America has been strong because, despite its flawed system, people built toward the future in the 1840s, and the 1930s, and the 1950s. During just the time when Frederick Law Olmsted designed Central Park, when Theodore Roosevelt set aside land for the National Parks, when Dwight Eisenhower created the Pentagon research agency that ultimately gave rise to the Internet, the American system seemed broken too. They worked within its flaws and limits, which made all the difference. That is the bravest and best choice for us now.Tonight is a night to celebrate a muddle-through breakthrough. One month ago, Barack Obama framed the struggle to pass comprehensive health care reform this way: "What’s being tested here is not just our ability to solve this one problem, but our ability to solve any problem."
The country passed this test because we have a leader who understands how broken our governmental machinery is and works simultaneously to fix our politics and our policies. We elected a President who appreciates how messy democracy is and understands the manifold constraints as well as the multiple levers of presidential power. His acknowledged errors notwithstanding, Barack Obama moved this mountain because he knows how to prioritize, strategize, execute and communicate.
Prioritize: Obama, as he reminds us perhaps not often enough, came into office as the world was teetering on the edge of a second Great Depression. The full extent of economic freefall came into focus during the transition period. As enormous budget deficits rose on the horizon and plans for a massive stimulus took place, many wondered whether the incoming President would have to postpone or curtail the domestic agenda he campaigned on - with health care reform as Exhibit A. In a press conference on Dec. 11, 2008, Obama answered: no.
Year after year, our leaders offer up detailed health care plans with great fanfare and promise only to see them fail, derailed by Washington politics and influence peddling. This simply cannot continue. The runaway cost of health care is punishing families and businesses across our country. We’re on an unsustainable course and it has to change. The time has come this year in this new administration to modernize our health care system for the 21st century, to reduce costs for families and businesses, and to finally provide affordable, accessible health care for every single American.
Now, some may ask how at this moment of economic challenge we can afford to invest in reforming our health care system. And I ask a different question. I ask how can we afford not to. Right now, small businesses across America are laying off or shutting their doors for good because of rising health care costs. Some of the largest corporations in America, including major American car makers are struggling to compete with foreign companies unburdened by these costs. Instead of investing in research and development, instead of expanding and creating new jobs, our companies are pouring more and more money into a health care system that is failing too many families.
From then until now, Obama maintained HCR as a priority because, as he emphasized at various points, a) the current system imposes unacceptable suffering on millions of Americans; b) health insurance insecurity is the single most debilitating element in the erosion of middle class prosperity and security over the past generation; and c) health care reform is entitlement reform, insofar as unchecked medical inflation is on course to bankrupt the Federal government. Politically, too, Obama must have recognized health care reform as a likely Waterloo -- for the Republicans.
Strategize: First thing we do, the Obama Administration seems to have determined, is neutralize the interest groups, as Ezra Klein notes:
The costs of some of that buy-in were high. The deal with Pharma has been widely criticized -- not only for getting only weak cost concessions, but for enabling overgenerous patent protections for biotech drugs. To Glenn Greenwald, Obama is a "corporatist" Democrat, willing to accommodate the interests of big business in exchange for relatively mild ameliorations of economic hardship for ordinary people. And the charge is true, to the extent that Obama is not planning to abolish capitalism, or even an industry, such as health insurance, that in its current form adds very questionable value to our economy.
This year, the Obama administration succeeded at neutralizing every single industry. Pharma supports the bill. Insurers are incoherent on it, but there's not a ferocious and united campaign to kill the proposal. The American Medical Association has endorsed the Senate bill. The hospitals have endorsed the bill. Labor has endorsed the bill. The business community is split, with larger employers holding their fire.
Obama, as Andrew Sullivan is fond of pointing out, is a conservative in the sense that he seeks to reform or revitalize existing institutions when possible, rather than tear them down and create new ones. At the same time, he is what I have called a radical incrementalist, intent on moving the ship of state a few degrees in the right direction, defining his initial goals as setting a new course on several fronts, and content to build on first steps over time.* The likely impact of the HCR bill on health insurers is unclear; when the Senate bill passed, their stock went up; they get new customers and suffer new constraints and new taxes. Over the long haul, however, more uniform rules on coverage and health exchanges that sort plans into defined categories should set insurers on course to become more like the utilities they are in France and Germany, following coverage rules set by the government and ultimately -- I hope personally -- charging fees set by the government.
