April 29, 2007
The Pursuit of Health Care Reform:
Lessons on Leadership from the Clinton Health Security Plan
In the United States, it is estimated that 45.8 million people have no health insurance (U.S.
Census Bureau News, press release, August 30, 2005). Many uninsured have full time
employment but do not have a health care benefit through their employer or cannot afford
to pay the premiums for the coverage made available to them. For those with health
insurance, the coverage is sometimes inadequate or the co-pays and deductibles are
unaffordable. As a result, people in these situations who need medical care incur bills they
cannot afford, sometimes acquiring huge medical debts. The costs of uncompensated care
are eventually built into health care providers‘ rates and paid by those with insurance
through higher premiums. So in the end, we as a society do pay for health care, just not
equitably or efficiently.
―The United States spends more on health care than other industrialized nations, and
[unlike the U.S.A.] those countries provide health insurance to all their citizens.‖
(National Coalition on Health Care press release, March 2006). While the public in
general believes that all citizens should have access to affordable, quality health care,
there is little understanding or consensus on how to achieve or pay for it.
A number of attempts have been made over the years to adopt meaningful health care
reform. In September 1993, newly elected President Bill Clinton unveiled his health
security plan. This case study will examine the Clinton administration‘s attempt to
achieve health care reform and the leadership approaches used to better understand what
worked and what fell short.
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II. Background: The Clinton Health Security Plan
In 1991, Democrat Harris Wofford was running in a special election for a Pennsylvania
Senate seat. He was 40 points behind his opponent in public opinion polls. His campaign
hired James Carville and Paul Begala, political strategists, and Mike Donilan, a pollster, to
help shape a winning campaign. Donilan conducted a public opinion survey and found
that Wofford‘s standing in the polls increased by more than 40 points when his support of
national health insurance was mentioned. ―As Begala would later tell reporters, national
health care reform was the policy issue that could ‗turn goat spit into gasoline‘‖ (Hacker,
1997, p 14). Wofford went on to win the election.
The apparent public mandate for health care reform was not lost on Presidential candidate
Bill Clinton. During the 1992 campaign, and again in his inaugural address, Clinton
promised to deliver a health care reform package within 100 days of taking office. He
appointed first lady, Hillary Rodham Clinton, to chair a task force on Health Care reform
and asked personal friend Ira Magaziner, a business consultant who had recently
completed a report on the costs of health care, to coordinate the overall effort. They
assembled a team, including political strategists Carville and Begala, and Princeton
scholar and health policy wonk Paul Starr, who already had outlined an approach to health
care reform that was compatible with the President‘s vision.
President Clinton had spent considerable time weighing the various models for universal
health care delivery. His framework for health care reform was already taking shape. Ms.
Rodham Clinton and Mr. Magaziner worked with a health care reform task force and its
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many subcommittees, comprising over 500 participants, to craft a viable proposal with
elements that would appeal to liberals, moderates, and conservatives.
After months of private meetings, the plan was crafted. It was comprehensive, comprising
1,342 pages of detail. Based on a managed competition model, people who receive their
health insurance through large employers would continue to do so. Large employers could
form corporate purchasing alliances. People who had no health insurance would receive it
through regional ―health alliances,‖ which would have purchasing power because of the
number of people in the purchasing pool. The President‘s Health Security Plan required
that people receive a Health Security Card that would ―guarantee a comprehensive
package of [health care] benefits‖ that ―would always be there,‖ and ―could never be taken
away‖ (The President‘s Health Security Plan: Comprehensive Overview, 1993). The plan
also provided both prescription drug and long-term care benefits. Medicare and Medicaid
program beneficiaries would be rolled into the new program. The plan had provisions to
ensure quality and choice for consumers. Costs would be managed by putting ―an
enforceable cap‖ on insurance premium increases, reforming malpractice laws, requiring
universal participation so everyone contributes, and simplifying paperwork and
administrative processes. The plan was funded through a reallocation of current funding
in the health care system, including Medicare and Medicaid, along with a ―sin tax‖ on
items such as tobacco and liquor (The President‘s Health Security Plan: Comprehensive
Overview, September 1993).
In September 1993, the President unveiled his health security plan in an address to the
Nation. Initial public support was high. Yet almost immediately, groups opposing the
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Clinton plan were mobilized. Television commercials depicted a couple, Harry and
Louise, worrying that the Clinton Health plan would take away their right to choose their
own doctors and would jeopardize the quality of their health care. Even groups that
supported health care reform, such as AARP, were slow to support the Clinton plan.
AARP ran ads supporting many of the elements of the Clinton plan yet failed to point out
that it was the Clinton plan that accomplished what they were seeking.
