About this Blog
About The Author
Email Me

RealClearPolitics HorseRaceBlog

By Jay Cost

« Already? | HorseRaceBlog Home Page | The Pivotal Politics of Health Care Reform, Part II »

The Pivotal Politics of Health Care Reform, Part I

President Obama has made an overhaul of the American health care system a major domestic priority this year. He's not the first Democratic President to do this. Health care was the cornerstone of the Clinton domestic agenda during the 103rd Congress, and Democratic presidents since Truman have been looking to implement some form of universal care.

Why has such an overhaul been so difficult to implement? According to some, the problem has been tactical. Take, for instance, Matt Bai's recent explanation in the New York Times Magazine:

The plan Bill Clinton took to Congress then, running to more than 1,000 pages of impenetrable new regulations, wasn't what you'd call politically savvy, but the strategy used to sell it was even worse...His wife, the current secretary of state, developed the health care plan largely without taking House and Senate leaders into her confidence, instead dropping it at the doorstep of the Capitol as a fait accompli. Ever jealous of its prerogative, Congress took a long look, yawned and kicked the whole plan to the gutter, where it soon washed away for good -- along with much of Clinton's ambition for his presidency.

The Clinton team certainly mismanaged health care reform in 1993; however, I think there's more to it than this. It's important to talk about the players, personalities, and tactics employed to turn a bill into law - but to focus relentlessly on this means we miss the forest for the trees.

Today, I want to examine the structural features that have conditioned past policy battles, and that likely will condition this year's fight on health care. That should help us better understand why Clinton failed, and the challenges the Obama Administration will face in the months ahead.

There is a stark historical fact about attempts to restructure domestic policy in a big way: they have a horrible track record. Typically, they either fail outright - or a small, incremental bill is passed in the place of the big, comprehensive reform the President initially envisioned. Presidents usually have lofty ambitions - but they are rarely successful in implementing them on the grand scales they envision, regardless of whether their party controls Congress.

Why is this?

Stanford University's Keith Krehbiel has the best answer. His Pivotal Politics is now 11 years old, but it is as relevant as ever. Krehbiel is interested in why gridlock is the norm - but that sometimes it can be broken, typically by large, bipartisan coaliations.

His answer is the relationship between the President and Congress, which he thinks is characterized by four "pivotal" players, whom Krehbiel arrays on a left-right dimension based on their policy preferences. These actors are the President, the median voter in Congress (i.e. the legislator who has half of Congress on his left and half on his right), the filibuster "pivot" (i.e. the legislator who has 2/5ths to his right and 3/5ths to his left), and the veto "pivot" (i.e. the legislator who has 2/3rd to his right and 1/3rd to his left). These players determine whether a bill becomes a law. They're not necessarily granted special powers or prerogatives, though they may happen to be committee chairmen or party leaders. They're important because of where their preferences sit in relation to the other legislators in Congress. If the filibuster pivot chooses to support a filibuster - it will necessarily be killed because there are enough Senators who also oppose it. He's the marginal member, which makes him the pivotal vote.

Let's take a hypothetical example. First, assume that all legislators have an ideal policy preference - and that this can be identified on a simple left-right scale. Second, assume that they're trying to legislate on some policy issue, on which there is a status quo (SQ) that an alternative bill (A) would change. These can also be put on the left-right scale.

One scenario might look like this.

Pivotal Politics in Action.jpg

How would the government resolve this issue? The median voter moves first, and supports the bill. It's not his first choice, obviously, but it's closer to his first choice than the status quo. This indicates that the bill gets the support of a center-left coalition. But then the filibuster pivot must make a choice. In this case, the bill is far from his ideal - farther than the status quo. Thus, he chooses to filibuster it - and the bill is killed by a right-leaning coalition in the Senate. The status quo wins. [Had the filibuster pivot supported the bill, it would have passed and the President would have to sign or veto it. If he had vetoed it - the veto pivot would then have to choose whether or not to override.]

Like any theoretical model, this simplifies reality a great deal. The real world is much more complex (we'll bring in some of these complexities tomorrow). Nevertheless - this model's explanatory power is quite great.

First, it helps explain why major legislative overhauls often fail. You can appreciate this yourself by playing around with different status quos and alternatives. Generally speaking, when the status quo is somewhere in the middle of the policy spectrum, it is extremely difficult to defeat it. Somebody - be it the president, the veto pivot, the median voter, or the filibuster pivot - will usually prefer the status quo to a given alternative.

Second, it helps explain why policy changes - when they happen - tend to be incremental. Again return to the above graph and play around with different scenarios. When you find an alternative that can beat the status quo, you'll probably note that it does not upend the world by that much.

Nevertheless, it does allow for major policy overhauls - like what we saw during the New Deal or the Great Society. What matters is the arrangement of the key players' preferences relative to the status quo. When preferences are relatively homogenous, and there is enough distance between those preferences and the status quo - significant changes in public policy can occur.

Third, it helps explain a peculiar finding noted by Yale's David Mayhew nearly twenty years ago (and updated just a few years back): significant legislation is approved with the same frequency, regardless of whether government is divided or united. Party control doesn't factor into legislative output. Similarly, the theory does not have much of a role for the legislative party, which doesn't coerce legislators to support bills for the sake of party unity. What matters are the preferences of the pivotal players. That, combined with the typical super-majority requirements of our system, implies that bipartisan coalitions are generally needed to get important bills passed. So, we shouldn't expect one-party control of government to make a significant difference.

The implication from this analysis is that, had Team Clinton improved their awful handling of the health care issue, they still very well could have failed. It wasn't simply a matter of tactics. The bottom line from the model is that comprehensive reforms such as the Clinton overhaul are hard to come by. Our system requires a great number of players to sign on - and that makes it difficult.

This year, a comprehensive health care overhaul is certainly possible. What matters is how the preferences of the pivotal players are arranged. I think it's fair to say that they correspond better this year than they have since at least 1993. The trick will be to find an alternative that they all prefer to the status quo. Historically speaking, that's been easier said than done.

Tomorrow, I'll continue this discussion by examining some of the features of the ongoing health care debate that I think are relevant, given today's general discussion.

-Jay Cost