The Obstacles to Real Health-Care Reform

American presidents have tried seven times to bring us into the community of nations that provide health care to all citizens. Seven times the effort failed. More accurately, it was blocked. In the 1940s, the anti-reform movement was led by doctors, through the American Medical Association. In the 1990s, it was led by the insurance and small-business lobbies.

This time everything has been different. The town hall meetings and right-wing distortions of this summer drew attention away from a far more significant fact: Most of the traditional enemies of reform have been quiet, absent, or divided. Many -- including the conservative American Medical Association -- are almost supportive of reform. Large and small businesses understand that reducing their health-care costs and making them predictable will be good for their bottom line, and the chief lobbyist for the U.S. Chamber of Commerce, Bruce Josten, has said, "The reality with the business community is that we want reform." Even the National Federation of Independent Business, which took the lead in opposing reform in the Clinton years, now participates in some pro-reform coalitions. And while insurance companies have much to lose from legislation that includes a public option and tight regulations, many large insurers know that they can survive and thrive when every American purchases insurance.

Still, new obstacles emerged to take their place. Some, like the traditional opponents, fought the legislative battle, using public fear and political manipulation to try to stop the bill from passing or to influence it so it fails to achieve the goal of universal coverage. Other obstacles will not fully emerge until a health-reform bill becomes law. The bill that is coming together as of this writing is a product of delicate and complex maneuvering around not only the outright opponents of reform but also around the fallout from choices made earlier in the game by supporters of reform. The course taken around those obstacles will define the legislation and its ultimate direction. Will it lead to universal coverage? Will it reduce costs and bring insurance companies under control? Or will it do too little and create the wrong incentives? Worst of all, will it lead to a public backlash, like the one that led to the abrupt repeal of catastrophic care for seniors in 1989?

Those questions won't be answered on the day that President Barack Obama signs a bill. His signing ceremony will be just one momentous step along the road to universal coverage. The forces that seek to undercut the promise of reform will still have plenty of room to maneuver. And the choices made by reformers will still define the path of what's possible, for better or worse.

Unhinged Republicans

Before the 1994 health-care battle, William Kristol wrote a legendary memo advising Republicans to block everything that had to do with reform -- but not everyone stayed on message. Moderate Republicans participated in the process because they did not want to be seen as obstructing a popular reform, and a bipartisan group of senators came surprisingly close to agreeing on a bill.

In the current episode, however, Republican legislators have been almost unanimous in taking Kristol's advice. Claims from critics like the long-discredited Betsy McCaughey that the legislation would create "death panels" moved smoothly into the GOP bloodstream and became arguments not just to delete the elusive offending provision but to kill the entire bill. Even the small-business and insurance lobbyists have been more cooperative than the party they bankroll. The result of opting out of the legislative process is that Republicans have sacrificed the opportunity to craft the bill, and if they fail to block it, they have one option: Incite a backlash.