Lesson: "Politics Comes First" by Jacob S. Hacker

The greatest lesson of the failure of comprehensive health reform in the past is that politics comes first. If real estate is about location, location, location, health reform is about politics, politics, politics. Again and again in American political history, well-intentioned reformers brimming with statistics and policy ideas have argued that change must finally come. And again and again, reformers have run headlong into a wall of ideologically charged opposition that has thrown exorbitant resources and energy into convincing Americans and their leaders that they will be made worse off by change.

Can it be different this time? I believe so-if reformers learn the right lessons from the past. When President Clinton was running for office in 1992, a three-slogan agenda was famously taped on the wall of his war room: "The economy, stupid," "Don't forget health care," and "Change vs. more of the same." With apologies to James Carville, the lessons for today's reformers are "The politics, stupid," "Don't forget fear," and "Changed politics vs. more of the same."

The politics, stupid. Even the best-laid policy plans are worthless if they lack the political support to pass. Putting politics first means avoiding the overarching mistake of the Clinton reformers of the early 1990s: envisioning a grand policy compromise rather than hammering out a real political compromise.

That means the locus of reform action should be Congress, not the White House.

Don't forget fear. It also means addressing the inevitable fears of those who believe that they are well protected by our eroding employment-based system. And this means, in turn, allowing workers to keep the coverage they have if their employers continue to provide it-the flaws in employment-based insurance notwithstanding-and it means giving people without workplace coverage a choice between a public Medicare-like plan and regulated private health plans.

Changed politics vs. more of the same. Finally, putting politics first means formulating political strategies that are premised on the contemporary realities of the hyperpolarized U.S. political environment, rather than wistfully recalled images of the bipartisan politics of old. Reformers may get bipartisan support, but the politics of reform will be more like President Bush's 2001 tax cuts than President Bush's 2001 education changes. The core elements of reform need to be put in the budget, where they are free of the threat of a Senate filibuster (which requires 60 votes to overcome), and organized pressure will need to be put on Republicans and wavering Democrats to ensure they do the right thing

Then maybe, just maybe, we will begin the difficult yet essential journey to universal health security.

Jacob S. Hacker
Department of Political Science, U.C. Berkeley
His books include The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security (Princeton University Press, 1997),