Why Health Care Reform Failed

...He expressed admiration for the Canadian system and suggested that perhaps we ought to take a look at it...

...The study held that the United States could save $50 billion in hospital costs by adopting a Canadian-style system...

...The support for single-payer was in some respects broad, but it was always on the margins of so-called respectable opinion...

...The unions were following an understandable impulse to try to stay in the game—only by publicly saying kind things about the Clinton proposal could they hope to influence it...

...Senate in Maine showed again how any talk of a Canadian model could scare the powers that be—and how susceptible such talk was, and is, to countervailing scare tactics...

...On the plus side, all the advantages raised previously—simplicity, universal coverage not tied to employment, and so on—would have had wide appeal and would have been much easier for people to grasp than the Clinton plan...

...still, as soon as Clinton announced his proposal, the left opposition began to splinter into the expected we-shouldworkwith-him and we-should-keep-pushing camps...

...currency...

...To continue to follow outdated New Left paradigms of protest and empowerment politics, using political tactics that engage activist representatives of various outgroups and not much of anybody else (who are in their turn inevitably written off as reactionary or racist or whatever), is a certain disaster...

...What was going on with the Clinton plan, in 52 • DISSENT Health Care the meantime...

...A Times article in May 1993, although largely patronizing in tone with its descriptions of single-payer advocates as "guerilla fighters" who were seen by some as "hopeless idealists," nevertheless did allow that the single-payer coalition in the House was one the president couldn't afford to anger too much if he wanted to have votes for his own plan...

...Single-payer has potential, then, not just as a health care fixative, but as a program that can bring middle-class and poor, black and white, into political coalition...

...In 1988, Jackson was able to force the platform committee at the Democratic national convention to add a plank supporting national health care, though not necessarily a government-driven plan...

...of critiquing conservative and liberal alternatives without offering any of its own...

...Developing this kind of majoritarian approach on a whole range of issues, making a point of trying to speak to and represent people we don't now consider to be "our" constituencies is the only way the left can revivify itself...

...Dennis Timbrell, president of the Ontario Hospital Association, struck at the heart of the matter in pointing out that Canadian health care costs less—at the time, $1,961 a person in Canada to $2,566 a person in the United States—because of the "overwhelming duplication of bureaucracies working in dozens of insurance companies in the United States, no two of which have the same forms or even the same coverage...

...it was to be a part of the New Deal as originally conceived, but theAmerican Medical Association (AMA), even then, made known to Franklin its rather strong feelings on the subject, and FDR backed off...

...With presidential leadership and polls showing that 70 percent of Americans favor the features of a single-payer system," he replied...

...In December 1993 the Congressional Budget Office released a report demonstrating that a single-payer program could save taxpayers $114 billion a year...

...but whether that translated into support for a singlepayer type plan is open to question...

...In Pennsylvania, Democrat Harris Wofford won a special election for the U.S...

...Republican incumbent William Cohen and campaign consultant Bill Mclnturff knew just what to do...

...Just the opposite: if the $110,000 household and the $35,000 household support you, you've created cross-class solidarity, putting these middle-class and poor (or nearly poor) houseWe receive requests from prisoners asking for subscriptions...

...Finally, people who can afford it and want to have it must be able to buy supplemental insurance...

...Certain other groups like Physicians for a National Health Program and the National Council of Senior Citizens supported singlepayer, but their numbers were small—the physicians' group numbers about 5,500 members, while the AMA has a membership approaching 300,000...

...With respect to health care, this was not the case...

...Ralph Nader's Public Citizen, the grassroots group Neighbor to Neighbor, and a few unions like the Oil, Chemical, and Atomic Workers took the harder line, while Citizen Action and the Consumers' Union sought compromise...

...In 1948, Harry Truman proposed a national health bill, but similar forces prevented its passage...

...But the label single-payer had already taken such a whacking in the major media that people often had a bad impression of it, perhaps without knowing that it advanced the very principles they favored...

...There are many polls on this, but their findings are inconsistent, depending on how the question was asked, whether respondents were asked about just one plan or several, and so on...

