Health Care Reform Challenge Appears More Jagged Up Close

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"The mountains...at a distance appear airy masses and smooth," observed the Greek philosopher Pyrrho, "but when beheld close they are rough." The same is true of Congress' attempt to fashion health care reform legislation.

When the new Congress and president came to power in January, one thing seemed certain: Health care reform was a top priority and Democrats had the strength, mandate and momentum coming out of the fall elections to enact a bill this year. The mountain seemed airy and smooth.

House and Senate leaders, at President Barack Obama's urging, set an August recess deadline for passing their respective bills. That way they could reconcile their differences in September and present the president with the crown jewel of his inaugural year before adjourning in October. Yet by early July, as the summit loomed closer, there was considerable slippage on the slopes, gashing of knees and gnashing of teeth. The terrain had become jagged and treacherous.

What accounts for the changing nature of the challenge? The obvious answer is that the difficulty lies in the details and that forging a consensus over those details among even a bare majority of House and Senate Members is a daunting task—especially given the complexity of the issue, public anxieties and disparate majority party factions.

Congressional leaders and White House officials were determined not to make the same mistakes that President Bill Clinton did with his failed health care reform effort. That meant not drafting a bill in secret White House sessions and then dropping it on Congress' doorstep with the expectation that it would be rubber-stamped into law. That approach netted zero bills passing either chamber in 1994.

Obama seemed so intent on not replicating Clinton's debacle that some wondered whether he was even in the game. None of the chips thrown into the ring bore his fingerprints. Instead he seemed content to float above the fray, chanting his three-part mantra: control costs, ensure access and choice for everyone, and improve the quality of care—letting the various committees hash out the details internally.

As things on Capitol Hill began to wobble in July over the issues of taxes, a public insurance option and health cost savings, leaders became nervous about the prospect of ever melding five competing committee plans without more direct presidential intervention. But the White House game plan remained one of avoiding any hint that the president was trying to dictate details (at least not until the final legislative stretch).

Instead, top administration officials, led by White House Chief of Staff Rahm Emanuel and health czar Nancy-Ann DeParle, engaged in quiet consultations behind the scenes with party and committee leaders. The president would play the inside-outside game of bringing key groups of legislators to the White House for pep talks and banging the drums for health care reform at town hall meetings around the country.

Congressional leaders were left the knuckle-bruising business of mashing policy palliatives to quell their quibbling caucuses—from Blue Dogs and New Democrats to the Congressional Black Caucus and progressives. Everyone, it seemed, had different demands and constituencies. Yet any attempt to fuse factional fixes would still fall short of majority support.

A week before the August recess, negotiations between House Energy and Commerce Chairman Henry Waxman (D-Calif.) and seven committee Blue Dog Democrats broke down. Waxman threatened to take his bill directly to the floor through the Rules Committee, circumventing a vote in his own panel. Almost instantly, Speaker Nancy Pelosi (D-Calif.) and Majority Leader Steny Hoyer (D-Md.) ordered both sides back to the bargaining table, indicating they would not bypass the regular order. That strong show of leadership intervention produced a compromise that in turn facilitated full committee approval on the eve of the August recess, 31-28 (with four of the seven Blue Dogs in harness).

That tenuous accommodation provoked a backlash among more liberal Democrats.

The only hint of bipartisanship in either chamber has been found in the Senate, where Finance Chairman Max Baucus (D-Mont.) leads the gang of six in seemingly interminable discussions, much to the consternation of nervous partisans in both parties.

At such an impasse in the policy process two options are available: Either you beat a strategic retreat and reassess what is needed for success before proceeding further or you plunge full speed ahead, applying the requisite amount of presidential persuasion, party pressures and proffers of pork to wring out the bare majorities needed. The fate of the nation may not hang on the vote, but the political fortunes of the new president and Congressional majority may well.

Given all the August deadline hype, some view delaying floor votes until September as a political setback. However, leaders were simply recognizing the realities of a still-elusive majority, eroding public support and the additional time needed to forge an acceptable compromise. And make no mistake, the substitute that emerges from the House Rules Committee will make substantial changes to the committee-reported bills.

Last month's hiatus did force a broader national conversation about the nature of our health care problems and what changes are both desirable and affordable. Notwithstanding some misbehavior and misrepresentations, the country benefited overall from this educational interlude. On Wednesday night, the president will tell Congress and the American people what he's learned and whether he's found a new way to lead the final assault on the summit.

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Experts & Staff