Health Care Rising

Obama’s end game for passing health care reform.

Barack Obama. Click image to expand.
Barack Obama

If Barack Obama has his way, health care reform will be completed by Easter. That’s fitting for a bill that was born on Christmas Eve, died, and that the president hopes will rise again. It’s also a story that, like the resurrection of Jesus, calls on its adherents to take a leap of faith into the unseen. In Obama’s case, he is selling the not-so-Biblical proposition that people will like health care reform that they don’t appear to like right now.

On Wednesday, the president is scheduled to make an afternoon statement about how to move forward with health care, but today he made his intention clear in a letter to Congressional leaders. He’s moving ahead. He’s not starting over as Republicans would like.

The president did outline several Republican ideas he would like to consider. These include a search for alternatives to resolve medical malpractice disputes, plus efforts to cut down on waste and fraud in federal health programs, to set Medicaid fees so as to keep good doctors in the system, and to rejigger the insurance system in a way that might allow for health care savings accounts.

Republican leaders weren’t buying any of it. Senate Republican leader Mitch McConnell called the president’s offerings an effort to “simply paper a few of these commonsense proposals over an unsalvageable bill.”

With these expected dance steps out of the way, Obama’s plan ends up back in the laps of Democrats in Congress. The first question that needs to be resolved is about timing and who goes first. The most likely scenario is that around mid-March, the House will vote on the Senate health care bill that passed by a supermajority in that chamber last Christmas. The president will sign that bill. Then, the House members will take up a second bill, full of fixes to the Senate bill they just passed. That bill will have to pass the Senate via reconciliation. (They’ll schedule the bill for just before the Easter recess, so that Republicans will eat into their vacation time if they delay with excessive amendments. Though reconciliation limits the number of hours of debate, it does not remove all opportunities for procedural mischief-making.)

The problem is that the House doesn’t want to go first. Its members worry about voting for the existing Senate bill, with its flaws, from their point of view, based on promises of future fixes the Senate might make in a second, reconciliation bill.

Nonetheless, White House Chief of Staff Rahm Emanuel has been pressuring Speaker Pelosi to go forward. But she is looking for some kind of assurance from the Senate that it will keep its promise. There has been a rumor going around about a letter that 50 Senate Democrats would sign and that would promise to do just that. But this won’t do the trick. The problem is not whether Democratic senators will act in good faith but whether they can. What if the Republicans propose so many amendments that the process gets out of hand and Senate Leader Harry Reid has to shut it down?

Or, as another senior House aide put it, what if a Republican senator comes up with an amendment that acts as a poison pill? Such an amendment would have to be so universally appealing—probably related to funds for Medicare—that no senator could vote against it. And yet by passing the amendment, the Senate would put in motion a policy that would have a catastrophic affect on the whole reform package.

Assuming the Democrats can solve their who-goes-first difficulty, the next question is whether they have the votes in the House of Representatives. The conversations I’ve had with people in the administration and on the Hill are all bullish. They talk about Pelosi’s talent for hitting the right number the way people used to talk about Barack Obama’s speaking prowess.

At a more practical level, faith in Pelosi is based on an assumption that the number of House members who previously voted yes for health care reform last year but who will now vote no (because they think the legislation does not sufficiently limit abortion rights) will be small enough to overcome. Democratic leaders hope to find new yes votes among the retiring Democrats who previously voted no and in the crop of members who voted no last time but who would have flipped to yes if Pelosi really needed them at the last minute.

Here are the main arguments the White House and Congressional leaders are making to win votes, in order from most high minded to most political: First, with this vote, you’ll be insuring 30 million people and giving people health security because they’ll know their coverage won’t be dropped. Second, once people see the benefits—closing the donut hole and holding on to their medical care—they’ll warm to the bill. Third, if you vote no, you’ll dispirit our base, which wants us to do something. Fourth, you already voted for health care last year—you can’t erase that political downside by voting no now. Fifth, you don’t want to hand your Democratic president a defeat on his signature domestic policy proposal. Or hand a win to Republicans who have obstructed us every inch of the way.

Of course, this endgame strategy all relies on the Senate using reconciliation, even though that’s a word White House aides and Democrats would like never to hear again. It’s a technical term, open to misinterpretation and hyperbole, and remote from the problems people face with health care every day. It’s an even more potent possible distraction than last summer’s debate over the public option.

For all of these reasons, Republicans would like to shout the word to each voter every morning. Along with repeating words like jam and ram to characterize the measure. With the public opposed to the legislation, such framing makes the president’s efforts to pass the bill not just wrong but sinister.

Right now, Democrats are fighting back by explaining that reconciliation is being used in a limited way (not for the whole bill). They also point out that Republicans have used it more than Democrats, so those who now oppose its use are disingenuous. They are also trying to erase the word from the conversation. “We’re talking about a process where we use a simple majority to pass the legislation. So without any fancy names, a simple majority,” said Nancy Pelosi.

The best course may be to do what the president did at his health care summit last week: ignore the reconciliation debate and when asked about it quickly return to saying that Americans will have less health care coverage and higher premiums if no legislation is passed. “When asked about reconciliation the response is Anthem,” said one senior House leadership aide citing the president’s favorite recent example of insurance company excess.

Of course, the country hasn’t bought those arguments over the last many months. White House officials and other Democratic strategists argue that popular support will follow once the legislation is passed and people see that the world didn’t end. It’s a lot to ask. If the president pulls it off, you might call it a miracle.

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