President Obama's kid glove theory of legislating on Health Care reform was too soft a touch for senior members of Congress who were tasked with writing health care legislation.
But last month, conflicts between Senate committees and between the Senate and the House reached a point where the lack of guidance from the White House about details was producing significant confusion about what Mr. Obama really wanted -- aside from the vague generalities about access to quality, affordable health care that he has stuck do since becoming president.
The White House was urged to be more specific on the following questions:
1. What role should states play in the health insurance exchanges? How much authority would individual states possess to regulate plans that were offered within their states?
2. Should there be a "public plan," and should it be "robust" -- the adjective used to describe a plan that could supplant private health insurance plans, or merely "competitive" -- revenue neutral and not receive any special attention or funding from the government?
3. Would Mr. Obama be willing to accept new taxes on health benefits?
4. Would he support proposals to give non-partisan, non-profit expert committees actual authority to streamline Medicare and Medicaid (absent a Congress veto)?
5. How much out of pocket money should individuals be expected to pay?
6. Did the White House want an expedited timetable? Was it content with the speed of legislative efforts?
Deciding whether to answer these questions put the White House in a little bit of a bind. Legislative director Phil Schilliro has made it his mission not to give Congress any rational reason to fight the administration on anything related to health care.
The more specifics Mr. Obama provided, the more fights there would be. From the start of the health care debate, Mr. Obama did not want the White House to be an obstacle.
Even his endorsement of the particulars was vague. The White House has not, in private, even, argued for a "robust" public insurance option. That's partly because there is no consensus among Obama advisers about the wisdom of a plan that would significantly increase government health care expenditures above and beyond the $1.2 trillion or so Mr. Obama expects to spend over the next ten years.
White House chief of staff Rahm Emanuel has floated the idea of a public plan that would be weak for a while -- perhaps five years -- and give the insurance industry the chance to cut costs, improve the quality of care and increase access (there would be metrics). And then, if the private sector failed, the public plan would suddenly be placed before the American people as an alternative to their current plan -- and it would be heavily subsidized, would cost less, and would cover more things.
Sen. Olympia Snowe (R-Maine), who often speaks with Emanuel, has proposed a hover-craft like plan in Congress.
The White House proposed to pay for universal health insurance by limiting charitable deductions for those in the top two tax brackets.
That proposal was DOA.
Senate Democrats, backed by the health care policy community, believe that the easiest and less intrusive way to pay for approximately half of the cost of reform over ten years would be to end the tax exemption for employer-provided health care benefits. Mr. Obama campaigned against this idea when Sen. John McCain (R-Ariz.) proposed it during the campaign, but he is not prepared to stand in the way of Congress.
How much would be taxed? Who would be taxed? This is a debate the White House will leave to Congress, too, although White House health care advisers clearly have some ideas and are sharing them privately.
For now, it's sufficient for members of Congress to know that Mr. Obama won't veto a bill that includes new taxes.
The Public And Doctors
The White House plans to stick to what it does best: using the bully pulpit of the presidency to convey urgency and to engage the stakeholders. That's been the strategy from day one, and we saw it amped up yesterday with the president's trip to Wisconsin, and will see it next Monday, with his speech to the skeptical docs at the American Medical Association conference.
The AMA's opposition to a public plan notwithstanding, the Obama administration believes that it's important, politically, to appear to be engaging the doctors in a way that the Clinton administration failed to do. The AMA's political and cultural biases aside, they worry that if the public perceives that doctors, as a community, oppose whatever plan emerges from the various Congressional actors, final status negotiations, to borrow a phrase from Middle East diplomacy, will be hard to achieve.
On the other hand, getting docs to buy into the idea of reform -- and making sure that the public is made aware of this buy-in -- gives the Democrats some maneuvering room.
On Monday, a White House official said, Mr. Obama will "offer the doctors a seat at the table. Whether they sit there is up to them. But everyone will know that they've gotten the offer."
By Marc Ambinder