Historic health-care legislation narrowly passed the House of Representatives, 219-212, Sunday night. The Senate will consider a package of amendments this week and the process is likely to be messy. But the main battle has been won and congressional action from this point forward amounts to clearing the battlefield.
In the aftermath, political and media pundits and affected interest groups have taken predictable cheering-or-jeering postures, depending on their predispositions. My own emotions are conflicted and this post-mortem thus likely will disappoint both the legislation's boosters and detractors.
Was the legislation's passage a Pyrrhic victory — that is, a victory gained at too great a cost — or was it a point of departure for further legislative victories for President Obama and Democratic congressional leaders? It will be many weeks, perhaps months, before we have an indication either way.
• The substance of the policy changes which will be triggered by the legislation: I felt genuine elation after the 1965 passage of Medicare and Medicaid and satisfaction after the 1990s approval of a Medicare prescription-drug benefit. Those historic changes got bipartisan support and met clear national need.
The bill passed yesterday barely made it through the House, where a heavy Democratic majority prevails, and fills some needs while leaving others unmet. It extends health-care coverage broadly, especially to low-income citizens, but does not include catastrophic coverage, meaningful tort reform, or changes allowing insurers to sell their products across state lines. It compels insurers to cover all who want coverage and to not cap their claims. It also puts new financial burdens on state governments and cuts Medicare expenditures — mainly by further reducing fees to health-care providers and eliminating so-called Medicare Advantage coverage carried by many seniors. There are new taxes and new costs for insurers and providers, most of which will be passed along to consumers.
The premises given by Democratic congressional leaders to the Congressional Budget Office facilitated a CBO projection, just before the House vote, showing federal deficits being reduced a bit over 10 years with passage of the package. However, the premises included some shaky and downright disingenuous information that cannot stand morning-after scrutiny. I know of no serious analyst who does not believe that it will result in more, rather than less, federal red ink over the next 10 years and beyond. Only the blindest partisans believe otherwise.
My greatest concern thus is the one shared by deficit watchdogs, such as the bipartisan Concord Coalition, founded by former Sens. Paul Tsongas and Warren Rudman and now chaired by Rudman and former Sen. Bob Kerrey. The Coalition issued a statement Sunday night warning that "expanding coverage without curbing costs is a recipe for fiscal disaster," pointing out that the legislation's cost-control measures are problematic. It pointed in particular to the new tax on high-cost insurance plans, believed to be the most important cost-control component of the legislation. As a result of last-minute concessions by the White House and Democratic congressional leaders, the effective date of this tax has been moved from 2013 to 2018.
There is no doubt that the principal components of the legislation will remain public law. Even if Democrats suffer losses of congressional seats this fall (see below), President Obama would be certain to veto Republican attempts at rollback in 2011 and 2012. No one believes the GOP will make congressional gains enabling them to override a veto.
Down the road, it is clear, emergency measures will be needed to save Medicare, Medicaid, and the drug benefit from the financial hole in which they now exist. The new federal health-care "entitlement" approved Sunday will make that hole even deeper and necessitate even more drastic bailouts which, in the end, will force big benefit reductions, tax increases, or both. But that is in the future.
One historic footnote: The benefits contained in the original 1965 Medicare legislation were quite modest compared to those which have been added since to the program. President Johnson, at time of passage, foresaw this expansion and was not concerned about it. "We have established a universal program here," he told a White House staff meeting, "and from this point forward nothing will turn it back. Over the years it will expand and that is good." Johnson made this statement, however, in a time of robust national economic growth, low federal budget deficits, and a national mindset that this would be the straight-line situation into perpetuity. Only two years later LBJ would be asking for tax increases to pay for the unforeseen expenses of the Vietnam War.
Now, what about critics' charges that the new legislation — reordering 17 percent of the economy — is a dangerous step toward European socialism and/or, gasp(!), a British or Canadian health system in the United States?
