Its the Institutions, Stupid!
Why Comprehensive National Health Insurance Fails in America

Sven Steinmo and Jon Watts
University of Colorado at Boulder

American constitutionalism goes beyond the general idea of a government of laws. It includes specific modern concepts of limited government and, accordingly, specific kinds and techniques of limitation. It holds that these are essentially embodied in the written Constitution, which is the fundamental law that limits ordinary government. (Diamond, 1981:100).
By the time this essay is published, both pundits and scholars will have analyzed and re-analyzed the failure of the Clinton health care plan. The most obvious explanations have already been put forward. They will blame Clinton, his plan, his advisors, his wife, the Democrats, the Republicans, the medical industry and the American voters. Hundreds of knowledgeable scholars and journalists will offer their suggestions... "If they would only have done this," or "If they only would not have done that..." health reform would now be a reality. Further, we are willing to predict today (Nov. 10, 1994) that the analysts will go on to argue that Clinton's missteps on health care explain the remarkable election results of November 9, 1994. They will argue that if Clinton had just been smarter, tougher or more savvy, or had his plan some how more "in tune" with America, the Democrats would have been able to hold onto their control of the Congress. Clearly, they will argue, Americans want comprehensive health r eform as much as the American economy needs it. If Clinton hadn't of messed up this golden opportunity, Congress would surely have finally passed what every other democratic legislature in the world passed long ago. Bill Clinton's burden must be heavy.< p> This paper agues that this line of analysis is wrong. We argue instead that the reason America did not pass comprehensive National Health Care reform in 1994 is the same reason that it could not pass this kind of reform in 1948, 1965, 1974 and 1978: The reason that the United States is the only country in the democratic would that does not have a comprehensive national health insurance system is that American political institutions are structurally biased against this kind of comprehensive reform.

This institutional bias begins with a political structure forged by the Founding Fathers which was explicitly designed to pit faction against faction in the interest of protecting minority factions against majority factions. This bias has been exa cerbated Progressive reforms which undermined strong political parties and subsequently by several generations of Congressional reforms which have in the end turned national politicians into independent political entrepreneurs. In sum, it is this institu tional context which explains (and could be used to predict) the failure of NHI in America - not flaws in the plan, the planners or the political strategy followed.

The following paper offers a brief overview of the history of NHI politics through an institutionalist lens. We believe that it does not make sense to blame the Clinton administration for its inability to pass NHI, but to forget the Roosevelt, Truman, Ke nnedy, Johnson, Nixon, Ford and Carter administration's failures. We will not attempt a comprehensive history in these few pages, but will instead focus on a few key junctures when NHI appeared to be close to passage. This history will attempt show how the structure of American political institutions shaped the political strategies of both proponents and opponents of reform and thereby explain the unique and often curious health reform policies which have passed in America. Finally, we suggest that th e policies actually passed have had the effect of confirming the anti-statist "public understanding" (Jacobs, 1993) which is part of the American political culture.

Culture
The most common explanation for the absence of a national health care program in the United States is that America is exceptional because of her unique political culture (Anderson, 1972; Jacobs, 1993; Rimlinger, 1971). The argument here is that America h as developed a unique set of individualistic and anti-statist political values which has biased the polity against the welfare state. National Health Insurance (NHI) would of course be a major step towards a more comprehensive welfare state and a major i ntervention of the public bureaucracy into the private market place.1

There is an intuitive appeal to the logic employed by these theorists. The United States, being a country founded by immigrants and those looking for freedom from the oppressive political chains of Europe, is a nation with a strong commitment to the valu es of individual responsibility, personal freedom and anti-statist beliefs. Americans have never been so concerned with what government will do for the individual, rather they seek to limit the power of government to control the individual. This is acco mplished through a system of clearly delineated rights, a standard against which all government legislation must be compared. In essence, Americans have sought to preserve the capacity for personal choice through a continued commitment to liberal values and market mechanisms. Anthony King (1973) in his oft cited explanation for American Exceptionalism argues as follows: " The state plays a more limited role in America than anywhere else because Americans more than any other people, want it to play a li mited role" (see also Lipset, 1991).

As intuitively appealing as this argument at first appears, flaws in both the logic and evidence which have been marshalled in its favor undermine the utility of this explanation. First, and most obviously, public opinion polls have consistently shown su bstantial majorities of Americans have favored some kind of comprehensive national health insurance system for most of the post-war era (see table below).

Table 1
Public Support for Greater Government Role in Health Care Industry

Year % expressing support for increasing government role in health care delivery*
1937 80%
1942 74%
1961 67%
1965 63%
1976 66.7%
1978 61.3%
1992 75%
*Data taken from different polls which asked similar, but not identical questions. See sources for exact questions.
Sources: Free and Cantril, 1937, p.10; Gallup, 1961, 1965; Fortune Magazine, 1942 July, pages 8-10;12,14,18 ; American Medical News, 1976, 1992, p.27; U.S. News and World Report, 1978, p.20.

Secondly, even to the extent that Americans are highly individualistic, it is far from clear that this general cultural predisposition translates into specific attitudes towards specific governmental programs. Political cultures, after all, contain a var iety of different (and sometimes competing) political values (Page and Shapiro, 1992; McClosky and Zaller, 1984). Thus, while it is true that Americans hold highly individualistic values, they are also widely known to be profoundly egalitarian -- especia lly with respect to the value of equal opportunity. American individualism did not prevent the United States from developing a massive, comprehensive, publicly financed education system, nor did it stop the U.S. from building one of the most generous Soc ial Security systems in the world (cf. Skocpol, 1988). In each of these cases, reformers successfully argued that these programs reflected and were supported by American values. Health care reformers have, of course, argued similarly. The real question is why in this case has the argument been less successful?

Third, a critical lacuna in the culturalist argument is the paucity of comparative historical evidence. The argument implies that Americans did not get NHI while Europeans did, because this program was demanded in Europe, but not in the U.S. In truth, h owever, there is little evidence that NHI was the product of widespread public demand in other industrial democracies. Instead, the various comprehensive public health programs initiated throughout the world were in fact, the product of governing elites' attempts to address pressing policy problems (Immergut, 1992; Helco, 1974). In many cases there was general public frustration with the costs and accessibility of health care amongst the public, and demands the government "do something" (Anderson, 1972; Rimlinger, 1971) but as Table 1 above indicates, this basic public preference has existed for some time in the U.S. as well. In short, if the culturalist argument were correct, one would expect to see compelling evidence that European publics expressed higher levels of frustration with privitized health care financing and demanded specific health care reforms.2 What is at issue is exactly what these different governments have done when faced with the political and fiscal incentives to "do s omething" about the problems of cost and access to their nation's health care delivery system.

Finally, culturalist analyses tend to ignore or at least under-emphasize the dynamic interactions between public preferences and public policy. For example, by trying so hard to prove the stability and coherence of the "enduring social understandings and more immediate public preferences" Jacobs (1993:226) undermines his own comparative analysis. He tell us he is deeply concerned with institutional change and with the relationship between preferences and policy outputs, he ignores the relationship betwe en institutional change and public preferences. Clearly what governments do (or do not do) affect attitudes towards government. But the emphasis on the permanence of cultural preferences belies this point.

In the end then, culturalists, offer quite static explanations. What is needed here is for those interested in the relationship between what people think about government and what government does (or doesn't do) to come full circle. Politics is an itera tive process, not a one-off game. Thus, if government does well, it builds support. If it fails to act in the face of public pressure, or acts poorly, one should not be surprised that people lose faith in public institutions.

In sum, while it is clearly the case that American political culture is unique (just as Swedish, Japanese or French political cultures are unique). It is far from clear that culture itself can provide an adequate explanation for any particular policy out come -- including the absence of national comprehensive health insurance system in the United States.

Interests
Many of the best political histories of the politics of health care reform in the U.S. either explicitly or implicitly forward what we call an "interest" explanation (Poen, 1979; Alford, 1975; Navarro, 1976).3 While often explicitly sensitive to the peculiar cultural context of American politics, these analyses essentially argue that the United States has not developed a National Health Insurance scheme because of the determined opposition of powerful interest groups. In contrast to the cult uralist argument, this thesis holds that the U.S. has not built an NHI system despite public support for the idea.

The interest explanation is substantially better grounded in empirical facts than the culturalist alternative. Indeed the evidence used to support this thesis is in many ways overwhelming. Any history of the politics of health care reform in the U.S. de monstrates quite clearly that reformers in this country have faced an exceptionally well organized and well financed opposition. While at the same time the proponents of reform have been demonstratably less well organized and less well financed.

Still, as empirically satisfying as the interest explanation can be, we believe that it suffers from important analytic flaws. The first of these is similar to the critique of the traditional culturalist explanation: While the explanation is in fact comp arative, little or no comparative evidence is generally provided. If the key explanation for the absence of NHI in the U.S. is that powerful interest groups fought the reform, then proponents of this argument should be able to show that countries that di d pass NHI legislation did not have powerful interest groups opposing their reforms. However, studies of the politics of health care reform in other democratic polities demonstrate quite clearly that doctors, hospitals, insurance companies, business inte rests and conservative political forces generally, fought bitterly to prevent national health care insurance in every country in which national health care policies eventually emerged.4 The real question is why were the forces of opposition ab le to stop some form of NHI in the U.S., but not in other democracies?

A second problematic for the traditional interest explanation is that it has difficulty explaining why some policy reforms have been successful in the U.S. while others have not. The for-profit medical industry was opposed to the creation of Medicare and Medicaid in the early 1960s, just as they had opposed NHI in the 1940s and 50s. They attempted many of the same tactics against this reform that they had successfully used against earlier reforms. So why, if powerful interest groups are able to veto po licies they oppose, did the Medi-care/caid legislation pass despite this opposition? The interest group analysis would of course argue that the different outcomes were a result of a different political calculus. In short, the outcome was different in 19 64 than in 1948, because the times were different, the politics were different, or the policies in question were different. This explanation, while in some sense correct, is for us, unsatisfying. The analytic model provided by this explanation forces us to look at each case separately and independently: A single issue can have quite different politics and policy outcomes depending on the infinitely complex political context in which it happens to fall at different times. Our problem is not simply one o f social scientists attempting to find analytic order where none in fact exists. Instead, we submit that there have been patterns to the health policy outcomes in the U.S. (and in other policy arenas for that matter.) Each case is not unique. There is in fact a structure to the mosaic of policy outcomes.

