On September 22, 1993, President Bill Clinton spoke to a joint session of Congress about the imperative of enacting health reform. It was a powerful speech. Clinton emphasized the need to fix a “badly broken” system that cost too much and left too many Americans without insurance. He eloquently cited stories of how ordinary Americans who “worked hard and played by the rules” were hurt by a system where insurance coverage had become unaffordable. And he drove home the importance of enacting legislation that, after decades of debate, would at last guarantee all Americans’ health “security.” In the speech’s aftermath, his advisers were euphoric when overnight polling showed that two-thirds of Americans favored health reform.

Almost exactly sixteen years later, Barack Obama addressed a joint session of Congress about the imperative on enacting health reform. This, too, was a powerful speech. Obama succinctly outlined the major goals of reform, made a compelling case for controlling health care spending to tame the federal deficit, and clearly explained how reform would help the insured. The speech’s conclusion was particularly poignant: invoking a letter from Ted Kennedy, the president eloquently framed health reform as a test of the “character of our country.”

Judging by the overnight polls, the speech was well received by the public, and it will give the Obama administration and congressional Democrats a significant (if temporary) boost as they try to push reform over the finish line.

Any momentum that the speech generates comes at a crucial time: August was a miserable month for health care reform, from talk of “death panels” and government “takeover” of the health system to the spectacle of town hall meetings. Meanwhile, the president’s public approval numbers slipped, while public concerns over reform intensified. There is no doubt that the administration lost control over the public debate, and there is also no doubt that health reform is in political trouble. Perhaps Obama’s eloquence will enable him to reframe the health care debate, and help persuade congressional Democrats who are nervous about their reelection prospects in 2010 to vote with the administration.

Yet we know from Bill Clinton’s experience that great speeches don’t guarantee enactment of major legislation. The day after Obama’s speech, the same serious hurdles to adopting health reform that existed before the speech remain: how to find a politically feasible way to pay for expanding coverage that the Congressional Budget Office will count; the problem of finding 60 votes in the Senate for reform and the question of whether Democrats are willing to pull the trigger on budget reconciliation; how to reconcile the competing priorities of progressive and Blue Dog Democrats; whether Max Baucus’s efforts at producing bipartisan compromise in the Senate Finance Committee will finally pay dividends; controversies over the fate of a public plan option and requirements on employers and individuals to buy insurance.

There has been much made in recent weeks about the Obama administration’s ostensible strategic mistakes in health reform, perhaps because it “over-learned” the lessons of reform’s demise in 1993-94: excessive deference to Congress, insufficient focus on how reform would aid Americans with insurance, and inadequate political attention to seniors and the political risks of relying heavily on Medicare savings to fund the plan.

There is, no doubt, some merit to these criticisms, though they also ignore the important strategic successes that the Obama administration and congressional Democrats have attained in 2009. Those successes include: securing the option to pass reform through budget reconciliation; largely coopting the health care industry and thereby minimizing its opposition to reform; achieving extraordinary coordination among the Democratic chairs of the three House health care committees; and moving quickly enough so that four committees have already approved health reform bills.

Facing Familiar Problems In A Difficult But Winnable Fight

Criticisms of the Obama administration’s strategic failings largely miss the point. It is no accident that Franklin D. Roosevelt, Harry Truman, Richard Nixon, and Bill Clinton all failed to secure comprehensive health reform. The Obama administration faces the same barriers that reformers have been unable to circumvent for the past century: an array of powerful interests who profit from preserving the status quo, fragmented political institutions that give those interests ample opportunities to block reform in Congress, Americans’ historical ambivalence about and often fear of government, and the political reality that many insured Americans are satisfied with their coverage. Moreover, the Obama administration has nothing like the Democratic supermajorities that FDR and Lyndon Johnson enjoyed in Congress when Social Security and Medicare were enacted — majorities that would help Obama surmount those barriers.

There is, in short, no perfect health reform strategy. No matter what you do, opponents will lie about your plan. No matter how much your plan costs or how much the federal budget deficit (or surplus) is, critics will say that it is unaffordable. No matter how much it relies on private insurance, opponents will decry reform as a “government takeover” or “socialized medicine.”

There will always be an ideological divide between the parties about the roles of government and markets. Insured Americans will always be anxious about how reform affects their medical care. It will always be difficult to navigate controversial legislation through Congress. And health reform advocates will always be disappointed with the inevitable compromises that must be made to get reform enacted into law.

Yet the sound and fury of the last month should not obscure the reality that while health reform has taken serious political blows, it still has much going for it. Give the Obama administration’s determination, Democrats’ majorities in Congress, and their political incentives to produce a bill before the 2010 election, there is still a good chance — though it is far from certain and this is an unstable environment — that legislation can pass this year.

Health reform is always a difficult fight, but in September 2009 it remains a winnable fight.