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In this diary, I discuss some strategic and tactical reasons why I believe it essential to pass and sign any kind of reasonably good health care bill (which I believe, with a few exceptions, the Senate one is) as soon as practicable.  In particular, I believe that the tactical situation is currently as favorable as it's likely to be any time soon, and if we miss this window, we may be in for a very long wait indeed.

One thing I want to note up top is that I give President Obama -- and Nancy Pelosi and Harry Reid -- tremendous credit for getting us to where we are today.  There have been no large-scale expansions of medical care since Medicare and Medicaid over 40 years ago, and this is the very first attempt to cover the broad mass of young to middle-age adults that has gone anywhere at all in Congress, much less passed both houses (albeit with plenty of work left), and these three leaders have put in a tremendous effort to get us as far as we have.

Caution: some of this diary is going to sound a bit macabre.  I apologize in advance for that, but I think that good planning has to consider the tactical situation, not just the strategy or policy goals.

Also, apologies for the length; it got rather longer than I envisioned.

First of all, in regards the particulars of the bill, I think that for the most part they're as good as we were ever going to get (and in some cases, such as Bernie Sanders's community health centers, very good indeed).  The abortion provision is the most glaring exception.  However, given that an even more restrictive amendment passed in the more liberal House, it's hard to see how that could have been beaten back.

As far as President Obama: while he has not been leading from the front particularly much, he got the issue on the table and kept things going, at least behind the scenes.  Good leadership is doing what it takes, and politics is the art of the possible.  A real leader is more concerned with accomplising goals than his or her popularity.  We can all identify possible mistakes that he has made -- and he has identified some himself -- but it's a lot easier seeing that in retrospect.  In this case, I believe he judged that his most useful role would be to set the stage and allow the House and Senate to work on the details -- having observed what happened in 1993.  To me, having gotten this far represents a sea change all by itself, and while we're far from home free, we're vastly further along than we've ever been on this subject.

Harry Reid in particular has taken knocks from a lot of liberals (myself included) over the years, but observing the events of the past several months I've found myself forced to re-evaluate him.  He has kept things going where it would have been very easy to let them drop in ways that would have not attached blame to himself.  For example, he could have declared that Joe Lieberman couldn't be satisfied and kicked him out of the caucus, which would have won him a lot of plaudits here but I believe would have been disastrous.  He didn't; he persevered, keeping the Senate in session longer than it has been for decades, working right up to the holiday break.  He really has been leading this effort, and in ways that don't give themselves to receiving kudos.  So I want to recognize that.  Nancy Pelosi, of course, is Nancy Pelosi, and she drove things hard in the House.  She is a real credit to the Democratic Party and a superb public servant.

I have a lot of difficulty believing that anything President Obama could have done would have changed matters in the slightest.  Joe Lieberman and (for different reasons) Ben Nelson are not particularly amenable to persuasion; Nelson believes strongly that he has to cater to his relatively conservative base and Lieberman simply is a maverick who all too often seems to have it in for liberal causes in general.  With the Senate makeup being what it is (which I'll discuss more under tactics below), it's inevitable that those last few Democrats -- the ones least convinced -- will have a lot of power.  We can argue ad infinitum about the merits of single payer vs. public option vs. anything else, but it's my belief that those details are much less important than first ensuring that everyone has access to health care, which this bill goes a long way towards providing.  I think it's entirely possible that President Obama never expected to have a public option to begin with; I saw one diary recently suggesting that it was simply a tactical ploy to misdirect the Republicans from the real business at hand.  It's also possible that he did intend to have a public option but events simply didn't work out.  I just don't see any reason why he'd simply knife us (the progressive community) in the back.  I just don't see a situation where that as a primary purpose would benefit him in any way.  It's not likely that we'll ever know.

I think a lot of us don't understand just how far to the right the Overton window has shifted, and specifically just how contentious health care reform really is.  Just as an example, I see a lot of arguments here that people are unwilling to accept a mandate if they have to buy insurance from a private provider, on principle.  To me, this is only a slight variant on the libertarian/conservative argument that doesn't accept government mandates at all for reasons strictly of principle rather than practice.  Principles are important, but it's also important to identify which principles really are important and which are subsidiary.  I think a principle that "government should, as part of providing for the general welfare, ensure that all people in the US have affordable access to health care" is a key principle, but a principle that "government must not require people under any circumstances to purchase something from a private vs. a public party" is distinctly subsidiary.  Shifting the window to the left isn't something that will happen overnight; the very fact that universal health care is very much on the table is a big shift in its own right.  And while the Senate bill doesn't extend coverage to everyone, the community health centers that Bernie Sanders added to the bill offer promise of helping the remaining 15-20 million.  We can argue details such as exact levels of funding, but this isn't simply a throwaway to keep us quiet.  In general, though, the fact that universal health care has been on the table ever since Teddy Roosevelt (100 years ago) but has never passed suggests that there is real opposition, whether we like it or not.

The tactical reasons to expedite passage aren't discussed here very much, but I think it's important to consider the tactical situation.  There are two key areas (at least for the next 3+, and hopefully for at least the next 7+ years) we need to focus on, the Senate, and the House.  I'm going to focus on the Senate because it's more complex and because we're more at risk in the Senate than in the House in the short term.