An interest group politics explanation, then, may be excellent at explaining why Truman's plan failed, or why 's plan failed, or why Carter's plan failed. But it provides us far too little analytical leverage for understanding why they all failed. (It d oes even less for helping us understand why President Clinton will not be able to bring his comprehensive plan to fruition.) Precisely because the interest explanation is focused on the micro-details of the political struggle, it is does not provide an a dequate analytic mechanism for stepping back from the details and searching out broader understandings of the policy process and/or political outcomes.

Institutions
Recently, a number of scholars coming from a wide variety of intellectual traditions have begun to explore what is sometimes called "the New Institutionalism."5 Of particular interest for our analysis are the several recent "historical institu tionalist" studies which look at specific public policies and have explicitly attempted to explain why different countries have followed different policy paths.6 These authors have not attempted to offer holistic theories of political history and behavior; but instead have offered middle range explanations for distinctive policy patterns followed in different political regimes over time. Two basic insights made by historical institutionalists are of relevance here. First, political institutions shape how interests will organize themselves, how much access and power they are likely to have and even the specific policy positions they are l ikely to take. Thus, as of health care reform in Sweden, France and Switzerland argues, "the analysis of policy making should focus more explicitly on the procedures for making policies and less exclusively on the demands themselves." In her study she f ound that "[t]hese procedures do not simply represent the views of interest groups. They select the groups whose views will be represented and they shape demands by changing the strategic environment in which the demands of groups are formulated" (1992: xiii).

Secondly, institutions can critically affect preferences. This argument suggests first that what people want is structured in some fundamental ways by what they can imagine achieving. People do not normally desire things that they cannot imagine getting . Thus, because institutions shape the rules and because institutions advantage some interests and ideas over others, they can also shape what people can imagine achieving. Moreover, in that people are not in reality the constantly recalculating rationa l decision makers, but instead tend to be habitual, satisficing decisions makers (Simon, 1985; Alford, 1991; Powell and DiMaggio; 1991), institutions shape how we lead our lives and thus can ultimately shape what we believe.

In sum, in the following history of the politics of health care reform in the United States we will attempt to show how institutions shape both what people attempt to achieve and what they believe they can achieve. Political values, elite and public atti tudes and interest group behavior are central to our analysis. But, rather than take these variables as givens, we explicitly examine them inside the institutional context in which they have been formed.

The Road Toward Reform

For most industrializing democracies, the foundation for the political battles over modern comprehensive national health insurance systems was laid in the first decades of the 20th century. In most cases the battle for protections against the ravages of industrial capitalism were bound up in the struggle for democratic participation. Social insurance (workmen's compensation, health insurance, old-age pensions) developed to be important policies with which modernizing bureaucratic leaders hoped to buy-of f worker discontent as well as important symbols which working and middle class parties used to mobilize support for extending the franchise (Rueschmeyer, Stephens and Stephens, 1992; Ashford, 1986; Rimlinger, 1971; Flora and Heidenheimer, 1977; Heclo, 19 74).

But the United States was already in a unique position. Whereas in European states, the right to vote for the lower and working classes had to be struggled for, in the U.S. this right had already been granted fait accompli. Thus the most fundamen tal institutional context within which the struggle for social insurance (including health insurance) was fought, separated the U.S. from virtually every other industrializing nation. The early extension of the franchise had enormous implications for the structure of political debate and reform in turn of the century America. As a number of political historians have shown, the early extension of the franchise in the U.S. -- combined with the post-Civil War division of power between the North and the Sou th -- allowed for the growth of localized one-party dominant regimes throughout the nation. Absent genuine two-party competition, political parties often grew to be patronage-oriented machines, rather than real channels of democratic participation and co ntrol (Burnham, 1970; Shefter, 1978; Sundquist, 1973). Political parties in America thus became objects of reform, rather than agents of reform as they were becoming in Europe. The result was that democratic reformers in the U.S. set their sights on dis mantling entrenched parties and bureaucracies, rather than building central political and administrative capacities in order to further working and middle class interests as they did in Europe. Reformers in America passed a series of reforms at the state and national levels that -- though designed to make government more honest and efficacious -- had the effect of further fragmenting political and administrative authority. Some of these reforms included the Australian ballot, referendums, initiatives, d irect primary elections and non-partisan local government (Burnham, 1970). In addition, the power of national party elites was taken away through congressional reforms (Polsby, 1968). Finally, administrative reforms designed to make public administratio n less partisan and more efficient were also implemented (Skowronek, 1982).

It is important to remember, however, that these reformers "were not anti-statist in their orientation" (Orloff, 1988:53). Indeed, despite the structural barriers to third parties in the American winner-take-all electoral process, Theodore Roosevelt's Pr ogressive party garnered over four million votes in the 1912 election (edging out the Republican Taft, but losing to the Democrat Wilson) on the platform of "the protection of home life against the hazards of sickness, irregular employment, and old age th rough the adoption of a system of social insurance adapted to American use" (Orloff, 1988:55).7

The Progressive impetus for reform did not, however, produce health care legislation. Roosevelt's defeat by Woodrow Wilson, along with the United States entrance into World War I are widely cited reasons for the lack of progress on the issue. Though Wils on was a progressive Democrat, his agenda was international in outlook, had an entirely different focus than the previous progressive reformers. Further, as Paul Starr, points out in The Social Transformation of American Medicine:

In America, there was no comparable unification of political authority to compare with the power of Lloyd George (England) or Bismarck (Germany). Even if an American president had wanted health insurance, he would not have had the leverage to force the opposition to compromise. Only a more serious threat to political stability in America could have so changed the terms of debate as to force interest groups to work within the framework of reform instead of against it (pg. 257)
In sum, the Progressives unable to push through health policies they favored, but they did manage to pass institutional reforms designed to take power away from the entrenched conservative politicians. The longer run result was perhaps the opposite of wh at they had intended because political power was now further fragmented in the US - thus making the policy reforms they favored even more difficult to pass. As Weir and Skocpol note:
Moreover, the successes of Progressive administrative reformers were scattered and incomplete, and their partial successes combined with the weakening of party competition in the early twentieth-century United States to exacerbate tendencies t oward dispersion of political authority within the American state structure as a whole. Conflicts increased among presidents and congressional coalitions, and the various levels of government in the federal system became more decoupled from one another ( Weir and Skocpol, 1985:135).
In sum, whereas in early 20th century Europe, democratic political reforms brought a merging of executive and legislative authority, as well as the further centralization of local and national authority: In the U.S., forces favoring 'democratization' won institutional reforms that further fragmented political power. This institutional reality has radically structured the political debate and strategic choices of health policy reformers and opponents alike.

The failure implement the social policy reforms desired by Progressives at the early century also affected public attitudes about the proper realm of public authority. Though Conservative European governments introduced these limited social policies in o rder to undercut support for working class parties, the extension of the state into these areas had the effect of legitimating state intervention. Once social policies were introduced they established a new policy floor upon which future political battl es would be fought. To paraphrase Heclo from his study of early social welfare policies, 'new policies create new politics' (Helco, 1974). Whereas in America the original battles over the expansion of the state into social welfare had yet to be won, in Europe it had already been settled.

Where Was FDR?
These political and institutional realities are the basic framework which are necessary to make sense of the subsequent politics of health care reform in America. If we forget the fact the US was a "social welfare state laggard" (Wilensky, 1974) and or if we forget the relative weakness of the executive in the American political system, it would be impossible to explain why Franklin D. Roosevelt did not introduce NHI.

There can be little doubt that President had a wide mandate to promote progressive social reform. Equally, as numerous historians have demonstrated, health care was a prime target for reformers of the era. But, despite the President's huge popularity an d the clearly perceived mandate for social reform, Roosevelt and his advisors came to believe that bringing health insurance into their reform package could "spell the defeat of the entire bill" (Witte, 1967:188, cited in Orloff). This however, was a str ategic choice based on the fact that in America, Congress writes law -- the President doesn't. The public was clearly in favor of governmental sponsored health protection (Schlitz, 1970:128-129) but the President and his advisors understood that the Sout hern Democratic chairmen of key committees were hostile to the entire New Deal agenda. Adding the opposition of the hospital and insurance industries, as well as the increasingly powerful American Medical Association8 might jeopardize the enti re New Deal (Patterson, 1967; Witte, 1985; Orloff, 1988).

We have to remember that the Roosevelt administration was in effect starting from social welfare scratch. Whereas in Europe, reformers of this era could build upon, reform, or add to existing social policies, the New Deal Administration had to confront t he very legitimacy of state intervention of the state into whole new arenas. As James Morone points out, reformers sacrificed health reform so that they could get other parts of their agenda through Congressional labyrinth.

[S]imply ascribing medical dominance to interest-group power is to miss the underlying structure of American politics. The state's right to take on new tasks is always open to question. Moreover, though much of the twentieth century, politic al institutions - Congress and the presidency - were divided over social programs. The political pattern rarely varied: public officials (usually Northern Democrats) proposed a program like national health insurance; reformers cheered; as public opinion polls came into fashion (in the late 1940s), they generally indicated that the public concurred. However, other public officials (Southern Democrats, Republicans) opposed the extension of government authority. Health care reforms were sacrificed for ot her programs and the maintenance of political coalitions - a victim of the American system of checks an balances as much as of the dreaded AMA (Morone, 1990:256).
Derthick and others have shown just how difficult it was for the administration to win over key congressional chairman - even without the explicit opposition of medical industry. To add medical care reform to the plan and thus political take on one of th e country's most powerful political forces would clearly endanger the entire New Deal package. It simply did not seem worth it (Witte, 1967). In short, despite the will to act, and despite widespread popular support and Democratic majorities in the House , Senate and executive, the fragmentation of authority in American political institutions forced FDR and his advisors to postpone their health policy reform goals (Morone, 1990:255-6).

