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4 Clinton’s Healthcare Reforms: Policy History and Causes of Reform Failure

4 Clinton’s Healthcare Reforms: Policy History and Causes of Reform Failure

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groups joined the insurers in opposition. Business support began to crumble. Organized labor, angry at the Clinton White House because of the

NAFTA free-trade agreement, was lukewarm at best. Liberal backing was

tepid, because the compromise plan the Clintons came up with fell short of

the single-payer universal-coverage plan that the left had expected from a

Democratic president.24



After 12 years of Republican control of the White House, and Reagan’s

consistently anti-government rhetoric, the Democrats faced a public and

political culture that was almost intrinsically skeptical of the government,

its value, efficacy, and capacity to promote genuine positive social change:25

the Clinton proposals come at a juncture when government is held in general disrepute. Taxes are not the only issue … more so are the public’s worries about governmental effectiveness. Many Americans believe, or are quite

ready to be convinced, that governmental “bureaucracies” bungle everything they touch.26



Public attitude surveys since the 1950s showed an almost continuous drop

in faith in the competence and integrity of government and in its trustworthiness. In 1958, over 70 percent of Americans expressed trust in “the

government in Washington to do what is right” always or most of the

time. The figure kept declining to a low of roughly 25 percent in 1980.

By 1992, it was even lower at 22 percent and, by 1994, it had dipped to

20 percent.27

Cognizant of these tendencies, part of Clinton’s rhetorical strategy was

to downplay the role of government in the healthcare plan. For example,

he was sensitive to public skepticism of government. Campaign posters advocating his Health Security Act listed three options: Government

Insurance, Guaranteed Private Insurance, and No Guarantee of Coverage.

“Guaranteed Private Insurance” was placed the middle in bold, seeking

to focus on the private component of his universal health insurance plan

rather than invoking the government role in its implementation.28 But such

rhetorical shifts were not enough to allay the public’s anxieties about the

government’s ability to implement universal health insurance reform fairly

and successfully, especially given the intensity of conservative attacks on the

very notion of the government having any role to play in healthcare reform.

Clinton and the Democrats had an uphill battle to face given the political,

cultural, and media climate—but there was nothing inevitable about their

failure to pass healthcare reform. The urgency to pass universal insurance



BILL CLINTON’S SEPTEMBER 22, 1993 ADDRESS ON HEALTHCARE REFORM...



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reform was lost amidst the competing healthcare insurance plans, infighting amongst Democrats, the lack of support of conservative and moderate-conservative Democrats,29 who shared conservative skepticism of a

major government role in healthcare reform, and the vigorous advocacy of

many insurers and their political allies against Clinton reforms. Finally, the

Clintons faced the same institutional and structural challenges of American

government we discussed in Chaps. 1 and 2: the US government’s highly

decentralized organization and system of checks and balances which have

long impeded the efforts of social reformers. Competing interest groups and

sub-sections of the population already enjoying health insurance, such as

the elderly—and therefore lacking incentive to support reforms—have also

contributed to the difficulty of advancing reforms.

Discursively too, the Clinton and the Democrats may have undermined

their reform efforts by choosing not to adopt the kind of rhetoric with a

strong dimension of ethos and pathos having the potential to move and

unite Americans in support of reform. It is only with robust and sustained

public support that the massive obstacles to healthcare reform can be

overcome:30

By early 1994, when the Clintons abandoned their plan, the central ethical argument for universal health care coverage—the notion that a wealthy

country ought to provide medical treatment for all who need it—was

nowhere to be heard. The moral issue … never got moving in the USA.31



The moral issue and the concurrent emotions it inspires of solidarity with

the vulnerable and indignation in the face of injustice and discrimination

was the most potent issue in terms of the reform’s potential to breach the

conservative obstructionism to healthcare reform, which was overwhelmingly ideological rather than concerned with the most effective way to

provide quality healthcare to America’s citizens:

Conservative rhetoric is meant to frighten middle-class Americans—especially those who still enjoy relatively good benefits through private insurance—dissuading them from supporting any kind of comprehensive reform.

In short, during the 1990s, just as in the 1910s and the 1940s, the opponents of any sort of national health insurance have quickly undertaken to

create ideological metaphors. They aim to fuel fears of reform among the

citizenry and bring together the worries about change of stakeholders in the

health economy as it is presently structured. Meanwhile, very little is being



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done by advocates of fundamental reform to create their own positive ideological metaphors for wide public dissemination.32



