Reforming the rules of American medical care is one of the most difficult tasks any reformer faces. At five different moments in the 20th century, promoters of national health insurance have tried. In the Progressive era, during the New Deal, under President Truman, and in both the early 1970s and 1990s, advocates thought that universal health insurance was imminent – and were bitterly disappointed. In each case skillful and determined opponents, representing entrenched interests, helped block national health insurance by skillfully manipulating our deepest fears to protect their interests.

During the last such fight – the Clinton debacle – those interest groups seemed initially to be on the defensive. In l992, the time for reform appeared to have arrived. The initial public response to President Clinton’s call for “comprehensive” health reform was favorable. But before the Clinton administration and the Congress could act, they had to cope with some of the nastiest ideological and budgetary conflicts American politics makes available. What can be learned by reviewing Clinton’s failed efforts to deal with – as with others – intractable problems of substance, symbol and support?

The Clinton administration understood that leaving cost control to market forces was likely to fail. That is why they built limits on premium increases into their managed competition proposal to limit the rate of growth of funding, and thus expenditures. Yet very early in the debate, the conviction about cost control simply disappeared. The “untouchable” piece of the Clinton plan became universal coverage for a basic package of health care benefits, with everything else on the table.

And then even the “untouchable” became vulnerable. By the summer of 1994, universal coverage had given way to a willingness to accept coverage for 95 percent of Americans as universal health insurance. By early September that number had slipped even further, something closer to 85 percent of the population then covered.

And there lies a continuing and fundamental dilemma for U.S. health reform. The rest of the developed world figured out some time ago that providing universal coverage did not have to mean uncontrolled costs, and that controlling costs did not have to mean foregoing universal coverage. Those simple facts are still largely seen (or at least promoted) within U.S. health policy circles as fundamental contradictions, and for good reason. Those with the most to lose have compelling reasons (controlled costs = smaller/controlled incomes) to keep the confusion levels high.

A second fundamental belief that stands as an impediment to successful reform is the notion that big government will mishandle it – or, taken the other way, that the private sector is more efficient at providing health insurance coverage than the public sector. This view continues to be promoted heavily by the private insurance sector, for obvious reasons. But that promotion is given weight by many American health economists, who seem to believe fervently that private markets (the invisible guiding hand) must (by assumption) be able to respond to the preferences of a population far better than any government or public sector structures.

National health insurance as the reform objective suffered a crushing defeat in the summer of 1994. But changes in American medical care actually accelerated. In this respect, the stalemated politics of national health insurance had consequences far wider than those initially expected from the legislative battle. The Clinton administration sought to find common ground between liberal and conservative. It adopted the language of market reform and explicitly rejected health insurance on the model of Canada. It sought the results of traditional health insurance while extolling the virtues of competitive plans vying for customers and bargaining hard with the providers of care. The result, during the rest of the decade, was declining insurance coverage, enormous pressure to reduce costs from payers, and enormous uncertainty about what medical care, or its public policy, will look like in the first decade of the 21^st century.

What lessons do these reform efforts provide?

1) If you lose a political struggle, lose the right way. The obstacles to enacting national health insurance are undoubtedly formidable. Reformers must confront the reality that political setbacks are not only possible, but probable. So it is critical to influence the terms on which you will lose some battles.

In l948, Truman’s national health insurance plan went down to congressional defeat, but he used that to beat up a “do-nothing” Congress. By contrast, the Clinton health plan politically imploded. By the end, even the administration had abandoned its own plan and no exit strategy cushioned the blame the President and the Democratic Congress experienced in the elections of l994.

2) Do not forget the long term. A related lesson is this: responding to short-term political and economic constraints is necessary, but does not require abandoning longer-term aims. The debate over Medicare offers an instructive example. From the time the reform idea was first conceived (1951), it took 14 years of political struggle before Medicare’s enactment. Medicare legislation was, for reformers, an incremental step toward national health insurance. But, in year-to-year adjustments, Medicare promoters never abandoned the campaign for the program’s enactment.

American politics supports short-term visions and encourages impatience. But reformers can reject the pressures by agreeing on the principles of a worthy health plan, and begin a long-term political campaign to secure its enactment. As with the campaign for Medicare, this requires a reform vision, considerable patience, the time to build and maintain a reform coalition, and the commitment to absorb defeats.

3) Do not let the perfect be the enemy of the good – or why the Canadian form of single-payer insurance is not the only answer. One of the most serious barriers to national health insurance success is the widespread view that we have only two stark choices available. One is to live with the unsatisfactory status quo of for-profit private health insurance that leaves 44 million Americans uninsured and medical costs uncontrolled. The other is to embrace Canada’s form of national health insurance.

This dichotomy does not, I believe, serve reformers well. It leaves the mistaken impression that Canada’s is the only available model of universal health coverage – ignoring the reasonably successful experiences in Western Europe, Australia and Japan. What we learn from all their experiences is that having most people in the public system ensures that public insurance has both a broad-based coalition and strong economic influence over the payment for medical services. What is not necessary is for everyone to be in a single system.

The most difficult task of all is to keep in balance the elements that make for a successful reform in American politics. Being clear about what one yearns for is crucial, but adapting the steps to be taken to the opportunities offered is equally important. For that, Medicare’s architects and advocates are worthy role models.

Theodore R. Marmor teaches politics and public policy in Yale University’s management and law schools, as well as in its political science department. A second edition of his groundbreaking book, “The Politics of Medicare,” was recently reissued. Click here for review.