The fact that medical interests opposed NHI was not unique to politics in the United States at this point in history. These interests opposed government "intervention" in virtually all industrialized states (Immergut, 1992; Heclo, 1974; Rimlinger, 1971; Ekstein, 1960; Heidenheimer, 1980; Klein, 1983). Immergut, for example, describes the French position in the following way:

The practice of medicine, it was argued, was a highly individual art that required a direct and private relationship between doctors and patients....First, patients were to be free to choose their own doctor; second, the doctor-patient relatio nship was to be subject to the strictest secrecy; third, physicians required complete liberty with regard to the choice of medical treatment; and fourth, all financial matters ought to be decided by a "direct understanding" (entente directe) between docto rs and their patients. (Immergut, 1992:87).
Nor were French doctors unique in Europe at the time. "For the views of Swedish and Swiss (the two other countries her study covers) physicians; the liberal model of medicine was simply a codification of the defense of doctors' economic autonomy, common to elite physicians throughout Western Europe." (pp 87-88)

Ideological differences on the part of doctors, nationally elected political reformers, or the mass public cannot account for FDR's failure to introduce a national health insurance plan. It was instead the entrenched position and enormous political power yielded to economic interest groups and entrenched (Southern) local elites that led FDR to conclude that "including health insurance in the proposed Economic Security Act was politically impossible" (Orloff, 1988:75). Roosevelt and his team believed tha t NHI could be brought forward in subsequent years. We now know, despite his continued national mandate for reform, virtually all of Roosevelt's progressive agenda was stymied from this point forward.

Truman Steps In
From the beginning of his presidency, strongly supported the idea of national health insurance. Reflecting the progressive sentiments of an earlier political generation, Truman felt that the key to a nation's strength lay in the health of its citizens a nd that one must be physically sound in order to participate in a democracy (Poen, 1979). Truman's beliefs were echoed with public support. Indeed, showed that 74.3 percent of Americans favored NHI.9 At the time, the extension of government regulation into the health care industry seemed like a natural continuation of the process begun during Roosevelt's New Deal. War time requirements had acclimated American society to a great deal of regulation by the federal government.(Weir, Orloff and Skocpol, 1988). It was assumed that such regulation would continue after the war, since government assistance seemed necessary to sustain economic growth and avoid post war depression. Thus, after Roosevelt's death, reformers had new confidence that pro gress would be made on the issue of national health insurance.

Work on health insurance was delayed, however, by other political considerations in which the Truman administration found itself embroiled.10 This delay at the time appeared fatal. Difficulties in providing a smooth transition from a war time economy left the American people with the impression that Truman was an ineffective president. Voicing their disapproval, the American people sent a Republican congress to Washington in 1946. This mid-term election obviously precluded any serious discu ssion of health care. Truman was perceived as a lame duck, at best only a temporary occupant of the White House.

It was, oddly enough, the issue of a challenge for national health care by Republican presidential hopeful that provided Truman the political means to regain his political momentum and, ultimately, to win the next presidential election. Late in 1947, Se n. Robert Taft (R:Oh) publicly challenged the Democrats to make health care reform a campaign issue. Unfortunately for Taft and the Republican party as a whole, the plan backfired. Truman seized the opportunity and made health care the centerpiece of hi s presidential campaign. The campaign targeted the Republican Congress precisely on the grounds that they opposed reform; "We worked out a painstaking plan for national medical care... It provided for new hospitals, clinics, health centers, research, an d a system of national health insurance. Who Killed it? The Republican 80th 'do-nothing Congress'"(From Address at Gilmour Stadium..Sept. 1948). Truman campaigned on a platform promising to extend the New Deal in which national health insurance was the top legislative priority (r, 1982).

Truman's strategy worked. The American people gave their stamp of approval for a progressive vision for America. Not only did Truman win the election, but the voters had also elected a Congress that promised to complete the task of extending the New Dea l. Democrats gained 75 seats in the House raising their majority to 263 seats versus the Republicans 171. There is no question that the mass public supported changes in the nation's system of health care delivery. were conclusive. Eighty-two percent of the population felt that the government should make it easier for all people to have access to medical care. Fifty-eight percent of Americans specifically endorsed national health insurance and were willing to pay for it with an increase in social sec urity income deductions. Indeed, only twenty-nine percent felt that it was a "bad idea" to pursue national health insurance. Truman thus came to office in 1949 armed with the clear mandate from the people to enact national health insurance.11

Of course, we now know that Truman's mandate did not bring about NHI. The key to explaining this curious failure lies the unique character of the American institutional process. In the American electoral system, every single legislator runs his or her o wn electoral campaign. Unlike the parliamentary systems found in other democracies, a win for the party does not necessarily mean that the party's electoral commitment will be passed.

NHI was not the only issue on Truman's legislative agenda. He had also campaigned for the "Fair Deal", promising to extend a variety of liberal programs and policies which the Democratic party had championed since Roosevelt. Civil Rights legislation was high on this agenda. But, unfortunately for Truman and NHI, the Democratic victory of 1948, which again partly was a product of Truman's coattails, worked to further entrench powerful Southern Democrats in leadership positions on key congressional commi ttees. Despite the Democratic Party's numerical superiority in the Congress, Truman could in no way command the Dixiecrats to pass his legislation. Instead, in retaliation for Truman's stand on social issues, these Dixiecrats chose to block essentially all of Truman's legislative initiatives (Campion, 1984: 153). Truman's NHI failure was not a reflection of deep seated cultural beliefs demanding personal responsibility and accountability. Given the American system of "Committee Government" developed in the context of the progressive reforms discussed earlier, pow er was put in the hands of committee chairman who were chosen on the basis of their seniority (Polsby, 1968). "Committee government" allowed Congress to protect itself against the growing powers of the executive branch, but it also made it almost impossi ble to pass legislation which was opposed by the most senior members, even when their ideology was widely out of step with the majority of the their party and even the nation as a whole.

In this system,

...party leaders did not possess the power to discipline committee members who blocked party legislation. A committee's members, operating without accountability to a majority within either the House or the Senate, could stop any legislation that fell within the committee's jurisdiction, no matter how widespread the support for the legislation in the Congress or the country. (Larry Dodd, Richard Schott, 1975)
The Constitution directed that any legislation requiring the raising of revenue had to originate in the House. Under the procedural rules in place in Congress in 1949, national health insurance legislation had to clear the House Ways and Means Committee. Despite the fact that the Democrats held a majority on that committee of fifteen to ten over the Republicans, disputes over Civil Rights assured a frosty reception for Truman's proposal. The committee was at that time chaired by from North Carolina. Also insulating the Ways and Means Committee from Truman's influence was the "closed rule" procedure used by the committee for all tax tariff and transfer bills. This rule meant that no additional amendments or changes could be added to the legislation which had been considered by Ways and Means.

Given the institutional rules in place at the time, if the Committee, (or its chairman) chose to kill legislation, neither the President nor the majority of the Party could force the bill onto the floor in all but the most extreme of circumstances. Thoug h extensive hearings committee hearings were held on Truman's NHI bills in 1948 and 1949, the committee did not forward any specific legislation for a full vote. This was also true in the Senate where the sponsor of the Truman health bill (No. S.1679), (D. MO.) could not find enough votes to report the bill out of the Senate Finance Committee. Finally (in a tactic which will sound familiar to modern readers) in order to further confuse and diffuse the issue in the face of widespread public support of N HI, Republicans and Southern Democrats sponsored their own versions of a health bill. There was of course no real intent to pass a conservative health care program, but this way voters could be lulled into believing that a diligent Congress was working o n a better plan than the one Truman had introduced (Poen, 179: 165). In the end, no substantive progress was made towards enacting national health insurance in 1949.

One could argue, of course, with the fact that ideology or political culture played an important if not dominant factor in determining the outcome of Truman's health policy initiatives in 1949. Clearly, the ideology and values of the southern Democratic Party elites was decisive. But it was the peculiar institutional framework of American politics that allowed these Southern elites to block the programs endorsed by the voting majority of Americans. Despite the fact that Truman was the acknowledged lead er of the Democratic party, despite the fact that his bid for re-election was defined around the legislation of health insurance and other liberal reforms, and despite the fact that the American people voted their approval of Truman's vision, America's pe culiar institutional structure allowed for the expression of wholly geographic preferences at the expense of the entire nation. In no small part, in reaction to this fact, Americans soon became frustrated with the Democrats. In a pattern tha t would be followed many times in coming decades, they had made the mistake of raising public expectations and not delivering on their promises. As a consequence, American's deep supposition that government is inefficient and untrustworthy was confirmed. Towards Compromise
We will not detail the politics of health reform in the 1950s. The story of the massive mobilization of the AMA's "war chest" and its successful attempt to tar the idea of NHI as "socialized medicine" is too well known to be repeated here (cf. Campion, 1 984; Marmor, 1973; Poen, 1979; Starr, 1982). We would like highlight a few points however. First, soon after the defeat of his health plan, Truman (like many other presidents before and after him) quickly had his attention directed towards foreign polic y crises. Foreign affairs is an arena in which the President has relatively high degree of authority and power. Secondly, the Truman administration's inability to deliver on its major domestic legislative promises also undermined public confidence in bo th the president and the presidency. Finally, the electoral battle between Truman and Eisenhower in 1952 was in no way a referendum on the welfare state or on the idea of National Health Insurance.

Much was said subsequently about the personal nature of Eisenhower's victory. While the majority of Americans signified that they "liked Ike", they gave only a slight majority to Republican candidates for Congress....Analysts would later sugg est that the American people saw in his character and experience a reflection of their own ideals and aspirations (Richardson, 1979: 21).
In short, rejecting the idea of national health reform was not paramount in the minds of Americans when they cast their vote for Eisenhower. But that was the result nonetheless. As a Republican, Eisenhower supported the anti-government rhetoric of his p arty; national health reform became an impossibility for the next few years. This did not stop the work of the Democratic Party or that in the health reform camp.