...John F. Kennedy concentrated not on national health care but coverage for the elderly ("Try to stay young...

...Wofford himself did not endorse a single-payer plan, talking instead in generalities...

...Joseph Califano, Jr., a former secretary of Health and Human Services, also looked to Canada and liked much of what he saw...

...There are two supposedly axiomatic political truths that a vigorous single-payer debate would have brought to head-on collision...

...Everyone would receive the same basic care, at little out-ofpocket cost, although those who had the money to do so could buy supplemental coverage...

...The singlepayer drive was spearheaded by several major unions, Ralph Nader's Public Citizen group, and more than a hundred and fifty grassroots organizations...

...He was intentionally foggy on the details, but explicit in calling for a universal health care system that would insure everyone...

...The seller, though, had to be willing to confront one of Washington's most powerful lobbies—something the Clintons weren't up to...

...Needless to say, the predicted bolshevism did not arise...

...The White House was pinning a lot on successful health care reform...

...It must be noted that a single-payer ballot initiative in California in 1994 lost badly-59 percent to 41 percent...

...it was a haphazard mish-mash of aspects of several competing plans...

...What two Roosevelts and a Truman couldn't do, two Clintons weren't likely to accomplish...

...About fifteen years ago, he said, progressive NewYorkers were gathered to make a determination about how to use federal funds given under a particular housing program...

...in 1989, the AMA, sniffing the dangerously shifting winds, planned to spend $2.5 million on a so-called "Public Alert Program," designed to tell Americans "the facts" about Canada's system...

...It took the momentum of the Johnson administration and the 89th Congress to pass Medicare, providing government-financed coverage for the elderly, and Medicaid, the similar program that serves the very poor...

...This was at precisely the same time that Clinton was pushing NAFTA (North American Free Trade Agreement...

...I learned of it in Nation's Health, a weekly newspaper devoted to health care issues...

...That study, too, fell into the abyss...

...The rally was held to promote a single-payer health care plan, the system by which the federal government would direct health care—would become, in the argot, the "single payer" of reimbursements to health-care providers...

...Finally, six weeks later, Clinton unveiled his managed care proposal...

...Senate Majority Leader George Mitchell, speaking informally with influential journalists in July, said bluntly that single-payer "will not be enacted...

...it truckled to the interests of the large insurance companies (the left, and, incidentally, the truth...

...Of course, those tax payments would have replaced insurance premium payments, and that could have been explained, although needless to say opponents would have had a field day with television commercials on that one...

...The same month, Jack Smith of General Motors told the Washington Post that he backed a single-payer system...

...In January 1994, McDermott and Wellstone announced their financing package, which included an 8.4 percent payroll tax on employers with more than seventy-five workers, a 4 percent tax on employers with fewer than seventy-five workers, and a 2.1 percent tax on workers' taxable income...

...The inability—or unwillingness— to do so reflects one of the left's largest problems: it has no middle-class constituency anymore...

...Not really...

...In March, Business Week suggested it may be time to give single-payer another look...

...How could health care reform, still at or near the top of voters' agenda, according to polls, not reach fruition...

...Steffie Woolhandler, showing that paperwork accounted for fully 25 percent of American health care costs, more than double the percentage in Canada...

...Health care, further, was one of those few issues on which the public seemed to trust Democrats more than Republicans...

...Singlepayer should also be adapted to make it less vulnerable to the standard criticisms: specialty care and technological innovation, which America does seem to do better than Canada, are real concerns...

...Canada and some Western European countries use a single-payer system, and though health care in those countries is obviExcerpted from Left for Dead: The Life, Death, and Possible Resurrection of Progressive Politics in America, by Michael Tomasky...

...Of course, this immediately opened the plan up to attack from conservatives and even from many Democrats who'd caught the antitax contagion...

...The Clintons pooh-poohed it, other moderate Democrats followed suit, and the press sloughed it off as too radical for America...

...Furthermore, several studies, from the respected Congressional Budget Office and elsewhere, have shown how single-payer would save money by reducing overhead costs (if it sounds incongruous that government takeover of private activity could save money, then you don't know the insurance business...

