In all the analyses of the California health reform, there’s been a lot of talk about all sorts of issues. But I think an overlooked issue was one of trust.
When Senate Majority Leader John Burton–a legendary figure and now chair of the California Democratic Party–ran his health reform, SB2, an expansion of employer-based coverage in 2003, he pushed it through his power and personality. And while he and various stakeholders worked very hard on the details, he was able to push a product to legislative passage and a Governor’s signature with support of many groups first of all because they trusted him. They trusted where he was coming from, what his intent was, and even his ability to fix something if it didn’t work out as intended.
Health policy can get pretty complicated, and many people can be concerned about the potential impacts of any changes, and so trust of the authors can go a long way in providing the benefit of the doubt.
Ezra Klein reports about a phone call by President Barack Obama had with bloggers today where he details his desire to move the process forward, and get a bill–even one that doesn’t do all that we want–through the House and Senate, so that we have the opportunity to influence the content in conference committee. As Ezra indicates, this is both a plea to not make the perfect the enemy of the good, but a plea for trust, that the President will work to make the final bill a good one, either in conference committee (and maybe in implementation). He may very well have that trust with the public, and perhaps with various stakeholders that are the base of a health reform effort.
In Massachusetts, there didn’t seem to be too much trust with Governor Romney by health advocates or the Democratic legislature. But they didn’t need to do so. He was a lame duck, and would not be around to implement the program. From afar, my sense is that they might have been more concerned about the details of the bill if they thought he would be the one carrying out the proposal.
In California in 2007, that trust was not there. Governor Schwarzenegger was enthused about health reform, but had gone through several transformations in his few years in Sacramento (as he has continued), and always seemed to relish the spotlight/limelight rather than the issue itself. He used his trust he built to get support from some business and Chamber of Commerce types, but he didn’t have it with the core health reform stakeholders. Folks were understandably skittish about what his implementation would look like.
The term-limited legislative leaders did not have the same built up history and relationaships as Burton, and had their own fights with their “base” constituency–with components of labor, for example, that made that mutual trust hard. Some who were predisposed not to trust the legislative leaders pointed to the term limits ballot measure, concerned that that was the major motivator rather than the issue at hand. (Somewhat unfairly, I would say). The lack of trust made people look a second time at legislative language, looking for problems that may or may not be there. This is not to say that a second look isn’t warranted. The issue is whether there is that trust in the first place.
In the present context, we should fight as hard as possible to get the House and Senate bills to be as strong as possible, to help create the best debate parameters within the Conference Committee. But it also means that we need the trust people have in President Obama to help us through.
So trust matters. Even when I did a post-mortem of California health reform, I downplayed trust because it is hard to extrapolate a tangible lesson for the future–after all, trust is not something that can be bought, but comes with time and experience. But I think that trust–whether of Representative Waxman, of Senator Kennedy, or of President Obama–will be a overlooked factor in whether health reform succeeds or not.