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Health Care: Can Obama Swing It?

Barack Obama; drawing by John Springs

Assessing how a president is doing at any given moment runs the danger of mistaking the momentary for the long run, and failing to take into account the political realities he has to face. Judgments of Barack Obama’s presidency have suffered from these failings, which in turn affect—negatively—his ability to govern. The Republicans in Congress have shown that they well understand that the more they can undermine public confidence in Obama’s ability to govern, the more they can undermine his presidency. This explains why they have been so intent on portraying—against much evidence—the $787 billion economic stimulus bill as a failure.

Thus, by Labor Day of 2009, not only his health care proposal but Obama’s very effectiveness as a president were widely—if not necessarily accurately—viewed as hanging by a thread. A White House aide told me that Obama was “very frustrated” by his inability to convince people that the stimulus program was working. And so, months after it had been passed, he began to explain more clearly than ever before what the program—which he insisted on calling the Recovery Act (its actual name is the American Recovery and Reinvestment Act)—was designed to do, and had already done. As was the case during the presidential campaign, Obama is sometimes slow in arriving at an effective formulation, and he presses his aides to sharpen his message. Finding a voice that is explanatory rather than oratorical can be difficult for him. This definitely has been the case with health care. On September 20, Obama told George Stephanopoulos:

There have been times where I’ve said I’ve got to step up my game in terms of talking to the American people about issues like health care. I’ve said to myself, somehow I’m not breaking through…. This has been a sufficiently tough, complicated issue with so many moving parts that no matter how much I’ve tried to keep it digestible, it’s very hard for people to get their whole arms around it. That has been a case where I’ve been humbled and I just keep on trying harder because I really think it’s the right thing to do for the country.

In fact, the question has arisen of whether Barack Obama’s particular—one might say idiosyncratic—governing style is right for these times.

The circumstances in which Obama has had to govern have been daunting. The polarization between the political parties is greater than ever before in modern history—particularly as the shrinking Republican Party has come to be dominated by white conservatives, if not radicals, and it enforces discipline more harshly than in the past. Lacking any real leaders now, the Republicans’ vacuum has been filled by the likes of talk-show hosts Rush Limbaugh and Glenn Beck, whose job it is to be outrageous, and before whom Republican politicians quaver. Those who stray from the conservative orthodoxy are more likely than ever to face a challenge from the right in their next primary. (When he announced in late April that he was switching to the Democratic Party, Senator Arlen Specter of Pennsylvania forthrightly said that he didn’t think he could win the Republican primary in 2010.)

The goal of the Republicans is not just to oppose Obama’s policies they disagree with but to destroy his presidency. Thus the Republican opposition to health care reform is part of a larger agenda, as some Republicans have been unwise enough to admit openly. Senator Jim DeMint of South Carolina said in July: “If we’re able to stop Obama on this [health care], it will be his Waterloo. It will break him.” Even the Clintons governed in a more felicitous setting; the economy was rebounding and a number of moderate Republicans were willing to make deals with the administration. Now, moderate Republicans are nearly extinct. And back when the Clintons were targets of an effort to undermine Bill Clinton’s presidency, the Internet and cable television weren’t the instruments for repetitious and vile attacks that they are today.

With nearly all Republicans determined to oppose him, the President is almost totally dependent on the support of his own party, which is itself split between liberals and moderate-to-conservative members.

Moreover, any record of Barack Obama’s first year in office has to take note of the fact that this summer, race broke open as an issue. The rise of the “birthers”—who claim he was born outside the US—and the uncommon incivility shown toward Obama by Republicans during his September 9 speech to Congress on health care suggest that a substantial segment on the right doesn’t see Obama as a legitimate president. He was not just called a liar by South Carolina Representative Joe Wilson, but also confronted with boos and rude signs; and vicious comments were made about him at the anti-big government (and anti-Obama) rally in Washington the following weekend.1

In fact, a number of leading Republicans, including House Minority Leader John Boehner, are concerned about the party’s getting too identified, or involved with, the movement on the far right. Vin Weber, a prominent Republican and former member of Congress (and ally of Newt Gingrich when they were backbenchers), says:

There’s a fringe out there that’s embarrassing. While it can gin up Republican intensity, the party can’t get too associated with the nutcases out there. The Republican leadership has a keen awareness of the benefits and the risks of this movement.

