Major health reform requires Democratic congressional dominance

The requirements for enacting “Medicare for all” — or any similarly dramatic health care legislation that would result in universal coverage — are apparent from the demise of former President Bill Clinton health reform effort in 1993-94, and the success of former President Obama’s Affordable Care Act in 2010. 

Both cases demonstrate that in order to enact any major health system — that would work for everyone —  Democratic control of the White House and both houses of Congress is needed.

In the Senate, control would mean that a filibuster-proof majority is able to withstand the likely defection of moderate Democrats who would face pressure from opponents in the health-care industry. A 67-vote majority could possibly work — that’s 20 more seats than Democrats currently hold. 

Control of the White House and Congress is not sufficient. A second requirement is a president who puts health-care reform at the very top of his or her priority list, even at the possible cost of abandoning most other first-term aspirations.

Despite opposition from his advisers, Obama made this commitment. Clinton, on the other hand, decided to pursue an economic agenda first — including balancing the federal budget and enacting NAFTA —  he lost critical time and political capital by the time his administration turned to health reform.

But even personal presidential commitment is not enough. We need a president who has fine-tuned command of the machinery of government and an understanding of Congress’s arcane byways. 

Clinton made the mistake of listening to congressional leaders who told him he needed to write the bill himself. The result was a long process led by first lady Hillary Clinton that further delayed congressional consideration of the issue, and produced a blueprint that even many of Clinton’s allies roundly criticized and opponents ridiculed. Having learned from Clinton’s mistakes, Obama enunciated broad principles, but left it to the Congress to draft the legislation. 

Though he was criticized for being too hands off, Obama recognized that whatever plan he introduced, Congress was going to rewrite it anyway — and once they did, would be more invested in its passage.

Another historical lesson from the Clinton and Obama experiences is that there is one job in the health-care reform realm that only a president can perform: creating national political support for congressional action by mobilizing public opinion. 

The president is elected for all the people of this nation, and his or her ability to speak to them is unique. Clinton and Obama didn’t fully realize the importance of health reform after their elections. In Clinton’s case, this allowed opponents — like the Health Insurance Association of America (HIAA), the association of smaller insurers that the Clinton plan might have put out of business — to vigorously fight against his bill. 

Obama’s failure to move forward with national health reform helped set the stage for the successful Republican counterattack after its passage; it led to their triumph in the House of Representatives in 2010.

As proponents and opponents of major health reform contemplate the 2020 contest, these historical lessons suggest that they should be focusing as much on the Senate as on the presidency in their advocacy. For proponents of health reform, getting the necessary control of the Senate may be an almost impossible task — much more difficult than recapturing the White House.

History also suggests that health reform advocates should look at the passion and commitment of candidates to health care — the extent to which they prioritize the issue; and their consistency and command of its nuances. Reform proponents should also favor a president who knows Congress and the mechanics of governing, and has the charisma and eloquence to create and maintain the national political support needed to pass and sustain major health reform.

David Blumenthal M.D., is the president of The Commonwealth Fund, a national philanthropy engaged in independent research on health and social policy issues.