No Harry and Louise

Chip Kahn is one of those Washington warriors who helped bury health-care reform. In the summer of 1993, he pitched a simple idea to advertising executives: "Harry and Louise," a fictional couple who earnestly discuss their worries about Bill Clinton's health proposals in a series of potent TV commercials. The now iconic characters were more successful than Kahn ever dreamed. The ads scared ordinary Americans, helped sweep Republicans to power in 1994 and won much credit for the destruction of "Hillarycare." So it was a bit surprising to see Chip Kahn, of all people, at a recent White House Forum on Health Reform, praising President Obama's efforts. What was he up to?

"Things are different today," Kahn insists. Like some other foes of the Clintons, Kahn worries that soaring health costs are reaching unmanageable levels, hurting hospitals, insurers and patients alike. There's now wide acknowledgement, he says, that quality of care has eroded since 1994, and that something needs to be done. Kahn doesn't see a role for Harry and Louise this time around. "I see us as part of the process and I don't even see Harry and Louise as an issue," he says.

Kahn's role—then and now—shows how the health-care debate has changed since the '90s, and also the ways it has stayed the same. In the Clinton years, Kahn was fighting to protect the interests of private insurers. Those companies were worried they'd be put out of business if government controlled the health-care system. That remains a huge issue today. But as a lobbyist, Kahn has changed teams. He's now the president of the Federation of American Hospitals, and they have a different concern: the vast numbers of uninsured people turning up at emergency rooms. Hospitals eat those costs; they need many more people to get health coverage.

The Obama administration has learned from the failures of earlier efforts. Lesson one: make sure everyone feels involved. Kahn is pleased that Obama is inviting industry participation, and also giving Congress the lead role in shaping a plan. But it'll still be up to Obama's team to cajole, coerce and somehow achieve a proposal that most parties can agree on. Hillary Clinton led that charge in the '90s, but it was chief adviser Ira Magaziner, a smart technocrat unversed in the ways of Washington, who seemed to get under Kahn's skin: "You had this fellow Ira Magaziner over at the White House who came up with an extremely rigid approach … and a plan [he] didn't want to deviate from." Kahn says he prefers Obama's leadership choices: Kathleen Sebelius as Health and Human Services secretary and Nancy-Ann DeParle as health-reform czar. This duo is "knowledgeable, practical, smart and savvy," he says.

Yet veterans of earlier battles recall there was great enthusiasm, too, when President Bill Clinton first raised the need for change. It makes sense for all parties to be enthusiastic in the early going, if only to be in a better position to defend their interests. As the Cato Institute's Michael Cannon quipped recently to USA Today, "they all want to be at the table because they don't want to be on the menu." Brandeis University health professor Stuart Altman, who has been involved in reform efforts since the 1970s, says the Clinton effort went "all downhill … when they started to put meat on the bones." He expects opposition to mount again. "Everyone is supporting this until it comes time for them to pay," he says.

There are plenty of ways the process can blow up. The proposed public insurance plan that Obama touted as a candidate is particularly explosive. Such a plan would allow individuals and small businesses to buy government-sponsored insurance. Companies fret they wouldn't be able to compete. "For the insurance industry, it could be a deal breaker," says Kahn. At the recent White House forum, however, Obama was noncommittal about the public plan. If all Americans could be insured at "an affordable rate and have choice of doctor, have flexibility in terms of their plans, and do that entirely through the market, I'd be happy to do it that way," he said.

On occasion, Kahn expresses a tinge of regret about past battles. "On the one hand, I felt that the country missed a bullet [by defeating the Clinton proposals]," he says. "On the other hand, I thought there were compromises that could have been wrought that would have been really helpful to people." He says that even back in '93, he was ambivalent about "Harry and Louise." "I wasn't enthusiastic about it … I felt like it was something we had to do because they just didn't want to pay attention to us." This time is different, he insists: "From my standpoint, we're all on the train together, and I expect to ride it all the way into a signing ceremony." Sounds good. All aboard?

© 2009