Learning from Defeat? Political Analysis and the Failure of Health Care Reform in the United States

The demise of President Clinton's 1993 health care reform plan provides a revealing window into the difficulties and hazards of drawing lessons from complex political events. In an effort to identify the causes and implications of the Clinton plan's failure, students of American health policy have offered a blizzard of alleged historical lessons that purport to explain why the plan, along with its leading alternatives, went down to such a crushing political defeat. On closer inspection, however, many of these putative lessons turn out to be hastily formulated, weakly grounded and prescriptively inadequate. These deficiencies are by no means unique to the commentary on health care reform in the United States. Rather, they reflect general risks of constructing lessons for action or analysis on the basis of just one or a few striking political events. Although these risks are endemic to historical lesson-drawing, they could be reduced by more careful attention to basic rules of historical comparison and counterfactual analysis. They could also be mitigated by a greater awareness of the fundamental uncertainties that, for a variety of reasons, characterize complex political interactions. Viewing outcomes as uncertain does not preclude forecasting and, indeed, may lead to more nuanced and accurate predictions, as well as to a greater appreciation of historical turning points and moments of meaningful strategic choice.