Americans, time and again, have signaled that they do not want a British/Canadian, national-goverment-run health system here. They clearly want a public-private system in which the national government will be expected to fill various gaps and, in particular, help the elderly, poor, and uninsurable get care they cannot get in a wholly private system. The legislation passed Sunday gives the federal government greater reach and responsibility in the health sector but certainly less reach and responsibility, for instance, than were contained in either Medicare or Medicaid. It is evolutionary, not revolutionary.
• The political effects of the legislation's passage: It is tempting to say that President Obama wanted to pass health legislation in the worst way — and that was the way he did it.
As readers know, I was quite skeptical a year ago when — in the midst of financial and economic crisis — he launched what would be a polarizing, sometimes brutal struggle for legislation that lacked majority public support and, in the Congress, could get only Democratic votes.
Why was Obama doing this before our financial/economic house had been put in order and when billions in federal red ink were being spent on recovery? Why not wait until recovery had set in and, then, present a proposal which could get consensus support in both Congress and country — as Medicare, Medicaid, and the drug benefit had done? Further, why farm out drafting of the legislation to Democratic congressional committee chairs rather than keeping it under White House control with, of course, involvement along the way of congressional leaders, affected interest groups, and with an eye toward attracting Democratic, Republican, and independent support in the electorate? Obama proceeded as he did, apparently, because he believed he had to act immediately, while he enjoyed the traditional Presidential "honeymoon period," and because he thought it important to his historic legacy. As it turned out, of course, the debate lasted well beyond his 100-day honeymoon period and consumed a full year during which partisan and ideological lines were deepened and the country polarized.
That is where the Pyrrhic victory interpretation applies. The term originated when King Pyrrus defeated Roman armies in an epic battle in 279 BC. Some 15,000 were counted dead on both sides — a huge number considering the relatively light population of Europe at the time. Afterward, the king said another such victory would end him. He had lost his key commanders, best troops, and closest advisors in the battle and been rendered weak thereafter.
Will this be the outcome for Obama, House Speaker Nancy Pelosi, Senate Democratic Leader Harry Reid, and congressional Democrats facing reelection this fall? Too soon to tell.
A win is a win and that is what Obama/Pelosi/Reid got Sunday night, despite all the difficulties along the way. They had no option, really, but victory. A year's draining work on the legislation could not end in defeat or they would be judged hopelessly impotent. And, importantly for this fall's elections, Democrats' core constituencies — the groups and people who turn out to work and vote at election time — would have been disheartened. Characterized as a gang who couldn't get anything done, they and their party's candidates were certain to be vulnerable if they lost Sunday.
Obama and his congressional leaders, Pelosi in particular, "did whatever they had to do," as Pelosi put it, to get the necessary Democratic votes for passage. This included expensive bribes with federal money to fence-sitting legislators. It included threats of excommunication and loss of congressional status to those with doubts about the legislation. The final, necessary votes for passage came via an Obama executive order spelling out that abortions would not be paid for with federal monies, thus causing anti-abortion Democrats to vote for the bill and give it its narrow final margin. (Both pro-choice and anti-abortion groups expressed displeasure with the Obama executive order although, in truth, it had more to do with atmospherics than with substance). Obama's final appeals to congressional Democrats had little to do with the legislation's provisions. He characterized it, instead, as a blow against unpopular insurance companies and pled for its passage as a means to save his Presidency.
It will be awhile until the political aftermath becomes clear. With the legislation's passage, Obama is likely to get an immediate uptick in his approval ratings, which had been at a record low for a President at this point in his term. Public approval also may rise for the legislation itself — opposed by between 55 and 60 percent of voters (almost all Republican and most independent voters) before Sunday. Republican congressional leaders' angry responses to the Sunday vote also could help bolster approval both for Obama and the legislation.
The effects on November elections will take awhile to materialize. Will voters consider the health legislation a settled issue and lose patience with those who do not want to move on? Or will they punish Democratic candidates for what they regard as arrogance in passing a bill a majority of voters did not want? Much will depend on the after-the-fact conduct of both political parties' leaders.