Such conservative ideological attacks on healthcare reform are about

more than a desire to maintain the interests of insurance companies and

the healthcare industry. They are part of a larger conservative ideological

battle against liberal efforts to advance justice and equality of opportunity

through government programs.33 As William Kristol, a major figure within

the conservative movement, openly acknowledged: “We at the Project for

the Republican Future want to use the health care debate as a model for

routing contemporary liberalism and advancing an aggressive conservative

activist agenda.”34 But the Clinton largely neglected ethos which would

have potentially mitigated at least some of the hostility generated by conservative attacks on the healthcare reforms. In focusing so much on the

logos and the practical aspects of his healthcare reforms, their appeals for

healthcare reform were emotionally flat—failing to inspire and energize

Americans. He was unable to generate sufficient support on the part of

both politicians and laypeople for the motivating the ethical principle of

universal health insurance: that American citizens are entitled to health

insurance, irrespective of their economic status and income. Because of

the complex nature of the reforms, the public was turned off by what

many perceived as an overly bureaucratic and convoluted restructuring of

health insurance with excess government involvement. Despite the best

efforts of the Clinton to focus on the way in which the reforms encouraged the private sector to provide health insurance and healthcare services,

this message failed to convince the public, which was powerfully influenced by the emotive Republican and health insurance industry rhetoric

attacking the reforms. Iwan Morgan characterizes the failure of his healthcare reforms as Clinton’s “greatest defeat” as President: “More than just a

failed proposal, the fiasco was a political disaster for Clinton … It obliterated his ‘New Democrat’ image that had helped to elect him in 1992 and

made him look like just another big-government liberal.”35 We will now

turn to the speech itself.



6.5



DIMENSIONS OF RHETORIC



Ethos in the speech manifests itself as a call for government guarantee of

security, echoing the use of the word “security” from the time of Franklin

Delano Roosevelt and his Social Security program through to Truman



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187



and Johnson, who, as we have discussed, made similar references to the

concept. Clinton makes no direct appeals to human rights or any rightsbased arguments. Instead, he favors appeals to equal opportunity and

communitarian social solidarity to enable a common standard of universal well-being, grounding this in civic references to the values found in

the Declaration of Independence, a strategy that all four presidents use

when seeking to support healthcare reform in relation to national texts for

which there is universal, apolitical reverence and shared agreement as to

their central place in the American social imaginary. Clinton uses pathos

to illustrate injustices and inequalities in the current healthcare system and

to advance the ethos of solidarity, bipartisanship, and equal opportunity to

healthcare irrespective of income. The logos dimension of rhetoric in his

speech is predicated on the principle of equal access to healthcare irrespective of economic resources based on the individual mandate requiring all

Americans to be insured. As such, it dovetails with the principle of security.

The bulk of the speech is devoted to detailing policy and explaining its

reasoning.

To articulate ethos, pathos, and logos, Clinton relies principally on the

following four rhetorical strategies:

• Historical temporality—primarily concerned with the ending of

the Cold War, but also with public policies from the past such as

Social Security and an intangible generalized historical sensibility.

This refers not to specific events and moments in time, but to broad

historical aspirations for equal opportunity grounded in founding

national legal texts such as the Constitution and the Bill of Rights to

justify Clinton’s healthcare reforms to provide a sense of continuity

and legitimacy to the healthcare reforms (ethos).

• Moralization emphasizing the need for immediate healthcare policy

change to guarantee quality healthcare that is dependable and accessible to all Americans, irrespective of their income, to communicate

legitimacy and urgency of the proposed healthcare reforms. Moral

muting, often seen when practical and pragmatic arguments dovetail

with moral ones, is the corollary of moralization, and conveys ideological moderation and conciliation (ethos).

• Personalization through references to individuals experiencing economic loss and psychological suffering due to a lack of adequate

health insurance to cultivate social solidarity. This enables a rhetoric

that minimizes ideology and abstract political and moral arguments,



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and instead argues for healthcare reform by illustrating healthcare

injustices facing individuals (logos, ethos, pathos).

• Selective appropriation of conservative values and ideas and anticipatory and defensive rhetoric (prolepsis) acknowledging conservative

concerns, particularly as they relate to cost saving, minimizing government bureaucracy, maximizing individual choice, and supporting

free markets so as to find favor with conservatives (logos).

We will now examine the structure of the speech.



6.6



THE STRUCTURE OF THE SPEECH



The speech follows a logical, linear structure. It begins by grounding the

speech in the progressive values of the Declaration of Independence, “life,

liberty and the pursuit of happiness,” and establishes them as guiding values for Clinton’s ethos and which situates healthcare reform historically at

the end of the Cold War, at a time of great possibility, while linking it to

past historical achievements of the American people—from sending a man

to the moon to settling the US during the country’s westward expansion.

