With President Obama's bipartisan summit behind them, the remaining question facing Democrats on health care is straightforward: Do they have the courage of their convictions?
After Obama's release this week of a plan that mostly tracks the Senate approach to reform, Democrats are completing a proposal that would expand insurance coverage and combat waste in a largely centrist manner. Their emerging plan broadly resembles the Republican alternative to President Clinton's 1993 health plan, the proposal that Republican Mitt Romney signed into law in Massachusetts when he was governor, and the blueprint that former Republican Senate Majority Leaders Bob Dole and Howard Baker endorsed last summer. Obama unwisely retreated on taxing high-cost insurance plans, but his proposal still embraces most of the major ideas that reformers have offered to tame rising costs.
The fact that even Republicans have defended Medicare suggests most Americans aren't unalterably opposed to a government role in health care.
Although Democrats arguably should implement those ideas faster -- or bolster them with stronger protections against excessive medical malpractice claims -- the Senate bill reallocates resources in the health care system effectively enough that the independent Medicare actuary has estimated that the measure would cover 33 million more people by 2019 while increasing total health care spending by less than a penny on the dollar. It's not perfect, but the plan does provide a solid foundation for a more equitable and efficient health system.
Yet it's undeniable that Democrats have not convincingly made their case. Although polling often finds majority support for individual elements of the plan, most white Americans have consistently indicated they do not believe that the overall package will help them. Opposition to the bill is much more intense than support.
Conservatives see this resistance as proof that America's political center of gravity tilts right. In their view, Obama is faltering because his agenda, with health care as symbol and centerpiece, expands government's reach more than most Americans will accept. "This is ... a test of their agenda, and it's blown up in their face," says veteran GOP strategist Pete Wehner. The predominant Democratic view, by contrast, attributes health care's troubles to tactical mistakes (Obama deferred too much to Congress, or let the process drag on too long) and a toxic economic climate.
Obama has undoubtedly underestimated public skepticism about government, especially after the financial bailout, and has certainly made tactical mistakes. But the fact that even Republicans have felt compelled in this debate to defend Medicare suggests that most Americans aren't unalterably opposed to a meaningful government role in health care. And it's difficult to blame tactical incompetence for health care's troubles when previous presidents who attempted reform, Clinton and Harry Truman, for example, found themselves in similar difficulties despite pursuing different strategies.
White House communications director Dan Pfeiffer recently offered a persuasive alternative theory that blends the first two. Given the public's doubts about government, he maintains, no president can win the argument over health care prospectively because the country is not inclined to believe that Washington can reform a system this complex. (That challenge becomes tougher when unrelenting partisan conflict denies a president any bipartisan validation for change.) The only way to sell comprehensive reform, Pfeiffer continued, is to pass it despite poor poll numbers and then build support through implementation. In short, he is saying that Democrats need the confidence to take a leap of faith.
Democrats are closely divided between those who accept Pfeiffer's argument that the only way to rehabilitate the plan is to enact it and those who consider it suicidal to move forward. That latter viewpoint embodies something much larger. After the post-2008 Republican victories in New Jersey, Virginia, and Massachusetts, and with polls showing Democratic vulnerability in November, it appears that more Democrats are growing fearful that conservatives are correct in describing America's natural political balance as "center-right." The simultaneously sanctimonious and timorous retirement this month of Sen. Evan Bayh, D-Ind., captured an ebbing of Democratic self-confidence that veteran party pollster Mark Mellman has described as verging on "panic."
Obama needs to learn from Clinton and better balance his activist agenda with convincing measures to streamline and discipline government -- efforts he has belatedly begun with his deficit-reduction commission and domestic discretionary spending freeze. Democrats also might need to trim the health plan's cost before moving ahead. But, however Democrats guard their flanks, their final decision on health care will still turn on the same fundamental question: Do they believe they can hold a majority of the country while implementing the agenda they feel is right? If the answer is no, the implications extend far beyond this one issue.
This article appears in the February 27, 2010, edition of National Journal Magazine.