Critics of health care reform have been hammering away at its substance for months. But, since last week's election in Massachusetts, they’ve been focusing their attacks more on the way reform has come together in Congress. As the argument goes, Democrats wrote the bill on their own and in secret, producing proposals full of shady back-room deals that aren’t in the public interest. The symbol of reform’s hidden corruption is the so-called Cornhusker swindle: A promise, extracted by Nebraska Sen. Ben Nelson, that the federal government would pay the entire cost of expanding Medicaid in his state.
You can’t really defend the deal on the merits. No other state got the special treatment that Nebraska did. But if you stop and think about why Democratic leaders cut that deal, you’ll realize just how wrong-headed the broader critique of the process is. If Democrats hadn’t been so determined to reach out to Republicans--and worked so hard for an agreement that didn’t seem overly partisan--they wouldn’t have made the Nebraska bargain, or many others, in the first place.
Remember how we got to this point--and how far President Barack Obama and the Democrats have gone to accommodate Republicans and the conservatives they represent. The plan Obama outlined on the campaign trail, the one Democratic congressional leaders endorsed, called for making sure nearly every American had insurance. But accomplishing that would have cost well over $1 trillion over 10 years and, by some estimates, closer to $2 trillion. That was more than conservatives could stomach. To get the price tag down below $1 trillion, they settled on a plan that covered far fewer people.
The original Obama and congressional plans all called for creating a public insurance option, into which people could enroll voluntarily. But that proposal, too, ran afoul of more conservative sensibilities--and was summarily dropped. (The House ended up including a public plan as part of its bill, but House leaders signaled long ago their readiness to drop it in order to reach a compromise with the Senate.)
These moves didn’t make health care reform more popular. If anything, they had the opposite effect. A plan that spent more money would have required finding more offsetting revenue or savings. But it also would have provided clearer, quicker benefits for middle-class people--many of whom now fear the bill does too little to improve their lives. As for the public plan, poll after poll has shown that it is popular. And the really crazy thing is that the Democrats might have been able to keep both features--with, at most, minimal compromises--if only they’d been willing to go it alone, the way the critics insist they did.
Under Senate procedures, the Democrats had the option of passing health care reform, or at least many of its elements, through what’s called the reconciliation process. In reconciliation, a simple majority of senators can pass a bill, without the threat of a filibuster. Rules limit what can and can’t be considered during the process, so it has definite drawbacks. But if Democratic congressional leaders were determined to pass something on their own--the way, say, Republican congressional leaders were frequently during the Bush years--they could have gotten much and maybe most of what they wanted.
But they didn’t--in no small part because they didn’t want to act in such a blatantly partisan way. Whether that was a matter of principle (i.e, they really believed bipartisanship is important) or a matter of perception (i.e., they thought voters would get mad), it ended up constraining them all year long. Instead of wrapping up negotiations and passing bills before the summer was over, the process dragged into the fall and winter. Over and over again, Democratic leaders (particularly Senate Finance Chairman Max Baucus) reached out to Republicans, only to be rebuffed. When that didn’t work, they were left trying to deal with the most conservative members of their own caucus--culminating in the negotiations with Nelson and the promise to cover his state’s Medicaid expansion. If Senate Democrats hadn’t needed Nelson’s vote to break the expected Republican filibuster--if they could have passed health reform with a “mere” 59-vote majority--they could have told Nelson to take a proverbial hike.
The same, by the way, goes for all of the other back-room deals made to pass this bill. If Obama and his supporters had a greater margin for error--if they could have passed health care reform with a simple majority of votes, instead of the 60-vote supermajority forced by the threat of Republican filibusters--they wouldn’t have had to make so many concessions to special interests that wield influence over the Congress.
But every special interest knew that the Democrats had a razor-thin margin for success--and that gave them maximum leverage. They understood early on that, by trying in good faith to reach deals with Republicans and conservatives, Democrats were falling into a trap--the one that’s ensnaring them now.
Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.