...Kennedy, too, gave in before the power of the AMA, which raised the usual warnings about "bolshevism" and "socialized medicine...

...This is a political criticism rather than a moral one...

...A New Yorker cartoon from 1969 shows a physician buying a yacht, in cash, exclaiming, "And to think I opposed the passage of Medicare...

...Insurers are moving aggressively into the delivery of care...

...Several polls did show that the features of a single-payer system—universal coverage, freedom to choose physicians, contained costs—had broad support...

...Prudential, Metropolitan Life, Cigna and Aetna have each acquired H.M.O.'s and other managedcare companies that enroll millions of people...

...The SPRING • 1996 • 51 Health Care New England Journal of Medicine, interestingly enough, gave single-payer a boost through the spring and summer of 1993...

...It was too complicated...

...The single-payer bill, spearheaded in the House by Washington's Jim McDermott and in the Senate by Minnesota's Paul Wellstone, ultimately accrued ninety-three House co-sponsors— not a majority of Democrats, but a larger number than any of the other Democratic bills (save the president's) had...

...Coverage not being contingent upon employment, everyone would have coverage from birth, and people could choose their own doctors...

...Canadians themselves were puzzled...

...Their ad program featured scenes of long lines at a Department of Motor Vehicles office...

...Bill and Hillary countered with some parody ads of their own, although they didn't really run as an ad campaign—they were seen only by journalists and other D.C...

...This congressman suggested that 15 percent of the money be set aside for middle-income subsidies, reasoning that if middle-income people were given a small stake in the program, the constituency for it would be more politically powerful...

...Finally, because there would be no need for health insurance as we know it, insurance companies would be out of the health care business...

...Practically all of Bush's notions— exaggerated accounts of rationed service, waiting lists, and high administrative costs— were exposed for what they were...

...He promptly declined in the polls and finished with 45 percent of the vote...

...Her response: "Tell me something new, David...

...The thirtyseven million of course are important—by and large, they're some of the poorest people in America, most of them working...

...One might have thought that Iacocca and Califano would have wielded some influence on the public discussion...

...Would you like to subsidize one...

...Progressive aspirations for a national health plan date back to at least 1912, when Theodore Roosevelt, running under the Bull Moose banner, incorporated it into his presidential platform...

...Consider also that this particular good, health care, is one that people have repeatedly said they want in better and more certain supply than they have now...

...During all this time, of course, public opinion polls showed immense popular support for national health care in one form or another...

...It didn't happen, of course, for the same old reason—the power of the lobbies, particularly the AMA and the vari48 • DISSENT Health Care ous insurance lobbies...

...White House aide Walter Zelman made it clear that the administration considered single-payer to be "not politically feasible...

...A little further down, Konner hit the bullseye: In the Prudential Insurance Company's 1993 newsletter, Bill Link, an executive vice president, said, "For [Prudential] the best case scenario for reform— even better than the status quo—would be enactment of a mananged competition proposal...

...Those are precisely the principles single-payer supports, with the exception that it is vulnerable to some attack on the question of quality, although those attacks, like all criticisms of single-payer, were grossly distorted...

...When Clinton finally announced his own plan in September of 1993, his report outlined six principles: security, simplicity, savings, quality, choice, and responsibility...

...It editorialized favorably about the plan in April, and in August published the results of a study, done by Himmelstein and his Harvard colleague Dr...

...A few plans were advanced in 1991, but a clueless George Bush, the man who bought socks in Frederick, Maryland to prove he knew how regular people lived, didn't have any idea what to do...

...it's just that the public is no match for the opposition...

...Back to single-payer: to sell the program in the future, there ought to be a little less talk of Canada, which, Neil Young notwithstanding, does not impress many Americans as a place from which we need to import things...

...It didn't take long for him to realize that he'd been invited for, in his words, a "pseudo-consultation...

...On welfare, immigration, and on affirmative action, the left has been guilty of not having a strong program to present to the public...

...There being no insurance pools or health maintenance organizations under single-payer, people would be free to choose whatever primary care doctors they liked...

...A New York congressman once told me a story that has some bearing on all this...

