The New Republic: How Will Health Care Reform End?

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Demonstrators at a Republican health care reform rally i i

Demonstrators chant on Capitol Hill in Washington, Thursday, Nov. 5, 2009, during a Republican health care reform rally. Jose Luis Magana/AP hide caption

itoggle caption Jose Luis Magana/AP
Demonstrators at a Republican health care reform rally

Demonstrators chant on Capitol Hill in Washington, Thursday, Nov. 5, 2009, during a Republican health care reform rally.

Jose Luis Magana/AP

Today, the full Senate will begin deliberations over the bill Majority Leader Harry Reid introduced before Thanksgiving. And the ultimate resolution of that process wouldn't seem to be in much doubt.

Republicans will do whatever they can to drag out the debate. But unless political circumstances change drastically, they probably will not succeed in stopping reform altogether. Instead, the Senate will vote for a bill, work out its differences with the House, and send legislation to the White House for the president to sign.

But the debate that unfolds over the next few weeks will be full of drama — and not just the manufactured kind. While it's hard to imagine opponents of reform stopping a bill from passing, it's not at all hard to imagine the opponents of reform drastically altering the bill before it goes forward.

You can look forward to amendments on abortion, immigration, employer responsibility, tort reform—amendments that plenty of more conservative Democrats will find hard to resist, out of either principle or political necessity, even as they further alienate the left.

You can also expect to hear complaints that the bill tries too hard to cut costs, as well as complaints that the bill costs too much. Often you will hear those complaints coming from the same people, which will make them hypocritical but not necessarily unsuccessful.

By the time all of this complaining and amending is done, legislation might end up a lot worse than it is now—which is saying something, since the bill is already full of compromises. Legislation could end up putting even less money into helping people buy insurance; it could have even weaker efforts to change the behavior of the health care industry; and, of course, it could have an even more timid version of the public insurance option.

And the debate that's about to take place isn't simply about whether legislation passes. It's also about how legislation is perceived after it passes—in the 2010 midterm elections, which suddenly loom large, and even the 2012 presidential race.

The conservative base hates the bill moving through Congress a lot more than the liberal base loves it. And while swing voters don't seem particularly moved by arguments about abortion or death panels, they will react harshly if they perceive health reform fails to improve their lives.

Some of this imbalance is inevitable, given the nature of the legislative process. When you're trying to pass a law—and have to clear an absurdly high 60-vote hurdle to do it—you're bound to make compromises that disappoint supporters while doing nothing to pacify the harshest critics.

But some of this also reflects the dynamics of the debate as it's played out lately, with the heavy focus on whether health care reform really will be fiscally responsible. Critics say it won't be; defenders say it will. In that debate, the best the advocates of reform can do is to avoid damage—to convince the public that, no, health reform really isn't going to cause the big problems that critics say it will. That's not exactly a recipe for generating enthusiasm.

One response is to remind the majority of Americans with insurance of all the ways in which health care reform really will help them. A new memo from MIT economist Jonathan Gruber, published over the Thanksgiving break, ought to help in that regard. The memo is a reminder that, thanks to reform, premiums for people buying in the non-group market should come down—in many cases, way down.

Of course, that won't actually happen until the new insurance exchanges are operating—something not scheduled for a few years, under both the House and Senate bills. In this sense, the ambivalence about reform is rooted in the fact that it's not everything it could be—that it really is, in some important respects, a disappointment.

That's why the architects of reform ought to look hard at a proposal Paul Starr has made and touted in Sunday's New York Times [1]: Providing federal funds to states that want to get their exchanges up and running early. It's the type of change that would seem to have a shot at passing, even in this limited fiscal and political environment. And it's the type of change that could help change perceptions about health reform for the better—precisely because it would result in helping more people, more quickly, than will be possible if legislation passes as is.

To be clear, you can count me among those convinced that health care legislation will never be repealed—that, once enacted, it will become a permanent part of the American social welfare state, something people cherish. But along the way to implementation, a lot of bad things can happen to the new system, not to mention the lawmakers who championed it.

The key for the next few weeks, as the Senate debate moves forward, is figuring out how to minimize that danger. And that alone should create plenty of drama.

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