Twenty-one years ago, Hillary Clinton, then leading the presidential committee proposing a health care reform plan, made these statements in speaking to a group at Lehman Brothers Health Corporation on June 15, 1994, as revealed by a transcript made public through the Clinton Presidential Library:
...if there is not health care reform this year, and if, for whatever reason, the Congress doesn't pass health care reform . . . I believe that by the year 2000 we will have a single payer system . . . I don't even think it's a close call politically.
I think that the momentum for a single payer system will sweep the country . . . it will be such a huge popular issue . . . that even if it's not successful the first time, it will eventually be.
. . . there are only three ways [to get to universal coverage]. You either have a general tax -- the single payer approach that replaces existing private investment -- or you have an employer mandate, or you have an individual mandate. (1)
Now, two decades later, it is helpful to recall what happened to the Clinton Health Plan (CHP). After heated battles among competing stakeholders and their lobbyists, the CHP became more complex, expensive and confusing (1,342 pages), and died in committee without getting to a floor vote in the House. Colin Gordon, historian at the University of Iowa, described what happened to the bill this way:
The CHP's fatal flaw, at least in these terms, lay in its attempt to combine employer mandates (which attracted health interests and repelled many employers) and cost control (which attracted employers and repelled health interests). This pairing made for a slowdance to the right, as reaction set in from all quarters against employer mandates, against spending controls, against any increased federal presence in health care. (2)
The unfortunate end of the CHP could have been predicted by how the Clinton Health Care Task Force was selected -- it brought together the key stakeholders in the medical-industrial complex, including the insurance and pharmaceutical industries, that themselves were responsible for health care system problems of access, costs, and quality. Though they might agree to a concept of "managed competition", there were deep divisions and separate agendas within and among stakeholders -- as examples, big insurers were at odds with small insurers, while Big Business could support employer mandates as small business opposed them. (3)
The status of the Affordable Care Act (ACA), or Obamacare, enacted in 2010, is more familiar to us, but has striking similarities to the CHP. President Obama again chose to primarily involve corporate stakeholders in the medical-industrial complex in the planning and development of Obamacare, with its (water-downed) employer and individual mandates. The interests of insurers, the drug and medical device industries, hospitals and organized medicine took precedence over the needs of patients for broad access to affordable quality health care. In fact, five years later, it is clear that these stakeholders have received a bonanza of expanded markets without real cost controls and still with many millions of Americans uninsured and tens of millions underinsured. Wall Street tells that story, as illustrated by health care stocks increasing by 40 percent in 2013, the highest of any sector in the S & P 500 (4) and venture capital funding for health technology firms soaring by 176 percent in the first eight months of 2014 compared to the previous year. (5)
It is still completely unclear where Hillary stands on health care reform. She voted for the ACA, and recent comments seem to support it as the best that can be done. Much of the public is concerned about her close ties to Wall Street and questions her trustworthiness on today's issues. Can she learn from the failure of the CHP and the problems of the ACA? She claims to want to champion the interests of the middle class, but will that include taking on corporate interests in our deregulated marketplace? How can we trust her punditry as a health care "expert" based on her apparent resistance to even bringing up single payer after her predictions twenty-plus years ago?
The upcoming debates among Democratic presidential candidates, followed by those between the two parties' candidates, will be a test of Hillary Clinton's credibility on health care reform as well as the integrity of the "mainstream" media covering them. Let's hope that substance prevails over misleading and disingenuous rhetoric.
What if Hillary took a bold position in support of single payer health care financing reform? If she did, she would follow in the steps of Teddy Roosevelt as a presidential candidate in 1910 and Harry Truman in 1948. She would have broad support of a majority of the American people, as shown by national polls over many years, and dating back to the 1940s, when 74 percent of the public supported a proposal for national health insurance. (6) She would also have the support of a majority of physicians and other health care professionals, who would find a single payer system far less bureaucratic than what we now have, with more time for more satisfying direct patient care. As one example of that support, 59 percent of U. S. physicians in 13 specialties support single payer national health insurance, according to a large national study in 2008. (7)
The time has come for real leadership on health care, not continuing misguided and ill informed rhetoric. We have 35 years' experience with marketplace-based "attempts" to make health care accessible and affordable--all have failed as the business "ethic" prevails over a service ethic in the public interest. Will Hillary step up to the challenge? If so, she can take charge of the health care debate, expose the lack of effective Republican plans for health care, win in 2016, and govern for two terms while setting a landmark legacy in this country.
1. Clinton, H, speaking to a group at Lehman Brothers Health Corporation, June 15, 1994, as reported by Health Care for All-WA Newsletter, Winter 2015, p. 9.
2. Gordon, C. The Clinton Health Care Plan: Dead on Arrival. Westfield, NJ. Open Magazine Pamphlet Series, 1995.
3. Geyman, JP. Health Care in America: Can Our Ailing System Be Healed? Butterworth-Heinemann, Boston, MA, 2002, p. 318
4. Soltas, E. Nobody should get rich off Obamacare. Bloomberg View, December 3, 2013.
5. Randall, D, Farr, C. In quest for next windfall, tech funds look to healthcare. Reuters, September 3, 2014.
6. Steinmo, S, Watts, J. It's the institutions, stupid! Why comprehensive national health insurance always fails in America. J Health Politics, Policy and Law 20: 329, 1995.
7. Carroll, AE, Ackermann, RT. Support for national health insurance among U.