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The Kristol Ball

If you're logging in for the first time in a few days and catching up on health care reform, you've probably read a few articles about how the issue will play in the 2010 midterm elections, assuming Congress passes a bill sometime early in the new year.

Some people think the issue will help the Democrats, because it's a huge, historic accomplishment that will (eventually) address economic insecurity. Others think it will hurt the Democrats, since it's a big government program and won't do anything to boost jobs in the next few months. Also, polls suggest that health care reform is not particularly popular right now, although that could simply reflect predictable (and fleeting) ambivalence about the legislation process.

I really don't know who is right. But I do have some ideas about how health care reform will play out in the long term. And for that I have to thank Bill Kristol, of all people.

In a blog item posted back on December 16, Kristol wrote an item for the Weekly Standard blasting the Senate Democrats' bill and urging Republicans to hang tough in opposition:

Republicans should say: No, No, a thousand times No.

And if the legislation passes, the GOP should immediately begin trying to repeal key parts of it. The moment it passes, Mitch McConnell might introduce free-standing legislation repealing the Medicare cuts. Republicans could highlight their opposition to Big Pharma and Big Insurance by trying to force votes--in 2010--on drug re-importation and more insurance competition, measures that could go into effect right away so as to be of immediate benefit to the American people. And of course they should promise to relieve the American people of the prospect of living under the Democrats' health bureaucracy regime by promising repeal of the whole thing in 2011.

Republicans invoked the same refrain during the final days of the Senate debate. And, at a time when voters were pretty clearly disenchanted with the legislative process, I'm sure it didn't help the Democrats in the polls. But did it help the Republicans? Will it help them in the future?

I can't imagine how.

Voters don't tend to associate Republicans with populist crusades against the drug and insurance industries. And for good reason. In debates over the balance between business and government, whether its the economy generally or health care specifically, Republicans have always been the one standing up for the corporations.

Back in 2003, for example, it was the Republicans who insisted upon creating a Medicare prescription drug benefit that channeled coverage exclusively through private insurers, padded insurance company profits with unjustified subsidies, and blocked efforts to let the government bargain directly over prices. The Democratic alternative would have provided prescription coverage directly through the government--which, by the way, would have meant less money for the drug makers and insurers, but cheaper drugs for seniors.

It's true that President Obama and the Democrats cut deals with the drug industry in order to pass a reform bill this year. And while they didn't reach such an agreement with the insurers, as far as we know, the final bill is friendlier to the insurance industry than many of us would like.

But it's not as if Democrats were, by and large, excited about these compromises. Most of the party's leaders saw them, rightly or wrongly, as an evil necessary for getting a bill through Congress.

And it's not as if the Republicans were proposing to come down even harder on the health care industry. You didn't hear Mitch McConnell demanding that the government bypass private insurers. You didn't hear John Boehner clamoring for direct government negotiation over drug prices. Instead, you heard them proposing to minimize government intervention in the business of medical care and calling to deregulate the insurance industry, which is what Kristol means when he says "more insurance competition." In case you were wondering, this is precisely the sort of change the insurance industry would love.

The future should make this distinction even more clear. Republicans are vowing to repeal health care reform if they get into power--and, I suppose, it's possible they'll succeed. But it seems far more likely that, once enacted, health care reform is here to stay. However unpopular this bill is today, the underlying concept--that government ought to make health insurance a right--remains popular. To repeal health care reform, Republicans would have to convince voters they're better off without laws prohibiting insurers from discriminating against the sick--and without subsidies that would help middle class people, as well as the poor, pay for their premiums. I just don't see that happening.

Instead, the coming fights over health care are likely to be over how to improve whatever measure Obama signs into law--which will mean, among other things, arguing over whether to regulate insurance practices even more aggressively, whether to use government bargaining power with the drug industry, and, yes, whether to start some kind of public plan.

In these debates, Democrats won't be the ones championing the interests of the health care industry. The Republicans will. It's hard to imagine the voters won't notice.

P.S. Speaking of the 2003 Medicare fight, Charles Babington of the Associated Press had the good sense to ask some Republican senators opposing this year's reform on budgetary grounds why they voted for the Medicare drug benefit, which had no offsetting revenue or taxes whatsoever. The answers are, um, interesting.

Update: Austin Frakt identifies a more likely line of attack for future Republicans.

Read Jonathan Chait's dissection of Kristol here.

Follow Jonathan Cohn on Twitter: @jcohntnr