With the Senate's passage Thursday morning of sweeping health care reform, President Obama took another giant step toward the biggest legislative achievement for any Democratic president since Lyndon Johnson muscled Medicare into law in 1965.
Comprehensive health care reform has defeated every president who has pursued it, from Franklin Roosevelt to Bill Clinton. But, even with some hurdles remaining, Obama is now on track to sign legislation early next year moving the U.S. toward universal coverage. Though the bill bears all the scars and imperfections of its arduous advance, it's likely to stand as the signal domestic accomplishment of his presidency, even if he serves two terms.
And so, naturally, the reaction of the most visible component of the Democratic base has been to link arms with congressional Republicans and the conservative grassroots to insist that the bill be killed. Even as conservatives denounce the bill as an ominous extension of government's reach, leading lights of the Internet-based digital left like Howard Dean, MoveOn.org, Markos Moulitsas and Arianna Huffington are portraying it as a Christmas gift to special interests. One side sees a socialist taking America on a sleigh ride toward Sweden; the other a sell-out surrendering to big business and reactionary "ConservaDems." Who says no good deed goes unpunished?
The new Internet-based left, because it is so heavily reliant on college-educated whites generally less exposed to the economy's storms, has a blind spot on kitchen table issues.
The right's fury is easy to understand. It has opposed universal coverage for generations both on policy (excessive federal intrusion into the marketplace) and political grounds. Though conservatives are now confidently predicting a short-term backlash against the legislation, the right's shrewdest strategists have long worried that if government-guaranteed health care ever takes root, Americans would become more inclined to look to Washington for economic security, which would weaken conservative anti-government arguments.
The left's outrage is more puzzling. The bill has been wrenched by many compromises. But it imposes on the insurance industry tough rules long sought by liberals, including a ban on the denial of coverage for pre-existing conditions. Once fully phased in, it would spend nearly $200 billion annually to help more than 30 million uninsured Americans obtain coverage. Yet it squeezes enough savings from inefficiencies in current health spending that the Congressional Budget Office projects it will reduce the federal deficit in the near- and long-term, and the independent Medicare Actuary calculates that it will vastly extend coverage while increasing total national health care spending (by business, government and individuals) by less than a penny on the dollar through 2019. And it advances almost all the ideas that cutting-edge reformers consider essential to slowing long-term cost growth by nudging the medical system away from fee-for-service medicine toward approaches that more closely tie provider compensation to results for patients.
Against all that, the aggrieved left has mostly focused on two concessions made to centrist Senate Democrats: restrictions on abortion coverage and the abandonment of a public competitor to private insurers. But each is a largely symbolic dispute: There's little evidence the legislation would seriously constrain access to abortion, and the CBO has estimated that only about 6 million people would choose a public option. (It was equally irresponsible for the Senate centrists to threaten to sink the bill over such tangential provisions.) Even political scientist Jacob Hacker, widely considered the father of the public option, wrote this week that it "would be wrong" to derail the bill because it still contains "vital reforms."
In some respects, the left's discontent may be unavoidable. Perpetual dissatisfaction is the nature, and arguably the role, of activists. It's easy to forget that not only did liberals issue similar complaints about Clinton, but conservatives like Newt Gingrich groused that Ronald Reagan cut too many deals with Democrats.
The new Internet-based left, because it is so heavily reliant on college-educated whites generally less exposed to the economy's storms, also has a blind spot on kitchen table issues. According to the Census Bureau, just 6 percent of college-educated whites lack health insurance, for instance, compared to 19 percent of African-Americans and 31 percent of Hispanics. But the idea that Democrats should just press restart after the grueling struggle to reach this point carries an air of fatal abstraction: If health reform fails now, the next chance for big change probably wouldn't come for years, if not decades. "The universal rule of health care -- there are no exceptions -- is you get what you can," says Brown University political scientist James Morone, co-author of The Heart of Power, a recent history of health care politics.
Still, the left is raising one legitimate concern: the risk that Republicans will seize on the deals the White House cut to secure support from individual senators or key constituencies like drug manufacturers "to rebrand Obama and the Democrats as the party beholden to special interests," as Huffington wrote. The left's prescription for that problem -- junk the health care bill -- is batty, but that doesn't mean its diagnosis is wrong. With a populist wave building against all large institutions, Obama could find himself deluged if he doesn't learn to surf.
The president's strategy of enveloping potential opponents has brought him to the brink of an historic health care victory. But if Obama is to keep his head above water next year as he moves to issues like financial regulation and climate change, he may need to tilt his dial from conciliation toward greater confrontation with the powerful interests blocking his way.