Obama's political strategy for the fight on health care

How does Obama win the health care battle?

Get a head start. The stimulus package included medical coverage for the unemployed and their families, for some laid-off employees, and for over-55s who want a bridge to Medicare when they reach 65; there are no means tests. The bill also spent money to streamline medical records and get them online. This, in addition to the expanded SCHIP health bill for kids and pregnant women, means that Obama is already fighting and winning the battle for universal health care (UHC) before the real health care battle even begins. Incidentally, no less than nine Republicans voted for SCHIP in the Senate – so much for unanimity.

Move fast. Obama, Kennedy and the Democrats are pushing for quick action. Hillarycare took a year to get started in 1994.

Keep the process open. Hillary, who is not invited for this round of health care deliberations, kept the 1994 process under the White House umbrella, drafting the tiny details of the legislation; a lot of people, including the big guns on Congress, were left out, an obvious booboo.

Keep it realistic. Some liberals want to go whole-hog with a European system, aided by people like the California Nurses Association and some players in the House. No no no no no!

Keep the Senate Democrats herded together. Kennedy gave up his seat on Judiciary to work full-time on this – he has no intention of failing. "This is the opportunity of a lifetime, and I intend to make the most of it”. But he is not the only big gun who is interested in this: Baucus has been working on it too. In 1994 inter-committee squabbling helped kill the health care plan, but this time Baucus and Kennedy are working together. And if a yellow-dog Democrat like Evan Bayh tries to gum up the works, Obama will pick up the phone and promise to roll a tank over his face if he doesn’t knock it off.

Win the marketing battle. In 1994 Harry and Louise won the PR battle by ten touchdowns. This time the market is more propitious: a recent poll showed that 73 percent of Americans not only want universal care but want the public, governmental option, and that included 63 percent of Republicans. But the package still needs to be sold. Or more precisely, the endless GOP lies need to be shot down.

Watch for the AMA, who along with Big Pharma helped kill the Patients Bill of Rights.

Consumer groups are on board. Labor likes the Obama plan, in part because high health costs depress wages. Some doctors and hospitals are on board; others fear their pay will decrease.

Obama could get help from the pharmaceutical industry, depending on the terms of the deal. Big Pharma helped the insurers to kill Hillarycare, but now the pharma leader, Dick Clark, says he wants a seat at the table so we can pass comprehensive reform, universal coverage and a restructuring of the health care market – but no drug price controls, particularly since the recession is hitting the drug firms too. The complicating factor is that at some point we must also go after the drug companies, on both prices and patents. Because there are no governmental price controls, prices are so high that people are shopping abroad to save money, and some call for letting the HHS department negotiate prices. Others argue for removing patent protection for drugs, to get generics out there. The trick is not to push so hard that it impairs innovation – or impels Big Pharma to fight Obama not only on drug prices but on the larger health care issues. So far, it seems that Obama is only going to push for better discounts for Medicaid prescriptions.

But the big issue is that businesses, especially the U.S. Chamber of Commerce, the automakers and the SBA, are in support of a universal health plan – during Hillarycare they were mostly on the other side. That support will help get the plan passed, and then they will buy into it in huge numbers, dumping their current plans with the big insurers.

So in the end, it may not matter that Obama set up a system consisting of the government plan and the existing insurers, instead of shoving the insurers out: the businesses will shove the insurers out anyway, because of the cost, unless the insurers cut prices, which may be impractical. The health insurers are dinosaurs like the Big Three.

The trick is, the insurers can see this coming, so they will fight bitterly on Capitol Hill. They have promised to make a few concessions, in order to try to buy off enough Senate Republicans and conservative (or vulnerable) Democrats to uphold a filibuster. They are already looking for interest groups to help them.

The insurers are putting forward their notion of a good plan: they include some of Obama’s propoals and they agree not to jack up rates so much on people with pre-existing conditions, but they want to require everyone to buy insurance, they oppose the public governmental option, and they oppose requiring companies to provide insurance or pay into a pool, referred to as the "play or pay" mandate.

Obama is dangling goodies in front the insurers: the prospect of new customers coming in for checkups, therapy and surgeries. But he insists on the public governmental option, to keep the insurers honest, and he only wants to require parents to buy coverage for their kids. EJ Dionne of the Post thinks the insurers will get the mandate that everyone must be covered, but if Obama also gets the public option, then the insurers will still be under some control, finally.

The insurers will get help from the Republicans, who are terrified. They acknowledged as far back as 1994 that they weren’t afraid universal health care would fail – they were afraid it would succeed, and help build an insurmountable Democratic majority for 50 years. They also know that once America actually sees how well UHC works, and how cheaply, the myth of government inefficiency will be exploded. They will no longer be able to argue that the market is always the best way to do things. They see, in UHC, the death of the GOP.

That explains their bitter opposition in 1994; their leader from that era, Dole, admitted even in 1994 that he was rounding up the votes to kill the plan although he had never even read it, and recently he admitted that they would be wrong to block up the drain again this time. Dole’s GOP successor, Mitch McConnell, is the master of filibusters and is already threatening obstruction. But McConnell may be betrayed by GOP moderates, particularly the ones who are up for reelection in 2010 and 2012.

Obama and the Democrats have two more weapons to use. First, they already have four GOP Senators working on their plan – Enzi, Hatch, Gregg and Grassley. Second, they may play the trump card and pass the health care bill by means of the budget reconciliation process which only requires 50 Senate votes. Reagan and Bush 43 used that to pass their budgets, and if Senate Republicans insist on going nuclear in their effort to prevent Al Franken from being seated, the Democrats won’t feel particularly guilty about playing the reconciliation card.