...And this is how the left should frame the question if it comes up again— not as the single pure and just alternative to a raft of compromised alternatives that will wipe out an idealized poor...

...But consider that people always tell pollsters they'd be willing to pay more taxes if they were sure those taxes went to a specific good in which they could be certain of sharing...

...Said the voiceover: "This is your health care system if we go to a national plan...

...Opponents might have fun dreaming up their ad campaigns about new taxes, but imagine the single-payer ads, with fretting, stogiechomping insurance executives worrying about having to sell the yacht...

...The Canadian single-payer system, consolidated into one national plan in 1971, had appeal for several reasons...

...Thornburgh kept silent on the issue until late October, when he pilloried universal coverage as "untried, untested, radical, and costly...

...Tellingly, his remarks were reported far more prominently in the Canadian papers than in American publications...

...The political decision to craft a careful and nottooradical plan was an understandable one...

...Nothing against them, but couldn't the unions have enlisted someone a little more up-to-date...

...health care just the way it is...

...Wofford won, after trailing by forty points in early polls, by identifying and stressing one issue: health care...

...Of course, American political discourse assumes that bloat and inefficiency are features solely of the public sector...

...We don't know whether the Clintons paid any attention to that rally, but we do know from subsequent events that they did everything they could to run away from the single-payer proposal...

...Neither bill ever made it to a floor vote...

...Labor opposed NAFTA vehemently, and apparently had decided to give the president's health plan qualified support so as not to appear too obstructionist...

...The AMA campaign was not the end of it...

...After Wofford's victory, health care legislation seemed as inevitable as the rising of the sun...

...For all the left's reservations about Clinton, health care reform was one area SPRING • 1996 • 47 Health Care in which many held out some hope...

...In his 1984 presidential run, Jesse Jackson committed his campaign to a Canadian-style system...

...It did require a tax increase, and a big one...

...But the AMA and insurance lobbies fought the Clinton proposal with the same intensity they'd have brought to a single-payer fight...

...A few developments served at least to keep single-payer in the conversation...

...In 1990, Chrysler head Lee Iacocca noted that health care costs accounted for $700 of the price of every car made in America, while the figure for Canada was just $223 in U.S...

...just the opposite, in fact, since the programs converted the elderly and the poor from (in many instances) charity cases to paying customers, with the government shelling out the fees...

...The "Harry & Louise" ads were paid for by the Health Industry Association ofAmerica...

...He was, naturally, upbraided, cursed, called a "moderate," all those awful things...

...Any honest analysis has to admit that they probably were, or at least that their position was entirely rational from their perspective...

...q SPRING • 1996 • 55...

...ously not perfect, far more Canadians, both recipients and doctors, profess satisfaction with their system than do theirAmerican counterparts...

...In February 1993, Quentin Young, a past president of Physicians for a National Health Plan and a past health adviser to Jesse Jackson, was summoned to the White House...

...With respect to the housing program in New York, the congressman— who lost his argument—told me that he was certain then that the program would eventually face the knife, as indeed it now does...

...In addition to the attributes noted above, the single-payer system in Canada kept health care costs under somewhat better control: Canada typically spends about 11 percent of its GNP on health care, the United States, almost 15 percent...

...TR's cousin, as one might expect, also supported a national health plan...

...And, after single-payer was out of the picture, why was there no health care reform at all...

...But he was right as rain...

...While Republican politicians are destroying programs for the poor, they're moving much more cautiously on programs that affect the middle class...

...Once the word came down from the Clintons, other leading Democrats followed suit...

...True to form, the Clintons found a way...

...Among the public there existed broad support for universal coverage...

...In the mid-1970s, Oregon Representative Al Ullman, who chaired the House Ways and Means Committee, grew so bold as to predict that Congress would pass, and President Gerald Ford would sign, national health legislation that stipulated universal coverage for all Americans through a mix of employer mandates—that is, making employers provide health insurance for workers—and an expanded federal role for the unemployed and others...

...We can't afford to waste much more time learning this lesson...

...whether it really was is well open to question...

