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Well, every politician for the past 100 years has known that health care reform is the “third rail” of politics. And, if they didn’t know before Massachusetts, they know it now. So, why did health reform fail this time? Is it for the same reasons it has in the past or is there something unique about this moment or this president’s strategy for health reform that seemed to get so off track? While the history of health care is fascinating and the commonality of failure can make it seem that there is a hex over health reform that has infected everyone who tries, each failure of the major efforts at reform actually has its own unique set of causes. What is common about all of them is that the public cares a lot about health care — it is truly a personal issue. What is also common is that the public generally is more comfortable with systems that are known — even if largely disliked – than with approaches that are unknown or unclear. That is, the public generally has a fear of change. Opponents have always had an easier time engendering fear among Americans about what is proposed than proponents have had in helping people see the advantages of proposed changes.

Beyond these commonalities, what was it about this current health reform proposal that led to such a negative view in a state like Massachusetts? Is it because the policies that have been proposed by either the House or Senate are so radical that they are inconsistent with American values? Is it because there really isn’t support for changing how we finance health care in this country? I don’t think either of these are the case.

Indeed, one of the great ironies of the vote in Massachusetts was that the bills in Congress are, in large measure, patterned after the health care reforms that were enacted in Massachusetts in 2006. Those reforms were bi-partisan and are still strongly supported by the citizens of Massachusetts. And they are by no measure considered a radical departure from the structure of health care that exists in the rest of the country. The current bills in the House and Senate are similar and were also designed to build on the current system not replace it (to counter a criticism of earlier national reform efforts).

So, if it is not that the proposed bills are so radical or even so different from what is already in place in Massachusetts, what was it that set off the voters such that many of them told pollsters that their vote was all about stopping national health reform? I believe the issue at its core was not the substance of the legislation, but rather the process of legislating.

Health care accounts for one sixth of the U.S. economy. As such, virtually every interest group has a stake in what happens and all want to be at the table. The process of legislating anything requires dialog and compromise. And, legislating something as complicated and sweeping as health reform means that dialog and compromise will involve a lot of moving parts.

So is that bad? Not necessarily, but for something this big, it is ugly, visible, and takes time. And through this process, provisions that are not very savory often find their way into the bill (exhibit A: the special deal for Nebraska on Medicaid payments).

Also, the bills in Congress are trying to change — all at once — many elements of the health care insurance, financing, and delivery system. Because there are so many components in play, the legislation is complicated and the change hard to communicate in simple terms. That means that media coverage is often focused on the process rather than content of reform — and certainly, the process and its ugly side is a lot easier to understand than many of the detailed changes in tax structure, subsidies, independent quality review commissions and the like.

This process has always been the way Congress gets things done. But, we live in an era of 24/7 news coverage, instant analysis and approaches to filibusters that have helped increase the partisanship in Congress. Indeed, if the Medicare negotiations were occurring today, I think it unlikely that that bill would have passed either, despite President Johnson’s prodigious legislative skill.

So, where does all this leave us? Can the current effort at health reform go forward as is? If not, what is the message about the political reality of tackling anything this big — now or in the future? While these proposals got awfully close to the finish line — so close that nearly everyone in health care had already started talking about implementation issues “when” health reform is done rather than “if” health reform is done — I am guessing these proposals will have to be scaled back greatly to reflect political realities. I do think something will pass — and it will be something meaningful: the Democrats and the President have made this issue too central to their agenda for nothing to move forward. But, given today’s world, whatever is ultimately passed will need to be more easily understood and be smaller in scope than what many had hoped.

I know that a lot of advocates and those who worked so hard on these bills are in deep despair about the prospects for this reform legislation. But, maybe it is better to recognize the reality of today’s environment and take it as a lesson for the future on how to deal with important issues. After all, Winston’s Churchill’s view of democracy is as important today as when he said it in 1947: “Many forms of government have been tried, and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government except all those other forms that have been tried from time to time.”