By Dan Balz
Washington Post Staff Writer
Sunday, March 21, 2010; A01
As the final round of the battle over health-care reform begins Sunday, President Obama and the Democrats are in reach of a historic legislative achievement that has eluded presidents dating back a century. The question is at what cost.
By almost any measure, enactment of comprehensive health-care legislation would rank as one of the most significant pieces of social welfare legislation in the country's history, a goal set as far back as the presidency of Theodore Roosevelt and pursued since by many other presidents. But unlike Social Security or Medicare, Obama's health-care bill would pass over the Republican Party's unanimous opposition.
Even Republicans agree on the magnitude of what Obama could pull off, while disagreeing on the substance of the legislation. Sen. Lamar Alexander (R-Tenn.) said: "Obviously, he will have achieved as president something nobody else has done. So in that sense, it's historic." But he added, "It doesn't end the health-care debate -- it just changes it. And if it does pass, it would be a historic mistake."
The lengthy and rancorous debate has inflicted considerable damage on the president and his party. It helped spark the grass-roots "tea party" movement and generated angry town hall meetings last summer that led to some opponents painting Obama as a socialist and a communist for advocating a greater government role in the health-care industry. The issue now is whether final passage of the legislation -- Senate leaders say they will take up the reconciliation bill this week -- will cause more harm or begin a turnaround in the Democrats' fortunes heading toward the November midterm elections.
This is not how the struggle over health care was supposed to unfold. When the president decided last year to push for comprehensive reform, there appeared to be the best opportunity in a generation to ensure that nearly all Americans have access to health insurance. There also seemed to be a consensus among business, labor and health-industry groups that government help was needed to rein in the escalating costs of health care.
A year later, Obama and Democratic congressional leaders are struggling to find the final votes in the House to push the bill through, against united Republican opposition and a country sharply polarized over whether and how health-care coverage should be extended to virtually all Americans. Liberals say the bill should have created a government alternative to private insurance; conservatives decry an increase in taxes and expensive new government programs.
The political stakes are enormous. Obama's approval ratings are below 50 percent in several recent polls, and more people disapprove of his handling of health care than approve. The outcome of the debate will stamp his presidency.
Democrats are afraid of failure and nervous about what success could bring. They fear substantial losses in November, with their majorities in the House and Senate possibly at risk if the country turns even more negative toward the administration and its policies. Republicans vow to continue challenging the program at the state and national levels.
Regardless of the political fallout, historians say health-care reform will take its place in the same category as the enactment of Social Security in 1935 and Medicare in 1965, and only a rung or two below passage of the major civil rights bills of the 1950s and 1960s. In addition to the bill's providing coverage for more than 32 million uninsured Americans, people would no longer be denied coverage because of preexisting conditions. The "doughnut hole" for Medicare prescriptions would eventually be eliminated, and young people could stay on their parents' insurance plan through age 26.
"I think this will be seen as a really major reform initiative," said presidential historian Robert Dallek. "How it plays out remains to be seen. But if Social Security and Medicare and civil rights are any preludes to this initiative, then I think it will become a fixed part of the national political/social/economic culture."
But there is a major difference between this health-care battle and the debates that preceded passage of Social Security and Medicare. Although there was opposition to those measures -- conservative opponents called Medicare socialized medicine -- in the end they passed with overwhelming, bipartisan majorities.
The House approved the Medicare bill on a vote of 313 to 115, including 65 Republicans -- nearly half the GOP caucus at the time. The Senate approved the measure by 68 to 21, including 13 of the 27 Republicans.
Social Security passed the House in 1935 by 372 to 77. On that vote, 77 Republicans joined the majority and 18 Republicans opposed it. In the Senate, the vote was 77 to 6, with five of 19 Republicans in opposition.
At the time, President Franklin D. Roosevelt's ambitions were even larger. Historian David Kennedy, a scholar of the New Deal era, said Roosevelt originally included universal health care as part of the Social Security legislation but pulled out those provisions before sending the bill to Capitol Hill.
"He thought it was such a significant political liability it could sink the whole bill," Kennedy said.
Today, Republicans and Democrats agree on the potential significance of what could happen over the next week in Washington. Where they disagree is on the question of whether it is necessary or wise to do it.
Former Democratic National Committee chairman Howard Dean has often been at odds with the White House over the health-care bill, but he said the current version is worthy of support as a significant first step toward real reform and because it could help Democrats politically. "Our team's got to win this one, and if they do I think they'll be rewarded. . . . A 'yes' vote hurts Democrats much less as a party than a 'no' vote," he said.
But former Republican House speaker Newt Gingrich said Obama and the Democrats will regret their decision to push for comprehensive reform. Calling the bill "the most radical social experiment . . . in modern times," Gingrich said: "They will have destroyed their party much as Lyndon Johnson shattered the Democratic Party for 40 years" with the enactment of civil rights legislation in the 1960s.
No one doubts that Johnson was right to push for those civil rights measures. And he was well aware of the potential damage they would do to a Democratic Party that was then a coalition including whites and African Americans, liberals from the North and conservative segregationists from the South.
Those battles over civil rights set off a political realignment that played out over decades and led eventually to a Republican domination of the South that continues to this day.
Still, the health-care battle has divided the country in ways that the Medicare debate of the 1960s did not. One reason is that partisanship and political polarization are measurably worse today. Another factor is that trust in government is far lower than in the 1960s. Finally, the political parties are far more homogenous, particularly the Republican Party, whose members decidedly identify themselves as conservative or very conservative.
Democrats are keenly aware of the risks ahead, which is why it has been so difficult for House Speaker Nancy Pelosi (D-Calif.) to round up the votes. Many Democrats, recalling the debacle after their failure on health care in 1994, think that another failure will be equally costly. Others say there will be a price to be paid no matter what happens.
"The political consequences of 1994 took a full decade for the D Party to undo and reverse," said William Galston, a senior fellow at the Brookings Institution and a domestic policy adviser in the Clinton White House. "If the political consequences of this effort turn out to be as long-lasting as 1994, that would be a very significant price that will have to be weighed in the historical balance."
But will Republicans regret their unanimous opposition? Historian Kennedy sees dangers for the GOP if a reformed health- care system turns out to be as popular as Social Security and Medicare.
"They confer real benefits on people that are palpable, and people believe in them," he said of those two programs. "What the political calculus is [among Republicans] that lets this come through a strictly Democratic proposal is a pretty high-stakes gamble."
Vin Weber, a former Republican House member from Minnesota, disagrees. He said this measure is different, not only because it has widened the ideological chasm in the country but also because the costs and benefits will fall unequally on different groups of people over the years.
"Medicare and Social Security immediately created a large group of beneficiaries who immediately understood what they were getting," he said. "That's not the case here."
Such differing interpretations guarantee that even if the bills pass, the fight over health care will continue long afterward. "The division we now have is not going to disappear," Dallek said. "It's going to be a continuing part of the national debate. This legislation is going to play out over the next four or five or six years."
Research director Lucy Shackelford contributed to this report.