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Presidential Health Care Plans

I've worked on only one presidential campaign in my life, and it was a notably unsuccessful one, so I'm probably as disqualified from giving advice on presidential politics as anyone other than Bob Shrum. But I did learn one thing from that campaign: Never, ever put out a detailed health care plan.

It should not come as a surprise that my limited presidential experience came on the campaign that Jonathan Cohn, in his plea for health care details from the Democratic candidates, admits is the "case study" for the opposite view: former Senator Bill Bradley's campaign in 2000. Bradley's lengthy plan to cover most Americans through a system of subsidies and structured insurance markets was quickly subjected to withering attack from both the left (it would threaten Medicaid) and the right (it would cost too much)--all from the same opponent, then-Vice President Al Gore.

Cohn is right that there were specific circumstances involving the Bradley plan that were not inevitable and might well be avoided in the future: The plan was too complex and had flaws, almost no one in the campaign fully understood it, and the campaign was unprepared to defend it aggressively. Most importantly, Bradley had staked his campaign on the contrast between his "big ideas" and the micro-initiatives of late Clintonism, with health reform as his centerpiece. By demolishing the plan, Gore managed to dismantle the logic for Bradley's entire candidacy.

But any detailed health care plan is going to be complex and imperfect, and any plan will embody some tradeoffs. No ambitious plan can promise the 240 million Americans who have health insurance that they will keep what they have, and the relatively young and healthy (except for the beer, bad food, and no sleep) policy wonks on a presidential campaign often forget how closely the idea of health insurance is associated with fear in many people's minds. Vice President Gore's opposition researchers weren't uniquely vicious. The temptation to pick at the threads of an opponent's detailed health plan will be irresistible. As a result, the health plan will be tattered and frayed before the candidate has the power to do anything with it.

The demand for a detailed health plan is a kind of hazing ritual for candidates, often coming from journalists who insist that candidates prove their seriousness about policy but who then ignore the plans in favor of covering the horse race. If there is a logic to the insistence on details, it rests on a dubious idea of presidential power, more suited to a parliamentary system than our own: That by campaigning on a specific policy proposal, a candidate's victory will carry such a strong mandate for the policy that the president will be able to roll it through. But presidential mandates rarely work this way. Most often--as with FDR or Ronald Reagan--successful presidents build their mandate in the first year, in the way they build and maintain coalitions in Congress.

Which is to say that getting the details right is less important than getting the politics right. And the politics won't be clear until after the election: Will Democrats strengthen their control of both houses of Congress? How close will they be to a 60-vote, filibuster-proof majority in the Senate? Will key players, such as Senate Finance Committee Chair Max Baucus, be willing to take risks?

Cohn is right that the key questions about candidates and health care are whether they are willing to pick a fight and who they are willing to fight with. Are they willing to challenge insurers? Are they willing to challenge those elements of the business lobby that will resist higher taxes or an employer mandate? Indeed, the key to health care is not designing the system, but figuring out what fights to pick and how to win them. But it is folly to pick those fights before one is in a position to win them. A candidate is powerless; a president powerful.

The biggest unknown about health reform in 2009 is where business will be. In theory, it should always be in the interest of most employers to support a reform that socializes some or all of the cost of health care, especially for employers who already provide health coverage and want the costs to be stable and predictable. But in 1993, business came to see its interest in the Republican Party as a higher priority than its health care costs. Will that be the case again, or will the slow trickle of executives, like Safeway CEO Steve Burd, willing to speak out for reform become a flood? And where will insurers be? Will some of them be willing to support a system that preserves a role for them, or will they oppose any change?

The answers to those questions will determine the nature of the fight. The details of many reforms are premised on the idea that the support of either business or insurers or both can be bought. But if they can't be brought on as supporters, one would go with a different plan, one that might have broader popular support, such as single-payer.

But it's too soon to pick that fight. For now, the Democrats who have not yet put forth detailed health plans should try something radical: Put forward a few basic principles and some benchmarks for reform. But let someone else own the details. Have the guts to say, "John Edwards has a pretty good plan to achieve those goals. So does Senator Ron Wyden. I like a lot of things in the approach Governor Schwarzenegger has proposed. I think the "Medicare for All" proposal designed by Jacob Hacker would achieve the goals as well. As president, I'll look at all those proposals and sit down with the Congressional leaders, and I won't let them leave the room until we have a plan that meets those goals."

By Mark Schmitt