By the time Hillary Rodham Clinton went on the road in the summer of 1994 to promote
the plan, conservative talk radio had inflamed right-wing conservatives and encouraged
them to protest at her public appearances. ―The call to arms attracted hundreds of hard-
core right-wingers, militia supporters, tax protesters, clinic blockaders‖ (Clinton, H. R.,
2003, p. 246). Health care reform floundered at the Capitol. ―By September 1994, Senate
Majority Leader George Mitchell pronounced health care reform dead‖ (Starr, 1995).
So what went wrong? Were there failures to provide leadership in certain domains? Or,
was it simply unrealistic to expect reform of this magnitude, regardless of the quality of
leadership? What are the leadership lessons learned from this experience?
III. Looking at the Health Care Reform Effort through a Leadership Lens
―While the executive office obviously bestows the status of leader and voice of the nation
on whoever holds the office, simply occupying the position doesn‘t not necessarily mean
that successful leadership will follow‖ (Dorsey, 2002, p. 17). This paper examines the
leadership displayed by President Clinton and key participants in the health care reform
effort in five domains: personal leadership, visionary leadership, leadership in context, team
leadership, and political leadership. The paper will show examples of exemplary leadership
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by President Clinton and others and also will note where leadership was lacking.
1. The Personal and Visionary Leadership of President Clinton: In the book,
Leadership for the Common Good, Barbara Crosby and John Bryson define personal
leadership as “understanding and deploying personal assets on behalf of beneficial
change” (Crosby and Bryson, 2005, p. 34). President Clinton has provided many
examples of personal leadership.
Rhetorical Leadership: During his Presidency, one of Clinton‘s strengths was his
rhetorical leadership. ―Rhetorical leadership could be defined as the process of
discovering, articulating, and sharing the available means of influence in order to motivate
human agents in a particular situation‖ (Dorsey, 2002, p. 9). Simply put, it is the ability to
lead and influence people with speech.
Clinton is a master speaker, known to be articulate and of quick wit. As President, he,
along with his wife, spent time working and reworking his speeches. Hillary Rodham
Clinton tells the story of drafting the health care reform speech. ―Just two days before the
speech, Bill and I and about a dozen staffers sat in the Solarium and tossed around themes
for the speech . . . .With constant editing and rewriting from Bill, they wrestled the text
into shape for the Tuesday night‘s appearance‖ (Clinton, H.R., 2003, p. 186).
Interestingly, this was the speech where an aid loaded the wrong speech into the
TelePrompTer. Because of President Clinton‘s close involvement in its crafting, and
attention to the message, he was able to deliver the speech totally from memory for seven
minutes until staff could load the correct speech. Commented Hillary Clinton, ―to his
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immense credit, not even I realized that something was wrong‖ (Clinton, H.R., 2003, p.
187). Paul Starr, wrote, ―At first it seemed Clinton would move the county. The next
morning, Stanley Greenberg, the President‘s pollster, crowed that the overnight surveys
showed we were winning two-thirds approval‖ (Starr, 1995).
Leroy Dorsey wrote, ―When Bill Clinton spoke of community, he displayed community.
He extended his respect to all Americans by speaking in their languages, voices, and
forms. People tend to return such trust‖ (Dorsey, 2002, p. 244). It is critical that leaders
build the trust of those that would follow them and Clinton could do this through his
words. This skill also enabled him to communicate his vision and to inspire others.
Vision and Public Policy Expertise: Health Care reform was of interest to candidate
Clinton. Although it was clear from the Wofford campaign that the topic had political
legs, Clinton also had an interest because of its public policy merits. Clinton spent time
educating himself on the various health care delivery models.
―Visionary leaders name and explain problems or issues‖ (Crosby and Bryson, 2005, p.
113). Clinton set out to create a vision upon which to base his domestic policy. Of
Clinton, Dorsey writes, ―He called it the ‗New Covenant.‘ He introduced the phrase in his
1992 nomination acceptance address and returned to it over the years, usually when he
was in trouble. Like other slogans, the New Covenant defined Clinton‘s vision‖ Dorsey,
2002, p. 241). It is important that leaders articulate a vision that demonstrates conviction
and sets forth a purpose that people can, together, move toward. President Clinton
demonstrated this well and people responded to it.
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An Ability to Prioritize and to Stay Focused. President Clinton came to office with an
ambitious agenda. His administration authored 22 pieces of legislation in the first two
years of his administration, fourteen considered large (Light, 1999, p. 290).
Paul Light wrote, ―Clinton lived for domestic policy innovation, priding himself on his
intellectual and physical endurance. Unfortunately for his staff, Clinton was also
indecisive. Aides devoted enormous time and energy that went nowhere‖ (Light, 1999, p.
287). So while it was good to have a President with the interest and the intellect to
engage in policy development, he drove his staff hard and created an environment in
which it was difficult to work productively and easy to burn out.
