The More Things Change...

“Voters expected change. The believed they have voted for change. [Now] they think they got more of the same.”

Steinmo and Watts (1995) draw attention to this quote from analyst Stuart Rothenberg, who, you guessed it, was referring to President B…ill Clinton. Rothenberg was talking about public disappointment with a professed reformer that was unable to effect significant change. Steinmo and Watts use the quote to make the larger point that individual leaders are insignificant in an American institutional system that (both intentionally and unintentionally) fragments power.

I want leave aside the merits of Steinmo and Watts’s argument for a second to highlight their critique of some alternative explanations of health care reform failure, which persist today and inform much of the unsophisticated “analysis” in the media. First, opposition to health care reform is not a function of American political culture. The authors’ critique of cultural explanations for Clinton’s failure holds today. I don’t have the polls on hand, but I would suspect the levels of people that support some kind of reform are similar to 1992- high. More importantly, however, cultural argument lacks comparative perspective. It is unable to explain why, if culture is relatively constant, reformers have been able to pass social welfare policies (education, medicare/medicade/social security) in the past. Demonstrating that the US has become more conservative since 1992 is an uphill climb indeed. Steinmo and Watts also point out that there is little empirical evidence to support the proposition that massive public demand resulted in health insurance reform in Europe. Like Steinmo and Watts, I find it more compelling that institutional change drives shifts in attitudes, rather than the converse.

Second, the authors argue that health insurance reform in 1992 did not fail because of opposition from powerful interest groups. This is the weaker of their two major critiques, especially since they show later how interest groups utilize particular institutional features to achieve their goal. Nonetheless, their critique is compelling. Opposition from entrenched, powerful interest groups is a constant in all reform efforts across time, and in different countries. Thus the strategies of interest groups cannot explain health insurance reform failure, except inasmuch as you are able to specify the unique institutional channels through which they exert influence.

Finally, although they (rightly) devote little space to it, the authors brush aside the sophomoric explanations that attribute health insurance reform failure to the abilities and strategies of Bill Clinton, his team, or idiosyncrasies of the plan itself. Their analysis traces the historical process by which the American institutional barricade to sweeping reform was constructed, intentionally by the founders, and as the unintentional byproduct of previous unrelated goals. Much is the same with Barack Obama. Steinmo and Watts published this article in 1995, but their descriptions of the reform effort, from the post-election atmosphere, to the effect of the media, to the strategies of the opposition, are uncannily familiar. When health insurance reform fails again in 2009 or 2010, Americans will once again express frustration at their leadership, failing to realize their beef is not with individuals, but with the rules that shape their leaders' options and strategies. Only this time, blame on the President may not be misplaced- for failing to heed Steinmo and Watts’s 1995 advice to change the rules of the political game before you attempt sweeping social reform.