Obama's Health-Care Realism
His Flexible Tactics Match Reform to Political Reality
The conventional wisdom is that President Obama and Democratic congressional leaders are on the run, that we seem to be heading for a replay of 1994, when the Clinton health-care plan went down in flames. The conventional wisdom includes the refrain that the White House is too weak, too slow, too naive, and, in the words of respected health policy analyst Susan Dentzer, "they're panicked."
But having watched the lawmaking process in all its glory (and messiness) for 40 years, as well as having watched the meltdown of the Clinton health plan up close, I am seeing from the administration signs of savvy, not weakness. While health reform is far from a done deal -- and could still be derailed by the lack of a vote to replace that of Sen. Ted Kennedy, an economic double dip or an international crisis -- the issue is actually on a fairly predictable path that fits both the realities of public opinion and politics in an age of sharp partisan and ideological conflict.
The Obama strategy since his election has been based on a gimlet-eyed and pragmatic assessment of the prospects and limits afforded by public opinion and the political process. A naive president would have assumed that, after a landslide victory, huge coattails, swollen partisan majorities and a high approval rating, he could have it all -- and pushed hard and early for a far-reaching, soup-to-nuts upheaval of the health-care system. Obama and his strategists understood that would not work.
On the public front, it was clear that there was no groundswell for broad change. There is public dissatisfaction with the health-care system, but it is framed most by the universal public definition of reform -- "I pay less." Without some guarantee that reform thus defined will be enacted for the vast majority of Americans, the likelihood has always been that the closer government gets to enacting change, the more nervous voters would get about embracing the devil they don't know. And the closer one gets to broad change affecting 16 percent of the economy and a hefty slice of the workforce, the more those whose incomes depend on the current system will fight to keep their share.
At the same time, enacting reform the way it should be done -- with broad bipartisan leadership support and broad bipartisan majorities -- was simply not in the cards in today's political universe. Bipartisan support was clearly a non-starter in the House, if less so in the Senate, but past experience also showed that finding partisan majorities, even with healthy margins in both houses, would not be easy. Bill Clinton had almost identical Democratic support in the House and Senate, but he could not find a formula to keep his partisans together. Trouble with Blue Dog Democrats in 1994 nearly derailed health reform in the House and slowed it enough to prove disastrous in the Senate. Ideological, regional and urban/rural splits always make uniting Democrats a challenge. In 2009, unlike in 1994, every issue has a filibuster line drawn in the sand, making the hurdle 60 votes more often than 50.
How to prevail under these difficult circumstances? The only realistic way was to avoid a bill of particulars, to stay flexible, and to rely on congressional party and committee leaders in both houses to find the sweet spots to get bills through individual House and Senate obstacle courses. Under these circumstances, the best intervention from the White House is to help break impasses when they arise and, toward the end, the presidential bully pulpit and the president's political capital can help to seal the deal.
No health reform bill can be enacted unless the House and Senate each pass a version, and that has been the single-minded goal of the White House. If the Senate has to resort to reconciliation, it can only work if more than 50 Democrats are convinced that it is the last resort -- that every effort was made to compromise to include significant Republican support. Thus, the White House signal on the public option. Once both houses pass versions, no matter how disparate, a conference committee can find a way to meld the bills -- no doubt with heavy White House input -- into one plan that goes back to each house for up or down votes. There, the pressure on lawmakers to support health reform will be much greater, as will the ability to break filibusters by urging all Democrats, even if they can't support a bill, to vote for cloture as a procedural issue.
The odds remain reasonable that a solid, if not dramatic, health reform bill can make it through this process and become law. Any bill, under these conditions, will be a major accomplishment. The odds have been improved, not damaged, by the president's approach.
The writer is a resident scholar at the American Enterprise Institute.