Health Care Reform, the Left, Campaign Promises and Christmas in Vermont: The Legislative Stocking is Half Full

When is health care reform not health care reform?  When it is largely insurance reform, which – according to critics – is precisely what the Senate is on the verge of passing.  The combination of individual mandates and no public option is, according to many on the Left, a giant payout to insurance companies because it forces people to rely on the existing private insurance system to pay for health care.  (That’s why, they claim, insurance stocks jumped on news of the Senate deal.)  Whatever the merits of this criticism (and I think it is a vast oversimplification of what the current legislation does), the Senate version of a health reform bill passed another procedural vote last night, and if the Senate is able to muster the 60 votes on Wednesday to invoke cloture on debate regarding the latest version of the bill – as it appears will happen – the bill is on track to pass the Senate on Christmas Eve.  At that point it will have to go to conference to iron out the differences with the House version – no mean feat.  This is a long way from a done deal, but it is progress.  Whether it is beneficial progress, of course, depends on to whom you listen.

At this point, however, nothing has happened to change my prediction, posted in an earlier blog here, that Congress was never likely to pass the type of health care reform that the Left wanted and that the final bill would be closer to insurance reform than health care reform. The reason, I argued, is that Obama lacks the political clout to fulfill his campaign promises regarding health care, particularly his pledge not to support individual mandates and to include some version of a public option.  In fact, the current Senate bill, with the inclusion of the individual mandate, does more than I anticipated, and in that sense can be viewed as a significant accomplishment.  But because it is not what Obama promised during the campaign, much of his party base has turned against him with a vengeance. The following comments by journalists Matt Taibbi and Bob Kuttner, in an exchange on Bill Moyers’ PBS show, capture the sense of disappointment by many in the Democratic base:

TAIBBI: “I mean, that’s what George Bush did when he wanted to get something unpopular passed or something that was iffy. I mean, he just took, you know, if there were any recalcitrant members, he just took him in the back room and beat him with a rubber hose until they changed their minds. I mean, he could’ve taken Joe Lieberman back there and said, look, if Connecticut ever wants a dime of highway money again, you’re going to have to play ball on this thing. That’s what the president does. I mean, the president has an enormous amount of power…. I just – the idea that they couldn’t do this was – is a fallacy.”

Kuttner, one of the founders of the influential American Prospect,  also takes Obama to task, but for failing to take his case to the people: “The other way you can do it is to try to rally the people against the special interests and play on the fact that the insurance industry, the drug industry are not going to win any popularity contests with the American people. And you, as the president be the champion of the people against the special interests. That’s the course that Obama’s chosen not to pursue.”

This is the type of fantasy that passes for analysis in many media outlets. First, Obama was in no position to threaten any Senator with a loss of funds. Instead, influence went in the other direction; it was individual senators who brought the rubber hoses to the Senate floor. Earlier I suggested that there are essentially two ways in which health care could achieve 60 votes in the Senate. One was to alter the substantive details of the bills to attract more moderates, but without losing votes on the Left.   The second was to make side payments to fence-sitting senators.  By last week, it was clear that Harry Reid could not devise a bill that would keep the Left on board and still attract moderate support without some additional “incentives” in the form of amendments to win over wavering senators. Recognizing this, Reid opened the legislative spigot to round up the remaining votes.  Consider my own state of Vermont’s Bernie Sanders, one of the Senate’s more liberal members who earlier introduced a single-payer health care plan. Last Wednesday he announced that because of the elimination of the public option, a step taken to attract moderate Senate votes, he could not longer support the Senate bill. Without his support, the bill was dead.

Yesterday, however, Sanders voted in favor of the bill. What happened?  Did Harry Reid acquiesce to Sanders’ principled stand and reinsert a version of the public option?  Of course not.  Instead, he bought Sanders’ vote by increasing Medicaid reimbursements by $250 million to Vermont and adding money to fund at least two additional community health centers.  Sanders is not shy about trumpeting his willingness to sell his vote for an increase in state aid – you can read about it on his own Senate website:

“One of the reasons I voted for the Senate bill was that we were able to get in an amendment for $10 billion over five years to expand community health centers and the National Health Service Corps,” said Sanders on Monday. “You’re talking about a program that benefits people in 50 states.”  Of course, what he downplays is the fact that his support was conditional on some of that money going to Vermont to fund Medicaid and the creation of more community health centers.

Note: I am not criticizing Sanders for using the threat of defection to leverage additional state aid – his was only one of numerous last-minute deals Reid made, in the form of the 383-page package of amendments to the initial Senate bill, to secure the necessary 60 votes.  The last holdout, as I suggested earlier it would be, was Ben Nelson who occupies the 60th most liberal position in the Senate based on voting studies. Much was made in the media about the carefully crafted abortion amendment that allowed Nelson to support the Senate bill.  Less well noted, however, was the increased Medicaid funding that he also negotiated in the final package for his state of Nebraska.

Sanders and Nelson and Mary Landrieu (D-LA) and Blanche Lincoln (D-AR) did what Senators are supposed to do in our system of shared powers based on geographical representation – use their influence to address the interests of their states.  And one can make a strong case that additional Medicaid funding and more dollars for community health centers is money well spent.  My larger point, however, is that again and again pundits overestimate the ability of the president to influence the particulars of health care reform. Too often the health care debate is portrayed as a test of Obama’s persuasive powers; if only he brought the rubber hose to his meetings with Congressional leaders, or used his rhetorical skills, he could have achieved his campaign promises. This, in my view, is a gross misreading of the president’s powers, something those on the Left continually fail to grasp.  In truth, Obama has almost no formal powers, short of threatening a veto, with which to influence legislative debate. Similarly, he can make all the speeches he wants, and the heavens will open and the petals will rain down and supporters will weep and Senators will largely ignore him. Contrary to what Taibbi and Kuttner and legions of other bloggers would have you believe, presidential rhetoric designed to mobilize the masses is no substitute for control over tangible benefits – benefits that Obama is not in a position to deliver by himself.  And threats to withhold federal aid or other resources are worse than meaningless – they are counterproductive in a system in which the president depends on Senate support in future legislative debates to achieve his policy goals.  I understand that many of Obama’s supporters voted for him in the hope that he would produce substantive policy change.  But by overestimating the strength of his electoral victory, and the power of the presidency more generally, they fail to see that even insurance reform as represented by the current Senate bill is a significant accomplishment.

Repeat after me: the presidency is weak.  Why is it weak?  Because that’s how the Framers intended it to be.  Ours is a congressional system of government – not a presidential one.  You wanted real health care reform?  Don’t blame Obama – blame Madison.

I’ve received several emails about the filibuster, which is back in the news now that Paul Krugman has decided it serves no useful purpose.  I’ll explain why Krugman is wrong in my next posting.

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