Tom Vellenga, in a March 7, 2007 lecture to the Leadership for the Common Good class,
spoke of the early disarray of the Clinton White House. At first, the Clinton White House
struggled under the management of Chief of Staff Thomas ―Mack‖ McLarty, who created
a flat management structure where many people had easy access to the President. This
made for inefficient and unproductive use of time. According to Vellenga, 1993 and 1994
were marked by significant amounts of staff turnover and instability in the White House.
Roles, goals, policies and processes were often ignored and it was difficult for people to
stay on task. In the end, it was President Clinton‘s responsibility to hire people that are
the right fit for the jobs. It was 18 months before Clinton replaced McLarty with Leon
Panetta, who brought structure and efficient processes to the White House.
Also, over that first year, Clinton began to prioritize and focus on his priorities. For
example, in 1994, he decided to set aside health care reform for several months while he
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dealt with NAFTA. In her autobiography, Living History, Hillary Rodham Clinton
reflects on the people who warned her about the difficulties of moving forward such a
major and challenging policy agenda. ―By late August, Bentsen, Secretary of State
Warren Christopher and economic advisor Bob Rubin were adamant about postponing
health care reform and moving forward with the North American Free Trade Agreement,
known as NAFTA. I argued that we could [also handle health care] and that postponing
health care would further weaken its chances. But it was Bill‘s decision and because
NAFTA faced a legislative deadline, he concluded that it had to be addressed first‖
(Clinton, H. R., 2003, pp. 182-183). Prioritizing is an important part of setting an agenda
and to President Clinton‘s credit; he realized that priorities needed to be made.
Credibility: Whether President Clinton has credibility depends on who you ask. Try a
Google search of ―slick Willie‖ and you‘ll find Willie Sutton, a prolific bank robber, and
Bill Clinton, our forty-second president. Coined with this name in 1980 by Paul
Greenberg, an Arkansas newspaper editor, the nickname went national when Clinton
became President and the name stuck. In a recent interview, President Clinton reflected on
this nickname and stated that he particularly disliked it. "‘No one could fairly look at my
political life and say I didn't believe in anything,‘‖ declared Clinton. States Greenberg,
―Really? And just what political belief wouldn't he modify if his popularity depended on
it? He didn't specify. He seldom does. It wouldn't be Clintonesque (another term he
inspired) to be specific.‖ (Greenberg, 2005)
It seems there are two sides to President Clinton. On the one hand, he is a smooth,
eloquent speaker. On the other hand, he is known for his indecisiveness and aptitude to
ponder many possibilities. Such a personality trait would result in a person apt to modify
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his public statements over time, which can erode credibility. But keep in mind that
Clinton did choose to bring forward a very specific, 1,342 page health care reform plan
during his first year in office, so it doesn‘t seem fair to say that Clinton can‘t be specific.
In fact, he may have learned that being less specific can sometimes be a better strategy.
History also gives us Arkansas state troopers reporting on indiscretions by then Governor
Clinton, Paula Jones‘ allegations of Clinton‘s sexual inappropriateness, and later the
Monica Lewinsky debacle. These situations, and Clinton‘s response to them, resulted in
damage to his credibility. These incidents were like an anchor on his character, pulling
him down. Kouzes and Posner state, ―Leaders, if they wish to be credible, have an
obligation to their constituents both to promote the higher morality of society and to teach
the skills of value-directed living‖ (Kouzes and Posner, 2003, p. 68). Given Clinton‘s
history, it isn‘t surprising then, that his credibility could easily be called into question by
his opponents and his trustworthiness and honesty at times to be questioned by the public.
The Ability to Listen: From the start, the Clinton team knew that their timetable was
ambitious. In her autobiography, Living History, Hillary Rodham Clinton reflects on the
people who warned her about the difficulties of moving forward such a challenging policy
agenda. She states, ―Treasury Secretary Lloyd Bentsen had warned about the timetable
for health care, skeptical that is could be passed in less than two years‖ (Clinton, 2003,
pp182-183). Several democratic leaders in Congress gave similar advice.
However, President Clinton felt pressed to abide by his campaign promise to deliver
health care reform within 100 days after taking office. As a result, he disregarded the
advice. Why would the President ignore the advice of seasoned political leaders? Paul
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Light explains, ―Presidents have never been under greater pressure to move it or lose it,
yet they have never been more vulnerable to making the mistakes that come with
inexperience. Facing an ever more impatient public and shorter news cycles, Presidents
continue to believe they have no time to waste and that they simply cannot afford to learn.
They must set their agendas early and repeat them often if they are to have much of a
chance for impact, or at least that is what they believe‖ (Light, 1999, p. 279).
Overall, during his Presidency, Clinton presented strong personal and visionary abilities;
relying on his speaking abilities, intelligence, personable nature, ability to craft and
communicate a vision, energy and wit. These helped to compensate for his weaker
personal leadership traits described above.