Obama’s preference for consensus, his inclination to listen to all sides but not reveal his own thinking, his occasional disinclination to take firm positions, his innate cautiousness (as with his evasion of his campaign promise to end the ban on gays in the military), and his desire to please—all these have conveyed a sense of weakness. He left it to Congress to draft both the health reform and the stimulus bill. (And weak not just domestically: “Est-il faible?” Nicolas Sarkozy was reported to have asked aides after meetings with Obama.) One purpose of Obama’s health care speech on September 9 was to project strength and portray himself as a force to be reckoned with; another was to reinvigorate disappointed and dispirited Democrats.

The economic crisis Obama inherited upon taking office forced him to use up a great deal of political and real capital on measures he hadn’t planned for and didn’t particularly want to carry out. The actions he took—the various bailouts, with help from the Federal Reserve—rescued the country from financial calamity. But unemployment remains unexpectedly high; employers have been unusually reluctant to rehire and employed people are more hesitant to retire. The recovery hasn’t been behaving like previous ones. Overlooking the fact that George W. Bush had initiated the bailouts—including of the banks and automobile industry—Republicans charged that the new president was intent on intrusive, big-spending government. They portrayed Obama’s health care effort as just another “big-government program” that “we can’t afford.”

Expanding the health care system to provide universal coverage means taking on entrenched interests, such as insurance companies that are extremely powerful and well financed. Most people who already have medical coverage like their plans well enough despite shortcomings, and aren’t interested in shouldering the financial burden of providing for others’ access to insurance. Lyndon Johnson limited the expansion of medical care to just the elderly—Medicare—because a convincing argument could be made that they were the most vulnerable segment of society, with a large number of them needing medical help they could not afford.

In order to get the prescription drug program (Medicare Part D) through Congress, George W. Bush assured the drug companies that the government wouldn’t negotiate the prices of medicines, thus surrendering the most effective way of lowering them. So when the Obama White House—despite denials all around—made a similar deal with the drug companies, in exchange for $80 billion in promised savings in their costs (too low, many Democratic critics said), he was following a precedent.

It is widely believed, including, apparently, by Barack Obama, that the Clintons lost their effort to enact universal health care because they sent up their own bill to Congress (that’s what presidents usually do). But they failed because they sent up a hopelessly complicated bill, drawn up in secret (excluding the views of powerful committee chairmen on Capitol Hill), and because Hillary Clinton refused to negotiate with Republicans who offered reasonable alternatives.

Because of the enormous and ever- increasing budget deficit—most recently projected to reach a staggering $9 trillion over the next ten years—Obama has to try to push through a health care plan under constraints that no other president has faced. This is why in his speech before Congress he pledged that the projected cost of the reform would be $900 billion over ten years—a political number chosen to avoid the dread word “trillion,” which he had earlier said was acceptable.

According to Joseph Califano, Johnson’s powerful chief domestic adviser, when Medicare was being considered, “LBJ raised hell with anyone who projected costs, and the costs we did project were lowballed.” And at that, Califano said, Johnson made deals with major health providers that discouraged efficiencies, and the cost of Medicare exploded; the program is expected to run out of money by around 2017. In any event “projections” of how much a piece of legislation will cost over the years are just estimates, another term for guesses, which is why they’re so often wrong: they can’t take into account perhaps the two most important factors—unpredictable technological developments and human behavior.

Califano, who has remained active in the health care field, told me:

It’s preposterous to project ten-year costs. When we passed Medicare no one foresaw MRIs, CT scans, transplants, or the explosion of life expectancy. And now we’re on the verge of a revolution in neurology and in genetics, stem cell research, and multiple transplants.

Earlier this year, Obama told congressional leaders that he would leave the details of how to pay for his health reform to Congress. He made some proposals that—as he must have, or should have, expected—wouldn’t be acceptable on Capitol Hill, but he essentially left the hard calls to the Senate and the House. Obama’s lack of specificity annoyed many Democratic legislators who essentially support him, and who clamored for months for more precise policies.

His recent speech before Congress continued to evade some of these questions. He remained vague about how his program was to be funded. The problem was how to enact a mandate that every individual had to have insurance (with the exception of certain hardship cases) and require that businesses either provide coverage for their employees or pay a fee (with the exception of certain small businesses), while also subsidizing those individuals unable to afford insurance—and find the money to pay for it all. He had already circumscribed his own options, not only for paying for the health care plan but also for reducing the deficit, by flatly barring tax increases for the middle class, and by pledging that the new health care program would not increase the deficit. (When, in August, his economic advisers—responsibly—floated the idea that taxes might have to be raised at some point to reduce the deficit, White House aides firmly knocked that down.)

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    See the piece by Michael Tomasky in this issue.

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