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Some Unsolicited Advice for Howard Dean, and for President Obama, Too

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I've been spending much time recently with primary care physicians across Chicago. Interspersed with the work, I hear many stories about the difficulties experienced by urban low-income patients.

There was the man with diabetes who was uninsured until age 65. Thanks to Medicare, he now gets excellent care. That won't restore the sight he lost to diabetic retinopathy a few years ago. There were the uninsured women whose metastatic breast cancer was diagnosed in hospital emergency rooms. There are the uninsured men recovering from gunshot wounds who face large bills. There is the woman with a serious chronic illness worried what she will do if she loses her job, and thus her good employer-based coverage. There are the people who suffered strokes after going years saving money by skipping doctors' visits or by skimping on their pills.

These are not horror stories ginned up by advocacy groups. These are commonplace occurrences within most low-income communities. Every one of these patients would have benefited from provisions of the Senate health reform bill. Within the catchment area in which I do my work, maybe 100,000 people would gain health insurance through provisions in the House and Senate bills.

Dr. Dean. I thought about these stories as I read various emails from you and from your affiliated group, Democracy for America. I read with special dismay your recent Washington Post op-ed saying that you would vote against the Senate bill. These missives may reach a receptive audience. I'm dismayed myself by the loss of the public option, by affordability concerns, by the ridiculously long delay before reforms take full effect, by the unworthy prominence of Senator Joe Lieberman, given the real disappointment progressives are feeling, it's important to note how foolish and destructive your message could be.

As others have noted, Democrats are on the brink of enacting an imperfect but historic bill that will cover 30 million people and correct egregious defects in our current health insurance system. Fully implemented, the bill would provide about $200 billion per year down the income scale in subsidies to poor, near-poor, and working Americans.

$200 billion is a big number. It exceeds the combined total of federal spending on Food Stamps and all nutrition assistance programs, the Earned Income Tax Credit, Head Start, TANF cash payments to single mothers and their children, the Department of Housing and Urban Development, and the National Institutes of Health.

More than that, this bill codifies the responsibility of the federal government to ensure decent and affordable health coverage is available to every American. The Senate bill does not yet live up to this responsibility in every particular. Still, by almost any measure this is a historic expansion in the humanity and the ambition of American government. Paul Krugman, Jonathan Cohn, Jacob Hacker, Ezra Klein, and Paul Starr disagree about many things. Not about this. Almost everyone I know with expertise in health policy, public health, and the politics of health care believes as I do: we just have to pass this bill.

Nine months ago, I was one of a small group of health policy wonks and bloggers who helped jump start Democracy for America's health care advisor website on in the health reform fight. In one of the very first postings, David Cutler noted:

Why, then, has health care reform been so elusive? The old folklore is apt: no one favors the current system over his or her ideal system, but the current system has always come in second place.

In the early 1970s, and then again in 1993/94, many people sat on their hands or rejected messy, imperfect, and politically possible compromises in the hope that we would eventually see a better bill. That stance was understandable, but eventually didn't come. Ted Kennedy and many others rightly concluded that absolutism fostered political defeat and to continued suffering by millions of uninsured or underinsured people. We see that stance today among some (though not all) single-payer advocates, some of whom have marginalized themselves into irrelevance by opposing every non-single-payer alternative from a robust public option on down.

In fairness, you were never this bad. You played a useful role with your emphatic support of the public option in the health reform debate. Yet there was more than a whiff of personal positioning in your approach. You oversold the public option, and undersold other equally important pillars of the current reforms: the positive possibilities of insurance exchanges and regulation, the nuts-and-bolts of affordability credits. Then there is the centrality of this health reform bill to the Obama presidency and to the broader Democratic coalition.

I fear that your rhetoric and the rhetoric of others -- Kos and Robert Reich, to name two -- threaten to at once undermine support for a politically fragile reform, and to sour progressive support for what is actually a hard-won victory pursued at real political cost by Democrats from President Obama on down.

