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Jonathan Oberlander, PhD, associate professor of health policy and administration and social medicine at the University of North Carolina at Chapel Hill, explores what lessons can be learned from past failures in health care reform in the lead perspective article in the Oct. 25, 2007 issue of the New England Journal of Medicine.

Oberlander, with appointments in UNC’s schools of Medicine and Public Health, compares the environment for health care reform now with the situation in 1993 to 1994 when President Bill Clinton’s administration presented a plan for health care reform. He explores why the Clinton plan was unsuccessful, and suggests what political and health care leaders today can learn from that failure.

Oberlander’s article, and an audio interview with him, are available at www.nejm.org.

In the article, Oberlander says, “Perhaps the Clinton administration’s greatest mistake was excessive ambition. The plan attempted simultaneously to secure universal coverage, regulate the private insurance market, change health care financing through an employer mandate, control costs to levels enforced by a national health board and transform the delivery system through managed care.”

He compares key factors affecting the demand for health care reform in the early 1990s and now, and suggests there is a similar window of opportunity to make significant changes in the nation’s health care system.

But he offers six lessons current reformers can learn from the Clinton plan’s failure.

1. No matter what the signs, health care reform is not inevitable in the U.S. because the status quo is deeply entrenched.
2. Many Americans are satisfied with their own health care arrangements and may oppose changes that threaten to unsettle those arrangements.
3. Expanding government authority over a health care system that accounts for more than $2 trillion in a country that is ambivalent about public power is inherently controversial.
4. Paying for health care reform is a formidable challenge.
5. U.S. political institutions limit presidential power, foster divisions in Congress, create opportunities for those with vested interested to block change and generally complicate the adoption of health care reform.
6. The window for enacting comprehensive reform never stays open long, and failure may result in the loss of political will to make any meaningful changes to help the uninsured.

Most sobering of all, Oberlander says, is the realization that Clinton is only the latest in a list of presidents who tried and failed to reform health care. Other include Franklin Roosevelt, Harry Truman and Richard Nixon.