Clinton's medical reforms - 11 November 1994

Well, for once the conventional wiseacres were right, if a prophet can be said to be right, who predicts that Manchester United will win the Cup Final by 2-0 and then they win by 10-0. I'd have guessed last Monday that timidity was the last thing you could accuse the pollsters of. I thought myself that the Republicans were pretty sure to take over control of the Senate, just. They ended up with 53 to 47. But to become the majority of the 435 members of the House, that did not seem to me to be in the cards, for two reasons. Two years ago 96% of the incumbents of both parties were re-elected, a pretty dazzling reflection of the power of a congressman to bag for his constituents a new dam, a school bond issue, a bigger subsidy for the farmers and do it in two years.

In Tuesday's unbelievable result, every Republican incumbent was returned to office and not a single Democrat. The odds on that result would have been from a cagey bookmaker about a thou-, no, no, let's say 434-1. An allied reason was that for the past 62 years since Roosevelt came roaring in from the pit of the Depression, with his radical reforms of an essentially conservative system, chief of which was massive borrowing and massive spending on public works, since then, the people have tended to elect a liberal congressman, who'd bring home the bacon and, for the presidency, they'd vote for the man who seemed to express the wave, the feeling of the times.

This has been such a dependable reflex that the Democrats have had majorities, mostly very large ones, in House, for 58 of these 62 years and I didn't spot on the horizon any Eisenhower or Goldwater or Reagan who was going to change that. Don't forget in all the obituary notices of Mr Clinton's presidency, that Mr Reagan in his eight years in the White House had four Houses packed with Democratic majorities. In each of these the Democrats had majorities respectively of 52, 103, 71 and 81.

The Republicans on Tuesday performed the remarkable but not miraculous feat. They needed 40 seats to take over, they wound up with 229 to 204, a 15-seat majority. You see that's a rather modest enemy, compared with the boys in the back room that Reagan had to face. How did Reagan manage to conquer against majorities in Congress three to seven times those that Clinton is going to have to fight or seduce? Reagan was a great seducer and in spite of his easy-going working habits, in spite of a rather hazy knowledge of his homework, in his first 100 days he had a personal meeting with every one of the 435 members of the Congress. Thereafter, he did, as Lyndon Johnson, the master, had done before him, he telephoned and flattered and nudged and begged, kept notes on the personal misfortunes of opponents, called them with prompt and touching sympathy. This was the secret, I believe of the three really commanding politicians of my time – Roosevelt, Johnson and Reagan.

The essence of the talent is first to sense what people might be prepared to swallow and then to persuade them to swallow it. The talent is called leadership and it springs from temperament, you know that, the 94-year-old Mr Justice Holmes said about Roosevelt, after the new president had broken all custom and instead of summoning the judge to the White House, went to call on him. After a half hour's talk, after Roosevelt had gone, Holmes turned to an old friend and said simply, second-rate intellect, first-rate temperament. The same may be said of Lyndon Johnson and, with a possible down-grading of intellect, of Reagan also – the gift of leadership, I don't think there's any formula you can learn to acquire it. As Bob Hope once said, either you got it or you ain't got it, I got it.

It seems that William Jefferson Clinton doesn't have it. The extent of his lack of it was the surprise to me anyway. There was no question when he first came bobbing and bounding over our horizon in 1992 that he had some of the attributes of a successful and popular leader. As intelligent as any president before him, he does his homework and he's able at all times, and without prompting or nervous aides, to expatiate on any policy, any crisis, any bill that's on either the front burner or the back one. He has courage and he has charm, he's incomparably articulate, sometimes rising to the peak of eloquence, so what happened?

What happened was something I feared after his first month in office. Here's a crude, but I think valid, contrast. Reagan campaigns, first thing he'll do, he says, is cut taxes and build up American defences. He comes in, he woos and eventually wins his opponents, he cuts taxes drastically and builds up the country's defences. Clinton campaigns around the country and says the first, the big thing, is to take apart the system of medical care and bring in a new national healthcare system. So he arrives and what is the first item on the plate? He'd like to see homosexuals admitted openly into the armed forces. Up from the Pentagon and down from the congressmen on Capitol Hill comes the incredulous cry, holy smoke, is that the most pressing item of business?

