Divisions over health care among congressional Democrats became even more apparent this past week, underscoring the importance for President Obama and Democratic leaders to hit the reset button and start anew after Labor Day.
The fact that the congressional Democrats most nervous about 2010 are expressing the most doubt now should be a tipoff that this agenda is ringing up "no sale" outside the Democratic base. Obama is still defining his presidency and Democrats are defining their approach to governing. It would be hard for anyone to argue that either side is helping itself. Democrats are making the Republican case for divided government and partisan checks and balances, with consequences that could be important in next year's midterm election.
Obama needed to give Republicans something important that they want badly and that Democrats generally oppose.
While losing their majority in the Senate is a virtual impossibility, it would not be hard to see Democrats losing two or three seats, setting up real fights for control in 2012 and 2014, when Republicans have few seats at risk and Democrats have many.
In the House, while losing six to 12 seats for Democrats looks almost inevitable regardless of the climate, a loss of half the party's 40-seat majority is not hard to envision if things go badly.
It would be painful but might be necessary for Obama to call on Democrats to pull the health bill, take a deep breath, re-examine their approach and take it back up in the fall, once things have settled and they can retool.
The economic and budgetary realities have created an inhospitable climate for the degree of change being advocated. Had the pre-recession deficits been lower, had the recession been on the milder trajectory most economists initially forecast, had the stimulus package kicked in faster -- though it isn't clear it could have worked much faster than it has -- then things might have been different. It's not hard for the president to argue that reforming our health system -- or, for that matter, addressing climate change -- are journeys, not one-shot events.
Historic, game-changing public policy shifts inevitably come as the result of building a broad consensus. It is important to have a clear consensus in the governing party and a level of respect in the minority party -- not just to pass the initial measures, but also to have when the programs are revisited. Not having that broad support means an ambitious program can be emasculated once the political seasons change. For health care, and climate change, there isn't anything remotely like a party consensus or real bipartisanship.
The danger for any big new Democratic health plan is the perception that Democrats are overly fond of big, budget-busting, expansive governmental bureaucracy. But the crisis of health care is about costs.
High and escalating costs have put the United States at the top of the world in what health care costs, but well down in terms of outcomes. Many countries somehow manage to do more and better with less money. Escalating cost is what keeps many people from affording health insurance. It also cripples both large and small businesses, and makes it prohibitively expensive for the government to provide health insurance for those who cannot afford it.
If you bend the cost curve enough, individuals, businesses and, as an insurer of last resort, the government directly or indirectly can ensure universal coverage.
But Obama and congressional Democrats let the size, scope and expense of the architecture dominate the early discussion, with little early on about how they were going to bend the cost curve.
Part of the problem is that many changes can't be scored, and were not counted in CBO's cost estimates.
However, Republicans also have legitimate points that Democrats have talked the talk of bipartisanship but haven't walked the walk. To show his sincerity and establish credibility in seeking a bipartisan approach, Obama needed to give Republicans something important that they want badly and that Democrats generally oppose. That's walking the walk.
When Obama addressed the American Medical Association in Chicago, then cavalierly took off the table any meaningful medical malpractice reform, that was a signal to Republicans that he and Democrats were not seriously looking to incorporate GOP ideas.
One can argue how big a problem defensive medicine is, how much cost it adds to our system in unneeded tests and procedures, but it can't be argued that Republicans see it as critical.
Dismissing it out of hand gave Republicans the signal that this was a Democratic bill.
For a long time, passage of important health and climate change measures seemed to be more a question of just how much the president and congressional Democrats would be willing to compromise, not whether something big would pass. But now, the "if" question is more real than ever.
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