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What Obama did, and didn't do, on health-care reform


Mark Schmitt is tired of reading columns about how Obama should have done this or that differently. Those things may be true, he says, but they are also, quite frequently, a cop-out:

The work underlying the current health-reform effort began years before Obama even announced his campaign for the White House. Drawing on the lessons of past failures, when reform had no organized constituency, advocates and funders put massive resources into groups such as Health Care for America Now. They picked up political scientist Jacob Hacker's idea of a public plan within a structured insurance marketplace and developed it to give progressive advocates of a single-payer system something politically realistic that they could get behind. And they worked to ensure that all the Democratic candidates for president (with the exception of single-payer stalwart Rep. Dennis Kucinich) converged around roughly the same basic model. Years of health-reform-policy development, projects to improve public awareness of health reform, and advocacy campaigns were able to lay the groundwork for health reform well in advance. It was never going to be easy, but the best possible mechanism for achieving the long-thwarted goal was constructed for the president to flip the switch.

Compare that with the slow and meandering path to financial-regulatory reform. Yes, it's possible Obama doesn't see the urgency of it, or maybe his economic advisers are too cautious or subservient to Goldman Sachs. But it also matters that few liberals were working on this cause before the Wall Street collapse. No coherent alternative model had been developed, and no effort had been made to build a constituency for financial reform. While we had think tanks keeping tabs on various aspects of the economy, from the federal budget to the labor market, no one was systematically watching the development of super-complicated financial institutions, noting the risk posed by financial derivatives and promoting alternatives. A counterpart to the health-reform effort, Americans for Financial Reform, was launched this year but obviously it has a lot of catching up to do.

Another way of saying this is that president is a follower who leads. Take health-care reform. Marcy Wheeler doesn't agree with me that the reform bill we're likely to pass is similar to the reform proposal that Obama campaigned on. She emphasizes the differences between the two, but consider for a second the size of those differences. Obama proposed, at least on the coverage side, a Massachusetts-style structure. So too did John Edwards and Hillary Clinton. The difference was that Obama initially fought the individual mandate.

In the end, he ended up supporting a ... Massachusetts-style structure with an individual mandate. In other words, he moved from the Massachusetts-plan with one real variation to the Massachusetts-plan -- towards the consensus, not away from it. The move wasn't to Medicare for All, or a Clintonian managed care within managed competition, or Wyden-Bennett, or some approach that Obama dreamed up in consultation with Peter Orszag and Tom Daschle. It was just the consensus campaign approach with some concessions to the realities of the policy and the demands of Congress. Wheeler may think that's a lot of movement. I'm surprised by how little of a stamp Obama chose to put on this policy, particularly given the work that past presidents, like Clinton, have put into developing an approach that is uniquely theirs.

Is that because Obama himself assessed the relevant options and judged this approach superior? Probably not. Same goes for Hillary Clinton and John Edwards, both of whom had similar plans. This was the plan that Democratic experts and legislators were uniting behind. It was the plan that Henry Waxman was willing to support and Max Baucus put into his white paper and Ted Kennedy was advocating and that the unions had agreed to. So Obama followed along. He might have been the leader, but his first decision was to accept the path that had been chosen for him. When people write the story of health-care reform, a lot more of it will take place in the years preceding Obama's nomination then I think people currently realize. The trick of health-care reform has been the underlying level of political consensus among congressional Democrats, and Obama does not deserve the credit for that.

Photo credit: By Susan Walsh/Associated Press

By Ezra Klein  |  December 21, 2009; 4:36 PM ET
Categories:  Health Reform  
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Next: The inside game


Well, when it comes to enacting health care reform, so far Obama is more skilled than FDR, Truman, LBJ, Nixon or Clinton. In other words, he's the best we've ever seen. He must be doing something right.

Posted by: Jasper99 | December 21, 2009 4:44 PM | Report abuse

I agree with the poster above. Two things:

1) Obama had a lot more to contend with this year than Clinton and every other President after FDR. Could it be that he didn't, basically, have sufficient time and staff to take on a bigger role in shaping the legislation? Maybe I'm naive about the levers of power in the White House, but he his only human.

2) To whatever degree he didn't fight for more progressive legislation, he did use up quite a bit of political capital and set deadlines and guided the process in a way that led it to be achieved in his FIRST year. Democrats were almost guaranteed to have fewer seats after 2010, regardless of what happened in 2009. The most progressive legislation had to be enacted in this first year while the Dems had the most power. If the President hadn't pushed and pushed with deadlines, or if he had chosen to push something else first (perhaps financial regulatory reform) or chosen to focus only on jobs and the economy, the resulting HCR in say, 2010, or 2011 or 2012 would've been far, FAR less progressive. Period. The President chose to do healthcare reform THIS YEAR. That decision was key to not only its passing, but its makeup.

Posted by: matthat121 | December 21, 2009 5:00 PM | Report abuse

Ok, then who's to blame for the disastrous tactical error of beginning the negotiations from the Democratic Establishment's desired end point? No rational politician does that. Even the guy selling one of the twelve cars on blocks in his front yard knows to ask for more than he's willing to ultimately settle for. This just doesn't pass the smell test.

Posted by: BigTunaTim | December 21, 2009 5:12 PM | Report abuse

During the campaign for the Democratic Party nomination, it seemed clear that Obama's opposition to the individual mandate was about politics, not policy. If he had agreed with Edwards and Clinton on that, then he would have missed an opportunity to differentiate himself. Adopting the anti-mandate rhetoric made him seem more fresh and outsider-ey to "independent" or "middle Democrat" voters during the primaries, but on a technical position that he could easily reverse later without facing accusations about breaking a campaign "promise". That explanation seems far, far more likely than that Obama and/or his campaign had carefully examined the work of Hacker et al and concluded that the mandate was bad policy.

Posted by: extensive_vamping | December 21, 2009 6:13 PM | Report abuse

Ezra - As you probably know, Medicare was, likewise, an idea that had incubated for many years before becoming part of JFK's campaign platform in 1960 and, later, one piece of LBJ's appropriation of Kennedy's policy legacy. Medicaid, though it was not an inherited policy idea, was not LBJ's either. It was almost an afterthought, an originally Republican idea, that Wilbur Mills drove into the final legislative package.

Posted by: RS22 | December 21, 2009 7:12 PM | Report abuse

It is in the details that this bill loses its progressive cred. For example, if we had exactly the same bill except for utility-like administered rates for all providers, it would be a HUGE victory. I believe something alone these lines was possible, but we'll never know because Obama didn't even try.

Posted by: bmull | December 21, 2009 8:21 PM | Report abuse

Many people fail to realize the internal battles fought within organized medicine to remain supportive of what we have so far. There was a loud minority that would have morphed into an angry majority opposing reform if "Medicare for all" or governmental rate setting had been a part of the package. I'm not saying that's right, just reality. This would have never even gotten out of the gate if it scared off physicians.

Posted by: CarlaKakutaniMD | December 21, 2009 10:53 PM | Report abuse

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