BioWorld Today Columnist

Can it really be different this time? The national call for comprehensive health care reform is sounded just about every couple decades . . . and then ignored by our nation's lawmakers. Now it's time to go through the process again. Some have suggested that doing the same thing over and over again and expecting a different result is an effective definition of insanity. Are we crazy to try this again?

President Obama, in his first formal address to the country last week, trumpeted "an historic commitment to comprehensive health care reform - a downpayment on the principle that we must have quality, affordable health care for every American." His new budget proposal released last Thursday creates a $634 billion "reserve fund" to be filled over the next 10 years. The idea is to have a pot of money available for reform that can be used as ballast in a discussion between lawmakers about exactly what shape that reform would make.

At this stage, there are few specifics - just a proposed pile of money meant to attract legislators, and some changes to the tax code to make it feasible. But there is already one specific part of the plan that hits drugmakers at home: They will be required to increase their Medicaid rebates from 15 percent to 21 percent.

And now the battle begins.

History would suggest there are low odds of any comprehensive reform happening. There was urgency for comprehensive change in 1992 when President Clinton first came to power, yet lawmakers rejected the package under a tide of heavy lobbying and sour public sentiment. (Remember the Harry and Louise ads?)

Wind the clock back another 18 years to 1974, when President Nixon introduced the Comprehensive Health Insurance Act - a sort of government-subsidized employer mandate - and the result was the same: failure. Ditto to attempts under the Truman and Roosevelt administrations.

The reasons are familiar to anyone who has paid even modest attention to the debate: entrenched interest groups with a financial axe to grind. In the Clinton years, it was the insurance industry. Before that, it was the American Medical Association. (President Eisenhower, frustrated with his own attempts at reform, once referred to the AMA as "just plain stupid . . . a little group of reactionary men dead set against any change.")

So with that kind of track record, is there any reason to hope for - or to fear - any kind of comprehensive reform?

But This Time it Could be Different

Time will be the judge, of course, but there are some reasons to think this time around might be different. The reasons are twofold. First, the failures of past reform plans can be attributed at least in part to specific missteps on the parts of their sponsors rather than simple intransigence among legislators and the general public; and second, there are now cultural and economic undercurrents that favor reform in a way we haven't seen for 45 years.

The mistakes of the past are fairly straightforward. The Clinton administration decided to craft a plan in secret and foist it on Congress as a fait accompli, simply in need of their imprimatur.

Whatever you think of the proposed legislation itself, it was a staggeringly bad piece of PR, as was the failure to work with any stakeholders, like insurers. The Nixon administration's problem was, well, Nixon. His proposed reform came right around the time of Watergate and couldn't survive the weight of the times.

Truman's 1945 proposal for compulsory health insurance smacked of socialism at a time when the Cold War was just beginning to heat up. The AMA launched a public campaign against it, claiming the plan would make doctors "slaves," and Republicans took over Congress the following year, killing any chances for that bill.

Franklin Roosevelt's similar proposal was an afterthought to the New Deal, coming only after Republicans and conservative Dixiecrats had formed an alliance against further social change, and it had only lukewarm support from Roosevelt himself.

Yet any one of those proposals conceivably could have succeeded in different circumstances.

And the currents favoring reform now? Consider the one major exception to the political status quo that has gripped health care policy for the past 70-plus years: the Social Security Act of 1965 that created Medicare and Medicaid.

As sociologist Paul Starr observed in The Social Transformation of American Medicine, the late 1950s were marked by recurring recessions, rising unemployment and a desire for change. John F. Kennedy campaigned for president on a platform of "getting the country moving again." His efforts at health reform met with more grassroots support than any past attempts, and in 1964 the extreme unpopularity of a senator from Arizona running for president, Barry Goldwater, led to huge gains for Democrats in Congress.

Until then, there hadn't been enough votes to pass major reform. But a major groundswell of support for change, along with a large Democrat majority, led to the creation of Medicare and Medicaid the following year.

Now, does any of this sound at all familiar? Of course, it's difficult to say at this point whether Obama's reforms would be a net positive or not, since we haven't seen the details. But it does seem that history is handing him a better chance at enacting major reform than we've seen in generations.

That's not to say it will happen without a struggle, or that stakeholders shouldn't fight for their own interests. But another feature of the current Zeitgeist, changed even since Clinton's attempt at reform in 1992, is a widespread recognition that something needs to be done.

The AMA discovered more than 40 years ago that, despite its strenuous objections to Medicare, the program was a huge boon to doctors. Insurers may discover the same thing if the concessions they make lead to more insured Americans.

And drug companies? They're better off accepting that change is in the cards this time and working with legislators on the assumption that a little sacrifice now is a trade-off more likely to keep a system that generally buoys their fortunes.

The scare tactics probably won't work on a nation already terrified.

Karl Thiel, an analyst for the Motley Fool, can be reached at kthiel@qwest.net. His opinions do not necessarily reflect those of BioWorld Today.