2. Team Leadership. Crosby and Bryson define team leadership as “building effective
work groups.” They state, ―Sooner or later, those seeking to accomplish major change
need to assemble and sustain productive work groups or teams and develop effective,
humane organizations‖ (Crosby and Bryson, 2005, pp. 34 and 64).
To develop a comprehensive strategy for health care reform, Ira Magaziner proposed
forming working groups to hammer out the details. Mr. Magaziner was in charge of
coordinating this effort. First lady Hillary Rodham Clinton was appointed by the
President to chair the committee. The approach taken was like a corporate structural
redesign. According to Paul Starr, ―‗Clusters, of sets of working groups proceeded in
parallel within a model taken from Magaziner‘s prior experience as a business consultant.
The paradigm was a corporate restructuring or technological innovation that required
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thinking through innumerable options and suboptions and meshing together previously
uncoordinated activities and groups into a coherent plan . . . . The scale of the project was
astonishing, even to some of us who had long advocated a comprehensive plan,‘ Starr
comments, ‗and rather than being scaled back, it expanded‘ as new planning groups were
added to deal with issues not encompassed in the original grand design‘‖ (Skocpol, 1996,
p.56, quoting Paul Starr, The Logic of Health Care Reform, 1994).
The problem was that unlike a corporation, where the Chief Executive can impose the
planned changes, this proposal would need to pass through the political process and
withstand stakeholder scrutiny. So even if the end product was a fantastic, well-designed
plan for health care reform, only the people that participated in its design were convinced
of that, and then, maybe only in support of the pieces that they were involved in creating.
Stake holder groups were not represented on the task force, nor were political leaders or
their representatives. How would the President gain their support for the proposal if they
hadn‘t been involved in its crafting? Crosby and Bryson state, ―Leaders ensure that
forums are designed so that the right people have access to them‖ (Crosby and Bryson,
2005, p. 128). This did not happen with health care reform and it was a critical leadership
mistake. While Ira Magaziner did meet with many stakeholders during development of the
plan, the effort cannot substitute for a true forum. Instead the plan was created by policy
experts from within the federal government. It was developed in secrecy, leaving
stakeholders out of the development. Early in the process there was a lawsuit that tried,
but failed, to open the meetings. Transparency in the process would have helped, but that
did not happen. Haynes Johnson and David Broder comment, ―Why was it that for all the
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good intentions and for all the popular support Clinton's attempt at health care reform was
a political disaster? Here I will name only one of several reasons for the fiasco: the
administration's failure to understand that leadership initiatives of this magnitude require
extensive collaboration over an extended period of time. What we got were covert
conversations and secret plans; what we got was a proposal owned by the administration
and disowned by nearly everyone else. In particular, Bill and Hillary Clinton's failure to
engage private-sector participation in their public-sector planning was a major mistake‖
(Kellerman, 1999, p. 225, referencing Haynes Johnson and David Broder, 1996).
A review of articles and books that document the communication with stakeholders
indicates that it was an insular process that excluded outside input. The Clinton team put
too much faith in a presumed mandate from the public for health care reform and the
ability of their internal group to craft a proposal that, once understood, would appeal to the
stakeholders. But Theda Skocpol wrote, ―Many participants in the 1993-1994 reform
struggle did not want to ‗understand‘ the Health Security proposal. Yet that proposal‘s
devisers were proud of it, and felt that if properly grasped, the proposal would seem
compelling‖ (Skocpol, 1996, p. 59). Finally, the Clinton team felt that there was plenty of
room for political compromise within the context of the plan, so were less concerned
about early consensus building with stakeholders.
A good communication strategy may have made a difference to win over the general
public and stakeholder groups that would have benefited from the health security plan. Ira
Magaziner had, in his original strategic plan, recommended that this to occur. However,
after the reform was rolled out in September 1993, a public communication plan was not
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implemented. Skocpol wrote, ―Supporters of reform had to be fast off the mark, and they
had to work together with clarity and consistency of purpose. But nothing at all like that
occurred – certainly not during the critical months following the launching of the Clinton
Health Security Plan. The President and his allies did not gear up to campaign for Health
Security until spring of 1994, which was certainly too late‖ (Skocpol, 1996, p. 76). ―The
most essential team leadership skill is fostering communication that aligns and coordinates
members‘ actions, builds mutual understanding and trust, and fosters creative problem
solving and commitment‖ (Crosby and Bryson, 2005, p. 67). Clearly, the Clinton
administration fell short in this regard.
3. Leadership in Context. Crosby and Bryson define leadership in context as,
“understanding the social, political, economic, and technological givens, as well as
potentialities” (Crosby and Bryson, 2005, p. 34). Leadership in context means
understanding and being able to provide leadership within society‘s expectations,
practices, and traditions and knowing how much change can be accepted. It was
important for the Clinton team to understand the context in which health care reforms
would be imposed.
