After the Show, the Real Plan

Stephanie Burt · Healthcare Reform

A year ago US healthcare reform seemed inevitable: no one knew whether it would include a public option (a government-backed competition with private insurers), or how much it would try to control costs, but all the smart money expected that some plan to insure America's uninsured, or at least many of them, would go through. Eight weeks ago the smart money went the other way: Republican Scott Brown's surprise election to the Senate not only killed the Democrats' Senate supermajority, but spooked already nervous Democrats in the lower house so badly that it seemed they would not, could not take the necessary votes.

And now healthcare reform is the law of the land. The president signed the underlying bill on Tuesday morning; the dignity of the ceremony was fortunately undercut by Joe Biden, who quipped, just near enough to an open microphone: ‘This is a big fucking deal.’ The White House press secretary, Robert Gibbs, endorsed the VP's verdict via Twitter: ‘And yes, Mr Vice President, you're right.’ (Will the Supreme Court overturn it? Anything's possible, but respected conservative legal minds say it's unlikely.) Reform is a big deal, not just for political parties, but for tens of millions of Americans who will have still imperfect, but far better, security if they get sick.

It very nearly didn’t happen. Both the House and the Senate passed healthcare reform in December, while the supermajority held, but the bills were not identical: the House version would never have passed the Senate and the Senate bill contained some obvious clunkers: a tax on expensive insurance of the kind that unionised coal miners, for example, really must carry, and some much-derided giveaways to individual swing senators' states (e.g. the ‘Cornhusker kickback’ for Nebraska). Most House Democrats would not have simply voted for the Senate bill: if they had, they would have got the blame for those clunkers. But they would also have been blamed if healthcare reform had failed. The White House knew that enough House Democrats might – just might – be persuaded to support the Senate bill if they could also pass a separate bill to fix its flaws, but they had first to be persuaded that this separate bill could pass the 59-Democrat Senate under a rule called ‘reconciliation’, by which budget measures require only simple majorities.

That work of persuasion has been underway for some time, and most of it could not have been done in public, since the people to be swayed were the lawmakers, whose particular hobby horses, policy preferences, scruples or local concerns had to be assuaged. The micropolitics, the back-scratching and hand-shaking and whip-counting won't be fully known for decades, but what we do know makes several people look good, among them the Speaker of the House, Nancy Pelosi. Also looking good, in the end, are most of the few dozen Congressional Democrats who oppose abortion rights, most of whom seem really to have been voting their consciences, and most of whom (even the attention-seeking Bart Stupak) came around. Stupak – who waited till 4 p.m. on the day of the vote – wanted very much to be seen as a forceful defender of foetuses, but once he had made his decision, he was a forceful defender of health for the already born: when Republicans tried to kill the House bill by amending it with Stupak's own ‘pro-life’ language, the Michigan Democrat spoke out against their move.

Had Stupak been as bullheaded as he was painted (and as he appeared to be); had Pelosi been less persuasive; had she or Steny Hoyer, the majority whip, done the arithmetic wrong; had even a handful of House Democrats from conservative-leaning districts decided to take more cautious or myopic views; had another handful of mostly Latino members not accepted assurances that their concerns about immigration would be addressed this year; had the Senate majority leader, Harry Reid, who will probably lose his seat in November, not been able to prove to enough House members that the reconciliation measure would get at least 51 votes – then healthcare reform would be as dead today as it looked on 21 January.

The president seems vindicated not only in his ideals, but in his management style. The State of the Union speech in late January, given the week after Scott Brown won Ted Kennedy's old seat, now looks like a turning point. In it Obama insisted that he would ‘not walk away’ from healthcare reform, even though (to progressives' dismay) he never specified how it was to be accomplished: he never said he would use reconciliation. Why not? He had to show the inattentive American, the ‘independent’ voter, that there was no less partisan way to get anything done.

The much-talked-about and (in policy terms) meaningless ‘healthcare summit’, televised from the White House, was the show he chose to put on, and only after the show was over could the real plan (have the House pass the Senate bill, plus a reconciliation fix) work. Designed to give the appearance of listening, the healthcare summit was also designed to give Democrat leaders in Congress time: time to count noses, time away from the news (or at least from the news about healthcare), time for the Scott Brown panic to recede, and time to convince skittish backbench Democrats to support reform, on pragmatic (failure makes all Democrats look weak) as well as on moral grounds.


