Who Won the Health Care Summit

An absorbing discussion. Surprising too. Before I say more, I'll remind you of my biases. I'm in favour of comprehensive healthcare reform. I'm aware of the substantive flaws in the Democrats' bills, and the political risks; even so I wish the House would pass the unrevised Senate bill. Failing that, I think the Senate bill plus revisions through reconciliation, as trailed in Obama's merged proposal, would be much better than nothing.

Nobody expected breakthroughs at the summit and none happened. If it mattered at all, which is debatable, the meeting was about political momentum and the mood of the Democratic party's wavering centrists. Measured that way, it was a good day for Republicans.

In a difficult role, Obama did well. But the Republicans (not counting John Boehner) did well too--much better than I would have guessed. They came across as serious and respectful. With only a couple of exceptions, the congressional Democrats were bad. They got off to a poor start with weary pro forma statements by Nancy Pelosi and Harry Reid, and never really recovered. Mostly, they made the case for reform in general--heavy as always on the personal stories--rather than for their bills in particular.

The trap the Democrats had hoped to spring was to say to Republicans, "Here is our plan. Where is yours? Why aren't you bringing anything to the table?" With the opposition exposed as a nullity, reconciliation would look more respectable. It didn't work. The Republicans outmaneuvered the Democrats, not the other way round. They mostly let spokesmen with relevant experience and expertise carry the burden, and they stuck to a simple script that said, "Let's do this step by step, starting with things we agree on, instead of trying to do everything at once, which we can't afford."

Substantively, that is a weak argument, in my view, for familiar reasons. Successful healthcare reform has to be a big package: crucially, for instance, you cannot do guaranteed issue and community rating without the individual mandate. But superficially the Republican line is very appealing, and Democrats failed to knock it down.

Obama's friendly and (until the end) accommodating stance--which in every other way was so appealing--actually undermined the Democrats' position on this. Though he drew back from it at the end, again and again during the course of the discussion he said he was seeking points of agreement. Far from embarrassing the Republicans, as he may have hoped to, this played into their hands. The implication of seeking agreement where you can is that there are boxes which can be checked one at a time. This concedes the key point to the other side. It is exactly what Republicans are saying. The Democrats do have a compelling argument--that successful reform is bound to have an all-or-nothing aspect--but they failed to make it.

Asked to name some steps, moreover, the Republicans offered a few: tort reform, interstate competition, health savings accounts, high-risk pools. Small stuff, to be sure, but the Republicans did not come across as the party of no. They looked well-informed, pragmatic, and engaged in the discussion. It was the Democrats who leaned more heavily on talking points, and seemed evasive and unspecific. Go figure.

After all this, Obama's closing statement was awkward. He said he had an open mind on Republican issues such as medical liability and interstate purchase of insurance. (So what's keeping you from proposing them, one wondered?) Then he tried to argue that many of the things that Democrats and Republicans agree about are already in the bills. Therefore, he said, if only the Republicans were willing to show some political flexibility, there would be no need to start over: everybody knows what needs to be done, and the bills are there.

Huh? Agreeing with things in the president's proposal does not oblige Republicans to support a measure that they think is far too big and full of things they don't like.

Obama's closing remarks did crystallise the key point of difference between the two sides. Democrats mainly want to expand coverage, and promise to contain costs in order to pay for it. Republicans have the opposite priorities: first contain costs, which they say would make insurance more affordable.

Again, on the substance, I'm with Obama. Getting to universal coverage (at significant cost to taxpayers) should be a top priority, up there with cost control. But there is a problem for the Democrats in taking this line. It seems a little at odds with what Obama and many other Democrats were saying earlier. Up to now he has emphasized cost control first, broader coverage second--because that is where most voters seem to be. Relatively little effort has been spent on making the case for wider coverage, and on persuading the country that this is worth paying for. Making the switch now comes a little late.

Meanwhile, the Republicans today managed to seem more serious about cost control than the Democrats. Their line--"Widen coverage later, when costs are under control and we can afford it"--will strike many voters as reasonable.

Obama ended by suggesting a pause for reflection, then implicitly promised to use reconciliation to pass a merged Senate-House bill, which was where we came in. As I say, I hope he succeeds. But his reasoning seemed weak. Step by step won't work, he said--having spent the whole day asking the Republicans to name steps that might command agreement. Starting over won't work, he said, because it is too late after all these months of work, and because the Republicans cannot be trusted: starting over means nothing will happen. Well, if it is too late now for big new ideas, whose fault is that? Obama should have called meetings like this at the start of the process. And if Republicans are not acting in good faith, why have a summit in the first place?

I tried to answer that question earlier this week. The aim today was to discipline and energize Obama's allies, and to weaken and embarrass the Republicans. It backfired. This turned out to be a good day for the GOP.