Tom Daschle's confirmation hearings showed emerging bipartisan support for health care reform. But that doesn't mean passing it will be easy for him and President Obama.

The last time most of us saw Bob Dole talking about health care was 1994, when he was burying the Clinton health care plan on behalf of his fellow Republican Senators. On Thursday, Dole came back to the Senate and back to the health care debate. But this time his agenda was different.

Dole was there to introduce Tom Daschle, whom President-Elect Barack Obama has tapped as his Secretary of Health and Human Services. Assuming the Senate confirms Daschle as expected, his number-one job will be to spearhead the Obama administration’s own reform effort--an initiative that, much like Clinton’s more than a decade ago, seeks to transform medical care and make insurance affordable for all. Far from attacking this effort, Dole lavished praise upon it--and upon the man Obama tapped to lead it. “I can testify to the American people ... about Tom’s integrity and fairness,” Dole said, adding that Daschle’s appointment suggested a real opportunity for “constructive, bipartisan action on health care.”

For nerds like me who follow the health care debate’s every twist and turn, Dole’s appearance was no great shock. For the last few years, he has been promoting the cause of health care reform through the Bipartisan Policy Center, a private project he’s led along with some other veteran Congressional leaders and policy consultants. And while he’s been characteristically vague about what that might entail, the sentiments are indicative of a broader change in American politics. As health care has gotten more expensive--making it unaffordable for many Americans while placing tremendous financial pressure on businesses, hospitals, and doctors--enthusiasm for sweeping reform has grown.

But the decision to have Dole introduce Daschle also reflected some deliberate stagecrafting by the Obama team. In Washington, the 1994 Clinton health care debacle has become the stuff of epic lore. And part of the legend is the way Republicans grew frustrated, then livid, with what they perceived as intransigence by Clinton and the Democrats. By recruiting Dole to introduce Daschle, Obama’s team sent a signal to the Republicans: This time, we’ll work with you. Daschle himself emphasized the point, vowing to work “in a collaborative way.”

The bipartisan outreach is just one sign of how determined the Obama team is to avoid the mistakes that bedeviled Clinton’s effort. Another--and far more important--example is the speed with which Obama has moved on health care. At this point in 1993, Bill Clinton was still assembling his infamous health care task force, in part because he hadn’t even settled on a general framework for reform until just three months before Election Day. It would be nearly a full year before he introduced his plan formally. Obama, by contrast, unveiled his plan in the early stages of the presidential campaign--back in May 2007, seven months before the first caucus and primary. And even before the general election campaign was over, Obama’s health care advisors--led by Daschle--met with key stakeholders and critical players in Congress in order to get an early start on a bill.


But amidst all of these hopeful portents, a very discouraging one landed like a thud last month--although the timing, just days before the political world shut down for the holidays, meant almost nobody noticed it. It came in the form of a report by the Congressional Budget Office (CBO), analyzing the budget implications of the many different reforms that politicians have proposed in the last few years. Its chief finding: Making better use of information technology, emphasizing preventative care, and reducing the use of less effective treatments were great ideas that would make people healthier. But they wouldn’t actually save that much money--at least, not as much as Obama and other would-be reformers have been suggesting they would.

The CBO report was not the final word on the subject; as it noted, it didn’t take into account how various reforms might interact. (In other words, it didn’t consider whether better information technology combined with more scrutiny of ineffective treatments might yield additional savings not possible if one or the other were tried separately.) The estimates carried high degrees of uncertainty, since they involved extrapolating from limited data. And they were confined to the ten-year budget window. It’s possible some of the reforms might not yield all that much savings right away, but could make a huge difference later on.

Still, if the report is right, expanding coverage and guaranteeing adequate insurance is going to take more creative budgeting than Obama and his team anticipated. And while there are ways to solve that problem, none of them are easy politically. Obama and his advisors could double-down on their commitment to scrutinize new treatments for effectiveness--an idea they tout but which they’ve yet to flesh out. But the harder they push in that direction, the more drug- and device-makers--who profit mightily on innovations of questionable use--will squawk. Obama could also hold fast on his promise to create a public insurance pool into which anybody could enroll--an innovation that would likely reduce the cost of health care, since the plan’s publicly set rates would drive prices down for everybody. (Interestingly, this was one option the CBO did not consider.) But the public plan is a non-starter for the insurance industry and its conservative allies; it also sets off alarms among doctors and hospitals, who fear declining reimbursements.

Conversely, Obama could decide simply to run higher deficits--or to raise more money by, say, changing the tax treatment of health insurance. But budget hawks will fight the former while Obama himself warned about “raising taxes on health insurance” during the campaign (although, to be fair, that was in the context of John McCain’s reforms--under which such changes would have had a vastly different impact). And while Obama can put some health care spending into the two-year stimulus package he’s proposing, the real financial difficulty of reform is the ongoing costs, which grow with inflation and which will require long-term, rather than one-time, solutions.


This is why, despite all of the careful planning, Obama will likely find himself reenacting at least part of the Clinton drama. The lore of 1994 tends to omit the fact that Hillary Clinton also dazzled Republicans during her testimony before Congress. And among those impressed was Dole himself, who for months waxed optimistic about the prospects for a deal. But the bipartisan comity didn’t last, as Republicans like Dole and kindred interest groups decided that, on second thought, they really couldn’t live with various proposals--like a requirement that employers contribute towards health insurance payments--that Clinton had embraced in order to pay for his plan.

All signs indicate that the Obama team grasps this. Back during the campaign, Obama strategists talked about how, once in office, they’d use their grassroots army to push for legislation. Over the last month, the health care team has sponsored hundreds of town meetings across the country, designed both to promote the visibility of health care and to help construct a constituency for reform--the kind that could overcome Republican resistance in Washington. Perhaps most important, Daschle on Thursday reiterated a stance he and other Democrats have taken before: They will not rule out trying to move reform as part of the reconciliation process, which prohibits filibusters and thus would allow Democrats to pass their bill with just 50 votes.

Daschle smiled when he said this, in keeping with the hearing’s altogether pleasant tone. But it looks like he understands as well as anybody that the good will on display Thursday may not last.

Jonathan Cohn is a senior editor at The New Republic.