How Rep. Jim Cooper became a fighter—and a target—in the health care wars 

It was Sept. 27, 1993, and Congressman Jim Cooper stood anxiously in the White House—not the tour-guided White House, but the family quarters upstairs. He was on tap to give a speech to the Tennessee Association of Broadcasters, and though it wasn't a big deal in the grand scheme of history, he was fretting that he would not make his plane. His host, a fellow Southerner and Rhodes scholar, would not let him leave.

"Mr. President, I'm going to miss my flight," Cooper said.

"I want you to stay," President Bill Clinton replied. "I'll make the speech for you over the telephone."

What? The sitting POTUS—the most powerful man in the free world—would pinch-hit as dinner speaker for an assemblage of local broadcasters? That didn't even happen when Martin Sheen was president. And yet, when his turn at the podium arrived, Cooper dialed TAB officials from Washington to say there had been a last-minute change of plans. He turned over the line to his host.

"He got on the phone, and the broadcasters will tell you it was probably their best meeting ever," Cooper recalls. "Even though there wasn't a physical speaker present. The president of the United States spent 15 or 20 minutes chitchatting on the telephone."

So why would a sitting president agree to be Plan B for a junior lawmaker's keynote speech? It all had to do with the elephant in the room—the subject Cooper's host went to great pains not to mention.

That was health care, a key issue for the Clinton administration as it devised a plan for universal coverage behind closed doors. At stake was nothing less than Clinton's legacy. Yet during their meeting, Cooper says, the president never brought it up.

Clinton's reticence was hardly lack of nerve. At the same time the commander-in-chief was wooing the rural Tennessee Democrat—asking him to go golfing, to go jogging on the Mall, to hang out in his beyond-restricted inner sanctum—his first lady had set up a war room to pick off opponents and obstacles to the administration's health care initiative. A particular thorn in Hillary Rodham Clinton's side was an alternative centrist bill, then gaining traction on both sides of the aisle. Unlike the Clinton plan, it carried little political baggage, hadn't polarized legislators, and didn't trip the "socialized medicine!" scare alarm. That made it dangerous.

Its sponsor was Jim Cooper.

And so Cooper found himself the subject of a good-cop-bad-cop hustle, being played out at the highest political level by masters of civic bloodsport. Suddenly, an ambitious junior lawmaker was up off the backbench and taking a starting position opposite the Clinton White House in the biggest game in town.

At the time, Clinton's popular presidency was riding a groundswell of positive public opinion. His youthful optimism was infectious. Yet his administration was plagued by the absence of a mandate, and the many splinter factions on the Hill seemed stalemated—even Democrats. When first lady Hillary Clinton and health czar Ira Magaziner met to concoct policy in the insular White House, away from the eyes of Congress, there was the very real sense that those factions couldn't be bridged, a firsthand observer tells the Scene.

"[During the Clinton administration] we didn't bring contradictory factions in Congress together, even among the Democrats," says Dr. Atul Gawande, a cancer surgeon at Brigham and Women's Hospital who was a health care policy advisor for the Clinton administration at that time (and is also a former health policy advisor for Cooper). "And that really hurt us." By "hurt," Gawande means that the Clinton White House strategy was essentially responsible for scuttling reform.

But the political divide ruined any chance of a Cooper victory as well. Young, Oxford-educated, aloof and cerebral, Cooper had more in common with Republicans on issues regarding government intervention in the marketplace. At a time when Democratic unity was schismatic at best, there was little hope for the Coopers in the House finding common ground with someone like John Dingell, then chairman of the powerful Committee on Energy and Commerce. A New Deal Democrat of the back-slapping union-hall school, Dingell embodied the belief that government is the shepherd watching over its flock, the American people.

Eventually, the game would go down as a loss for almost every player concerned—including the millions of Americans who watched the promise of health care coverage evaporate in puffs of hot air. Now, 15 years later, the battle for health care is being fought once more—and in the immortal words of Yogi Berra, it's déjà vu all over again.

As before, the Democrats are one beast with two heads. And for those familiar with the adversarial forces that swirled around the health care debate during the last Democratic presidency, that's not the only thing that hasn't changed. The health and insurance industries, along with conservative talk radio and anti-tax organizations, are ginning up Big Government paranoia just as they did before.