Understanding the Needs and Influence of Stakeholders: A huge obstacle to health care
reform was an inability of the Clinton team to gain stakeholder support for the proposal.
To understand why stakeholders were so opposed to the plan, it is important to put it into
context. In the book, Health Care Reform, Engstrom and Robinson wrote, ―Imagine a
health care system designed to protect health insurers from adverse risks and to expand the
profitability of health-sector markets. Imagine, further, that this system also seeks to
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provide professional autonomy for physicians. Add to this mix of goals the aim of
infusing even the most marginal improvements in drugs and devices into routine medical
practice to the greatest possible extent. A health care system ordered by such goals is not
an imaginative speculation, but a current reality‖ (Engstrom and Robinson, 2006, p. 199).
Now imagine threatening these powerful stakeholders by proposing to reduce the
profitability and autonomy they enjoy. This is what Clinton did with health care reform.
Some stakeholders, with so much to lose, would remain opposed to health care reform
regardless of what the Clinton team could have done. But other stakeholders had much to
gain and might have been persuaded, had the process sought it. Kouzes and Posner,
quoting a model created by William Ury, teach methods to resolve differences and
obstacles through understanding, starting with the other party‘s perspective and taking into
account, ―four common obstacles to agreement: it‘s not my idea; this doesn‘t meet my
needs; this may embarrass me; and you‘re asking too much, too fast (so it‘s easier to say
no). Instead of starting from where we are, pushing our ideas or values (which is
everyone‘s natural tendency) Ury urges beginning where the other party is ‗in order to
guide them toward eventual agreement.‘ (This method provides an avenue for
stakeholders to air their concerns, be heard, and have concerns addressed.) This process
means actively involving other people in devising the solution so that it becomes their
idea, not just ours‖ (Kouzes and Posner, 2003, p. 140, citing William Ury).
It is unrealistic to expect that Kouzes and Posner‘s technique would have worked with
stakeholders that had a lot to lose from health care reform. But there were also
stakeholders that had more to benefit than to lose. Had the Clinton team invested more
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time in bringing stakeholders on board, health care reform could have fared better.
This lesson was not lost on President Clinton. ―From that point on President Clinton made
it a point to involve business and industry in virtually every significant federal initiative.
Listen to Clinton on the subject of welfare reform in his 1997 State of the Union Speech.
‗Here is my plan. Provide tax credits and other incentives to businesses that
hire people off welfare. . . . And I say especially to every employer in this
country who has ever criticized the old welfare system: You cannot blame
that old system anymore. We have torn it down. Now do your part. Give
someone on welfare the chance to work. Tonight I am pleased to announce
that five major corporations—Sprint, Monsanto, UPS, Burger King and
United Airlines—will be the first to join in a new national effort to marshal
America's businesses, large and small, to create jobs so people on welfare
can move to work‘" (Kellerman quoting Clinton, 1999, p. 225).
President Clinton‘s experience with Health Care reform is a good illustration of the
importance of stakeholder involvement in developing public policy.
Understanding the Public Mandate: ―Opponents and proponents can distort public
understanding because the public lacks knowledge about the facts of the health care
debate. ―While Americans are interested and relatively attentive to the health care issue,
they do not necessarily understand the key issues and terms being debated‖ (Blendon and
Brodie, 1994, p 131). Blendon and Brodie point to surveys conducted by the Kaiser
Family Foundation conducted in 1993 – 1994 to substantiate this point. These surveys
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showed that the public had misperceptions about health care reform. For example, when
asked if the U.S. spends more on health care than other countries, only 35% of those
surveyed answered correctly. According to Kaiser‘s surveys, the U.S. does spend more.
Forty four percent of those surveyed believed that universal health care would primarily
help poor people and 36% thought of unemployed people. In realty, 88% of those who
would benefit from universal health care were working families (Blendon and Brodie,
1994, p. 133).
As mentioned previously, Ira Magaziner originally proposed to communicate with the
public during the process of developing the plan. ―There should likewise be a major
communications effort, Magaziner argued, because ―reforming the health care system will
involve government-led changes on a scale not attempted since social security‖ (Skocpol,
1996, p. 51, quoting Ira Magaziner‘s Preliminary Work Plan for Interagency Health Care
Task Force, January 1993, p 13). However, various books and articles that document
what occurred in 1994 indicate that a communication and education strategy was not
implemented, which was a major failure in leadership.
After the Health Security plan was made public, ad campaigns by those opposing the plan,
talk radio chatter, and fragmented news coverage promoted confusion and uncertainty.
