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Why We Lost Healthcare

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One of the most telling tales in politics is the one about the progressive activist who got a meeting with FDR to explain his great new policy idea.

As the story goes, FDR heard the fellow out, and then told him: "I agree with you, I want do do it... Now make me do it."

FDR's quip goes to the heart of how our system works. If you want to make a good idea law, it's nice to convince your elected representatives that it's a good idea. But it's a lot more useful to go out and create the political conditions that make it easier for your representatives to enact your idea than to avoid enacting it. Talk to the public, make the idea look reasonable, make the need seem urgent, knock its opponents off balance. If instead you rely on your leaders to spend their precious political capital on your idea just because it makes sense... well, good luck with that.

Even a brief comparison of how FDR and Obama treated the banks during their respective first hundred days in office makes clear that Obama is no FDR. But the difference in approach is even more stark in how the administration has handled healthcare. Because where FDR told progressives "Make me do it," on health insurance reform, Obama told progressives the exact opposite: "Don't make me do it. I'll handle this. Trust me."

From the very outset of the healthcare debate, the administration told progressives to forget about expanding Medicare to cover all Americans (Teddy Kennedy's preferred form of healthcare reform). That was not going to happen, the administration said, and what's more, the administration did not want them making a fuss about it. Instead, the President pledged that he would only sign a bill that included the option to buy into a Medicare-like plan - the "public option"- which might lead to a Medicare-for-all policy someday. The administration invited progressives to support its position, but the administration always wanted to run the show.

By honoring that request, progressives created exactly the political conditions that would doom the public option. By abandoning Medicare-for-all approach at the outset and instead strongly advocating the public option compromise, progressives made the public option appear to be a radical left position, instead of the moderate market-based approach it actually was. Predictably, the public option was ridiculed by conservative polemicists throughout the debate as a socialist big-government takeover. And in the end, conservative Democratic Senators (as well as Senator Lieberman) did not support the public option exactly because progressives had so noisily supported it. Conservative Democrats like Ben Nelson felt it was important politically for their relatively conservative constituents to see that they did not support the liberal position.

This same point was made more pithily by Bernie Sanders, Congress's only avowed socialist, after Democrats failed to get fundamental health insurance reform passed under President Clinton. As that story goes, not long after Clinton's health care reform proposal went down to defeat in the Senate, Bill ran into Bernie, and Bernie approached him gravely and said "Mr. President, I am so sorry. I failed you on health care."

Clinton was puzzled. Sanders had supported his healthcare proposal. "What do you mean, Bernie?" asked Clinton. "You were with me every step of the way!"

"Exactly," said Sanders. "I should have been burning you in effigy on the steps of the Capitol. Then people would have understood how moderate your plan really was."

Sanders' point is simple: The center does not hold without the left. If the left is not visible, then the center appears to be the left, and that makes moderate voters wary. Progressives could have gone out and created the political conditions to make elected Democrats reform our health insurance system - they could have advocated the Medicare-for-all approach they really wanted instead of throwing their lot in with the pragmatic center. If that had happened, we could be talking about bargaining away Medicare-for-all to end up with a robust public option, instead of bargaining away an already-gutted public option to end up with a bill that will force millions of Americans to buy from private insurance companies with nothing to control the premiums they are charged.

It is worth noting that this game is still not quite over. Progressives could still fight their way out of the impasse created by making the public option the progressive option. Some progressive Senator or other could still learn game theory - or at least how to play chicken - and stand firm for the public option, forcing the administration to work around Senators Nelson and Lieberman and company. That would probably require dragging this into next year and splitting the bill, passing the controversial parts with the reconciliation procedure and leaving the popular planks, prohibiting insurers from rejecting people based on pre-existing conditions and the like, to pass separately afterwards. But that strategy takes time and involves risk the administration does not want to take, and has been looking less likely by the hour.

As dispiriting as where this leaves us on healthcare is what it portends for the future. After this endgame, where the President and all the progressives in Congress have been brought to heel by a couple of conservative Democrats and crazy Joe Lieberman, these jokers will be emboldened to be even more stubborn in legislative fights to come. Next up we have Wall Street reform, a desperately needed jobs bill, and even more desperately needed energy bill and the reliably contentious issue of immigration reform. What are the chances of passing any decent bill on any of those issues in the wake of this historic cave-in?

That is why it is so critical for the left to learn the lesson behind this loss. Today immigration reform advocates begin the long process of moving reform legislation through Congress. Realistically, they may hope to achieve an "earned path to citizenship" to bring illegal immigrants who have lived here for years out of the shadows, but requiring them to pay fines and back taxes and to meet an English fluency requirement. To reach that legislative goal, their equivalent of the public option, someone needs to be visibly advocating something further left, the equivalent of single-payer: maybe something like unlimited amnesty with visitation for family members. (That is not impossible to argue for: we are a welcoming, pro-family country, built on immigration, and if we do a better job enforcing our employment laws then illegal immigrants won't find work here and will deport themselves, etc.) The key point is that without some further leftward position to balance the debate, conservative Democrats will not be able to support the moderate approach that progressive reformers want them to, because it will literally be the most liberal position in the debate. We know how that works because that's exactly what just happened on healthcare: conservative Democrats insisted on maintaining some daylight between their position and what is seen as the left's position.

So the next time the President asks progressives to follow his lead, the answer should be clear: no thanks. For Obama to do his job, he needs progressives to do theirs: let progressives fight on the left flank to make room for the President to steer a middle course. Yes, that will mean some strife within the Democratic family, and the President seems to prefer when we all just get along in public. But we have just witnessed what that gets us: taking forever to pass weak legislation that betrays the hopes that got Obama elected, sapping public enthusiasm for his Presidency.

This is a really bitter lesson. But let's learn it already, and never repeat it again.

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p.s. Reading the comments, it's clear and understandable how raw this all is. Let me just be clear: I am not saying progressives did not put forth enough effort - not at all. I am saying too many progressives made a strategic mistake at the outset in trusting in the administration's political strategy and abandoning Medicare-for-all in favor of the public option, and that mistake sowed the seeds of the defeat that now looms. In using the term "progressives" I have painted with a broad brush. Many have remained committed to the single-payer idea, but groups like the SEIU, a majority of MoveOn.org members (the organization's stance is guided by its members' opinions), and the Health Care for America Now coalition all backed the public option from the start and did little to keep single-payer on the radar.

Also, in no way am I letting the administration off the hook here. Given the administration's tepid support for the public option this fall (also duly noted in the comments), it is legitimate to ask whether they meant to trade away the public option all along. If so, in one sense their strategy might be said to have worked, if something in fact passes, but they tragically underestimated the appetite for real reform and squandered the opportunity this historic moment presented. Glenn Greenwald is now making that case robustly, and it explains a lot of what we have seen recently. The defense of that strategy would be that if the White House had not cut secret deals with the various industries involved, they would have brought their considerable resources to bear on the public and the Senate and sunk the effort entirely. From this POV, all those anodyne pro-reform ads industry has been running were there primarily as a warning: "See how much ad time we can buy? Be good to us with this bill, or we'll run ads that are not so nice." (Remember Harry and Louise?) To finish spinning out this theory, Obama could have even been in cahoots with Lieberman or Nelson to make sure they stood firm against a public option to keep industry on board, even though it meant making embarrassingly false claims about the public option driving up the bill's cost (it would do the opposite). The critique of that strategy, of course, is that the President should have used his allies on the left and his historic moment and his rhetorical skills and put this roundly-hated industry in its place.