But an unexpected player is emerging in the latest round of the health care wars—the lawmaker who Hillary Clinton tried, with some efficiency, to sideline during the last one.

True, Rep. Jim Cooper is, from an administrative standpoint, still on the backbench. He has no presence on any committee of jurisdiction influential in the current debate, in no small part because some Democrats still blame him for torpedoing reform in the '90s by challenging the Clintons. But he has the attention of moderate Democrats—and that increasingly has the attention of President Barack Obama.

With a 2009 budget deficit of $1.42 trillion and Medicare facing bankruptcy by 2011 or 2012 in Cooper's estimate, fiscally conservative Democrats like Cooper and his famed "Blue Dogs" may call the game. Especially since it is likely that not a single Republican will cross the aisle to support health care reform. It is therefore arguably the right time in history for a fiscal conservative like Cooper to lead the health care charge.

What's more, Obama is speaking Cooper's language. He is demanding that reform not add to the deficit and bend the cost curve for health spending, which is expected to become 20 percent of the gross domestic product by 2019, according to the Centers for Medicare and Medicaid Services. Recognizing his value, Gawande says, the administration has given Cooper a voice in the debate.

Of course, according to those who know Cooper, getting reduced to an advisory gadfly is an uncomfortable position for a lawmaker accustomed to being the most informed guy in the room. But in an Obama reform push where centrist Democrats are heeded, not crushed, it's far from a toothless role.

How did Cooper end up embroiled once again in the battle for health care, and is there any hope that the outcome this time might turn out differently? Any answer to those questions must begin with a hard look at the past. It is 1993, and there is no Republican Revolution, no inkling of impeachment—just two plans sitting at opposite ends of a seesaw, with the well-being of millions of Americans riding on which way it will tilt.

The philosophical roots of the reform plans proposed by Congressman Jim Cooper and the Clinton White House in 1993 really weren't so different. Both were derived from the Jackson Hole Group—a gaggle of academics and businessmen who developed an untested theory called "managed competition" during a vacation in Jackson Hole, Wyo.

In this model, the government sets a minimum bar for insurers and organizes customers into cooperatives. Insurers compete for the business of these cooperatives, and are forced to control their costs to retain customers. Thus their leverage over the consumer is reduced. It's not so different from the plans being discussed today.

Both Clinton and Cooper were educated on managed competition by the same person, then-Harvard Medical School student Atul Gawande. Cooper learned from him in 1990, when Gawande worked for him as a health care policy advisor. Clinton sought his counsel during the 1992 campaign, and later in the White House. Gawande would later pen a piece for The New Yorker that provided a particularly egregious example of just how wasteful the current system is: Medicare spends $15,000 per enrollee in McAllen, Texas, but $7,500 in the comparable El Paso.

In September 1992, Cooper, then a member of the Health Subcommittee of Energy and Commerce, introduced a bill embodying the principles of managed competition. If Jim Cooper can be labeled anything, it's consistent—even then his bill contained no employer mandate.

Instead, his bill taxed so-called "Cadillac plans"—i.e., supposedly top-dollar employer-provided coverage—and their generous benefits, a move that antagonized the unions responsible for negotiating them. (Ironically, Senate Democrats have looked at a tax on Cadillac plans in the new debate, a move now decried by Republicans.)

Meanwhile, the Clinton camp was internally split on how to proceed with reform. Its decision to craft a bill without input from Congress would later prove disastrous. But in the early summer of 1993, all the White House knew was that it needed to keep Cooper on the reservation.

First lady Clinton, who was in charge of the administration's health care policy, met with Cooper. But they made little progress. Cooper felt she had been dragged too far in the direction of a single payer-style plan. To obtain the support of the unions, the White House insisted on employer mandates and "alliances" that, to the conservative bloc, looked more like regulatory bodies that would institute price controls.

The entrenched industries fought back. The Health Insurance Association of America launched a damaging ad campaign starring "Harry and Louise," a pair of ersatz average-Joe seniors wringing their hands over government control of health care. Maybe it lowered public discourse on the topic to an "I've fallen and I can't get up!" scare tactic. But it struck a nerve. Clinton, meanwhile, had limped into office with a scant 43 percent of the popular vote, and his coffers were empty. He needed money to wage a PR war.

