At the Democratic presidential debate in South Carolina, the candidates were asked: “What is the most significant political or professional mistake you have made in the past four years? And what, if anything, did you learn from this mistake which makes you a better candidate?” Senator Clinton replied: “Certainly, the mistakes I made around health care were deeply troubling to me and interfered with our ability to get our message out.”
I would love to know what mistakes she thinks she made and what she learned from them. I would be sincerely interested in her full response–if she could give it candidly–because she is highly intelligent and experienced and she has a unique perspective as organizer of the 1993 health care reform effort. We cannot know for sure, but I suspect she would disagree with my interpretation, which is the following. …
The 1993 health reform proposal represented a particular kind of liberalism which is dead. The proposed system would have required an enormous degree of public trust. The details were extremely complicated, so that people (certainly including me) could not understand them. The structure that Clinton proposed would have evolved and shifted as public-sector organizations negotiated with private insurers. Thus the details of the health plan were not only complex; they were unpredictable. Why then should citizens entrust thousands of their dollars per capita to the government? The implicit reasons were: 1) We (in the government) are more trustworthy than those greedy people in HMOs and insurance companies. 2) We will represent you because we are elected. We will act like an interest group in the marketplace, bargaining for advantage; but you will own us. And 3) We are extremely smart. Ira Magaziner is a Rhodes Scholar; we’ve known him since college days–he has a high IQ.
Those three arguments could work in 1935, when Roosevelt brought lots of talented Ivy Leaguers to Washington to create elaborate programs. It could work in those days because there was more deference to expertise, more hostility to business, and a deeper national emergency–but also because people belonged to institutions with which they had real contracts. They were members of local party organizations and unions that had to pay attention to them in return for their participation. In turn, the New Deal administration was accountable to the unions and the party organizations.
By 1993, that infrastructure was gone. Less than 15 percent of the private sector workforce belonged to unions, which seemed unaccountable even to their shrinking membership. The parties were not organizations at all, but collections of political entrepreneurs. Although we have very pressing reasons to distrust private health insurers, we also have reasons to distrust the government, which gives us urban police departments, the Iraq war, etc.
In the South Carolina debate, Senator Clinton mentioned “getting the message out.” I don’t think a better message for government-funded health care could work, under these conditions. I’d argue that we cannot have a national health care reform plan unless we use one of these strategies to earn public trust:
1) We could design a government-run system: for example, a single-payer insurance fund that actually set prices for health care. This would give the state enormous power, but also achieve huge savings. In order for people to trust it, they (or a large representative group of them) would have to be actively engaged in writing the law and then revising it. We would need an ambitious series of public deliberations involving a representative sample of citizens. As a charter member of the Deliberative Democracy Consortium and a board member of AmericaSpeaks (which organizes such processes), I’m hopeful that this approach could work. However, I must concede that we have no idea whether public deliberations could build trust for an enormously expensive program, especially if well-funded special interests bitterly attacked it.
2) We could rebuild participatory local institutions as the base for stronger government. That’s an attractive idea, but one that would take decades to achieve, if we could figure out how to do it at all.
3) We could have some simple and transparent system that was trustable because it was understandable. I don’t think that the government could set prices, because that is inevitably complex. Instead, the government would probably have to issue vouchers that people would use to buy insurance. Unfortunately, we would then be stuck with insurance-company profits and marketing costs.