...Single-payer would involve the government more fully in health care coverage and policy, but it would strike terror into two of the most powerful lobbies in Washington, the doctors' and large insurers' lobbies...

...And that in turn means little or no choice...

...The lesson is not to abandon the poor, obviously, but to bring poor people's and middle-class people's interests together...

...Whatever the Clinton plan was, it was not a plan that 46 • DISSENT Health Care directly and simply addressed most Americans' concerns about health care...

...In reality, the levels were arguably less than many people already paid for their insurance premiums—Wellstone said most large businesses would actually see a saving from the roughly 12 percent of payroll they paid in premiums...

...In fact, candidate Bill Clinton already had run away from it, supporting on the stump either managed care or so-called play or pay schemes...

...As reform efforts failed and as health care costs shot through the roof, some Americans, progressives to be sure but others also, looked to a country from which America typically does not receive inspiration...

...Could the Clintons have passed a singlepayer plan...

...Certainly the AMA feared as much...

...It's hard to say...

...even with all of Clinton's evasions and double-talk, if he'd succeeded in getting health care passed, any health care, he'd have ensured himself lots of re-election support from the middle and the left...

...Were Hillary and Zelman right...

...As I said above, the left put too much emphasis on the uninsured and not enough on the many people, especially working parents, who have insurance but are terrified that they'll lose it next week...

...Until it finds a way to reconnect with one, it is sure to lose every one of these big fights...

...Copyright © 1996 by Michael Tomasky...

...In the face of all this, single-payer advocates pressed forward, hoping to get the administration to incorporate as many aspects of their bill as possible—notably, they wanted a guarantee that coverage would be universal, and the opportunity for states to adopt their own singlepayer plans if they so chose...

...Insurance companies, of course, are less satisfied...

...The Clintons strove, in light of the famous ads, to portray themselves as embattled slayers of the insurance dragon, but it just didn't sell...

...These were, unfortunately, easy marks for the mainstream press to ignore or deride, so when a campaigning George Bush made the ridiculous assertion that Canada's health care system combined "the efficiency of the post office with the sensitivity of the KGB" and labeled it "a cure worse than the disease," he got away with it...

...Wofford's victory gave single-payer advocates a new opening...

...The argument, in brief, is that advanced technology and specialty care in Canada lag behind that of the United States, and there does seem to be some truth to the claim...

...Under single-payer, health care would no longer be tied to employment and would thus be universal...

...Given the number of cosponsors single-payer had in the House of Representatives and the appeal of the plan's salient features, a single-payer system could, conceivably, have been sold to the public...

...went the lampooning slogan of Kennedy impersonator Vaughn Meader...

...Anyone who's ever had to call their plan's offices to straighten something out knows better, but such are the pinched parameters of public conversation...

...For the single-payers, it was a defeat that had to have been expected, while for Clinton, it was one of the low points of his presidency...

...Politicians are terrified of 54 • DISSENT Health Care middle-class wrath, and they're far less likely to cut programs that serve the middle class—and if they do, they lose votes...

...A platform is just a platform, but at least it bespeaks some degree of recognition...

...It's doubtful...

...This was the milieu in which the Clinton adminstration set about its work: support existed for a single-payer plan, but it paled next to the power of its opponents—the major lobbies, the New York Times, most mainstream politicians, the president-elect himself...

...The Senate passed a much more incremental bill, which sought to cover 95 percent of Americans by the year 2002 and set up a commission to make recommendations ifwhen— that goal were to go unmet...

...It is true that the House Education and Labor Committee voted out the McDermott bill, but barely: By a vote of 22-21, the committee voted to send it to the floor without recommendation, a stipulation a committee makes when it wants others to know it finds a piece of legislation distasteful or difficult in some way...

...Practically everyone there wanted all the money to go for low-income housing...

...but this, too, is something people clearly say they want their leaders to do more of...

...Similar essays began appearing in national and local papers by people identified as, for example, `a surgeon from White Plains.'" A mini-scandal over financing forced the cancellation of the campaign, but not before millions of Americans "heard that Canadian health care doesn't work well and that, even if it did, it couldn't work in the United States...

