Sampling The Sausage: A Health Reform Politics Explainer

1. Getting close to the deadlines -- which were always about concentrating the mind -- observe how health care is no longer a policy debate in Congress; it's now a debate about politics in Congress. Congress has been working on health care reform for 50 years. The Senate has been working on this specific set of reforms since before Obama was inaugurated; it's been the focus of Senate leaders since April. Paying for health reform was always going to be what the postmodernists like to call the site of contest. Getting to 60 in the Senate is now about protecting state industries and protecting fundraisers and protecting perceived electoral vulnerabilities. That's one reason why, behind the scenes, the White House is looking to make deals with Democratic senators. That's one reason why Democrats are thankful that the insurance industry, PhRMA and the AMA aren't spending money to oppose reform. Getting these allies on board may have complicated the process of writing a bill, but in the end, preventing these dogs from barking may be what gets the White House to 60.

2. Selling expensive health care reform that doesn't immediately benefit everyone, that threatens to disrupt the system (flawed as it is to many people) as Americans with insurance know it, that adds coverage for people who don't have it, that potentially saddles the government with more debt, that requires sacrifice from people who might not derive tangible benefits from it -- well, this is the stuff that one spends political capital on because it is the hardest type of lawmaking to do. It requires an extensive leap of moral imagination -- a moral argument that the system, as it is, may not be hurting you, but it is hurting your neighbor and will eventually hurt you if it's not fixed.

3. The biggest slap felt by the White House -- and the Democrats - was delivered yesterday by the model Mayo Clinic and Intermountain Healthcare specialists: the bills as written now do almost nothing to change the delivery system; they don't provide incentives for caregivers and hospitals to provide better care; they barely change the incentives to decrease the quantity of care. So the stated goal of reducing health care costs is belied by the very model-builders the White House has looked to. (One solution to this may be to allow states to set up health care payment/delivery commissions, like Massachusetts has done, and provide them with incentives to reduce the costs of care.) That said, I suspect that the health reform cognoscenti will look at the conference to add in the delivery reforms that will really change health care

4. As confusing as the political debate seems to be today, it actually revolves around just three inflection points: two are the historical tendency of Democrats to mess things up for themselves, and the just as habitual proclivity of the Republican Party to overplay their hands and give the Democrats something to unite against. Nothing concentrates the (independent) mind like liberal interest group infighting, as David Brooks touts this morning...nothing except Republicans forcefully becoming the "party of no" and openly, vocally, and aggressively working to kill reform for (what seems to be) political purposes. Remember: the Democrats are still much more trusted as a party to fix health care (in the generic sense) that Republicans are. The public buys in to the urgency of the problem, even as they're not officially sold on any solution. What's now known in liberal circles as the "DeMint/Kristol" strategy is an instinctual Republican strategy derived from the gut; it misreads the public's ambivalence about Obama and the health care debate as a sign that the public has soured on health care reform in general (nope) or Democratic principles in particular (not really). It may well have the perverse effect of generating sympathy among independents for Obama. Independents want to get health care done; they respect Obama for trying, even as they've begun to sour on his leadership skills.

5. The final inflection point is the most obvious: absent health care reform, Democrats will have nothing to run on in 2010. At the end of the day, even if they're not confident about Obama's popularity, vulnerable Democrats in the South and Midwest may conclude -- and if they don't conclude, then you can be sure that the White House will make them conclude -- that something is better than nothing, especially if the economy is slow to come around. 

NB: a point about reconciliation. In a conference call with liberal bloggers yesterday, Obama said he was open to the process if health care couldn't be done any other way. Let's be clear: Obama is barely open to the process. Reconciliation gets the White House an incomplete bill (or maybe, depending upon an independent arbiter of germaneness) no bill at all; it gives the industry and Republicans five years to fight its implementation; it will cost more money, in the end, and even if these hurdles are overcome, it will almost certainly take longer to implement than any bill that's passed with 60 votes. 60 votes, to the White House, means that the next Republican president won't run on a platform of undoing Obama-care. 60 votes means permanent reform: 50 votes mean a Pyhrric victory.