Democrats repeatedly make fundamental mistakes in dealing with voters. This showed up in the Brown-Coakley match here in Massachusetts, and it will show up again. If you can't get the tone of the message right, you'll lose people who are your natural allies. Brown showed that with the right tone of voice (and he's a masterful campaigner), you can sell almost anything.
What voters want most is to be treated with respect, not patronized. They do not want politicians to stand up and say "take your medicine, it's good for you". Bush called his opposition the "reality-based community", and sold voters a fantasy. It worked too, until reality intruded in a really big way. In ordinary times, we can't count on that.
The HCR message is thus not one of left-right, weak reform vs. strong reform. The message is all one of positioning. Massachusetts already has a state-level system in place that's the prototype of what's planned in Congress. So the stakes here were especially low! It's not a great system but people don't want to turn back the clock; they just want it improved, especially with cost controls. So turning to the Nelsons and Liebermans would miss the point entirely. The key point is to show respect.
One thing that totally galls white working-class voters is the idea of "welfare". In the 1960s, it became a strong dogwhistle term with special meaning for white backlash voters. Ronald Reagan got a strong majority of working-class Catholic voters on his side, even though his policies really hurt them, because he seemed to respect them, and he loudly showed no respect for "welfare queens". He talked about working people about lowering taxes as if it were their taxes he were lowering. Brown pulled off the same stunt.
People feel good about earning their own money. They don't want a handout. Americans are taught to feel bad about receiving handouts, and -- especially Republicans -- to feel bad about people who receive them.
So how do you fund health care, when a policy costs $15k/year and a family makes only $50k? Canada's culture values "fairness", so it's fair that everyone gets coverage. American culture focuses more on "self-sufficiency", so fairness alone won't do it.
Economists don't care about political consequences. They see the flow of money. Hmmm, we can set a limit of say 10%, and say that a family pays 10% of its income to insurance and the rest comes from somewhere else. Makes sense on paper. But in politics, it matters how you say it. The current plan has families of 4 making up to $66k or $88k getting a subsidy from the feds to buy insurance. Middle-class voters do not want subsidies! They want the price to be affordable, but they want to feel like they're paying their fair share, not collecting anything that even begins to resemble "welfare".
In Massachusetts, if your income is less than 3x FPL, you don't get a "subsidy" to purchase insurance from the Connector. You are entitled to enroll in "Commonwealth Care", a Connector program that sets the price of insurance based on your income. Get the difference? I seriously don't think that Obama, Rahmbo, Reid, or even Pelosi get it. They look at the numbers and the percentages and hope that people appreciate it.
Even the "Commonwealth Care" dodge is marginal, politically. But at least it shows a little more respect for voters. A single-payer plan could do away with explicit subsidies too, simply charging people a tax and averaging medical costs more broadly. A public-provider plan (like the NHS) also has no subisides; it treats health coverage like police coverage, just a service provided to all, with respect. So that could actually be even more popular. The Community Health Centers are great, but they too need to be positioned as a place for everyone, not the "welfare doctor". It's hard to imagine a politically worse stew than what's in Congress now, where the average voter is told that they'll need subsidies or be penalized.
We need economists who can document reality, but they need to be teamed up with smart advertising and political message managers. It's not left vs. right; it's all about how the message is sent.