Given historic precedent, Republicans stand to gain some U.S. Senate and House seats this November. But it is uncertain whether those gains will be big, giving them majorities in one or both houses of Congress, or quite modest.
The answer could lie in what took place in the aftermath of the failure of President Clinton's 1994 health-care proposal. The pendulum swung immediately toward Republicans. They indeed retook control of the House that November, for the first time in 40 years. On the other hand, Republican congressional candidates lost momentum in the final weeks before election day and some Democratic incumbents kept seats they thought they would lose. A few years later they were back in the majority. An historic realignment did not take place.
If you follow such things, consider the perhaps 50 House and 10 Senate races that will be truly contested around the country this fall. Possibly vulnerable congressional incumbents in Washington state include Sen. Patty Murray and Rep. Rick Larsen. The seat being vacated by Rep. Brian Baird will be contested but, in the end, I expect Democrat Denny Heck to win both his party's primary and the general election. He is a strong candidate without, at this point, opposition from a comparably strong Republican.
My best guess: Republicans will gain congressional seats, perhaps even enough to regain a narrow House majority, but not enough to control the Senate. But it will not be the historic landslide some Republicans are predicting. The second two years of the Obama term will, by necessity, have to be conducted on a more bipartisan basis than the first two. Democratic strength will not be enough to do a replay of a one-party-passed health bill.
Now, a final word about the principal political players in the health-care drama and how they fared:
President Obama won a victory but stumbled often along the way. It was clear that, until the very last minute, he still was uncertain about many of the legislation's provisions. At one point he and his key White House advisors were willing to settle for a much smaller package; House Speaker Pelosi faced them down and held out for the more comprehensive bill that passed Sunday. Obama campaigned personally for the bill in major media markets and in districts of undecided Democratic House members. Yet, survey data indicate his appearances made little difference in those places. I fear he will draw the wrong lesson from Sunday's victory and continue to believe that it was his personal magnetism and speechmaking talents that won the day. No, mainly it was the hardball played by Pelosi and Senate Leader Reid among their Democratic congressional flock and the carrot-and-stick rewards and threats which got the bill to passage.
Pelosi deserves huge credit for the bill's passage. (She also will get huge blame if it remains unpopular and results in Democratic congressional losses). An Associated Press photo Sunday night seemed to sum it up. When the bill finally carried, Pelosi threw her head back in exultant laughter. Standing next to her, Rep. Steny Hoyer, her more moderate House deputy (and longtime rival), displayed a restrained smile. Pelosi is a highly partisan leader from a highly partisan (San Francisco) congressional district who was raised at the knee of her tough, partisan father, Tommy D'Allesandro, the long serving mayor of Baltimore. She keeps a tight rein on Democratic House members. She has purged or attempted to purge her rivals within that body. In a last-minute White House meeting on the health bill, she openly insulted a powerful House committee chair, Rep. Henry Waxman, in front of Obama and other Democratic leaders. She plays for keeps and her play-for-keeps tactics were what put the health bill over the top.
Reid also played a heavy hand on the Senate side but with less skill than Pelosi. He publicly praised the policy bribes being dispensed to undecided Senate Democrats to get their votes for the legislation. Unlike Pelosi, he inspires no fear among his Senate colleagues nor much respect. Right now, he appears likely to lose his seat this fall. Illinois Sen. Dick Durbin, a close Obama ally, and New York Sen. Charles Schumer have been actively campaigning for months to succeed him.
On the Republican side, Senate Leader Mitch McConnell and House Leader John Boehner both ended up looking partisan and oppositionist. This was not the case, however, with several more junior Republicans who made impressive substantive cases publicly regarding the legislation's shortcomings. Republicans are more respectful of hierarchy than Democrats and thus unlikely to depose their two most senior and visible leaders on the Hill. Too bad for them.
Now, finally, we all can turn our attention to the rest of the country's public business.
Next up: financial-system reform.