The Sunday Take

The Take: Obama's Focus on Health Care Will Be Crucial to Reform

White House Chief of Staff Rahm Emanuel is optimistic about health reform.
White House Chief of Staff Rahm Emanuel is optimistic about health reform. (By Gerald Herbert -- Associated Press)
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By Dan Balz
Sunday, July 12, 2009

After a week of international diplomacy, President Obama returns to Washington this week facing an even greater diplomatic challenge: nudging the large and controversial health-care reform package toward consensus on Capitol Hill.

Headlines during his absence pointed to multiple problems -- beyond the virtual wall of opposition among Republicans. There is resistance among conservative Blue Dog Democrats over the potential cost. There is nervousness among progressives that the White House might compromise too much on a public insurance option. The all-important Senate Finance Committee appears stymied. As a result, the prospects of floor action in the House and Senate before the August recess now appear in jeopardy.

White House officials remain publicly optimistic, even while recognizing the hurdles ahead. "When you get this close, you get a lot of heat," White House Chief of Staff Rahm Emanuel said. "It comes with the nature of what we're doing. I'm saying that in an affirmative way."

But an administration loyalist who is deep into the health-care battle, and who was decidedly more optimistic a few weeks ago, offered a counter to Emanuel's assessment. "I think the headlines are accurate," he said. "Things are not going as well as I would have liked for a lot of reasons."

There is accuracy in both assessments. Emanuel rightly notes that no administration and Congress dating back half a century have enjoyed the kind of climate for passage of universal health care. Nor have they ever gotten as far as things have progressed this year. "I've seen passes, vetoes and failures," Emanuel said of his experience with health care that dates back to his earlier service in the Clinton White House and his time as a congressman from Illinois in the House. "We've never, on universal coverage, been this close to the goal line."

But pessimists are also correct in asserting that the battle has reached a critical stage and that, after significant movement earlier in the year, there are fissures opening up that threaten the prospects of crossing the goal line. Administration officials insist they want good legislation, not just any legislation, and on both fronts, they have a struggle on their hands.

Through most of this year, the administration has held together a fragile coalition of interest groups that have been on opposite sides in previous health-care battles. Administration officials have done this in part by creating the sense that this will be the year for health-care reform. That has encouraged previous opponents of reform to stay at the table in hopes of influencing the final shape of legislation.

In another contrast to the failed effort during the Clinton administration, proponents of reform are outspending opponents in the ad wars surrounding the legislative debate. That, too, has helped the legislative process move forward.

Part of the administration's success in keeping everyone involved, however, has relied on deferring the hardest decisions. Now, as the legislation nears completion in House and Senate committees, there is no way to avoid making choices, and that has disrupted the earlier momentum.

House Democrats are now looking at a surcharge on the wealthiest Americans to generate $550 billion in revenue to help pay for what is expected to be a cost of more than $1 trillion over the next 10 years. In the Senate, there is resistance to another revenue source, taxing some of the employer-provided health insurance benefits. The shape and timing of a public plan remain unresolved. And Obama's budget director, Peter Orszag, warned House Democrats that their legislation must do more to rein in health-care costs, which the president has argued is the key to economic viability.

Three House panels that have been coordinating their efforts on health care are hoping to unveil their legislation this week, and House Democratic leaders hope to enact the measure before Congress breaks in August. In the Senate, the timetable has slipped considerably, in large part because the Finance Committee, the last outpost for any hope of a bipartisan accord, appears gridlocked.

Senators are resisting pressure to finish their work before the recess. But there are obvious risks of delay.

The August recess affords proponents of health-care reform an opportunity to explain and sell the package to their constituents. People are generally receptive to enactment of a major health-care package, according to the polls, but there is confusion and nervousness about what might be coming. Lawmakers need concrete proposals that can be explained in simple terms. They cannot take a set of principles home in August and hope to close the deal.

Worried Democrats also see another danger if the House and Senate have not passed bills before the recess. If there is legislation pending on the Senate floor, that bill could become a prime target for opponents to begin chipping away at seemingly onerous provisions. Opponents of the bill can put pressure on wavering legislators. Obama's army of volunteers, who will be asked to help counter any such opposition, will be fully tested.

What is needed now in the estimate of reform proponents is a big dose of presidential leadership. Administration officials said over the weekend that they expect Obama and other officials to be visible and active on health care this week, even though the major event on the agenda is the opening of the confirmation hearings for Judge Sonia Sotomayor, the president's nominee for the Supreme Court.

The absence of the ailing Sen. Edward M. Kennedy (D-Mass.), a consummate legislator and dealmaker, is being felt particularly in the Senate. Obama's energies and persuasive powers will be needed to help produce consensus in the Finance Committee -- and to corral rambunctious Democrats on both sides of the Hill.

No one expects Obama to declare in dictatorial terms what shape the legislation must take, but lawmakers are now looking for much clearer guidance from the White House on the tough issues remaining. As one nervous administration ally said, "The president's involvement and engagement almost exclusively on health care the next two weeks is essential."

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