George W. Bush was known for his tendency to think in terms of black and white, good and evil, us and them. This was in opposition, supposedly, to the nuance favored by Democrats. But Barack Obama has his absolutist side, too: Some arguments are right, and some are wrong. Some are legitimate, and some are not.
And on health-care reform, Obama believes that his arguments are right. The basic structure of his plan is sound. The Republicans’ alternatives are inadequate. The problem is too serious to entertain thoughts of inaction. Comprehensive works better than incremental. Compromise only makes sense if the other side is willing to give something up in turn. Good policy will be electorally defensible even if it's not obviously popular.
The big story out of the summit is not that Republicans and Democrats extended their hands in friendship, but that the White House has dug its heels into the dirt. The Democrats are not taking reconciliation off the table, they are not paring back the bill, and they are not extricating themselves from the issue. They think they're right on this one, and they're going to try and pass this legislation.
Today was a boost for that effort. The Democrats got hours to make their case, at an event they planned, with one of their own controlling the discussion. For that reason, I imagine that this will be the last bipartisan summit we see for awhile. The format is simply too kind to the president, and he takes advantage of it ruthlessly. When the camera panned, you could almost see Republicans wondering why they'd accepted the invitation.
The people who came off best were those who knew the most about the issue. Paul Ryan and Tom Coburn on the Republican side. Dick Durbin and Chris Dodd for the Democrats. But above all of them, the president, who got to enter, adjudicate and conclude discussions at will -- not to mention say when others didn't know that much about the issue, or weren't offering comments in good faith. That willingness to put himself above Congress, combined with the structure of the event, allowed Obama to fully dominate the proceedings, and he used the opportunity to firmly assert ownership over the health-care bill. This is now his legislation.
But for all that he's made the bill his own, it still has to make a final pass through Congress. Importantly, Harry Reid and other Democrats were not only using the word reconciliation, but defending it from attack. Obama joined them in this effort. But the question is what the handful of ambivalent Democrats in the House and Senate thought. Obama spent the day trying to convince them that passing this bill was right: Not just politically, but intellectually and morally. That was his argument for why he's still here, lashing himself tighter to this legislation, and why they should stick by him.
* Now that Dems are all but certain to move forward on health reform alone, the spin war shifts to a battle over the meaning and implications of using “reconciliation” to pass their bill. Republicans are already outworking Dems, pushing the message hard that it would constitute “ramming it through” the Senate against the wishes of the American people.
* The GOP is also casting reconciliation as an extension of the Senate backroom dealing that even Dems concede has badly tainted their reform proposals. Michael Steele, for instance, is calling it a “parliamentary trick.”
* So: Will Dems step up and get serious about redefinining it as majority rule? All we heard from Dems yesterday was the constant use of the “reconciliation” phrase, which presumably has little to no meaning for many people.
* But: Nancy Pelosi did try to make the case yesterday for majority rule, albeit obliquely:
“We can’t say to [the American people], at the end of the day, well, we had an idea, we had a vision, we had a majority, but the process did not allow us to make a change for your lives. We need to have the courage to get the job done, and I think we will. And I think today took us a step closer to passing health care.”
*Senator Ben Cardin edges towards some slightly more felicitious language, telling ABC’s Top Line that majority rule in the Senate is “pretty Democratic.” Pretty hard hitting!
I'm not sure what else was accomplished at Thursday's Blair House summit, but surely one result is that we learned what Republican "leaders" really think about health care and health insurance.
The most important thing Republicans think is that if there are Americans who can't afford the insurance policies that private insurers are willing to offer, then that's their problem -- there's nothing the government or the rest of us should do about it.
"We just can't afford this," said Eric Cantor, the fresh-faced House minority whip from Virginia, while John Boehner, the House Republican leader, called it "a new entitlement program that will bankrupt our country." What they were referring to, of course, was the $125 billion a year that Obama and his Democratic allies propose to spend in subsidies so tens of millions of low-income households can afford to buy health insurance and handle the co-payments. But if paying for those subsidies means raising taxes on high-income households with lots of investment profits, or capping a tax break for people with extravagant health insurance, or charging a modest fee on medical device makers that refuse to moderate future price increases, then Republicans are agin' it.
