From Nearly Dead To Nearly Done: How The White House Refocused On Health Care To Finish It Off

Since no president has been able to get this close to passing anything in the last 50 years I would say it is an insane to consider the President a slacker. He was the single most productive president in his first year ever. Think of health care like graduating from college. It doesn't matter 3 years later whether it took you 4 years or 5 and 1/2. You have the degree and no one asks, did you make it through in 4 years? Once we pass it we win. And we'll win in November as well, which people discovered over xmas break.

J

I think it's more a matter of trying to apply the lessons of 1994.

The original Clinton plan WAS a good plan. While people nowadays take the lazy route in proclaiming it wasn't clear, it wasn't this, it wasn't that -- I had the good fortune of being in a public policy course at the time it was being debated, and we did spend a fair bit of time on it.

Why did it fail?

Well... a whole lot of congress -- including would-be progressives - threw a hissy fit because the WH was dictating policy. There were some wankers -- Jim Cooper for one -- who were strictly ***holes for purposes of their own glorification. There were puzzlers -- I still don't think I quite understand why Moynihan, whom I generally respected -- became a twit. There were leadership failures - George Mitchell fired the final salvo in killing it... and, well... the plan took on PhRMA, the AMA, and AHIP.

So what did the Obama administration do?

Well -

#1 They tried to avoid strong-arming congress. This ain't the 60s anymore (and frankly, a lot of the 'LBJ would have...' is based more in fanciful mythology than fact.. .remind me again how many dixiecrats LBJ arm-twisted into voting for, or even, not filibustering the CRA?) - so they tried to play to the new reality. They provided broad sketches and outlines, tried to assist in negotiations, but ultimately -- let congress do what congress is constitutionally SUPPOSED to do. I'm not claiming the early effort was perfect... 'round about September, they should have pulled Harry and Max into a room and said "Look... A for effort, but it's pretty clear this isn't working. Just ram it out of committee and let's get it on the floor. We've got the votes, just do it."

#2 They employed a divide and conquer strategy - they didn't go after the providers (though grand reform is going to require that in the long-term) in order to keep the AMA on board. They cut deals with big PhRMA -- even getting a few concessions, but largely just promising not to upset the status quo too much. They decided this round would be a matter of going after AHIP.... and obviously, based on the astro-turfing teabaggers and the way their supposed progressive allies spent most of the summer and fall more interested in attacking the White House and Congressional Dems than playing a little vanguard defense against the death panelers - AHIP was plenty.

Where did they come up short?

They should have let Obama be Obama. They guy is a wonk, so let him wonk. Put him in front of hostile audiences -- conservative and progressive -- and let walk through the actual issues and facts. He clearly knows them, and he's clearly at his best when he's left to talk about them rather than trying to issue simple sound bytes, so let him do that.

I have EVERY expectation it won't happen during his term (or hopefully) termS. They've become villains, and that's fine.

20 years from now, though... if they do get a bill passed, and even if it's in the form of the Senate bill -- mark my words. The honest history will be that this was really a pretty damn extraordinary thing.

How many post have you made demanding the bills provide generous support for comparative effectiveness research. How many posts on the need to revamp the medicare payment rules to encourage quality of care over quantity of care? I waiting for your essay extolling the virtues of experimenting with other delivery system reforms like encouraging medical homes, and accountable care organizations. I can't wait.

Since when did you have anything to say about health care?

Dumb idiots. Without a public option voters are going to look at those mandates and think their politicians sold them directly to the insurance monopolies. Staved off massive losses? More like guaranteed them.

I don't think the insurance companies were all that worried about the very limited public option offered by the House bill.

The public option appearing in actual legislation is more symbolic than people realize--still important as a first step, but not robust enough on the outset to be the alpha and the omega of reform that people think.

If the Senate does accomplish the passage of a public option, most of you who desperately want it will be loudly disappointed at how restricted it is, and you won't have sense enough to look down the field and see how it paves the way for improvements in the future.

This is not the last piece of healthcare legislation this nation will ever see. It's big, though, and we need it.

Joe Biden has no legislative depth? And for what it's worth, Obama has been in the legislature for over a decade, which is a lot more than any of the 7 or 8 presidents before him.

The big question is why couldn't we pass Medicare for everyone.

Yes, it's simple to understand and technically it's just an expansion of a large program we already have.

The problem is that this kind of legislation would put most insurance companies out of business altogether, and Americans are leary of destroying an industry with a government program.

Now, if you ask me, healthcare shouldn't be insured, just paid for. Health insurance just exists to suck money away from paying for actual healthcare.

But no matter how much you demonize health insurance companies (and no matter how much they help by being incredible jerks), Americans don't want to use the government to put private companies out of business.

This is not just a question of corruption (insurers giving big money to whoever is in power), but also of market ideology. And somehow, we don't seem to have developed a sense that some things are better and more efficiently done by the government. We really don't have the language or the culture for making that case, though evidence of it is all around us.

So I think we should work on that rather than putting all our energy into convincing people that the only reason decisions are made is because people are being paid off. There is an ideological question at stake here, too.