Even AARP, which favored health care reform, did not make it clear that the Clinton
health plan accomplished the goals they sought. These actions weakened the public
support that Clinton had assumed to be a mandate.
Understanding the Impact of the First Lady in Policy Decisions: Most books about the
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health care reform efforts of 1993-1994 touch on the leadership displayed by Hillary
Rodham Clinton in her pioneering role as both First Lady and policy advisor to the
President. Even though 1992, known as the ―year of the woman,‖ saw a number of
women elected to Congress, involvement of women in positions of high power was still
rare. ―The appointment of the First Lady to head the task force was a highly visible way
to put the President personally on the line behind this big reform effort‖ (Skocpol, 1996, p.
54). But Susan Bourque points out, ―Strong first ladies with interests in political life elicit
strong criticism and even censure if they are deemed too involved in the nonceremonial
aspects of their husband‘s political careers‖ (Bourque, p.89).
―As the administration got underway, the public was split on whether Hillary Rodham
Clinton should be involved in policy making – 49 percent said she should not be involved
in policy making while 46 percent said she should (Gallup 1993)‖ (Burrell, 1997, p 97).
The Clinton administration paid close attention to polls and understood the risks of
appointing Ms. Clinton to lead the initiative. Because both President and Ms. Clinton
were confident in her ability to lead a major policy initiative, they proceeded. But as
health care reform encountered difficulties, it became easy for opponents to blame
Rodham Clinton for a plan they did not like. In the end, Rodham Clinton was not
successful in her attempt to promote health care reform. In her autobiography, she wrote,
―Bill and I were disappointed and discouraged. I knew I had contributed to our failure,
both because of my own missteps and because I underestimated the resistance I would
meet as a First Lady with a policy mission.‖ (Clinton, H. R., 2003). But even though
health care reform failed, President Clinton showed leadership in regard to the women‘s
movement by his confidence in appointing Rodham Clinton to a leadership role.
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Understanding Economic Considerations: President Clinton understood the economics of
health care. Although it may have been easier to adopt a plan that did not control the
growth in health care costs, Clinton was determined to design a system that would manage
costs. Authors of several books and articles on the Clinton plan have commented it is
surprising to see this level of fiscal accountability in a Democratic President‘s plan.
However, Clinton was searching for a more moderate position that may appeal to
conservatives. Also, Clinton was searching for a model that would be affordable in the
long term. He was committed to devising a plan that would work economically.
Although his plan for fiscal responsibility didn‘t prevail, it was still courageous for him to
take this on. Health Care is consuming our federal and state budgets. Quality, access, and
cost are all legs of the same stool. In my opinion, if we as a society do not take action to
control costs, the quality and access to health care for many Americans will suffer.
Understanding the Political Landscape: From the beginning, Rodham Clinton and
Magaziner encountered problems aligning support within the Democratic Party. Ms.
Clinton remarks there were problems within their own party in supporting the health care
reform agenda. In her book she remarks that Magaziner told her, ―They think we‘re going
to get killed . . . . We‘ll need at least four or five years to put together a package that will
pass Congress‖ (Clinton, H. R., p.144). According to accounts in her book, the powerful
Senate Finance Chairman Daniel Patrick Moynihan was ―a skeptic about health care
reform‖ and ―wanted the President and Congress to take up welfare reform first, and he let
everyone know it‖ (Clinton, H.R., pp. 151-152). Political realities proved to be a major
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barrier to health care reform. We‘ll discuss this in more detail in the next section.
Overall, Clinton and his team failed in their leadership in context. They did not recognize
the role and influence of stakeholders and did not take sufficient action to gain stakeholder
support from some and prepare for opposition from others. They squandered the initial
public support by failing to follow up with good communication about the merits of the
plan. And, they didn‘t listen to advice from leaders in their own party. Using Lee Bolman
and Terrence Deal‘s term, they were ―clueless.‖
4. Political Leadership. Political leadership is defined as “making and implementing
decisions in legislative, executive, and administrative arenas” (Crosby and Bryson,
2005, p. 35). The political leadership required to pass health care reform was a
challenging test of leadership for President Clinton and his team. The Clinton team made
three critical political mistakes: 1) not garnering the support of their own party; 2)
assuming personal ownership of health care reform, which made it partisan; and 3) failing
to recognize how health care reform could be used to further the Republican agenda.
A Lack of Support within their own Party: It fell to Rodham Clinton and Magaziner, both
political outsiders with little Washington experience, reputation, or relationships, to
market health care reform to Congress. According to Rodham Clinton, ―Bill had assigned
Ira the task of setting up the process for health care reform, which turned out to be an
unfair burden for someone who was not a Washington insider‖ (Clinton, H.R., p. 152).
For that matter, neither the President nor Rodham Clinton were Washington insiders, he
having just been elected President and both just having moved to Washington.