That was their clear message Thursday. It was their message during all those years when their party controlled Congress and the White House and they did nothing and said nothing about the plight of the uninsured. And it is clear that they would continue to do nothing if, by some miracle, Democrats were to drop their plan or embark on a more modest approach. For Republicans, the uninsured remain invisible Americans, out of sight and out of mind.
Judging from Thursday's discussion, Republicans have much more sympathy for those who can afford to buy health insurance but are denied because of a preexisting medical condition. They oppose Democratic efforts to end this industry practice directly through regulation, preferring instead to refer those customers to special high-risk insurance pools where they would be guaranteed to find coverage.
In some versions of the high-risk pool, the cost of a policy would be so high that households with average incomes would have to set aside a third or even half of their income to pay for it. It takes a Republican to view this as a solution -- the equivalent of giving a starving man a coupon for $2 off his next dinner at Le Bernardin.
Or perhaps Republicans imagine high-risk pools that are subsidized sufficiently enough that the insurance policies are actually affordable. Unfortunately, the only way to finance such subsidies is through some sort of tax or fee, mostly one imposed on every insurance policy sold outside the high-risk pool. It's a fine idea but one that turns out to be the actuarial equivalent of what Democrats proposed in requiring that insurers charge pretty much the same premiums for everyone, with only modest variations based on age and health condition.
Another of the Republican "big ideas" was to make it possible for small businesses to collectively negotiate with insurance companies for better deals on health plans. But that's what Democrats have in mind with insurance exchanges that will do exactly that, not only for small businesses but also for the self-employed and workers at companies that don't offer health coverage. Although they never quite came out and said it, what apparently bothers Republicans about these insurance exchanges is that they would be overseen by governments -- the same state and federal governments that for decades have negotiated a wide selection of competitively priced plans for tens of millions of satisfied government workers, including members of Congress.
Then there's the issue of what minimal level of benefits a basic health insurance package should offer. Republicans, of course, used Thursday's forum to denounce the idea that such decisions should be made by Washington bureaucrats and politicians. But as my Washington Post colleague Ezra Klein points out, Republicans apparently would have no problem if those standards were to be set by bureaucrats and politicians in Nebraska, or North Dakota or whatever Republican state decided to offer itself up as the regulatory haven from which insurers could sell their policies nationwide.
To give them their due, Republicans did manage to raise some serious issues and make a few constructive suggestions in between their carefully choreographed talking points.
Sen. Jon Kyl of Arizona, among others, complained that the minimum standards set in the House and Senate bill weren't very minimal at all, but in fact exceeded the actuarial value of the average policy now sold in the individual and small-group markets -- and are certainly more generous than the high-deductible policies that have shown some success in restraining the annual growth in premiums. Why not, he asked, start with a more modest benefits package?
Rep. Dave Camp of Michigan raised legitimate concerns about the way malpractice suits and excessive damage awards can cause physicians to practice defensive medicine, needlessly driving up the cost of health care.
Sen. Tom Coburn of Oklahoma suggested using undercover agents to weed out the waste and fraud that he claimed were responsible for the fact that one of every three dollars in the Medicare and Medicaid programs is misspent.
And Sen. John McCain demanded that his former presidential rival renounce the special Medicaid funding formulas for Florida and Louisiana that were used to buy the support of those states' wavering senators.
What we didn't hear from Kyl, or Camp, or Coburn or McCain, however, was an offer to vote for a health reform plan if these problems were fixed and their ideas were incorporated. Without even the hint of such offers, there was little reason for a willing president and his unwilling allies to even consider serious compromise. Now the losers will be the American people, who could have surely benefited from such productive dealmaking.
