The dominant health care story that emerged from August is one of frenzied confrontation -- seniors standing on folding chairs to scream at senators; sign-wielding protesters shouting across parking lots.
Those conflicts were real and raw. But they are only part of the story. With much less notice, many key stakeholders in the medical establishment, including several that mobilized against previous efforts to overhaul the nation's health care system, have come together behind reform. "That's very different from what we've ever experienced before and why there is every reason to be optimistic that health care reform will happen," says Ron Pollack, executive director of Families USA, a liberal health advocacy group.
The dogmatic liberal insistence on maintaining a public plan constrains Obama from considering the one concession that might attract GOP support.
You wouldn't know it from watching cable television, but many traditional antagonists in the health debate now support the basic thrust of the Democratic reform bills. The Pharmaceutical Research and Manufacturers of America has long allied with the GOP; the drug industry has directed two-thirds of its political donations since 1990 toward Republicans, and it fiercely opposed President Clinton's universal coverage plan. Yet today, PhRMA is spearheading an odd-couple coalition called Americans for Stable Quality Care that is advertising heavily to support the reform plans advancing in Congress.
The American Medical Association fought Medicare in 1965 and attacked Clinton's health care plan just four days after he unveiled it. But the AMA has joined the Quality Care coalition -- along with the Federation of American Hospitals (another Clinton-care opponent), Families USA, and the Service Employees International Union.
The SEIU, guided by its shrewd president, Andy Stern, has also helped organize another odd-couple coalition called Better Health Care Together, whose members include AT&T, Intel, and even Wal-Mart, a perennial union target. On September 9, that coalition will gather in Washington to press Congress to complete work on reform legislation through "commonsense collaboration." Their event will be co-sponsored by the Bipartisan Policy Center, a group founded by four former Senate majority leaders, including Republican Bob Dole and Democrat Tom Daschle. (Full disclosure: My wife works for the Dole/Daschle group.)
In June, Dole, Daschle, and former Senate Republican Leader Howard Baker issued a reform plan that closely tracks the preferences of the Better Health Care and Quality Care coalitions, which in turn largely follow the approach progressing in Congress. "In August, we have lost sight of this ... but our event is to say, 'Let's take a deep breath here. There is an enormous amount of consensus,' " says Jody Hoffman, executive director of Better Health Care Together. "If Dole and Daschle can come together, and SEIU and Wal-Mart can come together, there is an awful lot we can do."
The participants in these coalitions don't agree on everything, such as whether to create a public competitor to private insurers and whether to include malpractice reform in the package. They may differ on nuances even on issues where they broadly concur. But they have generally united around two core ideas. One is to link a mandate that individuals purchase health insurance (with government subsidies for those who need them) to fundamental reform that requires insurers to sell to all applicants at reasonable rates regardless of their health. The second thrust is to combat the crushing rise in health care costs through prevention, computerization, more reliance on coordinated care, and experiments on tying provider payments to results for patients. If President Obama signs a reform plan, those two ideas will anchor it.
Some medical groups are undoubtedly supporting these plans partly because they have negotiated side deals (for example, more-favorable physician reimbursement rates and limits on drug discounts under Medicare). But these interests have also accepted the legislation's inherent trade-off: reforms that benefit patients (and potentially restrain costs) in return for more customers, as millions of uninsured Americans obtain coverage.
Such a win-win approach should encourage bipartisan agreement in Congress. But after August's conservative uprising, virtually all congressional Republicans look certain to oppose any reform plan, even one embraced by many traditionally Republican business interests. Maybe no compromise could now attract substantial GOP support, but the dogmatic liberal insistence on maintaining a public plan constrains Obama from considering the one concession that might.
All of this means that for any bill to reach the president's desk, Democrats will probably have to pass it alone. The hard-won consensus these outside groups are forging could still make that possible, even as it highlights the more inclusive path that Washington might have followed instead.
This article appears in the Sep. 5, 2009, edition of National Journal.