"Turns out the president of the United States has no money to spend on a PR campaign," recalls Len Nichols, now director of health policy at the New America Foundation, who was senior advisor for health care policy at the Office of Management and Budget during the Clinton reform push. "And the only source for air-war money the Clintons had access to was the unions. Internally, we argued quite eloquently why an individual mandate was better policy."

But the Clinton camp needed to answer Harry and Louise, and fast.

For Cooper, then answerable to the conservative 4th District (he now serves the 5th District), the compromises were unpalatable. Fellow conservatives feared the employer mandate would mean lost jobs and that cost controls would compromise the quality of care. "You probably don't even have the votes in the Health Subcommittee," Cooper recalls telling the first lady.

Plus he was tired of withholding his own bill. He'd found a co-sponsor in Sen. John Breaux, a fellow New Democrat from Louisiana. "I offered [the Clintons] my whole bill," Cooper recalls. "For six months I didn't even introduce my own bill because I wanted them to have it. Because I had found the middle ground. But all they wanted to do was this strategy of going way to the left in the House, then go to the middle."

According to The System, a breathtakingly well-sourced post-mortem published in 1996 by Washington Post reporters Haynes Johnson and David Broder, the first lady believed Cooper's political ambitions drove him. A Senate seat had opened up in Tennessee, and his gaze was fixed on it. To be sure, his bill made him a darling to insurance companies and the health care industry. In the last six months of 1993 alone, the consumer organization Citizen Action reported at the time, his campaign raked in nearly $200,000 from health and insurance interests.

In October 1993, a few weeks after Clinton announced his health care reform effort on national television, Cooper hit the national stage with Iowa Republican Fred Grandy to introduce a new version of his 1992 bill. It had 44 co-sponsors—26 Democrats and 18 Republicans. For the first time, there was actually legislation the public could see. And bipartisan legislation at that. Cooper called it "Clinton Lite."

White House officials were reportedly telling Cooper not to give up on his bill—to "hang in there," Broder and Johnson write. They believed, like Cooper, that the White House pendulum would eventually swing back to the center. Hillary would come around.

That never happened. Instead, the first lady and Energy and Commerce Chair John Dingell "stampeded" him, as Berkeley economics professor and former Clinton-era Treasury official Brad DeLong writes in his response to The System. Cooper was about to get a taste of Clinton-style hardball.

Sen. Don Regal of Michigan was called to the White House and asked to denounce Cooper on videotape, Cooper recalls. He declined, but Sen. Jay Rockefeller didn't. Cooper was "a real fraud. I hope he doesn't make it to this place," Johnson and Broder report that Rockefeller said, referring to the U.S. Senate. Ironically, this was right about the time President Clinton was taking on speaking engagements for Cooper and inviting him to go jogging. Cooper shrugs it off today with a joke: "He knows what Hillary's anger is like."

Meanwhile, Cooper was gaining traction with big business, a heavily courted group that was scared away from the regulation-heavy Clinton approach. This would make it more difficult for Dingell to round up the necessary votes on Energy and Commerce, and Republicans had made it clear they were unified in opposition then as now. It became clear that the chairman would have to rally all of his Democrats. In Cooper, Dingell saw his greatest obstacle. He decided to pull some strings to make life difficult for the congressman back in Tennessee.

According to Johnson and Broder, one headline in a March 1994 issue of the United Paperworkers International Union newspaper read, "Jim Cooper, Grand-Standing on Health Care, Forgets His Constituents." Then there was a piece on the "$30,000 Party," a Cooper fundraiser at the "lavish Nashville home" of Clayton McWhorter, then the head of HealthTrust Inc., a for-profit hospital chain.

That was just a warm-up. Copies of the Cooper-Grandy bill were burned in effigy at a union rally in Chattanooga. A flier distributed by the American Federation of State, County and Municipal Employees at a Memphis civil rights rally read, "Cooper's plan would punish African Americans more than others."

