Parallel Universe Health Care Reform

In a classic Star Trek episode, Kirk, Scotty and Uhura find themselves beamed aboard an Enterprise in a parallel universe where mankind is evil, their crew is filled with warriors, not explorers, and Spock has a goatee! The legislative push for health care reform has a similar through-the-looking-glass feel to it. Reform was never going to be easy, but as recently as the spring, there was more optimism than pessimism. What happened? Here's a list of factors that, in some parallel universe, contributed to health care reform successfully passing on schedule before the August recess -- but in this universe, simply didn't pan out.

(To be clear, these are factors that actually seemed likely to help health care reform when the year began.  I'm not including improbabilities like, "Obama would endorse single-payer" or "John Boehner would suggest House Republicans 'vote their conscience' on health care."  They're also strictly political factors... because it's Friday before Labor Day, people!  Let's have some fun with this!)

Ted Kennedy – How much would Ted Kennedy leading the charge, as had been the game plan all along, have helped the legislative effort? No doubt, the Senate Health, Education, Labor and Pensions Committee bill itself carries the distinctive Kennedy stamp, but how would he have improved the process were he there in person? Would we have had a shot at Sen. Orrin Hatch supporting the bill, whose affection for Kennedy made him an effective bipartisan collaborator in the past? Would the threat of Kennedy’s dominance have kept Max Baucus, as Ezra Klein puts it, “looking over his left shoulder?” On a parallel Earth, we didn’t just get Kennedy’s policy, we got Kennedy’s presence.

Max Baucus – Ezra and Matt Yglesias both wrote “What the hell happened to Baucus?” posts this week. Count me among those who became really optimistic after reading Baucus’ white paper on reform, which resembled a more robust version of the Obama campaign plan, with some features swiped from both John Edwards and Hillary Clinton, as well as novel approaches to graduate medical education, malpractice reform, and a whole host of other issues. And yes, for the record, it did promise robust subsidies, an employer mandate, and a public option -- the very items most prominently on Baucus' "gang of six" chopping block today. If the ultimate Senate Finance Bill resembles the details we’ve heard from the “gang of six” sessions, it’ll be a shell of the Baucus white paper. On a parallel Earth, that white paper formed the basis of Baucus legislation, and it was much easier to synch with the Senate HELP and House bills.

Tom Daschle – Daschle is now playing a behind-the-scenes advisory role, but we know he’s not in the legislative meetings, nor is he in the negotiating sessions. That was arguably where he was going to do the most good, with his years of experience at “getting to yes” in the United States Senate. Daschle also would have provided a charismatic public face for health care reform other than the president.  It’s pretty clear that the White House had to go to Obama as their spokesperson for reform early and a little too often. On a parallel Earth, Daschle became the public and private salesman for health reform, giving the White House more options.

America’s Health Insurance Plans and PhRMA – A fundamental rule of winning the media narrative is you need heroes and villains. When it comes to health care, the two players with the most potential to be villains have instead proven to be relatively cooperative. As I’ve blogged many times, that doesn’t mean they’re not looking out for number one -- they’re just trying to influence the debate from within rather than without. Put another way, health care reform isn’t a good idea in a vacuum;  it’s a good idea because it solves a problem. Without the real problem -- sky-high costs and abusive business practices -- the solution itself becomes the problem.  But the possibility of containing costs for prescription drugs in the bill went out the window when reformers realized Big Pharma was more valuable spending millions on pro-reform ads than being the subject of them. Similarly, AHIP mastered the art of having their public face (Karen Ignagni) seem reasonable and willing to accept commonsense regulations even while they lobbied, gave campaign contributions and pushed sub rosa tactics to influence the decision. But that meant only belatedly, with the new rebranding of “Health Insurance Reform,” is anyone willing to bash the unfair and unjust business practices of the disturbing anomaly of for-profit insurance. Very few people are motivated by the “bend the curve” cost control argument on a visceral level, no matter how true the argument is. They are visercally affected by having people denied treatment because of pre-existing conditions or out of a profit motive. On a parallel Earth, AHIP openly came out against reform, and that rallied reformers.

There are doubtlessly many other factors: the poisonous tone and politics of the debate on the stimulus, which has subsequently dogged most legislative actions since then; Chuck Grassley transforming from Max Baucus’ bff into a perpetuator of the “death panels” myth; the House breaking without voting on the health care bill, which created a window for a bona fide public relations disaster in August; even the whole notion of a bill being written by a bipartisan “gang of six” behind closed doors, rather than in the Senate Finance Committee. All of them helped land us in the spot where we’re in -- with health care reform on the precipice.

(Public domain portrait of the President, with some Photoshop magic by the author.)