the big stuff

The Idiot’s Guide to Health-Care Reform

Obama, July 29, at a health-care town hall in North Carolina.

Members of the House of Representatives have started their August break. Tomorrow, senators will follow them out of Washington, and Congress won’t reconvene until after Labor Day. Where does health-care reform stand? Here’s our guide to the major players — their goals, strategies, and odds of success.

Who: President Barack Obama
What He Wants: Substantively, to dramatically expand coverage while reducing long-term costs. Politically, to deliver a national health plan, succeeding where all other presidents going back to Teddy Roosevelt have failed. That’s all.

What He’s Done: As a candidate in 2008, his basic goals were to expand access to care, without requiring everyone to buy insurance, and to make the health-care delivery system more efficient. As late as mid-June, he also seemed agnostic about public insurance options to compete with private plans. As president, however, Obama realized how strongly many Washington liberals are wedded to universal coverage and a public option. So he signed on for both — and let congressional committee chairs, most of them old-line libs, put together the first reform bills. Critics derided this as the same approach that loaded the stimulus package with pork. But the president is hoping that he has corralled his left flank.

What He’ll Do Next: Obama is already deploying his political organization to drum up grassroots support. He also wants to reframe the current debate to focus more on consumer issues, thereby appealing to insured Americans who worry they might get dropped, face gaps, or exhaust their coverage. And eventually, he will have to weigh in on whether there should be a public option and how to raise the $540 billion or so in revenues that reform will require over the next ten years.

What He’ll Get: Some kind of bill — but unless he has a breakthrough while Congress is away, it’s hard to know whether that bill will be worth signing. Obama’s entire reason for pursuing reform comprehensively is to change the way money flows through the system: If patients see doctors more consistently and doctors reduce wasteful spending and insurance companies have incentives to keep patients out of hospitals, rates could go down while overall health improves. That whole construct will be put at risk if Obama is forced to make serious reductions in up-front spending to get a bill passed. If subsidies are cut, Medicare is blocked from using research on the effectiveness of treatments, or employer mandates are relaxed, costs could keep zooming while millions stay uninsured.
Who: House and Senate Liberals
What They Want: The reforms now on the table in Congress. Current bills would extend coverage to nearly all Americans, requiring individuals (with hardship exemptions) to buy insurance and employers (above certain size and income levels) to provide it; expand Medicaid for the lowest-income households and provide subsidies for people substantially beyond the poverty line; require insurance companies to cover anyone, regardless of preexisting conditions; and create a public insurance option. They would also cost from $1 trillion to $1.2 trillion over the next ten years.

What They’ve Done: Liberal committee chairs assembled bills that passed two key House committees and the Senate Health, Education, Labor and Pensions Committee in mid-July, and then the House Energy and Commerce Committee last Friday. As a result, reform is headed to a floor vote in the House of Representatives for the first time ever.
What They’ll Do Next: Liberals don’t quite have a working majority in the House or a filibusterproof majority in the Senate. Which means their game is to wait and see what opponents want to whittle away, then pressure the Democratic leadership for givebacks.
What They’ll Get: They’ll take what Obama signs on for — and spend the next 30 years arguing about whether he gave up too much to get it.

Who: The Blue Dogs
What They Want: This group of about 50 House Democrats is dedicated to lowering federal deficits and creating greater health-care cost controls (though not necessarily reducing spending in their districts).
What They’ve Done: Seven sit on the Energy and Commerce Committee, where Democrats have a margin of thirteen votes. If the Blue Dogs had stayed united in opposition, they could’ve strangled reform in its crib. Instead, Chairman Henry Waxman conceded enough that four flipped, moving the bill through committee while delaying a floor vote in the House until after the recess.
What They’ll Do Next: Keep yapping. Blue Dogs love attention, and the media loves to oblige them.
What They’ll Get: Satisfaction. As a member of the House Democratic leadership, Rahm Emanuel recruited many Blue Dogs to run in traditionally Republican districts in 2006 and 2008, and won’t want House leaders to alienate them. The White House and the Blue Dogs would both like to squeeze more money out of reform — for example, by giving more power over setting Medicare reimbursement rules to an independent commission instead of Congress. The Blue Dogs have already won $100 billion off the cost of the House bill, and may get more. And they’ve gained a provision, which might grow stronger, allowing states to create health-care co-ops that would compete with private plans and a public option.

Who: The Senate Finance Committee
What They Want: Nobody knows.
What They’ve Done: Chairman Max Baucus (the Democrat from Montana) leads a committee full of Democrats who have advocated reform forever, including Jay Rockefeller (Democrat, West Virginia), Debbie Stabenow (Democrat, Michigan), and Ron Wyden (Democrat, Oregon). But Baucus has holed himself up with two other Dems, Jeff Bingaman (Democrat, New Mexico) and Kent Conrad (Democrat, North Dakota), and three Republicans — Chuck Grassley (Republican, Iowa), Olympia Snowe (Republican, Maine), and Mike Enzi (Republican, Wyoming), desperately seeking bi-partisan support.
What They’ll Do Next: After months of giving Baucus leeway, Majority Leader Harry Reid told the Finance Committee to report a bill by September 15 — but Enzi and Snowe rejected deadlines. So the working group will keep talking — word is, about a deal with no public option or employer mandate.
What They’ll Get: Without a public option, they’ll court a huge fight with most Senate Democrats. Obama and Reid will then decide whether to accept the group’s substitute (probably some version of health-care co-ops). Obama will have to keep the left onboard. Or the Democrats will have to go it alone in the full Senate, where Ben Nelson (Democrat, Nebraska) or Joe Lieberman (Independent, Connecticut) could derail their plans.
Who: Republicans
What They Want: Whatever Grassley, Snowe, and Enzi settle on, the rest of their party is following a brutal strategy: Tag reform as budget-busting socialized medicine, kill it, and hang its carcass around Obama’s neck.
What They’ve Done: Relentlessly, and fairly successfully, attacked Obamacare as too expensive — while blocking money-saving reforms. Leaders have bragged that stopping Obama on health care will, as Senator Jim DeMint said, “break him.” As Howard Fineman put it: “Their whole strategy … is to stand on the sidelines with their arms folded while the Democrats try to work this thing out.”
What They’ll Do Next: Fire up YouTube and laugh while watching right-wing agitators lambaste Democratic congressmen at town-hall meetings.
What They’ll Get: Perhaps a seriously buckled president. Obama’s not only juggling dozens of political and policy calculations, he’s fighting the undertow of the calendar. The recession may be decelerating, but the economy is still trending downward, dragging his approval rating with it. There’s rising popular anxiety about deficits and debt. And while there’s broad support for the idea of reform and various particular Democratic proposals, the administration hasn’t yet connected its plan to increased security for the middle class.
Right-wingers risk a backlash. But win or lose, they’ve fired up the base for the 2009 and 2010 elections — and at this point, the Republicans don’t know how to appeal to anyone else, anyway.

The Idiot’s Guide to Health-Care Reform