But Cooper's bill wasn't the only problem for Dingell. Yet another bipartisan bill, Rowland-Bilirakis, was gaining in popularity both in Energy and Commerce and among Republicans. Cooper wouldn't budge. He believed the Senate Finance Committee would take up his own bill in some form. Dingell dispatched Oklahoma Rep. Mike Synar and Oregon Sen. Ron Wyden to try to convert Cooper.

"I remember those days very well," Wyden tells the Scene. "And one night Mike would take Jim to dinner, and one afternoon Mike and I'd get together, and had it been possible to get beyond some of that tension that sunk in in '93-'94, I think the country could be enjoying the fruits of health care reform today."

But it wasn't. By June, Dingell, one of the most effective chairmen in Congress, admitted he would not report a bill out of Energy and Commerce. And Cooper's vote certainly wasn't the only one he couldn't count on. Though the Clinton push for reform went on, most observers—including Cooper—say that's when reform died.

No other example of how the Clinton reform effort lost control of the debate is as stark as the campaign of his Reform Riders—a group of middle-class Americans with emblematic stories of health care hardships who toured the country by bus, spreading the message. By the time they set out across America, the discourse had devolved into reform opponents wielding the Big Government fear card.

This choreographed opposition, backed by Citizens for a Sound Economy—a conservative group supported by Richard Mellon Scaife, heir to the Pennsylvania Mellon bank and oil fortune—consulted daily with prominent conservative figures such as then-House Minority Leader Newt Gingrich and talking head Rush Limbaugh. They obtained a map of the Reform Riders' route and organized at each stop, using networks of the Christian Coalition and other conservative, anti-tax groups in a harbinger of today's tea parties. Level-headed debate of a complex domestic issue was replaced by sloganeering: "government-run health care." Sound familiar?

To blame such a sweeping, systematic policy bungle—beginning with lost time and momentum among the Clinton camp and spreading through a divided Democratic Congress—on one lawmaker seems simplistic. Yet it was with registered surprise that critics watched the "spoiler" become then-Sen. Barack Obama's health care policy adviser during the campaign.

Not surprisingly, Cooper picked his horse early when Hillary seemed the presidential candidate's strongest opponent. Cooper chaired Obama's Tennessee campaign and held a sparsely attended fundraiser in Nashville during the summer of 2007. Far more damaging, though, was a well-read, oft-cited interview he gave to The New York Times' David Brooks that ran on Super Tuesday. Painting her as a ruthless know-it-all, he recounted Hillary Clinton's campaign to "crush" him over their policy disagreement rather than find middle ground back in the 1990s.

Today, there is evidence that the lessons of what has been called "one of the great lost opportunities in American history" have been learned. The unbridgeable schisms of the Clinton years no longer gape so widely. Look no further than the open lines of communication between Cooper, the conservative Blue Dog, and a Great Society/New Deal Democrat such as California Rep. Henry Waxman.

The paw prints of Cooper's Blue Dogs and moderate Democrats can be found, for better or worse, on the compromises inching the current effort toward a vote. These include the negotiated rates of reimbursement in the legislation coming out of Waxman's Energy and Commerce Committee, not to mention the absence of an employer mandate in the Senate bill. Deficits have spiked because of the recession, leading House Democrats to get behind crucial Blue Dog disciplines like PAYGO (pay as you go). As a result of such delicate negotiations, the largest domestic reform effort in a generation has already progressed further than it got 15 years ago.

"Getting Henry Waxman and Jim Cooper talking is about the most positive and amazing thing that could happen," Gawande says.

But the Blue Dogs' potency has sent progressives scrambling for a shock collar. Specifically, the hard left has targeted Cooper, seeking not just to sideline him in the coming debate but to remove him from office altogether. Leading the drumbeat is Markos Moulitsas of the influential Daily Kos blog, who commissioned a Research2000 poll that says Cooper is too conservative for his comparatively liberal home district. Echoing a persistent criticism that has hounded the Blue Dog throughout his career, Daily Kos accuses Cooper of nestling snugly in the pockets of health care interests. estimates that over Cooper's years in office, he has taken $900,000 in conrtibutions from the health sector—or $11 of every $100 he has raised.