...Labor unions, by and large, fell into the accommodationist camp...

...Most of all, singlepayer had potential as an issue that working- and middle-class people of all colors and ethnicities could unite around, and this time not against the poor or the immigrant but against a real culprit, the large insurance companies, which, quite unlike the public, are relatively happy with U.S...

...holds together...

...The Clintons are creating an insurance business oligopoly that will own a seventh of the economy...

...The well-known and effective "Harry & Louise" ads, featuring the yuppie-ish couple who expressed various fears about the Clinton proposal, had already been on the air for several weeks...

...Konner wrote what everyone to Clinton's left knew to be the case...

...no one's saying the uninsured don't matter, simply that, as a political calculus, arguments should address those worried about losing their coverage...

...This does not mean that you're creating class divisions...

...This trend is likely to result in a vertical monopoly on America's health care, in which a few powerful insurers would control the delivery of care from the top down...

...Still, the fact that Thornburgh was unable to do to Wofford what Bill Cohen had done to his opponent seemed to suggest that something had changed...

...attorney general, and an overwhelming favorite...

...If the left did make a mistake in the way it pushed single-payer, it was placing too much emphasis on the "thirty-seven million uninsured Americans"—the phrase was repeated so often it began to lose its impact—and too little emphasis on the vast army of working- and middleclass underinsured people, who live in fear their coverage will be canceled or reduced...

...This swung the door wide open for Democrats, especially with an election, the season of grand promises, approaching fast...

...The only alternatives at this point were to try to bring the McDermott bill to the floor for a vote, knowing that it wouldn't pass with a Democratic president against it, or to support Clinton publicly while privately trying to amend his proposal...

...Senate against Republican Richard Thornburgh, a former governor, the sitting U.S...

...As it is, with the Clintons' bill, we know no more of what people want and don't want in health care reform than we knew before...

...A Democrat named Neil Rolde made Canadianstyle health care a centerpiece of his campaign— the first election to turn on health care as a major issue...

...Among politicians, Jerry Brown was SPRING • 1996 • 49 Health Care the only presidential candidate in 1992 to support single-payer, while other Democrats, including Clinton and most notably Paul Tsongas, dismissed it...

...The eventual failure of the Clinton health plan set off one of those orgies of post-mortem punditry that Washington reserves for just a handful of topics each year...

...and, it costs far less...

...In one of the rare jousts a singlepayer supporter was admitted to make on the Times's op-ed page—indeed, the overwhelming majority of pro-single-payer agitprop in the Times was relegated to the letters columns— Melvin Konner, a doctor who teaches at Emory University, skewered the plan and showed again the advantages of a single-payer system...

...The left had, and has, a position, and a good one: single-payer, although not without problems, would serve regular Americans' interests, both middle-class and poor people, in a variety of ways...

...without such a preemptive nod to the right, there was no realistic hope of winning with his nod to the left, which is what his plan was seen as...

...Clinton's proposal, contrary to the rhetoric, would limit choice of physician because "managed care isn't profitable without administrative efficiency: the plan mustn't deal with too many doctors...

...Clinton should have attacked welfare reform first, many argued...

...So the political gamble would have come down to: will people roll the dice on a government program provided it whacks the stuffing out of powerful lobbying SPRING • 1996 • 53 Health Care groups...

...For single-payer advocates, it did include an option for states to try their own single-payer plans, but that victory was undermined by a provision allowing large employers (five thousand employees or more) in those states to opt out...

...Reprinted by permission of The Free Press, a division of Simon & Schuster, Inc...

...The New York Times, which in its editorials had consistently knocked single-payer and backed managed competition, did work up the fortitude to run one piece in which Canadian providers and officials were permitted to speak up in defense of their system...

...How and why did these things happen...

...To be published in June 1996...

...Was the left culpable in this retreat...

...Some single-payer advocates oppose this, but it seems obvious that you'll never sell a $110,000-a-year family of four in this country on a plan that tells them they get the same treatment as a $35,000-a-year family of four and have no choice in the matter...

