Starting Over : Domestic Issues: Is Lack of Focus the Problem?

The party-line vote in the House Ways and Means Committee last week, where the Democrats prevailed, is not enough to pull President Bill Clinton’s version of health-care reform out of the deep trouble it is in. Though people say they like the plan’s goals, one recent poll disclosed that they disapprove, by 53% to 42%, of the plan itself. The same poll showed the public trusts Congress more to handle health care properly.

The response of the President and Hilary Rodham Clinton to the bad news, as well as to his generally low approval ratings, was to declare last week the week of the Great Midterm Shakeup--in which a President says that now everything will be OK because he has just sacked his old chief of staff (or communications director, or secretary of state) and gotten himself a new one. Clinton has moved his childhood friend, Thomas F. (Mack) McLarty III, out of the chief of staff’s office and replaced him with former Rep. Leon E. Panetta--a “Washington insider,” the reports emphasize--who moves to the White House from his current job as head of the Office of Management and Budget.

The President is said to have chosen Panetta because he has the skills needed to deal with Congress on health-care reform and produce a sorely needed win--or to help with White House and congressional midterm campaign efforts if the win does not materialize.

Is this shift likely to change the President’s fortunes? Not much. In health care, as in most of the domestic policy arena, Clinton’s troubles lie deeper than problems of political or communications skills. His message is not getting through because White House ideology has made for policy incoherence, and the issue of character has robbed both the President and Mrs. Clinton of authority.

Panetta has the experience and temperament to cut a health-care deal on the Hill. One of his first acts was to talk with Senate Finance Committee Chairman Daniel Patrick Moynihan (D-N.Y.), whom he has known for years. This is already a big improvement in White House-congressional relations.

But Panetta may have little control over the most important obstacles to a successful deal.

Clinton was quite right, during the 1992 presidential campaign, to identify anxiety over health insurance as a worry that dogged many Americans--and thus as an area in which the call for “change” would have concrete appeal to a great many.

Others have also recognized the pervasiveness of the insurance worry. In fact, nowadays the policy air hums and buzzs with possible solutions to this insurance puzzle. They range from mandatory catastrophic insurance to assigned-risk pools and medical savings accounts.

But when the Clintons finally produced their health-reform legislation, it turned out not to be clearly focused on the insurance problem. Instead, it aimed to do many other things as well: For example, to shepherd people into government-run “alliances,” speed the shift to health-maintenance organizations, control the prices of drugs, rationalize the conduct of health-care research, control the number of medical specialists and use employer mandates to avoid hitting most Americans with a direct tax bite.

The plan certainly did not look as if its sights were trained on the pressing matter of health insurance. It did not seem focused on the issue of health-care quality. Its scope made it look more concerned with power: the power to control decision-making in the health-care system.

Hillary Clinton helped foster this impression by talking of the plan in terms of a large transfer of power. In launching the health-reform campaign, she stressed the need for people to take control of the system from insurance companies tending their profit margins and the drug companies price-gouging on children’s vaccines.

But this rhetorical strategy and the plan’s general approach did not do well. Parts of the rhetoric fizzled: It turned out, for example, that drug companies did not make big profits on vaccines, and that the rise in vaccination costs was due mainly to doctors’ fees. Moreover, Mrs. Clinton’s ability to make persuasive “greed-and-power” arguments declined after revelations of her own profit-taking in the commodity futures business.

Meanwhile, the plan’s voluminous, overreaching character produced--well, lack of focus. The same features raised the suspicion that, in supporting the plan, people might be buying into more change than they really wanted. By being so inclusive and ambitious, the plan also identified itself with trends, like the HMO’s, already proceeding but which many people still feel ambivalent about.

Doubts of this sort made people receptive to advertising and other kinds of persuasion from those special interests that Mrs. Clinton says are the root of all opposition to health reform. In fact, a series of ads sponsored by the Health Insurance Assn. of America, featuring “Harry and Louise,” is regularly cited by the Administration and others as particularly effective in attacking the plan.

But the main obstacle facing Panetta is considerable: The spirit of the Clinton health plan is now seen as at odds with the nature of the problem as most Americans see it. That is a hard thing to fix.

This dilemma is not just in health care. You can see the same “mismatch” in other areas of domestic policy. Clintonites often say that, contrary to popular impression, the Administration has been immensely successful. They point to legislation on the budget, education, family leave, national service and gun control. They say their main fault has been in creating a flawed White House organization that is unable to “focus” and “get the message out” to the public. But critics say some initiatives the White House is so proud of are, in reality, not widely seen as likely to produce widespread change--or might only in the not-so-near future.

Panetta says he has been given authority to bring order to the staff, tame the various power centers now confusing the White House and bring more “focus” to the President’s image. As cynical Washington types say, we’ll see.

Meanwhile, one issue many Americans do feel strongly about is welfare. The President has talked tough on this topic. But we do not yet know how far the Administration is willing to go in changing the system. The welfare bill they submitted will not be many people’s idea of ending welfare as we know it.

Americans care even more deeply about crime--along with the social disintegration that causes it. But federal legislation can have only a marginal effect on crime--a President influences crime mainly by talking about it. But if he is to persuade people that their concerns are his, he must talk about social disorganization, families and religion. Clinton has spoken movingly about crime. But his recent scandals have put him in a poor position to talk about the need for morality in people’s lives. Moreover, he is at war with the religious right, which is trying to make sure his position does not improve.

These gaps--between public beliefs and concerns on the one hand and the Administration’s ideology and leadership capacities on the other--are the source of Clinton’s problems on health care and other domestic-policy issues. If Panetta can close them, the Midterm Shake-up will prove to have been not just an improvement but a revolution.