# Clinton Health Care Plan The **Health Security Act** was President [[Bill Clinton]]'s 1993 proposal to guarantee health insurance to every American. It was written over eight months by a White House task force chaired by the First Lady, [[Hillary Clinton]]; presented to Congress in a celebrated speech; attacked by the insurance industry, small business and a newly disciplined Republican opposition; and declared dead a year later without a final vote in either chamber. Six weeks after that, Democrats lost Congress. Nothing in the plan became law. Almost everything about how it lost became a model. The opposition's strategy memo, the industry's television campaign and the lessons Democrats drew about secrecy and deal-making all shaped the fight over the [[Affordable Care Act]] sixteen years later. ## What it would have done About 37 million Americans had no health insurance when Clinton took office, and he had campaigned on fixing that. The plan's design was an approach called managed competition: keep private insurers, but make them compete inside a regulated market. - **Everyone covered.** Every citizen and legal resident would be required to enroll in a health plan and would carry a "health security card." - **Employers pay most of it.** Employers would be required to cover their workers and pay roughly 80 percent of the premium, with subsidies for small firms and low-wage workers. - **Regional health alliances.** New purchasing pools, one per region, would collect premiums and offer residents a choice of competing private plans. Large companies could run their own. - **A standard benefits package**, with no exclusions for pre-existing conditions. - **A lid on costs.** A National Health Board would oversee the system, and premium increases would be capped if competition did not hold them down. The bill ran 1,342 pages. ## How it was written Clinton created the Task Force on National Health Care Reform on **January 25, 1993**, five days into his presidency, and named Hillary Clinton to chair it. Ira Magaziner, a longtime adviser, ran the policy work, organizing more than 500 experts into working groups. The goal was a bill in a hundred days. Two things went wrong before any bill existed. **Secrecy.** The working groups met in private and the White House at first declined to name their members. A physicians' group sued under the [[Federal Advisory Committee Act]], arguing that a panel led by someone who was not a government employee had to meet in public. A federal appeals court ruled in June 1993 that the First Lady counted as a government official for this purpose. The administration won the case and lost the argument: "secret task force" became a standing line of attack. **Delay.** The hundred days passed. The budget fight consumed the spring and summer, and Clinton did not present the plan until **September 22, 1993**. The bill itself did not reach Congress until November, as H.R. 3600 in the House and S. 1757 in the Senate. By then the opposition had been advertising against it for two months. ## Who opposed it, and how **The insurers.** The Health Insurance Association of America, the trade group for small and mid-sized insurers, began airing the [[Harry and Louise]] ads on September 8, 1993, two weeks before Clinton's speech. The group had earlier said it could accept universal coverage and an employer mandate; what its members feared was the plan's effect on their business. **Business.** Small business, through its main lobby, fought the employer mandate from the start. The [[US Chamber of Commerce]] had at first endorsed a mandate and then reversed itself after a revolt by its members. By February 1994 the Chamber and the [[Business Roundtable]] were both in opposition. **The Republican strategy.** On **December 2, 1993**, [[Bill Kristol]], then running a small Republican strategy group, sent congressional Republicans a memo that changed the party's approach. Until then the question had been how to amend the plan. Kristol argued that it should be defeated outright, because a successful health program would restore the Democrats' standing as the party that protects the middle class. He advised Republicans not to concede that there was a health care crisis at all. Within weeks the phrase was in circulation: [[Dick Cheney]] used it in December, and [[Bob Dole]] used it in the official Republican response to the State of the Union in January 1994. The shift is visible in what happened to the Republican alternative. In 1993, twenty-three Republican senators, Dole among them, had co-sponsored a bill by Senator John Chafee that reached for universal coverage through a requirement that individuals buy insurance. During 1994 Dole and most of the others walked away from it. Kristol's advice on the last Democratic compromise was to oppose it "sight unseen." **Democrats.** The party did not unite behind the bill. A bloc of conservative Democrats, led by Representative Jim Cooper, backed a rival managed-competition bill without a mandate. Supporters of a Canadian-style single-payer system had their own. Senator Daniel Patrick Moynihan, the Democrat who chaired the [[Senate Finance Committee]], said publicly that there was no health care crisis, only an insurance crisis. And Senator Robert Byrd refused to let the plan move through budget [[Reconciliation]], where it would have needed a simple majority instead of the sixty votes required to break a [[Filibuster]]. ## How it ended The [[Congressional Budget Office]] published its analysis in February 1994. Where the administration projected that the plan would cut the deficit by $38 billion in fiscal year 2000, the budget office estimated it would add $10 billion. Committees in both chambers produced competing versions through the spring and summer. In August George Mitchell, the Senate majority leader, offered a compromise that put off the employer mandate until 2002 and exempted small businesses. On **September 26, 1994**, Mitchell announced that health care reform was dead for the year. In November Republicans won the House for the first time in forty years, and the Senate with it. See [[1994 Midterm Elections]] and [[Gingrich Revolution]]. ## What came after - **1996:** The Health Insurance Portability and Accountability Act, a bipartisan bill, let workers keep coverage when they changed jobs. It was the one piece of the 1994 debate on which the rival plans had agreed. - **1997:** The children's health insurance program extended coverage to millions of uninsured children. - **2010:** The [[Affordable Care Act]] passed with a structure that echoed Chafee's Republican alternative: an individual mandate, subsidies and regulated marketplaces. The Obama administration ran its effort as a mirror image of 1993. Congress wrote the bill, not a White House task force. The drug industry and the insurers were bargained with before the bill was written, not fought afterward. In 2009 the Harry and Louise actors were hired again, this time to support reform. Hillary Clinton said later that both the process and the plan had been flawed. Paul Starr, who worked on the plan, has argued that the design was Bill Clinton's and that she took blame that belonged to him. ## Why it's on the map - **The Kristol memo is the template for total opposition.** The argument was not that the plan was bad policy. It was that the plan would work politically for the other party and so had to fail. That reasoning, stated openly in 1993, is the logic of the opposition to the Affordable Care Act and of the legislative strategy the wiki follows through the Gingrich years and after. - **"There is no crisis."** Denying the problem, instead of offering a different solution, became a standard move in later policy fights. - **It is the first modern case of an industry beating a bill on television.** The [[Harry and Louise]] campaign and the lobbying around it are the reference point for [[Advocacy Advertising]] and for the scale of health-industry [[Lobbying]] today. - **It moved the mandate from right to left.** A requirement that individuals buy insurance was a [[Heritage Foundation]] idea and a Republican bill in 1993. By 2010 it was the Democratic plan and Republicans called it unconstitutional. - **It helped make 1994.** The defeat is one of the causes usually given for the Republican takeover of Congress that year, which ended four decades of Democratic control of the House. ## Connections - [[Bill Clinton]] · [[Hillary Clinton]] - [[Bill Kristol]] · [[Bob Dole]] · [[Newt Gingrich]] - [[Harry and Louise]] — the insurers' ad campaign against the plan - [[America's Health Insurance Plans]] — successor to the association that paid for it - [[Affordable Care Act]] — the reform that passed in 2010 - [[1994 Midterm Elections]] · [[Gingrich Revolution]] - [[Lobbying]] · [[Advocacy Advertising]]