Something amazing may be about to happen in Congress: Republicans and Democrats coming together to pass legislation that will fix a longstanding problem. Does this herald a new age of bipartisan cooperation?

No, it doesn’t. But it is the exception that illuminates the rule. By examining why it’s possible for the parties to work together on this one issue, we can get a clearer understanding of why it’s so rare in the current environment. Sahil Kapur of Talking Points Memo has the details:

The House’s top two leaders are on the verge of securing a sweeping deal to permanently fix a gaping hole in Medicare that has haunted Congress for more than a decade while also securing significant long-term savings in the program.
And shockingly, it has broad support among Democrats and Republicans, including even some hardline conservatives who have spent years thwarting bipartisan agreements.
House Speaker John Boehner (R-OH) and Minority Leader Nancy Pelosi (D-CA) are aiming to finalize the deal this week and put it to a vote next week, leadership sources said. There’s always a possibility of it imploding, but if the plan passes and is signed into law, it would be the most important piece of health care legislation since Obamacare, and a huge achievement for a Congress that has so far been marked by unusual dysfunction.
The deal would end the perennial Medicare “doc fix” problem by replacing the widely-maligned formula for reimbursing physicians, which currently imposes steep annual cuts that Congress has regularly overridden since 2002. It’s a huge headache for lawmakers as powerful health industry groups have been clamoring for a permanent fix for years. The cost of repealing the existing “Sustainable Growth Rate” payment formula is $170 billion over a decade.
The plan would also extend for two years the Children’s Health Care Program, which helps insure families with children, and runs out of funding on October 1, lawmakers and aides said.

Just to clarify, the Sustainable Growth Rate sets the level of Medicare reimbursements; without the doc fix, doctors would see the amount they get paid for treating Medicare patients slashed. But because the fixes have always been temporary — not changing the SGR itself but only addressing it for a year at a time — Congress has had to come back and pass doc fixes over and over, every time finding some way to pay for it. It’s a ritual nobody likes, because they’re under pressure from doctors in their districts, it requires finding spending cuts or tax increases elsewhere, and it doesn’t get you a whole lot of credit with the voters. What Congress is contemplating now is essentially ripping off the bandage all at once and making the fix permanent.

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This is indeed a big deal, an important piece of legislation of the kind we thought Congress incapable of achieving (and let’s not forget that nothing has actually been accomplished yet). So why can they do it now?

Let’s compare it with other recent occasions when Republicans and Democrats ended up voting together. Multiple times in the past few years, Boehner has set up a confrontation with Democrats and the White House, promised his caucus victory, watched as the crisis developed and Republicans got the blame, and eventually came to Pelosi begging for the votes of her caucus to end things, which she granted. But this time, he started by negotiating with her.

Needless to say, some conservatives aren’t pleased about that. “[Boehner] didn’t come to us and say, ‘How do we fix the ‘doc fix’ working with Mitch McConnell?’ He went to Nancy Pelosi,” said Rep. Tim Huelskamp (R-Kan). That, however, isn’t a substantive objection, and the grumbling seems almost pro forma. To understand why plenty of Republicans will go along, you have to ask: What do they have to lose, and what do they have to gain?

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The answer to the first question is, not much. The doc fix is a wonk’s issue, not one that stirs partisan passions, so Republicans aren’t really risking the ire of their base by solving the problem. There are unlikely to be fiery denunciations from right-wing radio hosts over it, and no tea partyer is going to mount a primary challenge to a sitting member of Congress because he supported this deal.

And there are a few things to gain. The first is substantive: Republicans find the status quo as absurd as Democrats do, and no one likes having to come back year after year to pass temporary fixes. Second, Republicans would like to have something they can point to and say, see, we can govern responsibly and solve problems; this is as good a candidate as any. Third, it will get the doctors in their districts off their backs; that may be a small constituency, but it’s a vocal and wealthy one. Fourth, paying for it by making high-income seniors pay higher premiums is something Republicans find appealing.

That may sound strange, since Republicans are supposed to be the guardians of the interests of the wealthy. But when it comes to a social program, the calculus changes. Many conservatives have supported greater means-testing for Social Security and Medicare in the past, and the best explanation for why is that universal government programs are a little unsettling to small-government conservatives. Benefits equally shared by all, which join rich, poor, and middle class in a common set of interests, make for bulletproof programs. On the other hand, if you make different groups pay different amounts — and you have those with the most political influence (the wealthy) paying more, that can reduce their affection for the program in ways that make future change possible. When you then propose something like a partial privatization of Medicare, wealthier recipients may say, “Well, I’m already paying more than I’d like to for this benefit, so I guess that’s OK with me.”

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That’s a long-term and hypothetical connection, of course. But it explains why means-testing a program such as Medicare is something Republicans often advocate and why Democrats have traditionally been against it: They want to maintain universal support for the program by making the benefits as universal and equal as possible.

But it looks as though Democrats are willing to accept some higher premiums for wealthier recipients, if it means they get a permanent doc fix and an extension of the Children’s Health Insurance Program as part of the bargain, something they very much want.

So in sum, this deal looks like one in which both sides gain something they want, and neither side loses very much. That’s true not just on the collective level, but for each individual member as well. And this is a key point, because there are plenty of occasions in which the group can’t do what seems like the rational thing, because on an individual basis it’s actually irrational. The Republican Party would like to pass comprehensive immigration reform to appeal to Latino voters, but such reform is deeply unpopular in the districts of most Republicans in the House, so it goes nowhere. Causing a crisis over something such as the debt ceiling makes the party look bad, but those individual members need to show they’re standing up to President Obama to avoid primary challenges. And so on.

If you want to understand what political actors are going to do and why, look at the incentives they confront. The doc fix is a rare case where the incentives for Republicans and Democrats run in the same direction, one that may actually lead to solving the problem. If this deal actually happens, we should savor it, because we won’t see many more like it for some time.

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