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As previously discussed, House and Senate leaders were already unhappy with the timing
and pace in which health care reform was brought forward, and did not appreciate that
their early advice to slow down was not heeded. Rodham Clinton and Magaziner made
several hundred trips to the Capitol to meet with members of Congress on behalf of health
care reform. However, they were unsuccessful in negotiating the inclusion of health care
reform in the Omnibus budget bill, which would have been procedurally most expedient
and less difficult to pass. Instead, democratic leadership decided the proposal needed to
be debated and passed on its own merits. When the draft legislation was released in
September, 1993, Senator Moynihan ―decried the whole enterprise, saying it was based on
‗fantasy‘ numbers‖ (Clinton, H.R., 2003, p. 185). My impression is it was the
Democratic leaders who displayed leadership when they resisted tacking health care
reform onto a budget bill. Such a major policy initiative ought to be debated on its policy
Clearly, launching the proposal without first lining up the necessary support was a critical
error. The Clinton administration had failed to implement a strategy to sell the proposal
politically. ―Ira Magaziner and Hillary Rodham Clinton coordinated extensive resources
to devise the technical details that went into the Clinton Health Security proposal. But no
comparable organizational effort was made on the political side‖ (Skocpol, 1995 p. 90).
This was a devastating failure in political leadership, because it was up to the politicians to
support or reject the health care reform, but it was months before the Clinton
administration devoted time and resources to convincing politicians of the merits of the
plan. By then, it was too late. ―Months into the effort, they continued to believe they had
April 29, 2007
a chance of winning over enough moderate Democrats and Republicans to pass the
legislation. Meanwhile, the moment of bipartisanship had passed. Energized by the
ideology tilt the issue had taken, Republicans led by Newt Gingrich had begun to feel that
just defeating the plan was not enough. They were thinking in terms of retaking the
House‖ (Milton, 1999, p. 308).
Branding it ―the Clinton Plan:‖ Another major political miscalculation was the
President‘s decision to put his personal mark of ownership on the health care reform plan.
President Clinton believed he had a winning plan for health care reform. Theda Skocpol,
wrote, ―Understandably, the new President – who would face a tough contest for
reelection in four years – also wanted to be able to claim credit for a reform victory. By
putting the prestige of his office behind a plan that appeared to respond to widespread
public concerns, President Clinton surely hoped that he could rally public and
congressional support for change‖ (Skocpol, 1996, p. 54). However, this action turned a
proposal that was crafted for bipartisan support into a personal initiative of the President.
In the end, the ―Clinton Health Plan‖ was an attractive target for Republicans seeking
political gain. It invited and received political attacks as being big government oriented,
complicated, and apt to take away choices.
Not Reading the Republican Agenda: Probably the most devastating error made by the
Clinton team was underestimating the Republican political agenda. Blinded by the good
public policy merits of their plan, the Clinton team failed to understand how Republicans
could turn it into an opportunity to gain political power in the next election. Republicans
were dismayed by the election of a Democratic president and mobilized to retake political
April 29, 2007
power. The 1,342 page Health Security plan provided fuel for debate. Right-wing
conservative leader, William Kristol advised Republicans, ―The 1993-94 debate should
not be about how to reform the U.S. health financing system in the direction of universal
coverage. Instead, Republicans should use the debate as an occasion to embarrass
Democrats and ensure a political turnaround that would enable conservatives to replace
the ‗welfare state‘ with ‗free market initiatives‘‖ (Skocpol, 1996, p. 146). Republicans
launched criticisms of the health security plan, even before the plan was public. The
National Federation of Independent Business, Christian Coalition, and other groups joined
in opposing the Clinton plan. These groups pressured the Chamber of Commerce, which
was weakly supporting it, to oppose the Clinton plan. ―The job of mobilizing was made
easier by the fact that the Clinton administration put out a detailed 1,342 page bill without
conducting a credible public campaign to explain its elements, such as health alliances‖
(Skocpol, 1996). The media reported on it all, focusing on the controversy. Murray
Edelman would refer to this as a ―political spectacle.‖ According to Edelman, ―It is
chiefly news reports that stimulate the construction of political spectacles. Those involved
in making, reporting, and editing news accordingly have an incentive to shape it so as to
attract audiences and, sometimes, to encourage particular interpretations through its
content and form‖ (Edelman, 1988). The press was closely watching the roll out of health
care reform but was less interested in educating the public on its details and more
interested in the controversy, fueled by Republican opponents and disgruntled
stakeholders. For Republicans, it was an opportunity to cast doubt on the President‘s
proposal, and through association, on his ability as a leader.
Crosby and Bryson state, ―Political leadership achieves adoption and implementation of
April 29, 2007
policies, programs, and projects incorporating the solutions‖ (Crosby and Bryson, 2005, p.
