President Barack Obama's domestic agenda will be put to test next week when his health-care reform legislation officially is introduced in the Congress. The din this week over Guantanamo, interrogation techniques, and related issues has obscured developments relating to the health-care issue. The final outlines of the legislation are not yet in place, as relevant Congressional leaders are bargaining within their own parties and, in the case of the Senate, across party lines in an attempt to frame legislation that can be enacted.
Some of the following may seem inside baseball. But in the end these details will be important in determining if the 2009 Obama proposals are enacted or flounder, as Clinton health proposals did 15 years ago.
Moderate House Democrats, known as Blue Dog Democrats, have mounted a small rebellion against Democratic House leadership, claiming that they (as well as House Republicans) have been frozen out of discussions on the legislation's content. The Blue Dogs number about 50. A related organization, the New Democrat Coalition, has expressed similar sentiments. Perhaps 100 House Democrats altogether follow a moderate Blue Dog-NDC line. On the other flank, about 100 Democrats in the Progressive, Black, Hispanic, and Asian-Pacific Islander Caucus are pushing for a more expensive and government-centered proposal than the Blue Dogs will entertain.
Three key Democratic committee chairs are taking heat from both flanks: Energy and Commerce Chair Henry Waxman, Ways and Means Chair Charles Rangel, and Education and Labor Chair George Miller. House Speaker Nancy Pelosi generally leans toward the liberals; her deputy and sometime rival, Majority Leader Steny Hoyer, sides with the moderates.
On the Senate side, Finance Committee Chair Max Baucus has determined that no health bill can pass there without a sprinkling of Republican votes. He thus has been working with Republican Senators; his aim, he says, is to produce a bill that can get 70 Senate votes (meaning at least 10 Republicans would have to sign onto an eventual bill).
Obama earlier this month convened a media event at the White House which included health-sector, labor, and business leaders who said they shared his objective of enacting reforms which would a) reduce health-care spending growth; b) improve quality of care; and c) expand coverage to those presently without health insurance. Trouble is, depending on the legislation's final content, those objectives could prove mutually exclusive. The past track record is not promising. Whenever cost-containment measures have been taken, accompanying expansions of coverage have been thrown in to attract Congressional votes. In all cases, costs thus have increased.
Chances for a so-called single-payer plan, run by the government, are zero. Debate now centers around the notion of whether a government plan should be established to compete with private health-insurance plans, presumably driving premiums downward. Cost and reach of such a plan also are in doubt.
Most in the Congress, without regard to party, are nervous about the price tag of a comprehensive plan. With trillions already committed to financial rescue, economic stimulus, and an auto bailout — guaranteeing $1 trillion-plus annual budget deficits for at least the next decade — projected costs of the eventual Obama proposal are being estimated at an additional $1 trillion. (The Obama administration concedes these costs but has budgeted only $635 billion for them.)
The final version of the Obama 2010 budget, released last week, projects annual deficits totaling $7.1 trillion between 2010 and 2019, added to the $1.8 trillion projected for 2009. By the end of that period, the ratio of publicly held federal debt to GDP (Gross Domestic Product) would reach 70 percent, up from 41 percent last year. The Congressional Budget Office, using a less optimistic scenario, estimates deficits of $9.3 trillion between 2010 and 2019 with a debt-to-GDP ration of 82 percent by 2019.
Despite these daunting numbers, there is an emerging consensus among insurers, health-care professionals, business, and labor leaders that the present system needs overhaul. But, inevitably, the tensions between cost containment and expansion of coverage will be felt in the legislative process.
Obama is pressing forward on the health issue because he understandably believes his own popularity and leverage are higher now than they likely will be next year. On the other hand, the scheme's prospective costs are so high that only the most liberal and safe-seat incumbents are comfortable with its prospective outlines.
Outlook: Obama has said he wants health-care legislation passed this summer. Some kind of bill no doubt can be passed by then. But, to get passage, both the administration and Democratic Congressional leaders may have to settle for incremental, less expensive changes than they are discussing today. Obama has chosen a strategy of bold public advocacy but has left the legislation's content to a surprising degree in Congressional hands. Future political-science journals no doubt will be filled with retrospective articles relating the hows and whys of this effort's eventual success or failure.