Given both the enormous political power which forces against NHI could muster, and given the fact that the Republican President would almost surely veto an NHI bill in the extremely unlikely event that one should cross his desk. Reformers adopted a new p olitical strategy. Rather than focus on providing universal coverage for all Americans, they came to believe that they would be able to "get a foot in the door" by providing hospitalization coverage for the aged. By the early 1950s the Social Security s ystem introduced by FDR had already gained massive public support. The reformers thinking was clearly that they could build on this support by offering the aged protection against financial ruin due to illness and eventually expand this coverage to ever larger segments of the American community. In short, the reformers accepted the political realities given the fragmentation of American political institutions and began working for a new plan that would both do some good and begin to legitimate the state 's participation in the health care sector (Morone, 1990).

Thus, even when the Democrats retook the House of Representatives in 1954, they still faced the fact that the senior Dixiecrats controlled the key committees. Thus, following their reductionist strategy, Ewing, Cohen and Faulk worked to keep the idea of health reform alive by focusing on hospital insurance for the elderly. A bill was introduced every year, but was never given hearings in committee until 1958 (Marmor, 1973: 30).

The new political strategy was neither a product of general public resistance to comprehensive NHI, nor did it grow out of the reforming elite's understanding of what would be the best type of reform for America. Instead it was the institutional obstacle s to achieving the kind of comprehensive reforms which forced reformers to choose what they believed to be a second best incrementalist solution. In Europe too, there were many who argued that incremental reforms were better than broad comprehensive solu tions. But where majoritarian governments held power (eg. Britain), reformers were not forced to choose second best solutions and instead implemented health reforms that were dramatic and universal (Ekstein, 1960; Klein, 1983). In countries with minorit y or coalition governments, reformers were forced to compromise with elites of other parties. In these cases they often had to make "side payments" to the political agendas of other elected political elites (Immergut, 1992; Rothstein, 1990). But in thes e cases the institutionally defined strategies were quite unlike those facing reformers in America. In Europe, compromises could be made with elites who also had to face national elections. Thus the political appeal of providing comprehensive and univers al benefits was enormously powerful, and an appeal which few national political elites could resist. Knowing this, reformers in Europe had every incentive to hold out and insist on universal and comprehensive programs, whatever the temporal opposition. In America, the political realities were quite different. Here, reformers faced enormously powerful opponents who never had to stand for national election.

These political realities, then, shaped the strategic choices of reformers on both continents. In the American case, reformers began to see the merit of taking half a loaf now and fighting for the other half later. As we shall see, this strategy had its own consequences for future reform. Though it was unclear whether this was the original intent of reformers in America, it is clear that focusing benefits on a particular group had the effect of changing the politics of health care reform to an approac h more in tune with the structure of American political institutions: ie pit faction against faction.

Medicare Has its Day
The assassination of President Kennedy did much to change the politics in this country. While Kennedy himself only won the presidential election by a slim margin, won by a landslide. American voters sent him to Washington with an overwhelming liberal D emocratic majority in both houses of Congress.13 Sensing the inevitability of reform and wanting to protect his institutional prerogatives, Chairman Mills engaged in one of the most monumental turnabouts in U.S. political history. On March 2, Mills made a suggestion that fundamentally altered the final structure of the Medicare program. Mills asked whether the Medicare proposal of hospital insurance for the aged could be combined with a voluntary program of insurance similar to a Republican proposal which provided for physicians fees. Further, he ask ed if there could be a third component added that would work to cover the health care expenditures of poor Americans who were not included in the Medicare proposal. The Committee immediately began work on constructing a new bill to fit these expanded con siderations. In one move, Mills had become the champion of the Medicare movement and expanded the programs benefits beyond what any one had expected.14

There are several important features of the Medicare story that should be highlighted here. First, because of the institutional power vested in the chairman of the Ways and Means Committee, Mr. Mills was able to design the Medicare system in a way that w as specifically intended to take the wind out of the sails of future health care reforms. As , points out, Mills plan in effect "built a fence" around the social security program (1979:79). Secondly, the system which was finally passed was passed in the most "American" of fashions: In the final analysis, everyone was bought off and no interest group (faction) had its interests directly assaulted. As James Morone points out:

The liberal's long-sought triumph did not alter the traditional contours of American health care politics. Authority over the new programs was promptly ceded to the industry. The issue itself broke with legislative tradition: rather than pro mising everything to everybody, this law began by promising to change nothing. Its first three sections all denied the charges of government intrusion that had been repeated for five decades: 'Nothing in this title shall be construed to authorize any fe deral official or employee to exercise any supervision or control over the practice of medicine." The next five passages embellished this theme, forbidding state control over medical personnel or compensation or organization or administration or choice o f provider or selection of insurer... Indeed, Medicaid relieved the industry of much of its charity care, paying for indigents who had previously been able to pay little or nothing. In general, Medicaid paid the profession to continue doing what it had d one in the past. (Morone, 1990:263-4)
The contrast to the politics in which the Labour government introduced the National Health Service in Britain nearly two decades earlier could scarcely be starker. Though as Jacobs points out, in both cases the general preferences of the people was final ly accommodated, in the British case once the government had decided to move it was able to manipulate the very institutional structure though which elite decisions needed to be passed.15 "Labour's health legislation emerged from organized, ong oing bargaining among cabinet ministers and Ministry of Health officials; although continuing to weigh medical producers' claims, policy makers restructured the policy network to significantly curtail direct interest group participation" (Jacobs, 1993:1 68). The most obvious consequence of essentially isolating the reformers from the opponents of reform is that the system they finally designed (including nationalizing British hospitals) emerged as clear and bold steps in which the planners and policy ma kers were not forced to make concessions to the multiple interest groups who would of liked to have a hand in designing the reform.16 Interestingly, the designers of the British NHS specifically argued that they should not make major concessions to interest groups on the grounds that these concessions might undermine the boldness of their reform. Providing free public health care to al l citizens, they correctly believed, would build confidence in public institutions. "It now seemed inconceivable to politicians and bureaucrats that they would be 'cowered by the threat of the medical profession to oppose [the government's proposal]'" (Interview with John Pater, cited in Jacobs, 1993:175).

Addressing the Medicare Legacy
Medicare was both a "foot in the door", and an attempt to slam the door shut. Unsurprisingly, the foot became swollen and festered. Indeed, in many respects, the Medicare/Medicaid system contributed to the health care financing problems facing the Unite d States today. By attempting to appease the medical industry's financial and ideological commitment to fee-for-service medicine, Medicare/caid opened a revenue spigot from government to the medical industry. Soon however, government officials came to r ealize that this flood of red ink would ultimately drown other public programs -- if the flood was not slowed. Indeed, it is widely acknowledged that one of the consequences of setting the government up as yet another 3rd party payer for health care has c ontributed to health care inflation generally. The Medicare/caid compromise provided both a public subsidy to the health care industry and protected that industry from more comprehensive national health insurance plans. By the early 1970s the untenabil ity of this fact was well understood by virtually all health care policy participants. In July 1974, Alice Rivlin, was just one of the many observers who believed that these forces would soon bring about comprehensive health reform. She wrote in the NYT Magazine: "That some form of national health insurance will be enacted in the next couple of years now seems virtually certain. In the years between Truman and Nixon, the argument has shifted from "whether" to "what kind". Even organized medicine no l onger quivers at the thought" (Rivlin, 1974:8).

This common understanding provided the impetus for the next major step towards serious consideration of NHI began in the Fall of 1973 when Senator Russell Long (D-la), chairman of the Senate Finance Committee and Senator Abraham Ribbicoff (D-Ct) presented a moderate health reform bill that would offer Americans federally subsidized protection from losses due to catastrophic illness, and would attempt to restructure the administration of the Medicaid program. The potential political appeal of the Long-Rib bicoff catastrophic insurance plan motivated a variety of actors on both the left and the right. Fearing that another partial health insurance reform measure would undercut political support for universal single payer system he favored, Senator Edward Ke nnedy, for example, began to consider scaling back his more ambitious proposal. Kennedy was ready to compromise, the only question was when and with whom (National Journal, 12/15/93 pg. 1860). It is important to remember, however, that Kennedy's new wi llingness to compromise did not imply that he favored a less comprehensive plan than the single-payer system his earlier proposals had advocated. Rather, he calculated the political situation and determined that now was an opportunity to at least get a p lan that had universal coverage.

At the end of 1973 Nixon himself was also reconsidering his position on NHI. The Watergate scandal was becoming a serious issue and the President needed something to both refocus public attention and re-legitimize the office of the Presidency. The pass age of an ever elusive system of national health insurance, the bane of all previous democratic administrations, stood out as the method by which he could achieve this goal.17 In a speech to Congress on February 5, Nixon Stated, "Comprehensiv e health insurance is an idea who's time has come. I believe that some kind of program will be enacted in the year 1974" (NYT 2/5/94, pg. 16). The Vice President Gerald Ford wrote the following in support of the President's plan for the New York Times M agazine: "Positive, fast action on this new health insurance program this session will mean lifting a tremendous burden of worry and concern for many Americans. That reassurance is long overdue. It would build national confidence."(NYT 2/4/74 pg. 29) L ike Kennedy, the Nixon Administration was now ready to deal on NHI.

The most important figure in Washington health care politics had yet to weigh in for the new push for NHI. Though Mills was obviously no strong advocate on NHI, he like Nixon, began to re-think his position in order shore up support for his institutional position at the center of the policy making process. This authority had recently come under come under attack. In part due to the historical intransigence of the Ways and Means Committee in general and the conservatism of Congressman Mills in particular , the entire committee system was coming under scrutiny. As the legislative load of the Congress became more demanding and public perception towards the ability of Congress to produce quality legislation slipped, individual legislators had become signifi cantly dissatisfied with the House Committee system. The system was widely viewed, moreover, as placing the Congress in a weakened position when compared to the growing influence of the executive branch (Dodd, 1977; NJ 3/23/74 pg. 419) Pressure began t o build to reform the system in such a way as to tip the balance of power from the Executive back towards Congress.

