November 7, 2012

George Shultz once offered advice to Cabinet secretaries seeking to make a difference, advice that applies equally well to presidents. It’s easy to be consumed by your in box in these big jobs, Shultz explained. The flow of “incoming” could keep anyone fully occupied from the moment they were sworn in to the day they left office. The key to leaving your mark is to be sure you work on priorities you select and put into other people’s in-boxes. Don’t just work off your own.

This sound counsel captures why Barack Obama’s devotion to major health reform was so important — and why the risks he took to pursue that course must make his vindication Tuesday night especially sweet.

Obama didn’t “have” to do health reform. It wasn’t in his in box. A historic economic collapse was. He could have devoted himself exclusively to economic crisis management. (Though even if he’d done that, it’s not clear the recovery would be further along. After all, the Republicans blocked the sensible infrastructure investments in his Jobs Act a year ago that would have left 1 million more Americans working today — and unemployment at 7.2 percent, not 7.9 percent).

But Obama took the longer view. He knew U.S. health care was a scandal, with outsize costs and 50 million people uninsured. Now, thanks to the president’s reelection and the certainty that the law will be phased in by 2014, everything will change.

For the first time, Americans will have guaranteed access to coverage at group rates outside the employment setting. This fact got zero discussion in the campaign, but it’s impossible to overstate its significance. We’re the only wealthy nation where such access isn’t the case today. It’s been bad for people and disastrous for entrepreneurship (because budding entrepreneurs routinely stay in jobs they dislike in order to keep health coverage if there’s illness in their family).

The status quo has been bad for business, which carries the cost of health care on its payrolls. It’s also been bad for workers, because the cash devoured by employer-paid health premiums would otherwise be available for higher wages.

With Obama’s reelection, the great hope now is that in the years ahead, as politicians and business leaders in both parties realize that the new insurance exchanges are a safe and sensible way for folks to get coverage, more Americans will be allowed to migrate to the exchanges, with sliding-scale subsidies for those who need help to buy decent policies.

Everyone needs to realize that this development would be terrific — good for people, good for business, good for the economy. Republicans have talked inanely about people at risk of being “dumped” into the new exchanges, when in fact private plans will be offered exactly like those employers have offered, except that people will have many more choices.

Smart employers see this trend coming and know it makes sense. When I spoke to an audience of human-resource executives not long after Obamacare passed, I polled the audience on what it expected. Today about 20 million people get coverage outside the job setting (not counting folks on Medicare and Medicaid). What would that number be in a decade, I asked. 20 million? 40 million? Or 100 million? Most said 100 million — which would obviously represent a dramatic shift in so short a time. It may be a threat to the benefits empires these folks run for their companies, but it represents huge progress for the country.

This progress will have been possible only because President Obama took a bigger view and then persisted. He wasn’t going to make his entire presidency about his in box — which meant cleaning up George W. Bush’s mess. Instead, he fought for major changes that mattered for the long term. He paid a big price for this choice. Not only did he face the GOP’s fury but, because his team didn’t design health reform to phase in fully until 2014, voters had to go through this election without any sense of the security Obamacare will bring.

Republicans who grasped the stakes opposed it so fiercely because they knew that if Obamacare wasn’t killed in its cradle, it would eventually be popular and deepen the public’s attachment to the party that authored it (this same sentiment accounted for the violent opposition to Clintoncare in the 1990s).

Well, these GOP fears were well-founded. By 2016, Obamacare will be immensely popular. Mark my words.

There are surely 100 reasons why reelection must be satisfying to the president. But one of the biggest has to be the vindication of his choice to go big on health care. Long after the damage of the burst financial and real estate bubbles is healed, Obamacare will be his legacy. It will have improved our society and laid the groundwork for greater economic security in an era in which Americans will increasingly be buffeted by global economic forces beyond their control.

The law is hardly perfect. Twenty million to 30 million Americans will still lack coverage even after it is implemented. Some of its regulations amount to micromanagement (such as rules requiring insurers to spend 80 percent of premiums on health care). The decision to finance the bill partly with fees on employers who don’t offer coverage created needless business opposition and may lead some to cut workers’ hours to stay below the threshold that triggers such fees.

But these things can easily be fixed. The big point remains: By instinctively heeding Shultz’s advice and keeping his eye on America’s unfinished agenda even as economic storms raged around him, Obama is now certain to leave America a more decent society in ways that business will come to recognize are good for the economy as well. (The fact that Mitt Romney’s health reform inspired its design gives the achievement a kind of tacit bipartisan poetry as well.)

Not bad for a night’s work. All we need now is filibuster reform, and we might really be on to something.