I had hoped that the proposed Medicare buy-in would provide a dignified path for you to sign on. When we lost that, you seemed to have no way to climb onboard. And you've kept talking, digging yourself into even greater difficulty. That has attracted a major backlash from liberals and progressives, which you deserved.

In the midst of Governor Mark Sanford's amazing scandal earlier this year, and his even more amazing series of public comments in press conferences, a South Carolina clergyman stated that he was looking forward to a period of silent reflection from Governor Sanford. John Stewart provided the requisite translation of the minister's remarks. There is some sign this morning that you are stepping back into the Democratic fold. If not, you might profit from a period of silent reflection of your own.

President Obama, I have some other unsolicited advice for you, too. You have genuine fence-mending to do with your progressive base: not with liberal incrementalist professors, but with larger progressive constituencies that look to you with such hope and that play such a key role in your 2008 victory. Dr. Dean's recent statements are only one symptom of a broader and potentially dangerous problem.

Progressives have taken their lumps this year. Single-payer was off the table. Then there was the robust public option, which steadily evaporated into a residue of its former self before being jettisoned. Then there was the Medicare buy-in. Then there were the Stupak provisions, and more. Democrats needed to make these concessions. As I noted above, we needed to pass this bill.

Most of your supporters understood that this would require unpalatable deals to reach that crucial 60th Senate vote. By and large, progressives have been pretty good sports. They bit their tongues watching the White House and Senate moderates spend weeks reaching out and making painful concessions in the vain search for a few moderate Republican votes. They've accepted costly giveaways to rural blue-dogs to secure critical votes. They have been polite in expressing their anxieties regarding affordability and regulatory vulnerabilities in the Senate and House bills.

Yet the frustration is building. At times, it is stoked by the comportment of your top advisors, some of whom speak a bit too evenhandedly about the excesses of both right and left, and who can be casually condescending about the need for progressive constituents to appreciate the realities of hardball politics. The same frustration is stoked by your administration's visible reluctance to expend political capital to pursue the public option and other progressive goals in health reform and in other policy arenas, too.

I understand the reluctance. The administration couldn't back itself into a corner and thereby risk passage of the final bill. Yet these decisions brought a real cost. Partly because of them -- more because of the inherent difficulties and frustrations of navigating a complicated bill -- there is a real gap emerging between the Obama administration and a segment of Democratic Party activists. It's hardly surprising that people emerge to fill this space.

Without dissing moderates whose votes you still need, you could address many progressive concerns by laying out in specific and visceral terms your own disappointment about provisions that have been lost. Delivering the following paragraphs from the Oval Office might help:

I should speak for a moment to my progressive supporters, who are rightly disappointed that we could not secure a public option or better protection for women's right to choose, who want greater help to middle- and low-income families, who want swifter action for people who need help now.

My job at this critical moment is to lock down a historic achievement: securing coverage for 31 million people who would otherwise be uninsured, hundreds of billions of dollars in desperately needed help to tens of millions of people, protections for people with chronic illnesses and disabilities. Millions of Americans will benefit from this bill. My first responsibility -- and Senator Reid's, and Speaker Pelosi's -- is to get this difficult job done.

Thank you for standing with me, even when I asked you to acquiesce in some painful compromises we needed to reach those 60 critical Senate votes. We did what needed to be done. Yet I share your concerns about every one of the above items. I'm proud to be the first President to take this bold step forward. My pride is bittersweet given my disappointment that we couldn't do more. So I will be back next year and every year after that, standing with you to improve this bill.

That might be a hard speech to give. It might include acknowledging your own mistakes, such as casually floating that $900 billion figure which forced House and Senate leaders to backload key provisions in the final bill. It might include an acknowledgement of the inherent limits on your ability to lead given current Senate rules.

It's important to communicate these difficulties, so that your supporters can appreciate what has actually been achieved. You enjoy a tremendous reservoir of good will among millions of grassroots supporters. Don't take that for granted.