The Ways and Means Committee was singled out for particular attention. For example, Richard Bolling, chair of the "Committee on Committees" and a leading congressional reformer argued for the creation of a new committee on Commerce and Health which would adopt the responsibility of defining benefit and policies for Medicare, Medicaid and any future national health insurance legislation (NJ 6/22/74 pg. 913). Mills, not wanting to lose any of his, or his committee's authority over health care issues, bega n a crusade to restore faith in the ability of Ways and Means to formulate the nations health policy. Mills and his committee members knew that the best way to preserve their authority over health care was to produce important, high quality legislation. The administration's renewed interest in NHI provided the perfect opportunity and the task was clear; produce a quality National Health Insurance bill. Veteran committee member Rep Charles A. Vanik(D-Oh) summed up the pressure, "The committee has been under pressure to produce. To maintain our jurisdiction..sic(on health care legislation) we'll have to produce." (NJ 6/22/74) Thus, in ironic twist of fate, Mills had taken up the flag for the cause of NHI and the stage was set for the most serious co nsideration of national health insurance in the history of the United States.

In April a real breakthrough occurred. Kennedy and Mills had come together to produce a compromise plan of NHI that, while still preserving crucial differences from the administrations plan, took a large step in closing the distance between the Republica n and Democratic proposals. Even better the Administration was ready to deal. Earlier in March, Weinberger reported that the president had ordered him to use the HEW's, "full resources to secure passage of the Administrations health insurance legislati on this year."(NJ 3/16/94 pg. 381) By May, Nixon himself was pushing for action calling the Kennedy-Mills compromise, "constructive proposals which deserve consideration, we are not ruling out compromise."(NYT 5/21/74 pg. 1)

Wrenches in the Works
We now know, of course, that no NHI bill finally passed. The explanation for this non-occurrence can be found in the level of consensus required to pass complex legislation through the American institutional labyrinth. In any other country at any other time, a meeting of the minds such as had occurred over NHI legislation would have led to the passage and implementation of some sort of legislation. Not so in the United States. Despite the fact that the political leadership in both the Congress and the Administration wanted legislation, not all parties were satisfied. Our Congressional system provided these dissatisfied players with ample opportunity to throw a multitude of wrenches and grind to a halt the entire legislative process.

Specifically, Labor groups which had for a long time been loyally represented by Kennedy chose not to support his compromise with Mills. Sensing that Nixon was in lasting trouble over the Watergate scandal they chose to withhold support for Kennedy's com promise and wait until the fall elections which would ensure a solid democratic majority. Max W. Fine, executive director of the Committee for National Health Insurance which also represented mainstream labor views, summarized his organizations strategy: "We will resist action this year because we need a Congress so Democratic that it will be able to override a Presidential Veto." Thus, Kennedy's ability to influence votes had been undercut as his major base of political support abandoned him to the wol ves.

Another key to the lack of action is found in the lack of support given Kennedy and Mills by Russell B. Long(D-La) in the Senate. Long was chairman of the Senate Finance Committee which was the leading committee with jurisdiction over health legislation in the Senate. Long had sponsored his own less aggressive incremental approach to national health insurance. While promising to not impede the progress of any bill reported out of Ways and Means, he failed to lend his endorsement to the compromise effor ts choosing instead to keep alive a chance at passing his own legislation.(NJ 4/6/74 pg. 527) Further, Long's proposal was not the only alternative available to the members of the Ways and Means Committee. All told, the committee was faced by seven dif ferent serious health care proposals emanating from every possible health care interest. In short, at the verge of compromise toward NHI, Labor on the left balked because it thought it could get more and right balked because they believed they could get less. Taking their cues from their most powerful constituents, members of Ways and Means defected as well. The more liberal members opted to side with labor and wait for a better opportunity -- Conservative members opted to support the incremental prop osal generated by Long and Ribicoff. In short, despite the fact that the majority of concerned leadership wanted legislation reported, they could not effectively control the individual legislators on the committee.

Ford
In May, Mr. Weinberger provided a potent summation on the lack of progress on NHI in his plea to the members of Ways and Means to report a bill out of committee: "It would be callously cruel to delay action on something so vital to all the people just be cause a few had adopted a reckless attitude of rule or ruin, our plan or no plan."(NJ 5/11/74 pg. 702) Needless to say, this is exactly what happened.

Soon Watergate came to dominate Congress' attention and it looked like further action on NHI would be impossible. But by the beginning of August, Nixon had resigned freeing up space on the legislative docket which would have otherwise been used for impea chment proceedings. Nixon's resignation had a powerful effect on lawmakers throughout the capitol. The battle to remove the president was over, but now the politicians in Washington had to face the fallout of the scandal: The public perception that gov ernment was both ineffective and not to be trusted. Our national political elite needed a legislative package that demonstrated the efficacy of their institution and their commitment to the people. Many believed that comprehensive health reform could be used as an opportunity to rebuild the nation's confidence.

The new vice-president wasted no time in making his intentions known. Ford had argued that NHI was a means to boaster falling national confidence in government back in February and he restated his call for legislation in his inaugural address, "Why don't we write--and I ask this with the greatest spirit of cooperation, a good health bill on the stature books before Congress adjourns?" The day before on NBC's Meet the Press all of the health care superstars including Wilbur Mills, Edward Kennedy, Casper Weinberger, Martha Griffiths, Russell Long and Russell Roth (President of the AMA) had gathered to discuss prospects of health care legislation. Most members, with the exclusion of the president of the AMA suggested that compromise might be possible. T his fueled prospects that some sort of bill might finally be reported out of committee. (Campion pg. 321) It seemed that at last, all parties had been heard from clearing the way for Mills to construct another health care miracle as he had done back in 1965.

In pursuit of this goal, Kennedy and Mills agreed to another compromise. Mills introduced the new compromise that also closely resembled the Administration's plan. He immediately brought the bill to markup. Once again, however, the fragmenting forces of American political institutions undermined the reform effort. A series of close votes on the issues of financing and compulsory participation demonstrated to Mills that he did not have the consensus required to report the bill out of committee. In t he end, Mills conceded defeat. In late August he announced,," I've never tried harder on anything in my life than to bring about a consensus on this bill, but we don't have it. I'm not going to go before the Hose with a national health insurance bill ap proved by any 13-12 vote."(Campion pg. 323) Mills new that in order for a NHI bill to have a chance at passage it would require a strong demonstration of consensus by his committee.

Consensus in committee was necessary, he reasoned, because of the traditional absence of party discipline in this great federal republic. But the problem was exacerbated by the fact that the Congressional reforms passed in 1974 undermined the Ways and Me ans Committee by taking away the 'closed rule' which meant that now committee recommendations could be re-opened on the floor of the House. Without a strong show of support for the legislation from his committee and without the protection of a closed rul e, Mills new that the bill would have been a candidate for slaughter on the main House floor. Once again, NHI was relegated to the Congressional dustbin, a good idea but too controversial.

The lack of consensus in the committee itself was of course attributable to all of the factors that are endemic to the American political system. Neither Mills, nor the party leaders, could enforce party discipline over the members of the committee - no less the entire House. President Ford, despite the fact that he had been a powerful Congressional player himself, was also powerless to force Republicans to toe the line. Labor was still holding out for something better and the incremental proposal off ered by Senator Long still harkened to the conservatives on Ways and Means as an easier option than passing a full program of NHI. Worse, public opinion on issues of health care reform had fallen into complacency. The incremental strategies of the past had removed the immediate hardship of poor health coverage from most Americans.18 A crisis in financing was not a tangible reality which influenced public opinion. If we could imagine a scenario where NHI had a realistic chance of passage, 1974 might well have been it. Both the Republicans and the Democrats had a direct interest in passing some sort of bill. Key leaders in Congress desperately longed to pass somet hing to not only shore up the authority of their committees, but to also offer evidence for the effectiveness of the Congressional body. In any other democratic government in any other industrialized country, such consensus would have guaranteed the pass age of a national health insurance program. But barring a national emergency, it could not happen in the United States despite such overwhelming elite consensus.

The institutional consensus required to pass NHI had to complete in the most absolute sense of the word. It was not good enough to have the leaders of both parties and the executive branch committed to reform. It was not good enough that they were willin g to compromise on practically every aspect of the legislation . It was not good enough that the country was facing a health financing crisis. In order for NHI to pass, every possible interest had to be satisfied, every contingency accounted for. Alic e Rivlin, who predicted the passage of NHI earlier in July, provided a cogent insight into why such a plan might fail with one key exception when she wrote, "If national health insurance fails to pass this Congress, it will not be because the idea is too radical, but because there are too many competing proposals. Furthermore, this is a bad year for hammering out legislative compromises." (NYT magazine 7/21/74 pg. 8) What she failed to account for was that when it comes to complex, inclusive legislative packages like NHI, its always a bad time for compromise.

One should not assume, however, that no health care legislation was passed during these years of political turmoil however. Faced with their own commitment to "do something" about the mounting cost crisis the Washington political establishment felt compe lled to pass legislation that fit both American political logic and ideas. In 1973 a program promoting Health Maintenance Organizations (HMOs) was passed under the hope that it would foster competition in the health care market place. Though the medical lobby certainly did not approve of this legislation, it feared it far less than the draconian measures. Similarly, Congressional conservatives found it difficult to argue against a program whose explicit goal was to avoid government intervention by encou raging market competition.

Secondly, as the authorization for the Hill-Burton Act19 expired in 1974, Congress was able to pass the National Health Planning and Resources Development Act. We will not examine this reform here other than to point to some of its most obviou s features. The Health Planning legislation appeared impressive if viewed from afar. Its central goals were to rationalize the health care marketplace and to broaden public participation in community health care decision making. These were very admira ble goals, but as Morone points out: "When the incoherent American state faces vexing problems, it reflexively musters up this op of rationalization without fundamental change" (1990:272). In the end, the program passed was as incoherent as the communit y based planning agencies were toothless. Health policy experts quickly and resoundly criticized Congress' failure: "Impossibly flawed," wrote Marmor and Morone. "A fatuously implausible construct," judged Lawrence Brown. "We designed it backwards," s aid one official. "Upside down" wrote another. "The awesome list of goals," wrote Frank Thompson, "strained the limits of credibility."20 In the finally analysis, Congress once again had done what it does best - attempt to deal with pressing national problems by placating powerful constituents. In passing the Health Planning Act, Congress could convince itself that it had moved towards reg ulation, but could also show the industry that they had nothing to fear. The local health planning boards were given almost no real powers and would clearly be dominated by medical industry at any rate. "Surely, this was the essence of pork-barrel polit ics," James Morone summarizes, "highly individualized choices about distributing benefits, each made without reference to any other, none of them taxing any fixed budget" (1990:278-9). This may have placated these powerful interest groups, but it certa inly did not inspire confidence in American political institutions on the part of American citizens.

