After a tumultuous few weeks, the latest news in health reform is still worth savoring. On Friday, the House Energy and Commerce Committee voted out a comprehensive reform bill that would, if enacted, bring insurance coverage to nearly every American while making moderate, but important, progress towards controlling the rising cost of care. This means that all three of the House committees with jurisdiction over health reform have now passed nearly identical pieces of legislation, a remarkable feat in its own right. More important, it also means reform has managed to get out of committee with significant support beyond the Democrats' liberal base, since it took a deal with Blue Dog Democrats to secure passage.
Given that reform legislation has also passed one Senate committee--and, perhaps more important, given that Democrats control the presidency as well as Congress--it seems unlikely that the year will close without some sort of health care legislation on President Obama's desk. The White House wants a win and will, I tend to think, get it. But what kind of win will it be? There is a yawning gap between legislation and legislation that is good. And the prospects for getting something approaching good legislation remain shaky.
The trouble is the Senate, where the last committee to consider reform, the Finance Committee, remains exactly where it has been since early summer: Stuck. The committee remains divided over several issues, chief among them how to come up with the approximately $1 trillion (or more) it will take to pay for coverage expansions in the first ten years. And while some of the problem seems peculiar to the makeup of that committee--and the determination of its chairman, Max Baucus, to include Republicans who are highly suspicious of the whole enterprise--the same problem exists in the overall makeup of the Senate, where not even all Democrats are yet on board with the kind of effort the party leadership in mind.
On Sunday, Ceci Connolly of the Washington Post reported that administration officials have changed their rhetoric--and that some now talk, quietly, of putting the country on a "glide path" to universal coverage rather than achieving it in the next few years. This is an important development although not an unexpected one. The White House and its allies plan for all contingencies. There has always been a "Plan B" in case the support for full coverage, along with comprehensive reform, wasn't there. And there have always been key players--both in the White House and Congress--who have thought maybe "Plan B" should be "Plan A." After a rough few weeks, when the president's poll ratings began to slip and the opponents of reform managed to gum up the works in Congress, such an outcome seems increasingly likely.
We have a pretty good idea of what that would mean, in terms of policy. Leaks out of the Finance Committee suggest that, absent support for a program with all of the funding and regulation reform needs, legislation would be far from ideal. It'd mean less financial assistance both for people who don't have insurance and those who now struggle to pay for it. It'd mean less financial protection for people who get sick. It'd mean less choice for people who want a range of options, including a public insurance plan, from which to choose. (For more details, the Center on Budget and Policy Priorities has a full analysis.)
Working- and middle-class people, many of them now struggling to pay for insurance or at risk of financial catastrophe in case of illness, would be the ones to receive less in a watered down reform. This makes for both bad policy and bad politics, in no small part because the two are closely related. A reform that the middle class perceives as offering few benefits at substantial cost would be a prime candidate for rollback in coming years.
And that's really a best-case scenario, assuming the political situation doesn't deteriorate over the next month. The reason Obama, among others, once sought full votes on reform before the August recess was a fear that the coming weeks would be--to borrow GOP Senator Jim DeMint's phrase--reform's Waterloo. The opponents of health reform seemed disorganized and lost for most of this year, but now they have actual legislation to target--and they have found their footing.
They have a set of arguments that, while not particularly honest or (from where I sit) convincing, make for good sound bites. They are also starting to get organized. Americans for Prosperity, the conservative interest group, recently had tea party protesters show up at a town hall meeting being held by the staff of Missouri Senator Claire McCaskill. Groups like this plan to spend August doing the same thing, dozens of times over, while they simultaneously flood the airwaves with ads picking apart reform legislation, bit by bit.
A lot of this will be classic astroturf organizing, in some cases bankrolled by the health care industry. But these outbursts will be effective all the same. A big reason getting health legislation through the House was harder than expected was the experience freshmen and moderate Democrats had in early July, after voting for a cap-and-trade bill. When they returned to their districts, all they heard was complaints--in many cases, angry complaints.
Now the right has a chance to channel that anger before a final vote is cast. And so the question going forward is, will the left answer it?
Lately, there's been a lot of Monday Morning Quarterbacking of how the Democratic Party leadership, and Obama in particular, have handled the reform debate. As the new conventional wisdom goes, the president got too wonky and gave Congress too much leeway. For the record, I agree with most of that. (In fact, I think I wrote something to that effect once or twice in the last few weeks myself.) And I was pleased to see the White House shift its messaging just in the last few days, to focus more on the tangible benefits--the "goodies"--that reform would offer every American. (More on those shortly.)
But let's not kid ourselves about why health reform has suddenly hit a rough patch. This was always going to be difficult. No strategic genius can overcome the fact that our political system is hostile to change, particularly liberal change, given both the power of money in politics and the small-state, conservative weighting of the Senate. Passing reform was never going to be possible without a groundswell of support--a bigger groundswell than we've seen so far.
True, groups on the left are better organized--far better organized--than they were last time around, when President Bill Clinton tried to pass reform and found himself fighting that battle almost alone. Labor unions and groups like Health Care for America Now have both money and a plan for getting out their own message. The old Obama campaign machine, now called Organizing for America, is also kicking into gear. This will be its first (and, if unsuccessful, perhaps its last) test as an apparatus that can pass legislation as well as elect a president.
What's not clear is whether these organizations will send the right message. Right now, the energy on the left is all about securing support for a public insurance option. I'm a strong supporter of a public option, but, as I've written before, it's not the sine que non of reform that many of my fellow liberals think it is. If the left makes August all about the public option, I fear they will lose the fight over everything else.
I don't pretend to be 100 percent certain about that judgment; I know a lot more about policy than strategy. (That's why I will spend most of my time for the next few weeks focusing on the former.) But I also know I'm not the only one on the left who worries about this--or who worries that, more generally, the left just isn't up for this fight, whether because they're ambivalent about the measures moving through Congress or just ambivalent period. As one liberal operative in Washington asked me recently, "Do they understand what is at stake? ... Do they get that recess isn't about improving the Senate Finance bill but about getting a bill at all?"
August is where reform will be won or lost. And while the critics have certain momentum right now, the supporters have one big tactical advantage. Now the debate moves out of Washington and away from Congress. It's a chance for reform's supporters, from the president right down to neighborhood grassroots organizers, to return the focus to where it should be--to real people, the insecurity they face now, and the ways reform could change that. If they can do that--and I remain confident they can--then Friday's victory in the House will be a taste of things to come.
By Jonathan Cohn:
Reprinted with permission from The New Republic