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Reflecting on 'The System'

May 25, 2013

    Dan Diamond, Managing Editor

    I sat down with a few folks on Friday to discuss the vagaries of health reform, such as why the Affordable Care Act took so long to pass despite Democrats' supermajority in 2009-2010. It's not the first time I've had that conversation; I generally try to explain the complex intermingling of Congress, the Executive branch, and lobbyists.

    But it struck me today that I should have just pointed them to "The System," a deeply researched and reported portrait of the failed 1993-1994 Clinton health plan. 

    I've been paging through "The System" since learning that Haynes Johnson, a Pulitzer Prize-winning reporter and the book's co-author, passed away on Friday. (David Broder, the other co-author and a wonderful journalist in his own right, passed away two years ago.)

    It's one of several books that consistently informed my reporting during the health reform debate—both when seeking parallels for how Republicans moved to oppose the White House's reforms, and in understanding the lessons that Obama's team tried to implement from Clinton's failures.

    For example, "The System" captures how the decision to allow First Lady Hillary Clinton and a White House task force to assemble the 1993-1994 health plan stoked tension and resentment on Capitol Hill, with many Congressional Democrats feeling cut out from the process and less willing to fight for the bill's passage. That was a key reason why the Obama administration instead allowed Congress to shape so much of the ACA, reasoning that party leaders would be more invested in a bill they helped craft themselves.

    (And interestingly, that choice almost killed Obama's health plan, too: With less hands-on direction from the White House, the ACA dragged along in Congress, a delay that nearly backfired when the Democrats lost their supermajority in February 2010.)

    Less understood, outside of health care and policy circles, were the reasons why Obama's team also struck so many controversial deals with lobbying groups across 2009: The president was trying to head off the wave of industry resistance that helped sink the Clinton plan, battles that were well-chronicled in "The System." From the book:

      "For the first time, [the lobbyists] had learned to use all the tools of modern politics and political communications for their special-interest objectives ... The interest groups for which they worked were almost indistinguishable from presidential campaign organizations in the scope of their fund-raising, the scale of their field organizing, the sophistication of their advertising and public relations skills, and the speed of their electronic communications."

    I asked Don Taylor, a public policy professor at Duke and a fellow fan of the book, for his own thoughts.

    The professor's biggest takeaway? "How many hurdles there are to passing comprehensive reform," he wrote me in an email. "Leafing through 'The System' ... I can't believe the ACA actually passed."

    On the blogs today

    • Care Transformation Center: Lisa Bielamowicz explains how to target your care management efforts with one simple question.
    • Service Line Transformation: You're never too old to innovate, says Cabell Jonas, who reviews what Dignity Health is doing to spur innovation.
    • Cardiovascular Rounds: Jeffrey Rakover collects the Cardiovascular Roundtable's resources on how to manage the outpatient shift.

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