  • 24 March 2010 at 7:05pm
    bilejones says:
    This Bill is possibly the worst of all possible worlds.
    The health care system in the US has, for decades been carefully tailored to funnel ever increasing resources to the politically connected.

    Movement in either direction: Toward Single payer or a libertarian opening up of what's a stunningly controlled industry with more barriers to entry than you can imagine, would have been preferable to the expanding and cementing of the oligarchical/corporate system that this bill achieves.

    Now that health care reform has been "done" nothing will change in the basic system and the looting will continue with Vigor and Abandon.

    As Avedon Carol pointed out back in December

    "In 2007, public expenditure (i.e., tax money) on health care per person, was around $3,300. That's before you paid your "insurer", before you paid your doctor, before you paid for any form of treatment, you paid $3,300 whether you needed it or not. (As an American, you also had the privilege of paying even more than that for commercial costs, bringing your total to an average of $7290.) In that same year in England, the total expenditure of taxation and private expenditure was$2,992 per person. *

    Let me put that another way:

    US paid by your taxes: $3,300 (or thereabouts)

    UK taxes plus private: $2,992

    And the kicker is, even relatively low-income minorities in the UK get better health care than the well-off in America."

  • 24 March 2010 at 8:42pm
    A.J.P. Crown says:
    Unlike the first comment, this article says absolutely nothing about the new US health reform act. The article tells me who did what to whom in the Congress, what the different parties' strategies were, what it will mean the next time around and lastly that the US president's "management style was vindicated". That's all you can read about in the NY Times too. It's all fluff. Don't Americans care what actually got passed, what's in this act?

  • 24 March 2010 at 9:20pm
    A.J.P. Crown says:
    Now that I look at your website I see you aren't a journalist, Steve Burt; so I apologise for being grumpy, and I'll just assume you've been reading the same Times articles I have.

  • 25 March 2010 at 2:07am
    Stephanie Burt says:
    Bilejones appears to take the position, common among US opponents of health care from the (supposed) left, that it's not worth doing anything to help anybody unless we can change the whole system. I'd hate to say so to a diabetic with two kids making $12/ hour, 20 hrs/ week.

    AJP Crown is right to say that I'm not a professional political journalist (usually I write about poetry), and that I didn't explain exactly what the health care bill will do, except in the broadest possible terms.

    Crown is right to say that US pro journalists have focussed too much on the process, too little on what the bill does, but it's pretty easy to find out what the bill does if you read the right sources. Try Ezra Klein (this is a link to a whole set of columns):

    Here's a good piece, with some numbers and policy details, on why pro-choice feminists should support the bill:

    And here's a very good, short, somewhat angry, defense of the bill (and of bills like it) against critics such as Bilejones:

    • 25 March 2010 at 9:20am
      A.J.P. Crown says: @ Stephanie Burt
      Thank you for the sources, I'll take a look. My point was intended as a good example of standard US journalistic practice on many hot political topics--as if the analysis were the real story. However, for most of us, what gets put into the legislation is the reality, and it's far more important than the process.

  • 26 March 2010 at 9:44pm
    bilejones says:
    Actually Stephen, I'm a fairly hard line Libertarian. My Wife works for big pharma and we have a Health Care plan that we are satisfied with but
    I would rather have Single Payer than the Obama plan because of the cementing of the stunningly corrupt system in place.
    I guess at the end of the day I'd prefer socialism to fascism but something approaching a Constitutional Government would be best.

  • 27 March 2010 at 1:51pm
    Julia Atkins says:
    That the passing of the Health Bill is a huge propaganda triumph for Obama is indisputable; that it will benefit the most needy is much less obvious. That it will make the insurance companies and the giant pharmaceuticals incredibly happy is obvious. Seventy-seven House Democrats were intending to oppose the Bill because it rejected the single-payer plan which has now been consigned to oblivion. Slowly the opposition of the 77 was whittled away and finally the last of them, Congressman Dennis Kucynych was given a free ride on Air Force One and told 'My Presidency is on the line here.' He caved. Concessions were given to the anti-abortionists, but not Kucynych and friends. The fact that the Bill will not be operational till 2014 means that its main utility is to ensure a second term for Obama. How it works is something that will be the responsibility of his successor.

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