Think Smaller on Health Care
Posted on April 24, 2009(CNN) -- President Obama has taken the advice of famous Chicago architect Daniel Burnham. "Make no little plans," Burnham said, "they have no magic to stir men's blood."
The president has called for the complete restructuring of education in this country. He wants to recast the energy industry. He promises to tackle the looming problem of Social Security and Medicare. He wants to raise taxes on the rich and give money to the poor. He plans on redoing the banking and investment industries.
He has even weighed in on the college football bowl system.
But when it comes to another of his ambitions, health care reform, history shows that it is the littler plans that usually get done.
The president certainly has big ambitions when it comes to health care. He wants to boldly restructure the insurance market so that everybody is covered. He also wants to dramatically cut costs so that everybody can afford to get the health care they need.
But universal access doesn't necessarily go with cutting costs. And having the government control every aspect of the health care delivery system not only will inhibit creativity and progress, it will also cost a lot of money.
And there is the nagging question of how to pay for it all. Congress has rejected a couple of the president's revenue raisers, including a plan to nick charitable contributions and to take away the mortgage deduction for some homeowners.
I am going to give the president and some of his team some unsolicited advice: Think smaller. And think bipartisan.
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The experience of the past hundred years of health care reform suggests that efforts to nationalize the whole industry usually fail, but smaller, discrete bites of the apple usually succeed.
As part of his Square Deal program, Teddy Roosevelt, the man who preached the doctrine "walk softly and carry a big stick," promised universal health care. But when he ran on such a plank in 1912, it certainly didn't help him win.
When Harry Truman decided to try to nationalize health care after World War II, he ran into the buzz saw known as the American Medical Association.
Bill Clinton made another run at universal health care when he got elected in 1992. I was working for House Minority Leader Bob Michel at the time, and Republicans were very concerned about how they would counter the president's wife and his big majorities in the House and the Senate. As often happens in one-government rule, the Democrats over-reached.
Hillary Clinton created a task force and then came up with an incredibly complex piece of legislation that was easily lampooned by the Republicans.
They were able to work with provider groups and insurance companies to come up with a simple alternative that appealed to moderate and conservative Democrats who didn't like the heat they were getting from the provider groups and didn't like Mrs. Clinton much, either. The effort collapsed. But the issue didn't go away.
There are plenty of examples of success when the expectations are scaled back and where specific problem areas are targeted.
For example, Medicaid and Medicare, created in the 1960s, were aimed at discrete groups (the poor and the elderly) who quite clearly needed some help with their health care expenses.
In the late 1990s, health care portability was identified as a problem. The result was HIPAA, and it was passed with a bipartisan majority and wouldn't have happened without a partnership between former Republican Rep. Dennis Hastert (he was a whip at the time) and Democratic Sen. Edward Kennedy.
It also became clear during that time that too many kids weren't getting access to health care. It is hard to be against giving more health care access to kids. The result was the State Children's Health Insurance Program. It was passed with a bipartisan majority and, in fact, was initially pushed by Republicans.
Around the turn of the century, another need was identified. The Medicare program didn't include a prescription drug benefit.
The grass-roots efforts were pretty straightforward: Seniors wanted help in paying for the drugs that kept them alive.
It was the most difficult vote I have ever seen in my life. You wouldn't think spending $400 billion would be that hard. But it was. Conservatives didn't want to expand government with a new expensive entitlement.
The Democratic leadership didn't want to give Republicans a victory, especially on an issue as popular as prescription drugs, and although there was bipartisan support, ultimately, for the final bill, it was a hard-fought bipartisanship.
And when the vote came on the House floor, it was basically a tie for three hours.
Three hours while opponents scrambled to kill it. Three hours while proponents scrambled to pass it.
It was truly a remarkable compromise and an impressive accomplishment. And it remains a popular program that actually saves lives.
I go through this history because I think it helps put the current debate in some perspective. Passing universal health care is hard -- and perhaps impossible. If it were easy, it would have been done by now.
Taking incremental steps is more effective and usually more successful. And trying to craft a bipartisan solution is essential.
The president and his team have learned a few things from the Clinton experience.
First, they have shied away from creating a huge bureaucracy that will scare the public. Second, they don't have a controversial figure, like a Hillary Clinton, driving the process. Third, they have decided to let Congress lead the process, not the administration. And fourth, they are working hard to get some buy-in from the business community.
But those aren't the only lessons to learn from past efforts. The Obama administration and its allies need to remember that pushing a product that is too big and too partisan may lead to its doom.
They have seemingly decided to adopt health care under budget reconciliation, a procedural maneuver that allows it to pass with a simple majority, making the Republicans irrelevant to the process.
And they still seem intent on their big plans.
Daniel Burnham was a great architect, and his admonition to "make no little plans" may fit well when it comes to building a city. But when it comes to building a health care policy that can get enacted, if history is any judge, making small, bipartisan plans is the surer way to success.