Harry and Louise and the Collapse of the 1994 Clinton Health Plan

The kitchen is ordinary on purpose. A middle-aged couple sits at a table covered with papers, bills perhaps, or forms. They are comfortable but not rich, the kind of people who own a house in a decent suburb and worry about paying for it. He reads something; she frowns. They talk, in calm and reasonable voices, about how the government wants to choose their health plan for them, and how complicated and costly it all sounds. They were actors, and they were called Harry and Louise, and starting in September 1993 the insurance industry paid to put them on television. Within a year the most ambitious health reform proposal since Truman's was dead, and it never even reached a vote on the floor of the House or the Senate.

In short: The Clinton Health Security Act collapsed in 1994 because of a long list of mistakes and enemies, but the Harry and Louise ads showed how a modest ad budget could shape a national debate by speaking to people who already had insurance and feared losing it. The plan's failure left reformers with lessons they used fifteen years later.

A plan built in a closed room

Bill Clinton ran for president in 1992 promising to fix health care, and once in office he gave the job to a task force led by Hillary Rodham Clinton and a policy adviser named Ira Magaziner. The task force brought in hundreds of experts, worked largely out of public view and produced a plan of extraordinary ambition and complexity.

The core idea was called managed competition. Every American would be guaranteed coverage. Employers would be required to pay for most of their workers' insurance. People would buy coverage through large regional purchasing groups, called health alliances, which would offer a choice of competing private plans. A national board would keep premiums from rising too fast. Small businesses and low-income people would get subsidies.

On paper it was a clever attempt to combine universal coverage with private insurance and market discipline. In practice, it was hard to explain in a sentence, and that turned out to matter enormously. The secrecy of the task force also became its own story, and a court fight over whether its meetings had to be open fed the impression that something was being cooked up behind closed doors.

The speech that went right and the months that went wrong

On September 22, 1993, Clinton went before a joint session of Congress to make his case. The speech is remembered partly for a mishap: the teleprompter initially displayed the wrong text, a speech he had given months earlier, and Clinton began speaking from memory while aides scrambled to fix it. Most viewers never noticed. The speech was well received, and early polls showed broad support for the general goal.

That was the high point. The bill itself was formally introduced in November 1993, and it was very long. Opponents waved it around as a symbol of bureaucracy. Meanwhile the administration's attention was split. The North American Free Trade Agreement fight was consuming political energy in the fall of 1993, and the Whitewater investigation began dogging the Clintons in early 1994.

How the kitchen-table ads worked

The Harry and Louise ads were sponsored by the Health Insurance Association of America, a trade group that represented many smaller and mid-sized insurers, the companies most threatened by the plan's purchasing alliances. The ads were not saturation advertising by national standards. They ran heavily in Washington and in selected markets, and they got enormous free coverage because news programs and newspapers kept writing about them.

Their genius, if that is the word, lay in whom they spoke to. Most Americans in 1993 had health insurance, usually through work. Those people were not the ones the plan was mainly designed to help, and they had reason to worry that any big change might leave them worse off. Harry and Louise did not attack universal coverage. They worried about choice, cost and bureaucracy, the anxieties of insured, middle-class families. The ads closed on a line that boiled the argument down to this: if the government chooses, we lose.

The White House understood the threat. Hillary Clinton criticized the ads publicly, which only drew more attention to them. Every response made Harry and Louise more famous.

It would be wrong to say a few television spots killed a national health plan. Polls showed support falling for many reasons. But the ads became the symbol of something real: the opposition had found the plan's political weak spot, the fears of people who already had coverage, and the supporters never fully answered it.

The strategy that said do not amend, defeat

Through late 1993 many Republicans in Congress were prepared to negotiate. Senator John Chafee of Rhode Island led a group with its own plan for universal coverage through an individual requirement to buy insurance, with subsidies. Bob Dole, the Senate Republican leader, initially signalled interest in a deal.

Then a different strategy took hold. In December 1993, the Republican strategist William Kristol circulated a memo arguing that the party should not try to improve the Clinton plan but should defeat it outright. His reasoning was political: a successful health plan would revive the Democratic Party's reputation as the party of middle-class security and hurt Republicans for years. Over the following months, Republican leaders moved from negotiation toward opposition.

It is worth stating the opponents' substantive case too. Many critics, including some Democrats, believed the plan was too big, too complicated and too reliant on new government structures. Small business groups, especially the National Federation of Independent Business, campaigned hard against the employer mandate, arguing it would cost jobs. Those arguments had supporters in both parties, and the plan's designers underestimated them.

Death without a vote

The bill was split among several congressional committees. Several produced their own versions. None of them could produce a version that could pass both chambers. Democrats held majorities in the House and Senate, but they were split among single-payer supporters, conservative Southern Democrats and members who preferred Representative Jim Cooper's narrower alternative.

In the summer of 1994 Senate Majority Leader George Mitchell tried to assemble a scaled-back compromise. It did not hold. In late September 1994 Mitchell announced that health reform was dead for that Congress. No version of the Health Security Act was ever voted on by the full House or the full Senate.

Six weeks later, Republicans won control of both the House and the Senate for the first time in forty years. Health reform did not cause that result on its own, but it was widely seen as part of the story of an overreaching president.

