Healthcare reform -- a plan in search of a strategy

If President Obama and his Democratic allies are still hoping to eke out a victory this year in their long struggle for healthcare reform, they’re going to have to agree on a strategy. Democrats in Congress -- and on Obama’s own staff -- are divided over what the next step should be. House Speaker Nancy Pelosi (D-San Francisco) and other liberals are pressing for enacting the bill the Senate passed last month with adjustments that would need only a simple majority to pass. But moderates and campaign strategists worry that voters would see that as a shady backroom deal.

Last week, Obama characteristically came down in the middle. He said his heart is with the liberals but his head is with the pragmatists who are calling for a pause in the healthcare campaign.

For now, he said, the top priority should be a jobs bill, because unemployment is “the thing that’s most urgent right now in the minds of Americans.”

After that, he said, he’ll call on Republicans to join in a new national debate on healthcare. But he didn’t sound like a man in a hurry. “We should be very deliberate, take our time,” Obama said, and he acknowledged that Congress might not pass a bill at all this year.


It was an underwhelming call to arms from the man whose job is to lead the charge, and liberals in Congress weren’t pleased.

“Why don’t you ask him?” Pelosi said tartly when a reporter asked her what Obama’s healthcare strategy was.

Even back when reform seemed likely, Democrats were divided over what it should look like. The House passed a bill that raised taxes on high-income Americans and offered relatively generous subsidies to low-income people. The Senate passed a bill that didn’t increase taxes on the wealthy but levied a fee on high-end “Cadillac” insurance plans, and offered smaller subsidies. The differences seemed bridgeable back when the political environment for Democrats was more benign.

Now, it isn’t. Democrats in Congress are running for reelection in a year when public sentiment has turned sharply against them. And the polls on healthcare look particularly brutal. A CNN poll last month, for example, found that 58% of respondents said they opposed the Democratic healthcare bills, while only 38% approved of them. The opposition comes mostly from conservatives who think healthcare reform is too expensive, but it also includes liberals who think the current bills don’t go far enough.


Democratic strategists are debating what to do next. One camp, mostly liberals, argues that the worst outcome for Democrats would be to pass nothing. “The voters are likely to say: If you’ve got 59 seats, why can’t you get something done?” said Celinda Lake, a pollster who advised the losing candidate in the Massachusetts special Senate election last month that cost the Democrats their filibuster-proof majority of 60 seats.

But another camp, mostly moderate Democrats from states that are leaning Republican, fears the consequences of passing an unpopular bill. “It’s a hell of a lot easier to explain a ‘no’ vote than a ‘yes’ vote at this point,” said a strategist for one of those senators, demanding anonymity because he was breaking with the party’s official line.

In the middle are Obama and Senate Majority Leader Harry Reid (D-Nev.), searching for a way to reframe the debate and rebuild support for a bill that never had massive public backing to begin with.

That’s easier said than done. One of the most unpopular parts of the Senate bill is that it includes special breaks for individual states, but they are the result of deals cut to win reluctant votes; without them, support will wane.

Other unpopular features include the “Cadillac tax” on high-end insurance and the “individual mandate” requirement that people either buy insurance or pay a penalty. The “Cadillac tax” can be scaled back, but it will be hard to finance healthcare reform without some taxes. Most important, health policy experts say, an insurance system that doesn’t require everyone to sign up will be costly and unstable; sick people will sign up, but healthy people won’t.

If Obama, Reid and Pelosi want to pass a bill this year, they can start by agreeing on a list of changes to reassure worried voters that their voices have been heard. Reid and Pelosi will have to persuade their fractious Democratic caucuses to walk in step, which is no small task. They’ll need more help from Obama to do that.

And Obama will need to appeal directly to the public to rebuild support for reform. He did that once before -- in September, after conservatives touched off public alarm about the bill in congressional “town meetings” -- and met with some success. But last week, the White House wasn’t yet ready to say how much of a campaign Obama was willing to wage.

Unless Democrats agree on a strategy soon, the more likely scenario is a months-long deadlock between the Senate and House that will end by giving Democrats in the House a choice they will find unpalatable: Either pass the Senate bill many of them dislike, or allow healthcare reform to die.


There are only a few narrow pathways to passing a bill, and a dozen different ways to fail.