Carter
By the 1976 election the budgetary fires were still flaming. Moreover, it was becoming increasingly obvious that large segments of the American public were being left out of the health care system.21 The Democrats once again seized upon healt h care reform in an attempt to show the American public that they were the best party to deal with national problems. Even the Republicans, acknowledging both the fiscal incentives for reform and the popular will to move in this direction, acknowledged t hat reform was inevitable and necessary. Thus when Jimmy Carter defeated incumbent Gerald Ford, and when the voters sent 292 Democrats to the House against only 143 Republicans, it was widely predicted -- indeed assumed -- that major health care reform w as just around the corner.22

Unfortunately for Carter and proponents of health reform, the Congressional reforms passed in the wake of Watergate made decisive action on controversial political issues like health reform less and not more likely. As mentioned above, the Congres sional reforms passed in 1974 was intended to undermine the controlling power of conservative Southern Democrats committee chairman (especially Wilbur Mills) and to redistribute that power to party elites as well as to more junior members of Congress. S everal of these reforms are relevant for our story. First, participation on the Ways and Means Committee was dramatically expanded - thus making it more difficult to build consensus even within the committee. Secondly, jurisdiction over health reform wa s now subdivided to four committees in Congress. (This way more legislators could 'get in on the action.') Finally, the 'closed rule' was removed from House Ways and Means committee reports. Whereas before, bills reported out of Ways and Means had to b e considered as a whole on the floor (no amendments could be made) now anything that came out of the committee could be picked to death by individual legislators wishing to score points with particular constituencies back home.

This basic institutional context, combined with the increasing fiscal pressures on the federal government brought about by the Medicare/caid programs that encouraged the Carter administration to pursue a two-stage political strategy. Believing that they could face insurmountable institutional obstacles if they began with a comprehensive plan, the administration decided to first get cost-control legislation through Congress and then move towards broadening the net through a more comprehensive reform.

The Administration first targeted hospitals in their efforts to control expanding medical costs. This choice was informed by several political considerations. First, hospital cost increases had outpaced other areas of the medical field for several years .23 Thus, hospitals were an obvious target for cost control regulations. Moreover, everyone knew that the Health Planning legislation passed two years earlier would not have the cost controlling effects that it supposed to have. Secondly, Cart er's advisors argued that our political system made it easier to divide and conquer, rather taking on the whole of the medical industry. This was especially important since the Administration hoped to employ the plan quickly and make immediate gains in c ontrolling costs. They believed this would facilitate the introduction of a national insurance program (Inglehart, 1977:685).

The proposal ran into immediate trouble. Sensing another "foot in the door", every major medical lobby came out against the plan. Both the American Hospital Association and the AMA launched lobbying campaigns against the President's proposal.24 Interestingly, the industry did not launch into a massive public education campaign condemning "socialized medicine." Instead, the medical lobby employed a strategy of focusing on the individual legislators, noting that "Virtually every Member of Con gress has a hospital in his or her district and these institutions effectively apply pressure on the legislators" (Inglehart, 1977:685).

It would be tempting to argue that it was simply the raw political power of the medical industry that defeated Carter's proposal. But such an analysis would gloss over the ways in which American political institutions shaped the strategies of the propone nts and opponents of reform. Now there were even more legislators with a hand in health reform. Moreover, as Morone points out, now there were even more interests who had a stake in the system. But in contrast to both Morone (1990) and Peterson's (1993 ) analyses, in our view the increasing density of the health policy making space made it even more difficult for reformers to impose costs on powerful groups than it had been before.

As more and more interests lined up against the Carter plan, the legislature began to give reform a cold shoulder. A key to the frosty reception of Carter's reform legislation was the dissenting opinion of the Chairman of the Senate Finance Committee, (D :Ga). He chaired the fourth committee under which the Administration's proposal fell. Talmadge disliked the short term objectives of Carter's cost containment legislation, preferring his own long term plan which emphasized the preservation of the Medica re system (Congressional Quarterly, 78, 623). Like Medicare, which had been blocked by Wilbur Mills who hoped to preserve the integrity of the Social Security program, Carter’s cost-containment proposals were opposed by a Senator who wanted to preserve the integrity of the Medicare program. While Talmadge’s lack of support for the bill did not constitute a veto of the program, his dissent did work to fracture support for Carter’s initiative. In the new post-reform Congress, no one chairman had the inf luence to take responsibility for the bill, it required consensus from all four. This left the other legislators who sat on the four committees to their own devices. Thus the four committees wrangled over the form the bill should take, and each committe e proceeded in its own direction. Thus health care was typical of Congressional politics of the day.

The new policy process is characterized by a proliferation of overlapping and competing policy subsystems, with legislative proposals spewing forth from hundreds of subsystems in an often conflicting and contradictory fashion. Because so many congressional actors have some degree of significant authority, the role of the central leaders is extremely difficult (Dodd and Schott, 1979: 154).
This tangle of competing jurisdictions radically complicated the Administration's task in promoting the bill. Despite an impressive list of Congressional co-sponsors,25 Carter was never able to collect the necessary votes to get the bill out o f committee. In the words of , “ There is a whole new brand of politician in Congress, the seniority system is gone. Before, the President had a chain of command to work with and through, but it has disappeared. Now, no one can deliver the votes. Now you have to build whole new coalitions for each issue" (quoted in Bonafede, 1977:1759). The source of leadership that used to be embedded in the House Ways and Means committee (which acted as a double edged sword) was no longer available. In the past, e fforts at health care reform were frustrated by the strength of the seniority system and the partisan fractures in Congress (i.e. the southern Democrat, Republican Coalition). These two sources of conflict were no longer as relevant in the Congress servi ng under Carter. However, Carter's legislation had run into a new source of legislative blockage: extreme fragmentation of the 'reformed' Congress itself.

This would set a pattern that would be repeated in each of the following years. The Administration tried to push the program through Congress, only to be frustrated by the variety of attempts to reduce the bill's effectiveness in order to bypass the intr ansigency of the committee deadlock. The AHA and the AMA strenuously lobbied against the bill and in the end, won an endorsement of the voluntary cost control effort. This allowed the Congress to make a symbolic declaration in favor of cost controls, wi thout having to actually take any action on the issue. The Congress walked away from the cost-control debacle still looking as though it had taken action, thus, soothing voter concerns. The reality was the cost-containment bill failed in 1977, 1978 and 1979 with no part of the cost-control proposal ever becoming law. By 1981, the voluntary effort by the hospitals was condemned as a failure but no further action on behalf of hospital cost control was taken.

The failure to pass any sort of cost-containment legislation killed any chance for the President to successfully promote a NHI plan. Carter did eventually develop a plan which was introduced on June 12, 1979. However, the proposal was dramatically reduc ed from the promises he had first made during the 1976 campaign (National Journal, 5/6/78). The bill was never taken seriously and Edward Kennedy, the leading NHI advocate in the Senate, expressed a vote of no confidence by introducing his own competing legislation which addressed the concerns of labor more directly than the Carter proposal. This marked the end of any attempts by the Carter Administration at health care reform as election concerns began to dominate the political landscape. Interestingl y, public support for national health insurance remained high throughout the Carter Administration. In December of 1979, public opinion was still showing strong support for a NHI program. In 1979 Public Opinion Polls, ironically reported in the Journa l of the American Medical Association that 70% of Americans still supported NHI.26

The American political system had once again defeated itself. Once again, the public's attention was focused on the need to reform our health care system by progressive reformers. Once again, our national political institutions proved incapable of deali ng with the very problems that they had brought to the citizen's attention. Unsurprisingly, citizen's confidence and faith in those institutions ratcheted down another notch. More than 60% of the American public felt that they could not trust the govern ment to do what was right most of the time. Having viewed the history of health care reform up to this point, we must acknowledge that their skepticism was well justified.

National Health Reform Finally Comes of Age?

A long-term crying need has developed into a national moral imperative and now into a pragmatic necessity as well... An aura of inevitability is upon us. It is no longer acceptable morally, ethically, or economically for so many of our peo ple to be medically uninsured or seriously underinsured. We can solve this problem. We have the knowledge and resources, the skills, the time, and the moral prescience. (Journal of the American Medical Association, May 15, 1991)
With the election of Bill Clinton it once again appeared to almost all observers that comprehensive National Health Insurance would finally become a reality in America. There were a large number or reasons to predict the success, and they are all familia r to readers of this journal: Health care costs had clearly spun out of control. Now, even traditionally powerful anti-state interests like the corporate sector indicated their readiness to accept fundamental reform - even if that meant greater governme nt involvement in health care sector (Martin, 1993). Over 30 million Americans without health insurance and tens of millions more were seriously worried about losing the insurance, therefore even the middle class felt a clear need for reform. Poll after poll indicated that between 70% and 82% of the American public favored NHI (Roper, 1994). Bill Clinton had also made National Health Insurance keystones of his electoral campaigns. Finally, as the quote above indicates, even the provider community app eared to conceded that health reform was not only politically inevitable, but also morally and economically necessary.

So what happened? Why were almost all predictions wrong? Why, given the fact that virtually all of the cards appeared to be stacked in the direction of health reform, did nothing pass? The answer, of course, is that reformers like Bill Clinton are not playing on a level card table. The game of politics in America is institutionally rigged against those who would use government - for good or evil. James Madison's system of checks and balances, the very size and diversity of the nation, the Progressive reforms which undermined strong and programmatic political parties and the many generations of congressional reforms have all worked to fragment political power in America.

