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CommentIf Democrats are interested in passing a health care reform bill with Republican support, Rep. Charles Boustany, R-La., is the kind of vote they need. Boustany, who was a heart surgeon until he entered Congress in 2005, is a true believer in reform. "We have far too many individuals and families who do not have access to a physician," he said in an interview last week. He favors pragmatism over ideology. And he calls bipartisanship "essential."
"This is too big to do without it," Boustany says. "It's 17-to-18 percent of our gross domestic product. It's a very important kitchen-table issue that affects every single American. Everybody cares passionately about this."
But the House Democratic leadership, he says, isn't reaching out to Republicans. Just the opposite: "We feel shut out completely." As do some bipartisan-minded Democrats, he adds. So, when Boustany gets back from the July Fourth holiday, he intends to bring together a working group of House members, six or so from each party, to launch a rank-and-file bipartisan effort. "I've got six Republicans, five plus myself, ready to go," he says. "And I've got others who are willing."
Can six Democrats be found to join in the effort? "Easily," says Rep. Jim Cooper, D-Tenn. "Very easily." Like Boustany, Cooper thinks that only a bipartisan reform can command broad enough public support to work. "I also think you get better-quality legislation when more people from different perspectives are included."
For Republicans, the likely price of compromise is to drop or neuter a feature of reform that Democrats regard as, in President Obama's words, "an important tool to discipline insurance companies": a public-sector health plan. By passing along administrative savings and cost reductions to consumers, the public plan is supposed to keep private insurers honest. If the Democrats abandon the public option, "clearly a deal is do-able at that point," Boustany says.
Give up this key component of reform for the prospect of a handful of Republican votes? Bah! liberals say. "If winning this epochal battle takes a 50-49 vote with no Republicans among the majority," syndicated columnist Gene Lyons writes, "then that's what it takes."
After all, no one expects a majority of congressional Republicans to vote for Democratic-sponsored health reform. Boustany and Cooper are talking about getting support from a minority of the minority. Cooper thinks that a good bill could bring aboard two or three dozen House Republicans. Obama talks in terms of passing a bill with 70 or so Senate votes, which implies support from maybe a dozen Republicans. Looking at numbers like those, liberal Democrats snort: So what?
So, a lot. Even that limited degree of bipartisanship is worth the trouble. It is worth dropping the public plan for. In fact, going all-Democratic would be a lose-lose proposition: bad for the country, bad for the Democrats. Maybe good for Republicans, though.
One-party reform would give Democrats ownership of the health care system. That might be fun for a little while. But just watch as everyone with a gripe about his or her health plan or medical care blames the Democrats.
Republicans, for their part, will have a stake in the reform's failure and will delight in stoking public resentment -- something that Republicans are pretty good at, in case Democrats hadn't noticed. Many voters, especially among the independents whom Democrats' current resurgence depends on, will prove receptive. Though confidence in Obama is relatively high, confidence in government remains low. (A March Gallup/USA Today poll found 55 percent of respondents identifying Big Government as "the biggest threat to the country," far ahead of Big Business and Big Labor.)
Right now, when it's hard to imagine the health insurance system getting any worse, Democrats are tempted to assume that health care reform will delight the public. In gratitude, they believe, the voters will reward Democrats with larger majorities. Far from being a liability, Democratic ownership of a successful health reform would be a tonic for the party's brand, in this view.
Some Democrats are inclined to remember, too, how the New Deal strengthened the party by building government programs, whose clients become reliable members of the Democratic base. Other things being equal, subscribers to a government-run health insurance program are likely to vote for politicians who support that program. What's not to like?
The answer can be summarized in two words: Karl Rove. He, too, had a plan to use policy reforms to reshape the political landscape. Social Security private accounts were going to give Americans larger pensions and more control over their lives, which would induce grateful voters to reward Republicans. Moreover, private accounts would reduce the public's dependence on government and draw millions of Americans into the stock market, inducing them to vote more like investors (Republicans) and less like welfare recipients (Democrats). Big Government's constituency would shrink, and so, along with it, would the Democratic Party's base.
Rove's fate stands as a cautionary tale for Democrats today. One-party reform of the country's largest entitlement program collapsed, doing to the Republicans' political ambitions what Hurricane Katrina did to their reputation for competence.
The Democrats have more congressional votes today than the Republicans did in 2005, but the politics of health care is, if anything, more complicated and volatile than the politics of pensions. Not even Social Security accounted for anything like one-sixth of the economy, and not even a pension check approaches the personal sensitivity and importance of medical treatment.
Reform of a sector that channels such unfathomably vast resources and touches so many interests requires broad public buy-in. Any reform that passes on a party-line vote is a consensus-breaker by definition. Using health care reform as a wedge issue risks a political comeuppance that could send Democrats reeling back toward minority status.
Even on its own terms, the public health plan is a riskier proposition than most Democrats seem to realize. It would keep private insurance plans honest only if Congress kept the public plan honest, by refusing either to subsidize it or to hobble its private competitors. The odds of that are not great to begin with, and they decline over time as Congress comes under mounting pressure to keep the public plan solvent while doling out more benefits.
Remember, the whole point of the public plan, for many of its advocates, is to create an "accountable" alternative. Accountable to whom? Well, to politicians. And, through politicians, to interest groups and activists and everyone else.
In other words, the whole point of the public plan is to be lobbyable: by doctors, patients, insurance providers, and the whole gang that brought health care to its present unlovely pass. Their efforts, plus fiscal pressures and the occasional emergency of one kind or another, could turn the public plan into an incoherent mass of handouts that staggers from one chaotic crisis to the next. Think of the farm bill, but an order of magnitude messier.
"If private insurers say that the marketplace provides the highest quality health care, if they tell us that they're offering a good deal, then why is it that the government -- which they say can't run anything -- suddenly is going to drive them out of business?" Obama asked last week. The answer, of course, is that private insurers worry about competing with Congress, not with federal bureaucrats. Inefficient federal programs tend to be rewarded with bigger budgets, not punished with bankruptcy. Who would want to compete against that?
Of course, we don't know what a public plan would look like or how it might work out. But the best you can say for the idea is that it's risky. To count on a smooth-functioning, apolitical, efficient public corporation requires some heroic assumptions in this world of Amtrak, the U.S. Postal Service, and the Commodity Credit Corp. Farsighted Democrats might want to remember, too, that once set up, the public plan will be, like all major federal programs, effectively impossible to get rid of. If it proves to be a tar baby, they can expect to be stuck to it decades from now.
"I don't trust the Republican leadership, but there are many rank-and-file Republicans who are smart and decent folks, and they want better health care for their people too," says Cooper, the Tennessee Democrat. "Those votes are of immense significance."
If he and Boustany can round them up for a reasonable bipartisan compromise, the Democrats would be wise to embrace it. The Democrats have had six months to rejoice in Rove's failure. The question now is whether they can learn from it.
This article appeared in the Saturday, July 11, 2009 edition of National Journal.
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