With President Bush's approval rating hovering in the 30s, just about everyone has an opinion on what George W. has done wrong in the past seven years. But not everyone can explain what the next president must do to fix it. So we've called in some experts to tell us. Fixing It is a 10-part series to be published over the course of the week by some of our favorite writers, offering detailed policy prescriptions for the next president, whoever that may be, on how to quickly undo some of the damage that's been wrought. One of our contributors wryly describes the series as "News You Can Use. If You Happen To Be President." Read the other entries here.
Much of the next president's job will involve cleaning up George W. Bush's messes: Iraq. Guantanamo. A government starved for revenue. Cheetos under the desk in the Oval Office. But in the case of health care, it's more about cleaning up a mess the president mostly ignored and only occasionally exacerbated.
Here's what has happened: Since 2000, employer-based health insurance premiums have shot up 100 percent. Wage growth has hardly represented one-fifth of that. About 10 million Americans have joined the ranks of the uninsured, and according to at least one estimate, more than 100,000 Americans have died because they lacked access to quality care. Health costs have continued their double-time march, and economists now estimate that, if left unchecked, government health spending will be about 37 percent of the GDP by 2050. Add in private health spending, and the Brookings Institution's Henry Aron estimates that "the income that's left over for everything else in the economy, other than taxes and private health care spending, stops growing and … actually declines."
On health care, the vital question for the next president isn't merely what to do but how to do it. Reform requires much more than a willing executive, as anyone who worked in the Clinton White House between the years of 1992 and 1994 can tell you. The problem is not just policy—Washington is stuffed with wonks and idea entrepreneurs eager to explain how to fix the health care system—it's politics. Without 60 votes in the Senate, you don't have a policy. You have a position. And nobody is going to get good, affordable medical care from a position paper. Sadly, there's a long history of executives coming in with a clear position paper explaining what they want to do to fix health care but no political strategy for how to achieve it. The next president need not repeat that mistake. He or she needs, first, a clear political approach—based, in part, around a solid understanding of the mistakes made by the Clintons in 1994—that's backed up by a solid set of policy principles.
• Do it first.One of the problems with the Clinton health care process was that it took so long to get a bill to Congress. By the time Clinton actually sent solid legislation to Capitol Hill, in November of 1993, he'd already spent most of his initial political capital on the North American Free Trade Agreement, gays in the military, and the Deficit Reduction Act and had been battered by the beginning of Whitewater; the crisis in Haiti; and the massacre of American soldiers in Mogadishu, Somalia.
At the risk of offending other contributors to this series, I'd advise the next president not to leave Congress to dither while you take your hits and pursue other priorities. Having run, in part, on the issue of improving health care, he or she will have something of a mandate upon entering office. Do not let that dissipate. On Day One, the next president must ask Congress to begin an open process that will put a bill on his or her desk by Day 100, include public hearings in the process, and, on the 100th day, give a prime-time presidential speech to a joint session of Congress. The president should ask for meetings with both the majority and the minority leader on this issue every 25 days. And if there's no bill by the 100th day, it's time to start using the bully pulpit to press those who would delay.
• Don't write a bill. Speaking of Congress, remember that old Schoolhouse Rock skit "I'm Just a Bill?" Remember how the bill described its birth? "Some folks back home decided they wanted a law passed, so they called their local congressman, and he said, 'You're right, there ought to be a law.' Then he sat down and wrote me out and introduced me to Congress, and I became a bill." Well, perhaps in 1994, Bill Clinton had forgotten that teaching. He convened a massive task force that eventually grew into 30 separate working groups that boasted 500 separate participants. The point of this task force? Er, to write a bill.
Predictably, those arms of government actually tasked with writing bills felt a bit left out. Sara Rosenbaum, now the chair of health policy at George Washington University, was eventually charged with drafting the Clinton plan. Looking back, she says, "I was the biggest mistake of the Clinton health care bill. It was a terrible error to have the president doing what Congress was supposed to do. It was a misuse of the relationship between the legislative branch and the executive branch. The executive branch is supposed to generate action, and the committees are supposed to actually take the action. By sending a 1,300-page bill, you're writing a detailed blueprint for the policy rather than using the congressional process to create a consensus."
That last bit is important. The policy-creation process centered in the executive branch is good at creating policies. But the congressional process is good—or at least as good a system as we have—at creating working legislative coalitions. And that's what we need. So the next president needs to announce that he or she wants to do health reform, but through an open process, centered in the Congress, that includes lots of public feedback.
• Let someone else take the credit. In part, the 1994 effort was foiled by simple Republican intransigence. Bill Kristol, then a Republican strategist, wrote a famed memo titled "Defeating President Clinton's Health Care Proposal," in which he warned, "Any Republican urge to negotiate a 'least bad' compromise with the Democrats, and thereby gain momentary public credit for helping the president 'do something' about health care, should be resisted." Similarly, Bill McInturff, a Republican pollster, advised that the party's midterm hopes relied on "not having health care pass."
Cynical? Sure. But Kristol and McInturff were responding to very real electoral incentives. Much of the electorate still considers health care a Democratic issue. This is particularly true when the reform charge is led by a Democratic president and named after him or her. For Republicans to assist in passing health reform, then, would be to give Democrats a massive accomplishment they can take with them into the election. If the next president to try ambitious heath reform is to succeed where the last failed, he or she will need to hang back a little bit and change the political incentives. Let the congressional process work, and allow the bill to be named after two powerful senators—one of whom should be a Republican looking for a legacy. He can pull in a few of his powerful colleagues who also see themselves as historic legislators, and you'll be closer to your majority. And don't worry: Even if the bill is called Baucus-Grassley, you'll still be the one signing it.
• Have a political strategy.Health care is complicated. Voters are afraid of losing what they have. The electorate has a lot of status quo bias. Powerful stakeholders will oppose the final bill. So the next president needs to deploy an aggressive communications strategy from the first day. The commander in chief will need to make sure that his or her allies are well-funded and ready to rebut attacks; that the war room is well-staffed with a powerful set of talking points; and that the various stakeholders know that attempts to kill reform will not only lead them to be written out of this bill, but to seeing their own political priorities impeded in the future. Remember when Teddy Roosevelt said, "Speak softly and carry a big stick?" Well, by letting Congress write this bill, you're speaking softly. The political strategy is your big stick. In the past, the executive branch has been so concerned with creating a bill, they've forgotten to sell it. By outsourcing the creation to Congress, you can free up resources for the PR blitz.
• Have principles more than a policy. Don't take the above to mean you should go into the reform process without any idea of what you want. It's just that what you want shouldn't be too specific. Health reform is meaningless if it isn't actually universal, if it doesn't make the system more seamless and integrated, and if it doesn't reform the insurance industry so it can begin competing on price and quality rather than risk-shifting and denials of coverage. Optimally, you'll also break the link between employers and health insurance and create a public plan that can compete with private plans, so consumers can choose between health insurance that seeks profit and health insurance that seeks health. So those should be your principles: universality, integration, insurance industry reform, a transition away from employer-based insurance, and public-private competition. You can advocate for those things without getting too hung up on the details. Rather than being dogmatic about policy and agnostic about politics, as your predecessors were, you should be dogmatic about politics and, if not agnostic about policy, more focused on ends than means.