A public option or Medicare buy-in would accelerate that evolution. And when Obama promised progressive House members this past week that he would work for a public option next year, he was not blowing smoke. He was not willing to go to the mat for the public option this year because insisting on it would have put passage of the bill at risk. But he recognizes as well as anyone its potential for controlling costs.
Another key strategic element for Obama-- as a matter of policy rather than politics -- was emphasizing cost control at the expense of more generous coverage expansion. That decision reflects I think a fundamental calculation that only effective cost control will enable lasting coverage expansion -- and more broadly, only evident progress in deficit reduction will enable a domestic agenda that includes new government initiatives. Perhaps a failed related strategic calculation was that an emphasis on deficit reduction would win some Republican buy-in. The cost control measures that have won the approbation of a broad range of health care experts were largely the work of the Senate Finance Committee's Gang of Six.
Finally, Obama's strategic masterstroke was the response to the crushing setback represented by the Massachusetts Senate election on Jan. 19, which erased the Senate Democrats' fillibuster-proof majority and so cut off the seemingly essential step of merging the bills passed by the House and Senate. Pelosi deserves major credit for the successful salvage operation -- she never wavered in her determination and public commitment to passing comprehensive health care reform by hook or crook. But the enabling strategy was Obama's work.
After leaving the Democratic caucus in agony for a week in the wake of Massachusetts, Obama set a course that was a combination of conceptual clarity and inspired improvisation. The procedural path to comprehensive reform was clear to all supporters: the House would pass the Senate bill along with a series of fixes, representing the points it had gained in the interrupted bill-merger negotiations, that would be passed as a budget reconciliation bill, requiring only a simple majority in the Senate. What Obama added was the impulse to pause and regroup -- that is, to re-present the basic architecture of the Democratic bills to the American people and re-engage publicly with the Republicans, exposing the basic bankruptcy of their ideas, and creating political cover for a new push. This plan that was already visible in faint outline in Obama's Jan. 20 interview with George Stephanopoulos. The inspired improvisation, I believe, grew out of the happy accident of Obama's 90-minute confrontation with the Republican House caucus, where he so successfully highlighted the bill's centrist pedigree and the fact that Republican plans would not reduce the ranks of the uninsured. That very public "debate" victory may have crystallized the idea of a bipartisan health care summit, conceived and pretty successfully executed as a replay. Roughly halfway between the two events public opinion started to move back in the bill's favor.
The plan also reproduced a recognizable pattern in Obama's approach to setbacks - pause, regroup, rethink, collect new input, amend and re-present plans, and set a deadline.
Execute and communicate: The flip side of Obama's perhaps naive belief that he can win Republicans over is his ability to show them up. Americans are confused about the plan, but they are not confused about the man. By large margins they trust Obama more than they do the Republicans to produce rational solutions to the country's problems. In the past month, he exploited his mastery of policy detail, his pragmatism, his focus on effectively alleviating the suffering he spotlighted, and his willingness to stake his political future on getting this bill passed to the utmost. The full eloquence and passion of the campaign came back to his lips in forum after forum and speech after speech. To Democratic legislators, his message was that this bill epitomized why they had sought public office and why they were Democrats; it was the raison d'etre for their careers; in effect, passing it was worth their careers (and would make or break his own). In the bipartisan summit, he framed a core contrast: the Democrats would rein in the health insurers' worst practices; the Republicans would further enable them by weakening existing regulations. In rallies, he emphasized human suffering caused by leaving people uninsured and underinsured and enumerated the bill's benefits for ordinary people. As noted before, too, he presented the effort as a litmus test as to whether the Federal government was capable of taking meaningful action to solve national problems. He moved the needle of public opinion enough to move enough House Democrats to "yes."
The process may have been frustrating, and long, and ugly, as Obama told the crowd at George Mason on Friday. But it was also glorious. Obama has been telling crowds since 2007 that change wasn't going to be easy, but that it was possible with focus and persistence and courage. He just proved it.
* Update: As the President said tonight, after the bill passed: "This isn't radical reform... it is major reform. It doesn't fix everything that ails us but it moves decisively in right direction. This is what change looks like."