hardworking senator. I'd work with her any day of the week -- but not on a single-payer [health insurance] system.... Her goals and desires are for more and more government controls and mandates."

What Hillary Clinton needs to prove to voters is that on health care she shares their goals and desires, and that as president she could get a majority of the House and Senate to share them, too.

[an error occurred while processing this directive]

Need A Reprint Of This Article?
National Journal Group offers both print and electronic reprint services, as well as permissions for academic use, photocopying and republication. Click here to order, or call us at 877-394-7350.