The Inevitability of Health Reform


If changes in atmosphere could mark the flow of time, then the transformation of the health care debate represents the somber passage of geological ages; entire opinions have expired and fossilized since the summer spirit of animus and encumbrance. The strange and raucous town hall meetings seem to grow tamer in reflection, now that politicians are committed to the process and the inevitability of health care reform has seemingly been inculcated into the national narrative.

The process has been filled with too much good-will for the passage of the bill to be refused an existence in some kind of form – this time reform was too important, even to the hospitals and insurance companies. What was in question was the passage of a substantial bill in volume and dimension. During some dark days it looked to have a dull curvature without any kind of bite.

A substantial bill, of course, could only work like a legislative godfather – you either pay your respects or you don’t, but if you don’t, then you pay the price for crossing it. Whether or not ideas alone have enough power to change the world, surely a bill’s detractor is shielded from the political fallout when the common confluence of discourse hangs a bill as a turgid and incomplete piece of legislation that is simply subject to natural decay; no one will blame you for putting a dead dog to sleep. It’s in a whole other universe to be known as the guy who killed health care reform, which makes for a nasty political slogan come election time.

There are, as history will attest, many seminal moments that define an eventual outcome, and so how we got from one atmosphere to the other is worth a look:

Max Baucus, as addled as his bill was, reoriented the process after the recess; Olympia Snowe became the most powerful Republican voice, a voice of policy, casting aside the Chuck Grassleys of the world and their insistence of death panels; the AHIP report backfired, and further aspersions were cast on an already vilified industry, as the insurance companies strayed from any protective aegis they might have had – no politician who accepts money from the insurance industry would dare speak out on their behalf for fear of negating themselves from the process; the CBO became a major player, scoring points for policy wonks and turning attention back to fiscal responsibility; continued strong support of a public option by the American people; and the cry of government takeover seemed to diminish away into rehearsed and powerless platitudes. Ever since “you lie” was injected into the rhetoric, the attacks haven’t seemed quite as pernicious.

In fact, most of the rhetorical blustering seemed to fizzle itself out like a firework that gave too much too soon. The narrative turned back toward the process, its movement and momentum; as long as it moves forward, it’s alive. With expectations galvanized, there was a serious effort to make the bill better, and shield it from the worst. And once reform gained steam, the psychological factor loomed larger: reform is going to win and so becomes a position of strength.

Bargaining power, now, rests with those in power. With Harry Reid currently in control of the process, the opt-out public option is assured at the moment after a series of compromises, having already been watered down from other more robust forms: it is now only accessible to those already on the exchange in states that choose to have it. In spite of the compromises, it is important to include it now because it will be difficult to reverse once it goes to the floor.

As Ezra Klein points out, there is always the possibility that it becomes mired there without sixty votes either way; the public option as a stumbling block, unable to proceed, unable to be stripped out. But when so much is at stake, there will be more pressure than ever to succumb. Whichever way it goes, those who feel the most heat will probably be the Democrats because none of them want to be left out in the cold. One arm of the party will be forced to capitulate.

Out of all of the compromises that the public option has had to endure, the opt-out may be the least of them. Instead of a policy decision, the opt-out has the rough texture of a political move. After all, when it came time to dole out the stimulus package, even the conservative states accepted most of the money simply because it was offered. States that opt-out are going to look worse as time stretches on, as long as the public option is not neutered. The compromises can only go so far.

Likewise, the state of individual/employer mandates and subsidies, which are prevalent in the HELP bill, will come under greater scrutiny, and compromises will need to be engineered. Despite the presence of inevitability, the shape of the eventual bill is far from certain, but there is now a greater push than ever for substantial reform.

The place that President Obama has to play is more complicated. He is both in favor of a public option and yet committed to reform with or without it. Short of influencing votes, the administration could guide the narrative, whether they want to continue courting Olympia Snowe or galvanize the base with certain signals. It’s often been said that Obama has over learned the lessons from the Clinton administration, but it is also important to be pliable in these precarious times, influencing the process in subtle and cautious ways. He is the face of this bill, rightly or wrongly, and so must work toward its inevitable end.