108). In terms of its political leadership on health care reform, the Clinton Health Care
team failed to achieve these outcomes. It was more than a decade before this country
again saw much discussion of health care reform. Paul Starr wrote, ―The Republicans
enjoyed a double triumph, killing reform and then watching the jurors find the president
guilty. It was the political equivalent of the perfect crime‖ (Starr, 1995).
In the end, not only did the Clinton Health Security Plan fail, so did every other health
care reform plan in 1994. Thus, the status quo was maintained for stakeholders who
feared change. The Democrats were blamed by the public for their inability to bring forth
an acceptable plan to provide health care for the public and the groundwork was laid for
Republicans to take over Congress. And a broader Republican political agenda was
advanced, one that did not include health care reform.
Could the Clinton team have done a better job in providing leadership to promote the
health care reform agenda? Certainly. Would it have been enough to succeed in the
passage of health care reform? No one really knows. Paul Starr wrote, ―Explaining the
outcome of a single political initiative poses a dilemma to the structurally minded
sociologist. The basic problem of historical sociology -- too many variables, too few cases
-- here finds its purest expression. In any complex chain of events, if one or another
background condition or strategic choice by an actor had been different, the outcome
might plausibly have changed. But since the counterfactuals can't be tested, many
conditions and choices may seem plausible causes of the outcome‖ (Paul Starr, review of
April 29, 2007
Boomerang, Contemporary Sociology, March-April 1997, p. 150-153).
Leadership is a living, evolving practice; a series of behaviors, decisions, and actions that
lead to outcomes. President Clinton demonstrated many examples of fine personal
leadership, including his speeches-- his mastery and communication of issues, and his
ability to create a vision. However, some of President Clinton‘s actions damaged his
credibility, including behaviors that earned him the ―slick Willie‖ label or created
lingering questions about his personal behavior.
Clinton developed other leadership qualities over time. His Presidency started with an
overly ambitious agenda and not enough focus. This made it hard to devote the time
needed to move health care reform forward. Over his years in office he developed an
ability to prioritize and better focus on what mattered. In hindsight, it was an error to
attempt to create and sell a health care reform agenda within a year. While he and his
team were able to create a detailed proposal, they were unable to garner the political and
stakeholder support needed to promote and sell the proposal in that amount of time.
Rodham Clinton and Magaziner seem to have done an adequate job of team leadership,
facilitating a task force of executive branch employees and contractors to create a health
care reform proposal, but, along with the President, were unable to effectively mobilize
the public, stakeholder, and political support needed to pass health care reform. Because
the plan was developed in secrecy, stakeholders were excluded. A more transparent
process would have allowed opportunities to build support with potential allies, including
the groups that would have benefited from health care reform. It seems the Clinton team
April 29, 2007
failed to provide leadership in context because they were oblivious to it. A critical error
was their belief that the strength of the public mandate and the policy merits of the plan
would be enough to overcome the challenges. The Clinton team believed that if critics just
understood the policy merits of their proposal, they would come to support it.
Finally, critical mistakes in leadership occurred in the political domain. President Clinton
and his team did not listen to the advice of Democratic leadership to slow down. They
plowed ahead; rolling out their plan, then did not have the political support needed and
were fair game for the Republican opposition.
V. Lessons learned: This examination of the Clinton Health Care reform effort has
provided me with the following lessons on leadership.
1. Prepare. Successful personal, visionary, team, and political leaders are prepared.
To be successful, do your leg work. Have a strategic plan, follow it, communicate
it to your team and colleagues, and refine it when needed.
2. Understand the politics. An effective leader understands the context in which an
issue is presented, as well as the political environment. Invest the time to work
with others and gain their support.
3. Be Realistic. Not everyone will believe your public policy change is wonderful.
Others may be threatened by it. Idealism can color the view of people who are
enamored with their proposals and fail to hear what others believe. A person with
excellent personal and leadership in context skills will expect this and plan for it.
4. Build support and keep the momentum. After the plan was released in
September 1993, Clinton never made another national speech on the topic. There
was no obvious agenda to market the proposal. To be successful, a proposal needs
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broad-based support to provide the momentum for acceptance. Leaders need the
personal and team leadership capacity to build the support and momentum needed
to reach their goals.
5. Listen. Rodham Clinton and Magaziner were compliant. President Clinton told
them to move the health care reform agenda and they did it, ignoring warning signs
that they needed to do more relationship and political development. The lesson for
building personal leadership skills is to listen. Do not be afraid to reevaluate your
course of action in light of new information.
Health Care reform will not be easy. It is a complex public problem with diverse
stakeholders, some of whom stand to win and others to lose. Until reforms are agreed
upon, the notion of change from the current system creates a perceived risk. Progress will
require skilled, trusted leaders. The debate is ongoing.
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