He emphasizes the importance of the courage to change and defines the

healthcare system as broken and in urgent need of fixing.36

Clinton then turns to six guiding principles that inform the “journey”

toward the successful implementation of the healthcare reforms: security, simplicity, savings, choice, quality, and responsibility. He provides an

overview of what is wrong with the healthcare system, both practically

and morally, and invokes the story of an individual American to illustrate

this in an emotive way. He emphasizes the bipartisan nature of his reform

plans and the importance of uniting around the principle of universality of healthcare provision. He reviews each of the six principles, making

the case for each one and explaining how they interact and support one

another.37 His arguments focus on logos and incorporate ethos, addressing

the principles of mutual responsibility and solidarity extensively, showing

how healthcare cannot be made universal in a sustainable way unless every

US citizen is mandated to carry health insurance, such that the healthy and

the young subsidize the elderly and the sick, and all are guaranteed healthcare at any and all points in life, especially when they are most vulnerable

and in greatest need of it.38 As the speech approaches its conclusion, he

focuses intensely on pathos and ethos, urging members of Congress to

prioritize the suffering and the vulnerable, and to look beyond narrow



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economic arguments that may prioritize the needs of the few in the form

of businesses and some members of the healthcare industry rather than the

American people as a whole.39 Clinton returns to history and the possibility

of change, the need for courage, and the harnessing of a spirit of bipartisanship and openness to achieve universal healthcare. He anchors the final

paragraphs of the speech in the values of freedom and solidarity, returns to

the metaphor of a journey, and urges Congress and the American people

to continue and complete the journey, and to culminate in a program of

affordable, accessible universal health insurance for all Americans.

I begin by analyzing the ethos of the speech and the role of pathos

within ethos. I begin with ethos because although logos is quantitatively dominant in the speech, Clinton uses ethos to justify his healthcare

reforms and to frame the logos of the speech. He opens the speech with an

emphasis on values: “We know the cost of going forward with this system

is far greater than the cost of change. Both sides, I think, understand the

literal ethical imperative of doing something about the system we have

now.”40 His use of the phrase “ethical imperative” is significant because

in its explicitness, it defines the entire healthcare reform effort and corresponding debates as being primarily one about re-aligning public policy

to reflect the American ethos; in making this argument, he is affirming

that however intricate the arguments he makes may be in their technical

details, there is an overarching ethical motivation that propels them. I

incorporate pathos within ethos because Clinton uses pathos to illustrate

his ethos and it almost always appears embedded within ethos. The section on examining ethos is divided into four sub-sections, followed by a

bridging section which links ethos and logos. The section on logos is also

divided into four sub-sections and is followed by the conclusion. Before

beginning the analysis of the distinct strands of ethos, pathos, and logos

in the speech, I will examine the principle that incorporates all three as a

common thread of the speech: security.



6.7



THE CARDINAL PRINCIPLE OF CLINTON’S SPEECH

THAT INCORPORATES ETHOS, PATHOS, AND LOGOS:

SECURITY



The principle of “security” is the foundational principle of Clinton’s ethos

and it is centered on the principle of universality of health insurance for all

Americans at all times:



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First and most important, security. This principle speaks to the human misery, to the costs, to the anxiety we hear about every day, all of us, when

people talk about their problems with the present system. Security means

that those who do not now have health care coverage will have it, and for

those who have it, it will never be taken away. We must achieve that security

as soon as possible.41



As we have already explored, “security” is critical to the ethos of the speech

because it refers to the guarantee of health insurance to all Americans, irrespective of income, on an equal and universal basis. It is also fundamental to the logos of the speech and the principle of responsibility because

the individual mandate which requires all Americans to be insured is the

practical policy mechanism which ensures security for all Americans, irrespective of income. It ensures the financial viability of insuring all people,

including the sick and those with pre-existing conditions, as the young

and healthy in effect subsidize the sick and the elderly and those prone

to illness and disability. Finally, security also refers to pathos in that it

provides emotional security and freedom from fear. Addressing the miseries and anxieties he argues the healthcare reforms will do away with, he

explains with repetition and detail the absolute guarantee of healthcare

security that his reforms provide:

With this card, if you lose your job or you switch jobs, you’re covered. If

you leave your job to start a small business, you’re covered. If you’re an early

retiree, you’re covered. If someone in your family has unfortunately had an

illness that qualifies as a pre-existing condition, you’re still covered. If you

get sick or a member of your family gets sick, even if it’s a life-threatening

illness, you’re covered. And if an insurance company tries to drop you for

any reason, you will still be covered, because that will be illegal. This card

will give comprehensive coverage. It will cover people for hospital care, doctor visits, emergency and lab services, diagnostic services like Pap smears

and mammograms and cholesterol tests, substance abuse, and mental health

treatment.42



Clinton uses the word “covered” or “coverage” eight times in this paragraph to stress how dependable coverage will be and to emotionally reassure the audience that they will never be abandoned without healthcare

or with inadequate healthcare, as so many are now. Thus, “security” is the

unifying principle of ethos, pathos, and logos, and is the core signifier and

value of the speech which informs the sub-arguments made and the rhetorical strategies used to advance them in each of the three rhetorical domains.



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