Our effective working majority in the Senate is razor thin.  We have exactly the number of votes required to pass regular legislation over the objections of the Republicans if they stay united -- and they have shown every indication of remaining so.  I suspect that that's what all the courting of Olympia Snowe was all about, to try to probe just how solid the Republicans are, and it looks like the answer is "rock solid".  Something we've been saying all along -- which underscores just how narrow our effective majority really is.  I guess we were not as unified in the minority.

While we may not like them, the rules of the Senate are what they are.  There are very few things not subject to cloture, so unless we want to invoke one of those exceptions, we have to live with the supermajority rule.  Others more expert in the Senate than I have discussed problems with reconciliation; the only thing I'll add there is that there are a lot of traditionalists, even among the more progressive members, in the Senate.  I suspect a lot of these would not have gone along with anything that tried to get around the fundamental purpose of reconciliation; if Robert Byrd, for example, decided that it wasn't right to do so, I suspect more than 10 Democrats would have gone along with him.

So with that in mind, let's look at the tactical situation in the Senate.  We're very fortunate to have even 60; the expectation before the election was that we'd have 57 or 58, but due to a few things going our way (Begich and Frankel), Lieberman ultimately deciding to remain a Democrat, and Spector flipping, we wound up with the magic number.

What happens next year?  Well, the Republicans are defending 19 seats and we're defending 15, which superficially puts the arithmetic in our favor, particularly since the 2004 election was +4 Republicans (which means a good number of those 19 are held by freshmen, who are presumably more vulnerable).  But look more closely at the 2004 Senate electoral map (see for the details): the 6 seats the Republicans picked up were all in the South, except for South Dakota, so those seats are likely more solid than they might otherwise be.  We picked up two seats, in Illinois and Colorado; Illinois is often fairly blue, but Colorado isn't.  In addition, midterm elections are typically difficult for the party of the incumbent president.  That's going to make the task of holding on to our 60 seat majority more difficult than it might otherwise be, especially if we don't succeed in one of our stated goals.  So in my view it's essential that we pass something helpful by then.

Beyond 2010, the situation becomes more difficult.  2012 is a Presidential election, so turnout and enthusiasm should be high, but we gained 6 seats in 2006 and have to defend 24 seats vs. 9 Republicans (see for the breakdown).  Note that I'm counting both Lieberman and Sanders as Democrats for this purpose, but both seats caucus with us.  That's very difficult arithmetic for us, especially since most of the Republican seats are in very red states.  In 2014, we have to defend 20 seats vs. 15 Republicans, which is difficult enough, but many of the Democratic seats are, of course, first term.  Those elections are typically very difficult indeed for the incumbent party.

But it gets worse than that, and here's where we have to look at really macabre possibilities.  As nasty as Tom Coburn's comment may have been, it does contain a kernel of truth.  We currently have 60 seats, but it's not impossible to lose seats between elections, either by death or resignation, or by someone flipping.  If a Democrat in a state with a Democratic governor (or where the rules require the governor to appoint someone of the same party) were to leave office, the seat would stay in our hands, but if the governor is Republican and there's no such rule, we'll lose the seat.  Even if the state requires election of a new senator, we're not necessarily in the clear -- look at the example of my home state, Massachusetts.  We effectively had only one senator for much of the year, because Kennedy was incapacitated, and it took some fast maneuvering to allow Deval Patrick to appoint a temporary replacement.  If not for that, we wouldn't have had a second senator until late January, and hence would not have been able to win cloture votes that the Republicans stayed unified on.

This, more than anything else, is why I'd like to get a bill passed by both houses ASAP even if there are a few things that I'd like to see improved.  Obviously different people have different appetites for risk, but I'd like to minimize that risk as much as possible within reason (one thing I'd like to see is to start more things next year rather than in 2014).

(Incidentally, this is the issue that I am most unhappy with Joe Lieberman over.  In 2000, he refused to pull out of the senate campaign in Connecticut while he was running for VP.  If Connecticut had had a Democratic governor I still would have been unhappy because it would have demonstrated less than complete commitment to the ticket, but it wouldn't have caused any real damage.  As it was, his actions guaranteed that if Gore had won the seat would have flipped to the Republicans, because John Rowland, the governor at the time, would have appointed a Republican.  Since the Senate was obviously going to be very close, it could have made the difference in control -- and in practice it would have.  Lieberman was surely aware of this, yet insisted in doing what was best for him personally rather than the party.)

The House has different dynamics.  It obviously doesn't move in complete lockstep with the speaker (think Stupak), but it has a simple majority rule.  So given our current majority+38 seats, we should be reasonably secure on major issues between now and 2010.  Assuming we gain (or don't lose too many) seats in 2010, we should continue to have a working majority.  However, in 2012 there will be reapportionment, which will likely result in significant gains in southern states (which, of course, are mostly Republican), and Republican-controlled legislatures will surely do what they can to increase Republican numbers.  So things may get more difficult for us at that time -- and, of course, there are never any guarantees for 2010.

If you're interested in the subject of Congressional apportionment, I recommend you read -- the details are quite interesting, but not immediately relevant to the situation.

In summary, while reasonable people may differ on the bill, I think it's critical for tactical reasons that we pass a bill as soon as possible.  The tactical situation, particularly in the Senate, is particularly favorable for us right now and is not likely to improve.  We also need to look at the public opinion and morale issues of having something substantial passed now.

Originally posted to rlk on Fri Dec 25, 2009 at 06:36 PM PST.

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