What the failure taught the next generation

Reformers who came of age in 1994 spent fifteen years studying it, and their conclusions shaped the Affordable Care Act.

They learned to write the bill in Congress rather than in the White House, giving committee chairs ownership. They learned to promise people with coverage that they could keep it, which is why the line about keeping your plan became so central in 2009, and why it became such a liability when some people's plans changed. They learned to bring industry groups inside the tent early: in 2009 the administration struck deals with drug makers and hospitals in advance. And they learned that complexity can be survived if the public message is simple.

Interestingly, Harry and Louise came back to the story too. The same actors appeared years later in ads supporting a new push for reform. The detail is a reminder that messages and messengers are not owned by one side.

There were also quieter results of the 1994 wreck. Two years later, Congress passed a bipartisan law, sponsored by Senators Nancy Kassebaum and Edward Kennedy, making it easier for workers to carry coverage between jobs. In 1997 a Republican Congress and a Democratic president created the Children's Health Insurance Program. Incremental progress continued, built from the ruins of the big plan.

The media lesson that still applies

The Harry and Louise campaign is taught in political communication courses because it worked so efficiently. A focused message aimed at the swing audience, repeated through paid ads and amplified by press coverage of those ads, can set the frame for a whole debate.

Progressives should be honest about this. Supporters of the 1993 plan spent much of their energy explaining how it worked: alliances, premium caps, standard benefit packages. Opponents spent their energy on how it would feel. In politics, feelings about security and choice usually beat diagrams. That does not mean reformers should stop explaining. It means the first sentence matters more than the hundredth, and it should speak to the fears of people who are comfortable now.

Where managed competition came from

The plan's central idea did not come from the Clinton White House. It came from a Stanford economist named Alain Enthoven and a group of health industry figures, academics and policymakers who met in Jackson Hole, Wyoming, and became known as the Jackson Hole Group. Their argument was that health care markets fail because buyers are scattered and weak and sellers are organized and strong. Gather the buyers into large purchasing pools, make insurers compete on price and quality for a standard package, and costs would fall without the government setting prices directly.

That was an idea with real appeal across the parties. It promised market forces rather than a government monopoly. But the Clinton version added universal coverage, an employer mandate, mandatory regional alliances and a backstop limit on premium growth. Each addition had a reason. Together they turned an elegant theory into a structure that ordinary people could not picture and opponents could easily caricature.

There is a policy lesson buried here that progressives still argue about. A design that is clever on a whiteboard can be a liability on a doorstep. Medicare, by contrast, was easy to explain: when you turn 65, the government helps pay your hospital bills. The Clinton plan's own architects struggled to describe in one sentence how a family's coverage would change. Harry and Louise did not have that problem.

Fire from the left as well

It is sometimes forgotten that the Clinton plan was attacked from both directions. Supporters of a single-payer system, led in Congress by Representative Jim McDermott of Washington and Senator Paul Wellstone of Minnesota, had their own bill, modelled loosely on Canada's system. They argued that keeping private insurers at the centre would waste money on administration and marketing and would never control costs. Some of them backed the President's effort in the end; others kept pushing their own alternative.

At the same time, conservative Democrats from the South and the West worried about the employer mandate and the size of the new structures. The President's own party never agreed on a single version. When the opposition from outside arrived, there was no united front inside to meet it.

That division is a recurring pattern on the left. Disagreement about the ideal plan is healthy; it is how ideas improve. But in 1994 it meant that when the moment came, the coalition could not agree on what it was for. Opponents only had to agree on what they were against.

The fight that came next

The story did not end with the Republican wave. In 1995 the new Republican majority proposed slowing the growth of Medicare spending and turning Medicaid into block grants to the states as part of a plan to balance the budget. Clinton vetoed the budget bills, and the standoff led to two government shutdowns over the winter of 1995 and 1996. Public opinion largely sided with the President, and Medicaid stayed an open-ended entitlement. Seniors, who had barely noticed the 1993 plan, noticed immediately when their own program was on the table, and they called, wrote and voted accordingly.

The irony is sharp. Having failed to expand coverage, Democrats spent the next two years defending the programs they already had. That defensive fight succeeded, and it shaped Clinton's re-election in 1996. It also showed that the existing programs, Medicare above all, had built their own public following in a way the 1993 plan never had time to build.

What you can do

The next health debate will also be fought in ads, feeds and kitchen-table conversations. You can help it go better.

• Notice who pays for the message. When a health ad runs in your area, look for the sponsor named at the end and look it up. The money in politics page gathers reporting on who funds political campaigns and issue advertising.
• Follow how the press covers it. The media and democracy topic page collects reporting on how news coverage and paid media shape public debates, including health care.
• Speak up where it counts. The representatives lookup gives you your U.S. representative, senators and state legislators from your address, with phones, contact forms and recent votes. Members of Congress count calls and letters, and a constituent's own experience with coverage carries weight that an ad cannot.
• Bring the comfortable into the conversation. If you have good coverage, talk with friends who also do about what they would need to hear to support help for people without it. That was the audience Harry and Louise won in 1994.
• Find groups already organizing. Patient advocacy and health access nonprofits in every state are listed in the organizations directory.