...Looking back, not passing a health care bill in 1993—or even having one brought to a congressional vote—required monumental bungling...

...First, that people hate big government...

...By the summer of 1994, the House Ways and Means Committee passed a bill that was basically the Clinton plan, with some aspects of the more conservative bill offered by Tennessee Congressman Jim Cooper...

...The unions hauled out Stiller and Meara to do an ad...

...insiders at a dinner...

...all the big five companies, save the Travelers, had always pushed for managed care and had helped finance the research of the Jackson Hole Group, an organization of policy experts that conceived a managed competition plan on which the Clinton proposal was in good part based...

...It was pretty easy, in other words, for the Clintons to ignore single-payer advocates...

...Although the rally drew about a thousand people, it was little noted in the major media...

...But a group of underfinanced public interest lobbies trying to do something is one thing, a piece of federal legislation with the full support of a president quite another...

...it was "socialized medicine" (the right, and hogwash...

...But single-payer never really got to first base...

...Clinton asked Himmelstein how the White House could beat the insurance industry...

...So did the insurance and medical lobbies, the New York Times, and other influential newspapers, and most elected officials...

...Jackson deserves credit for putting a singlepayer alternative forward, but it took others to make the establishment pay more attention...

...And if the people didn't go for it, at least we'd know precisely where we stand...

...Mclnturff later bragged that "we trashed the hell out of the Canadian system," and Cohen, even though slightly outspent by the wealthy Rolde, carried the day in a landslide...

...In 1990, a year before Wofford's victory, the campaign for U.S...

...50 • DISSENT Health Care Around the same time, David Himmelstein of the Harvard Medical School met with Hillary Rodham Clinton...

...A political calculation to trim sails is defensible if, without sacrificing too much in the way of principle, it gets you more votes...

...Health care is an admittedly immense and slothful beast to tame with one piece of legislation, but remember how the stage was set in 1991...

...The Clinton calculation did not do that...

...As researchers Theodore Marmor and Jerry L. Mashaw write, "the doctors' association placed advertisements in major media and supplied press kits for a blitz of editorials, opinion pieces, and reports about Canada...

...Finally, with Clinton's election, Democrats controlled the White House and both houses of Congress...

...The vote was permitted by the chairman, William Ford, only on the condition that the fifteen single-payer supporters on the committee vote for the compromise version of Clinton's bill...

...Stiller and Meara...

...Second, that people hate big lobbies and vested interests...

...The Reagan and Bush years were predictably bleak...

...On the right, Republican proposals consisted of variants of the above two schemes or were centered around the concept of medical "savings accounts," which would set an amount a family or individual could spend on health care each year, with any unused balance being refunded to them...

...Of course, the Republicans were tenacious in their attacks on the Clinton plan, which was also roughed up a bit in the press, particularly by an oddly influential article in the New Republic, which seemed to win people over by simple virtue of the fact that its author had evidently read the 1,364 page document...

...Given all these factors, people might defy the experts and say yes to just this one government program...

...As the Prudential executive quoted above by Melvin Konner makes clear, Prudential had little difficulty with the Clinton proposal...

...The HIAA represents small and medium-sized insurance companies, which did indeed stand to lose business as a result of the Clinton plan, as well as the largest five companies—Aetna, Prudential, Cigna, Metropolitan Life, and the Travelers...

...In February, representatives of the 60,000-member American College of Surgeons, testifying before Congress, announced "qualified approval" of single-payer...

...On Capitol Hill, the leaders were McDermott, a former psychiatrist who was never among the most influential members of Congress, and Wellstone, who, let us say, does not have a terribly high reputation in Washington circles...

...But a strategy that emphasized uninsured and underinsured alike could have spoken to a larger audience and could potentially have paired poor and middleclass interests with each other, instead of isolating the poor as the only class whose interests the left really had in its heart...

...the payment of insurance premiums, which finance health care now for all Americans except those on Medicare and Medicaid, would end, to be replaced by taxes...

...Furthermore, single-payer could be combined with other offerings—like a general tax cut for middle- and low-income people, for example, or some form of relief for small businesses— that would make the tax aspect less onerous...