The PAC Accountability Now has taken the effort further, announcing its intent to unseat the entrenched congressman. Labor voices like Doug Collier of the Service Employees International Union are openly critical of Cooper, particularly for what they perceive as, if not opposition, a failure to provide concrete support for a public option. And support from Blue Dogs is by no means concrete at this point. Cooper is no fan of reimbursement tied to Medicare rates, and House Democrats may not reach the magical 218 votes needed to include a public option if House Speaker Nancy Pelosi forces the issue.

"The thing is, there comes a time where Congressman Cooper's self-professed expertise in health care needs to balance with the needs of and the desires of not only his constituents, but the community," says Tony Cani, Tennessee director for the SEIU Change That Works campaign, a service-employees-union push to help Obama reform health care and revive the economy. "I do think he's an important piece of the puzzle when it comes to getting Democratic support, whether it's [Tennessee congressmen] Lincoln Davis or Bart Gordon."

The irony is that Cooper the health care loner has clung so hard to the issue that threatened his career that he's become something of a wise man on the Hill.

"He's been, I think, a go-to person for just about anybody who's interested in thinking seriously about how you're actually going to get health care reform," says Wyden, co-sponsor of the bill Cooper supports, the Healthy Americans Act. "The White House wants his opinion."

By all accounts, they've received it. (White House health care czar Nancy-Ann Min DeParle used to be a commissioner for the Tennessee Department of Human Services and is close to Cooper.) And indeed, Obama has soft-pedaled the public option, putting him in line with Cooper but at odds with House Speaker Nancy Pelosi.

"The president has been great on this because he said the real reason for a public option is to keep the private insurance companies honest," Cooper says. "If we focus on that as a policy goal and realize that to keep insurance companies honest we have to have [a public option] doctors will participate in and hospitals will participate in, that will be sustainable. That's why I've been open to different models of the public option that meet his goals."

This influence, however, worries some. Will Cooper doggedly hang on to a model based on his own intellectual preferences—letting, as he often says, the best become the enemy of the good? At almost every speaking engagement, Cooper mentions the Wyden-Bennett legislation—a fiscally conservative bill that would create state-based purchasing pools, an indvidual mandate and near universal coverage by roughly 2014 without adding to the deficit. The bill is not under consideration, giving some Democrats flashbacks to his unyielding commitment to his own bill in the 1990s. Cooper says he's just trying to be realistic about what can actually pass in the Senate.

Then again, Cooper has never seemed too uncomfortable being the man without a country. Those who know him well say he is, if anything, principled, even if some in his party cringe when he's quoted by The New York Times sniping at the process: "The lobbyists are winning."

"To be in a comfortable place politically, you have to be in a camp. He's comfortable with not being in a camp. The intellectual weight of the argument is number one with him," says Vanderbilt University health care management professor Dr. Larry Van Horn, who is currently working on a book with Cooper examining the economic forces driving what we see today in health care. "He's like a Boy Scout, man. You just feel like Jim is going to try to do the right thing. It might not make everybody happy, and it might not be politically expedient."

Is there any reason to expect actual reform from the renewed debate? Cooper predicts two scenarios. In the first, a throwback of sorts to the Clinton White House strategy of starting at the extreme left, House Democrats are trying to convince moderates that starting with a more liberal version in the House gives them negotiating room with the Senate, aiming for a more centrist bill they can reach consensus on in committee. The farther left the House bill, the farther you can drag the Senate in that direction. Like Cooper's managed care bill in the '90s, the Senate seeks to tax the Cadillac plans. The House, on the other hand, would tax the wealthy.

The other scenario is troubling: a take-it-or-leave-it proposition from the Senate refusing to allow the bill to go into conference committee. "I've been hearing more and more about that from Senate types," Cooper says. "We've already seen how difficult it is to get even one Republican."

And yet Cooper remains cautiously optimistic. He predicts a 70 percent chance we'll see a bill the president can sign—perhaps by December or January, he estimates.

Either way, as President Barack Obama looks to build consensus in the House, moderate Democrats are expected to loom even larger in the debate. And when the time comes, he may land in the same position as President Clinton 15 years ago: courting a Blue Dog from Tennessee who doesn't sit well in anyone's lap.


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