This fragmentation of political power - which has become more severe in the past twenty years, and not less so as some recent scholars have argued (cf. Peterson, 1993) - offered the opponents of reform huge opportunities to attack Clinton's plan. But a v ery brief overview of some of the new cards that are stacked against health reform is instructive.

First, as Mark Peterson has suggested, American political institutions are not the same as they were 20, 30 or 40 years ago. As he points out, with the reforms of the 1970 "[t]he oligarchy had been changed into a remarkably decentralized institution.... C ongress as a whole generally became a more permeable and less manageable institution than ever before" (1993:418). Whereas policy making could at one time be characterized as 'iron triangles' it now looked to be dominated by 'issue networks' (Heclo). Bu t where Peterson sees this a making it more likely that health care reform would pass in the 1990s, we believe that the increased decentralization of institutional power makes it less likely that meaningful reform can pass.27

Secondly, out the 1990s is marked by "an entirely new type of policy community." According to Peterson, it "has lost its cohesiveness and its capacity to dominate health care politics and the course of policy change" (Peterson, 1993:408, 411). Now with h ealth care is 1/7th of the U.S. economy there are an ever larger number of interests who have something to lose if meaningful comprehensive health reform were passed. The fact that there are so many more interests (factions) who now have a stake in the e xtant system (a system that is enormously profitable) does not suggest to us that reform is more likely in the 1990s. Quite the contrary. Reformers now have to battle a medical/industrial /insurance complex which has over $800 billion dollars a year at stake.28

Third, it is important also to remember that the Clinton's bill needed support from more than 50% of the members of House and 50% of the members of the Senate. Congressional rules (ie. institutions) in force in 1994 allowed a minority to block legislati on as long as they could control just 40 out of 100 votes in the Senate. No other democratic system in the world requires support of 60% of legislators to pass government policy. This institutional fact appears even more absurd when we rem ember that the Senate so radically malapportioned.

Fourth, despite the fact that there the 1990s was marked by the highest level of public support for government intervention in health care financing (Peterson, 1993:406-7), the incredible $3,000,000,000,000+ debt facing American taxpayers (most of which h as been accumulated in the past 15 years) make government financing of health care reform exceptionally unlikely indeed.29

Fifth, changes in the technology of electioneering have worked hand in hand with the increasing fragmentation of power in Congress to the point where Congressmen and women have become independent policy entrepreneurs. This means money. Between January 1, 1993 and July 31, 1994 candidates for the House and Senate received $38 million in campaign contributions from the health and insurance industries. The AMA was had the single most generous Political Action Committee in the country contributing over $1 ,933,000 in 1993 and 1994 alone.30 These figures do not include small donations made by local constituents -- nor do they include donations from small business, another bitter foe of Clinton's health reform plans. "By the end of the year we e xpect that the health and insurance industries will have spent over $100 million to crush health care reform," reports the public interest research organization, Citizen Action. "They will have spent over $40 million in campaign contributions and another $60 million in advertising, public relations, organizing and lobbying. In addition, previous reports have identified over $13 million in campaign contributions from other opponents of comprehensive [health] reform" (Citizen Action, 11/3/94:2).31

The world around our political institutions have not remained static either.32 Undoubtedly the most important change in modern politics is the role of and importance of the media. This point was not lost on the opponents of the health care re form. The American Hospital Association, for example spent over $14 million on the famous "Harry and Louise" advertisement alone. It is interesting to note that more money was spent in TV adds opposing Clinton's health care plan than was spent in the fi rst three years introducing Snapple to the American consumer.

Finally, the repeated failure of American political institutions to address the polity's problems - even when there has been clear public will for action - has worked to dramatically undermine the public's faith in their governmental institutions.

Health Care Reform and American Attitudes Towards Their State
Conservatives and culturalists suggest that comprehensive health care reform can't and won't win in America because Americans don't want it. Of course public opinion data does not support this thesis. In fact 68% of respondents to a CBS/NYT poll taken i n early September 1994 said that they were 'disappointed' that Congress never passed health care reform. Only 25% said they would be pleased with this outcome. In the same poll 73% said they think there is a 'crisis' in health care today and only 25% s aid they did not think there was a crisis today (CBS, Sept. 18, 194). Moreover, American's think that fundamental reform is necessary. At the end of June 1994, only 19% felt that only minor changes were necessary while 48% agreed with the following stat ement: "Our health care system has so much wrong with it that we need to completely rebuild it." (Roper: June 28, 1994).33

In our view, there clearly is a relationship between American's distrust of government and the government's inability to implement comprehensive and successful social policy reforms. But, in contrast to those culturalists who appear to view the relations hip between culture and public policy as a one way street, we believe that it has been the repeated failures of American national political institutions to adequately deal with the social problems facing Americans that has fanned the fires of distrust wit hin in the American polity.

Obviously, the relationship between attitudes and policies is both interdependent and iterative. We in no way mean to suggest that Americans are really in love with government and wish for the government to intervene in their private lives more and more. We hope the reader (and commentators) will give us more credit than this. Instead, we mean to suggest that there have been competing values and preferences within American political culture; clearly the basics beliefs in personal independence and indiv idual responsibility are important components of our political culture. But as DeTouqueville and others have long ago argued, American political culture also has also been profoundly egalitarian. It is not obvious to us, given the conflict between these values, that America would be the only county in the modern world that did not insure that families could be destroyed and lives could be ruined because someone's child became ill. It is clear to us, on the other hand, that the persistent inability of o ur government to address the felt needs of the citizens has mightily contributed to the distrust we hold for our political system and its institutions.

In short, citizens have increasingly come to believe that the system does not work.34 The problem has been dramatically exacerbated by the election of a President who promised a broad social agenda. As political analyst Stuart Rothenberg said the day after the November election, "Voters expected change. They believed they has voted for change. A year and a half later, they think they got more of the same" (Thomma, 1994:8a). Public opinion polls confirm what many observers have noted. " In g eneral, do you approve or disapprove of the job Congress is doing in handling the issue of health care reform?" 26% Approve, 65% Disapprove, 9% DK. (Roper, Sept. 1994)

Table 2
Growing Distrust
Date of Poll Government is run for a few big interests Government is run for all the people Government wastes a lot Government wastes some Government wastes little
March 1993 68% 23% 75% 22% 3%
January 1994 83% 16% 1%
Q. 1) Do you think government is pretty much run by a few big interests looking out for themselves or that it is run for the benefit of all the people?
Q. 2) Do you think the people in government waste a lot of money we pay in taxes, waste some of it, or don't waste very much of it?
Source: Roper, 1994

The massive campaign run against the Clinton health reform plan, was a campaign against government generally. And, given the repeated inability of this government to act on the will of the people, this theme fell on receptive ears. The opponents, we sho uld remember, were very careful to not argue against any health care reform The opponents of health reform instead tried to say this reform would be just like all the rest.

Louise: This plan forces us to buy our insurance through these new mandatory Government health alliances.
Harry: Run by tens of thousands of new bureaucrats.
Louise: Another billion dollar bureaucracy.

Clearly, Clinton and pro reform forces lost the public relations battle. A key is the fact that the anti-reform forces spent an estimated $300 million lobbying and advertising against Clinton's health care bill.35 But, as the Washington Post reminds its readers, "Four other congressional committees have jurisdiction over health care legislation, and the association is free to advertise if and when a bill gets out of Ways and Means." (Post, Mary 24, 1994, Front Page, "Harry and Louise to Vaca tion During Hearings." But part of the explanation must be that they were singing a tune that Americans had heard many times before -- and, as this history demonstrates --they have also been given many reasons to believe that when the American governmen t does something, it too often does it badly.

Table 3
Decline in Support for Clinton's Health Plan

Date of Poll Q. 1 - % Favor Clinton's Plan Q. 1 - % Oppose Clinton's Plan Q. 2 - Congress should pass Clinton's Bill with No or Minor Changes % Q. 2 - Major Changes Needed, or Congress Should not Pass Clinton's Bill, %
Sept. 1993 59 33 57 33
Nov. 1993 52 40 48 45
Jan. 1994 57 38 47 45
March, 1994 44 47 49 48
June, 1994 42 50 42 53

Q. 1. "From everything you have heard about the plan so far, do you favor or oppose President Clinton's health reform plan?"
Q. 2 "What do you think Congress should do with Clinton's health care plan: Pass it without any changes, pass it with minor changes, pass it but with major changes, or not pass any of it?"
Source: The Roper Center, "Health Care Update" Vol. 5. No. 5, p. 94, July/August 1994

Certainly, there are shades of the Whitaker and Baxter campaign in this new ad campaign. But in the 1990s the emotional image presented by the anti-reformers was not German or Russian inspired "Socialism." The new boogie man, the medical and insurance i ndustry's focus groups told them, was now government itself. Health care crisis or no health care crisis, whether the health care system was in need of fundamental reform or not, 62% of Americans feared that "the plan would create another large and inef ficient government bureaucracy" (Feb. 24-27, 1994). This was after Harry and Louise had been running for 21 weeks (Roper Center Sept. 1994).

It may well be true, as Peterson suggests that "[p]ublic sentiment can overpower private interests when its desire of change is unambiguous, when it is clear which policy alternative the public will accept, and when elected officials realize that the issu e will affect votes" (1993:399). It is equally clear that these conditions do not now, and our estimation never will, be present with an issues as large as restructuring of one seventh of the American economy. This kind of clear public consensus is espe cially unlikely around a particular policy proposal when there are powerful private factions who have their interests at stake. Finally, this type of consensus is not necessary in any other democratic polity. We are willing to venture, in fact, that if this level of public consensus around particular reform proposals had been necessary in other democracies, no country would have ever developed a national health insurance system.