Now whether it was an admirable thing to do or not is not the point. Harry Truman had a similar ambition, but he did not take it up at once with the Congress. He'd have fuelled a blazing debate that might have crackled on for months. He quietly talked to interested parties, he consulted the chiefs of staff, he went out and looked at a couple of army camps, he said nothing. One day suddenly, without fuss or the sound of trumpets, he announced by executive order, as commander in chief he can do that, as Clinton could, he announced that from then on, the armed forces of the United States, all of them, would be integrated. No more black regiments. The fighting forces had been segregated all through the Second World War. There was grumbling of course, a round of curses on former Captain Truman by old-timers, but it was done.

So, how about the big deal, the one overwhelming reform that had to take place, the national health system? Well Mr Clinton's bill, Mr and Mrs Clinton's bill, represents the biggest single failure of his administration so far. Because he kept ignoring the negative signs in Congress, it died by inches and over 18 months and so the failure seemed worse than it was.

Let us admit at once that Mrs Clinton had spent the better part of two years studying healthcare systems at home and abroad, The two that appealed most for copying or adapting to America were the German and the Canadian systems. Nobody, by the time the Clintons published the text of their bill, nobody knew more about running a very complicated healthcare system than Mrs Clinton. So mightily and so plainly complicated with regional alliances of services, enclosing or supporting a system of health management organisations, that everybody but the Clintons could see it was bound to breed two new, enormous bureaucracies and where was the money coming from for them?

The main complaint about the present system is that the paperwork is five times as weighty and three times as expensive as Canada's. The Clintons' great campaigning cry was, 35 million Americans have no health insurance – the shame of it. What was never said was that 220 million Americans do have insurance and are pretty happy with it. With it they get prompt attention and access to all the technology and as for two voting blocks whose support was anticipated, you might think would be all for extending total treatment to everybody, they turned out to be the most antagonistic to change. Namely the very poor and the old. Over 65, poor or comfortable or rich as Croesus, they get to the doctor, venture their suspicions, same day or tomorrow, they have a CAT scan, a magnetic resonance imager, a photo emission scan, PSA, a Doppler test, all the gleaming and marvellous modern technology at, of course, a hideous price, maybe just to make the diagnosis it would cost five, eight, 10 thousand dollars. Not to worry. The doctors don't. They get a whacking cheque from the government.

So the United States pays pre capita more than three times for the medical care of its citizens than any other industrial democracy. And the Clinton's bill never discussed with Congress, but presented as an accomplished fact, was 1,372 pages long. Any bill of 1,372 pages has not thought itself through as a workable act of policy. It was dead on arrival and all the subsequent efforts by various groups and alliances to revive it and inject some life into it, failed. The failure, which I think the voters came to see, if not to define clearly, was the astonishing failure of a professional politician to get any sort of bill through. It was a failure that demonstrated Mr Clinton's woeful inability to persuade Congress to do what he now proclaims as his duty, to compromise effectively.

So the root of the matter, of the whole election is the shattering of confidence in Mr Clinton as president. He ran himself ragged and hoarse for three weeks, campaigning for candidates who seemed in trouble. All but three of them lost and many said his appearance harmed them. Disappointment in hopes unfulfilled was extended to his party and the pounding Republican message that, if it was true that politicians are tired or corrupt and that the label that stigmatises them is liberal, then the Republicans succeeded in breaking several Democratic state machines. To the great indignation of Mr Dan Rostenkowski, who is under many indictments for embezzlement and fraud and was once the most powerful man in Washington, chairman of the committee that oversees all money bills, he lost his ancient seat in Chicago. The old rascals are certainly going out. The new rascals are about to take over in happy droves.

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