Citations
  1. By far the most sophisticated of the culturalist analyses is the recent book by Lawrence Jacobs The Health of Nations. In this tremendously interesting and well documented book, Jacobs attempts to show that the Britain and America created radi cally different health care systems due do to differences in basic public preferences. We strongly recommend this book to the readers of this essay as the best counter argument to the thesis presented here. While sympathetic to the analytical aims of Ja cobs' analysis, however, we believe that he errs. In his attempt to demonstrate the policy relevance of public preferences, he overstates his case and in the end presents an overly static understanding of those preferences. See discussion below.
  2. Jacobs (1993) makes the most careful attempt to argue that differences in policy outcomes are a product of differences in public opinion. But even his very extensive comparative historical analyses of public opinion in Britain and America does not de monstrate that the British citizens demanded the National Health Service structure that the 1945 Labour Government implemented. British citizens clearly believed the health care system needed reform at the end of the war, and they strongly believed that " everyone should be included," but while very interested, most citizens were hazy on the details and not clear on the specifics reform they preferred (Jacobs, 1993:113-114, 169-170,173-175).
  3. Of course, not all analysts of the development of the American health care system can be fit easily into these to categories. Indeed, two of the finest histories of the development of the American health care system, Paul Starr's, The Transformati on of American Medicine, and Theodore Marmor's, The Politics of Medicare, do not make explicit in their explanation for the particular policy outcomes they describe. In these cases, one can find evidence for, and inferences towards, both the c ulturalist and the interest group explanations.
  4. There are few genuinely comparative political histories of the politics of health care reform today. Two of the best of these are Anderson (1972) which compares the politics of health care in Britain, Sweden and the United States and Immergut (1992) who compares Sweden, Switzerland and France. Excellent single country studies of health care politics written in English include: For Britain see Ekstein,1960 ; Klein, 1983; For France see, Wilsford, 199 ,for Sweden see, Heidenheimer, 1980.
  5. See for example: March and Olson, 1989; Hall, 1986; North, 1990; Ikenberry et. al. 1988; Weaver and Rockman; Steinmo et. al. 1992.
  6. See for example, Dunlavy, 1992; Hall, 1986; Hattam, 1993; Immergut, 1992; Steinmo, 1993; Weir, 1991.
  7. Socialist Eugene Debbs won another 900,000 votes in this election. Due to America's unique electoral college system for electing presidents, Roosevelt received only 88 votes, Taft received 8 votes, Debbs won 0 votes. Woodrow Wilson, however, who had received less than 42% of the popular vote, won 435 electoral votes. It is interesting to ponder in this context, the political and policy implications for American development, had the US had a proportional representation electoral system like that com mon in continental Europe.
  8. The New York Times reported that already by the 1920s the AMA was perhaps "the most powerful [lobby] in the country." The went on to suggest that "The American Medical Association is the only organization in the country that could marshall 140 votes in Congress between sundown Friday night and noon on Monday." (cited in Morone, 1990:256).
  9. A Gallup poll taken the following year demonstrated continued support for the plan with 59 percent of Americas still favoring the program.
  10. Truman first voiced his support for NHI in 1945 (Poen: 1979:64).
  11. Public opinion data from Hearings before a Subcommittee of the Committee on Labor and Public Welfare: The United States Senate, Eightieth Congress, First Session on S. 545, 1947: US Government Printing Office, pages 1510, 1511. Data collected by the National Opinion Research Center, Denver, Colorado and the Opinion Research Corporation, Princeton, NJ.
  12. For a similar argument with respect to other policy issues at the time, see Hansen, 1993
  13. The Democrats increased their majority in the Senate to 68 vs. 32 and 295 vs. 140 in the House.
  14. The product reported by Mills's committee came to resemble a "three layer cake" of legislation. The original Medicare bill remained largely unchanged and became known as Medicare Part A. The second layer consisted of a voluntary program of insurance to cover physicians services much in the same manner of the Republican proposal. The third layer was an expansion of the Kerr-Mills program designed to specifically administer to the needs of the poor. This final section became known as Medicaid and re presented the most substantial expansion beyond the pro-reform groups original legislation. For a more comprehensive detailing of Medicare policy and politics see Marmor, 1973.
  15. The Prime Minister Attlee faced a cabinet which was deeply divided over health reform and as a consequence centralized control over the issue to an "inner inner" cabinet consisting of himself, Herbert Morrison and well known left-wing Minister Ernest Bevin (Jacobs, 1993:173).
  16. Indeed, "the crucial policy decisions on NHS, were made before legislative consideration" (Jacobs, 1993:173). When the Bill was finally introduced to Parliament, strong party discipline insured that there would be no changes to the legislation withou t the specific approval of the programs designers.
  17. Nixon had also had a proposal on the table since 1971. But his National Health Insurance Partnership was not a comprehensive measure. It would have only covered employees through the use of employer mandates and provided group plans for small employ ers, the self employed and low income groups. His 1974 Comprehensive Health Insurance Act was still to be administered through private insurance companies, but it offered a more liberal package of benefits to be offered by employers and it would have gre atly expanded the Medicare program by offering the same set of benefits to low income groups as well. (CQA, 1971 pg. 544 and 1974 pg. 388)
  18. Info lifted from Campion's Book "The AMA and Health Policy Since 1940" Stephan . Strickland, U.S. Health care: What's Wrong and What's Right? (New York: Universe Books, 1972): 26-30. In therapy 1970's polls done by LIFE magazine, the Washin gton Post, the Continental Illinois Bank of Chicago, Black Opinion Survey of Washington DC, Roper Reports and the University of Michigan Institute for Social Research indicated that from 70-85% of the publics sampled were "satisfied" or "well satisfied" w ith the health care they received.
  19. Hill Burton was a massive piece of health care pork-barrel written in the late 1950s that subsidized health care facilities across the nation. We refer the interested reader is to Morone's excellent discussion of this issue (1990:258-284.)
  20. These quotes taken from Morone, 1990:275.
  21. Health care costs had grown from 5.3% of GNP to ??? by 1975. Federal health care outlays had skyrocketed from $9.5 billion in 1965 to $41.5 billion in 1975. Moreover, a HEW study estimated that 24 million Americans were lacking in basic health care coverage and another 19 million had inadequate coverage.
  22. In no small part, due to the attention of national elites to the problems of cost of the health care system, the American public soon came to identify this issue a key concern. Eighty-five percent of Americans felt that medical costs were rising fast er than all other segments of the economy. In line with this perception, seventy percent believed that "the health care system is out of control and needs to be changed" (). Further, many Americans felt the federal government should be involved in the c hange. When asked about federal involvement in the health care system, 65 percent responded that "The government should have a greater involvement in the country's medical and health care system" (Lou Harris, 1977).
  23. In 1975, hospital costs increased at a rate of 15 percent which was a full two and a half times higher than all prices as rated by the consumer price index (). Further, the department of Health, Education and Welfare estimated that the cost of a one- night hospital stay had risen over 1000 percent since 1950.
  24. J. Alexander Mahon, president of the AHA stated, "Our strategy is to blow the Administrations bill out of the water" (Congressional Quarterly, 1977:502).
  25. In the House, the bill was co-sponsored by Paul Rogers (D:Fl), chairman the Subcommittee on Health and the Environment; and Dan Rostenkowski (D:IL), chairman of both the House Ways and Means Committee and the House Ways and Means Subcommittee on Healt h. In the Senate the legislation was sponsored by Ted Kennedy (D:MA) chairman of the Senate Sub-Committee on Health and Scientific research and a long time advocate of national health insurance legislation (National Journal, 5/21/77).
  26. The American Medical News reported a Gallup study showing that 67% of Americans supported NHI and that 42% would support NHI even if it meant increasing their taxes.
  27. Whereas under the old rules health care reform had to pass through the Ways and Means and the Senate Finance Committees (no small task given the conservatism of these institutions) by the mid 1990s no less than five major Congressional committees clai med authority over health care legislation. This meant that no matter how perfect a bill the administration might produce in point of fact, the final bill would necessarily imply a compromise between the personalities (not to say egos) as well as the pol itical predilections of five chairman and five committees. Five committees, moreover, meant five obvious "veto points" for opponents of reform.
  28. For contrary views see Peterson, 1993; Morone, 1990.
  29. Each comprehensive reform that was floated in Congress in 1994 crashed at the door of Robert Reischauer director of the CBO who was continually forced to give reformers the bad news: Comprehensive and universal coverage will cost money -- at least in the short run.
  30. Since 1979 the AMA has contributed over $16.8 million to Congressional campaign coffers. The American Dental Association contributed over $7 million and the National Association of Life Underwriters contributed over $8.3 million in the same period. All together the 15 largest health and insurance PAC contributed over $60 million since the last year President Carter was in office.
  31. Unsurprisingly, members who were in particularly pivotal positions with respect to the health plan were particularly favored by the interests who had the most to lose. Interestingly, Jim Cooper, one of the key players whose "bi-partisan" plan did muc h to take the wind out of the Clinton plan's sails in August 1994, was the single largest recipient of health and insurance company money. They liked him so much that they gave him over $668,000 dollars in less than two years.
  32. See Steinmo, 1993 for a fuller elaboration of the theme of the interaction of political institutions and the political and economic context in which they operate.
  33. In Fall 1991 a Princeton Survey poll found that 82% of Americans agreed that government should guarantee everyone health insurance coverage (only 16% disagreed). Moreover, as Jacobs (1990) points out "Polling results consistently indicate that the pu blic's support for national health insurance is greatest when the reform promises to cover all Americans rather than target the uninsured and poor." (1993:632-2)
  34. In early September 81% said they believed that Congress would be unable to agree on a health care plan.
  35. $50 million spent on TV adds alone (NYT, Aug. 29, 1994). Health insurance industry spent over $14 million on the first set (by March) of Harry and Louise adds alone. The Harry and Louise adds were so successful that by May, 1994 Ways and Means chairman Dan Rostenkowski (D. Ill.) was forced to make explicit concessions to the insurance industry while a health care bill was to be considered in his committee. In exchang e for Rostenkowski "snuffing out proposals it [the insurance industry] considered most threatening" the insurance industry would withhold the Harry and Louise adds from the TV airwaves while Ways and Means considered the legislation. But, as the Washing ton Post reminds its readers, "Four other congressional committees have jurisdiction over health care legislation, and the association is free to advertise if and when a bill gets out of Ways and Means." (Post, Mary 24, 1994, Front Page, "Harry and Louis e to Vacation During Hearings.")

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