After enduring weeks of criticism over their efforts to retool the U.S. health system, President Obama invited all 60 members of the Senate Democratic Caucus to a White House lunch last week for a round of commiserating and chin-up encouragement.
By all accounts, the gathering largely echoed past exhortations from Obama to speed a bipartisan approach to health care through Congress — stressing that the measure remains the White House’s most urgent domestic policy priority. The idea, participants at the meeting reported, was to keep Senate caucus members keenly focused on the big picture, even as they venture into often-rancorous meetings with constituents over the August recess.
Still, for all the rhetorical morale-boosting, some lawmakers are growing restive over the question of just what sort of big-picture health plan they’re fighting for. Throughout the health care debate, the president has focused more on the importance of completing an overhaul and enumerating the shortcomings of the present health system than explaining precisely what any changes will deliver.
That’s frustrated some rank-and-file Democrats in the House and Senate, who expected Obama to take a more hands-on role in getting deals made — or at least to offer explicit guidance when factions within the party bickered over how to cover the $1 trillion or more cost of an overhaul.
Instead, Obama’s posture has put the onus on the Democratic-led Congress to deliver a coherent message — and as legislative momentum builds behind various health care proposals, that goal has proven quite elusive. Last month, for example, fiscally conservative “Blue Dog” Democrats staged a revolt over costs associated with a so-called public plan to pay for care — stymieing an overhaul bill in the House Energy and Commerce Committee and prompting the Obama administration to intervene, none too calmly or definitively, at the behest of White House Chief of Staff Rahm Emanuel.
Meanwhile, when Obama has weighed in on questions of policy and strategy, the discussion has pivoted mainly on broadly shared goals — extending coverage to the estimated 47 million Americans who currently lack it while bringing down long-term costs that threaten to swamp the federal budget — rather than the concrete means of achieving them. Conspicuously missing in last week’s lunch gathering, for instance, was any talk of the contentious public option that had spurred the Blue Dogs’ rebellion.
Nevertheless, Obama officials are maneuvering behind the scenes to keep industry players on the same page. Just last week, The New York Times reported that top White House officials assured drug manufacturers that they would stick to a June agreement and secure the companies from provisions in the House health bill that would give the government the power to negotiate outpatient drug prices and demand rebates from manufacturers. That concession came after the manufacturers agreed to supply $80 billion in consumer discounts over the next decade to help fund the health care overhaul.
The ‘ClintonCare’ effect
The calculated deference to Congress on policy matters is no accident. Obama’s West Wing is stocked with Clinton administration veterans who remain haunted by the failed attempts to overhaul the health system in 1993 and 1994 — an effort that was effectively crippled after the White House developed a 1,342-page health overhaul bill, then demanded Congress pass it. In addition to Emanuel — who was a senior adviser in the Clinton White House — other Obama officials involved in that fight include Secretary of State and former first lady Hillary Rodham Clinton; Jeanne M. Lambrew, the director of the Department of Health and Human Services’ Office of Health Reform; and John D. Podesta, Bill Clinton’s former chief of staff, who serves as an informal adviser to the president.
Such figures come to the debate with a clear cautionary message, observers say: The president should stay on the sidelines and keep Congress invested in an outcome until the time for serious horse-trading arrives. At that point, Obama will probably have to mollify centrists concerned about the cost of a plan, while preventing liberal Democrats from peeling off from what they view as a watered-down compromise.
“Many of the Democrats are frustrated that he won’t come in real hard on policy, but that’s hard to do. Chairmen have strong feelings; members have strong feelings; and there are many lessons to recall,” said Rick Weissenstein, a health care policy analyst for the Washington Research Group. “There will come a point where he really has to push and prod people and convince them there’s a lot of good in the bill and not let the perfect get in the way of that.”
Obama insists he has clearly defined what would work best in a revamped health system and has helped forge consensus on critical questions such as insurance regulations to keep health plans from basing coverage decisions on pre-existing conditions or proposed “insurance exchanges” that would provide consumers with a menu of options to expand choice. “The truth is we’ve actually, I think, provided more guidance than has been advertised,” Obama said in a recent interview with Time magazine.
But fairly innocuous insurance fixes don’t really require heavy lifting from the White House. By remaining on the sidelines as Congress thrashes out the more divisive approaches to an overhaul — such as a public plan, or proposals to increase taxes on high-earning Americans — Obama conveys the impression that he’s much more thoroughly versed in the ills of the current health system than the best approaches to fix it, critics say.
“Initially, the administration’s focus was on cost and making the plan pay for itself. Now, it’s about needing reform to keep what you have secure,” said Mark McClellan, a former administrator of the Centers for Medicare and Medicaid and FDA commissioner in the administration of George W. Bush. “It becomes a real challenge to on one hand explain how people’s relationships with their doctors won’t change and they get to keep their coverage secure, while at the same time stressing how important it is for the system to change in order to stop this unsustainable trajectory in spending.”
This rhetorical bind has contributed to Obama’s recent decline in public approval. A Quinnipiac University poll of 2,409 registered voters from July 27 to Aug. 3 found that 52 percent disapprove of the way the president is handling health care, a 10 percentage point increase from early July.
The survey found that 46 percent of respondents trust Obama to handle health care, compared with 37 percent support on the issue for congressional Republicans.
Keeping his powder dry
Democratic strategists say they’re not troubled by the polls. Most Americans have yet to home in on the details of the overhaul, they say, leaving the president with a crucial opening to recast the debate beyond the trench warfare in Congress. By stressing the perils of inaction, Obama hopes to engage Americans who have health insurance but are worried about losing their coverage or paying higher out-of-pocket costs and getting priced out of the market.
“There’s no doubt there has been some erosion of support from outside, but the fundamentals are the same,” said Democratic pollster Anna Greenberg. “Americans understand the status quo is not working. When people have more information about a comprehensive plan the president or Congress is pushing ... and when you present that plan, the majority of people will favor it.”
But the administration has been frustrated by Republican countercharges that Obama is intent on engineering nothing short of a government takeover of the health system. In town hall meetings, talk radio appearances and ad blitzes, the administration’s conservative foes have raised the specter of Obama-backed cuts to Medicare and even government micromanagement of end-of-life decisions.
“There’s been a relentless effort to distract. The issue is to come up with a constant set of points — what seniors and the middle class will get, how small business won’t be hurt, how there won’t be Medicare cuts — and go out on the road with members reinforcing the same points at town hall meetings,” said Democratic pollster Celinda Lake.
While he engages in campaign-style advocacy, Obama has to keep his eye on ongoing talks on Capitol Hill — and to keep tabs on the Senate head counts so as to avert a Republican filibuster.
Late last week, Obama made a preliminary overture to three Democrats and three Republicans from the Senate Finance Committee who are negotiating a bipartisan health plan. In an hourlong Oval Office meeting, the president asked what he could do to advance the talks. Still, one senator in attendance, North Dakota Democrat Kent Conrad, said that Obama’s basic message was focused on them, not him: “Keep working.”
That might not be enough for other, less patient Democrats, who suspect Republicans are using Obama’s hands-off approach to drag out the process. Until the president issues an ultimatum, they suggest, the incremental status quo benefits opponents of an overhaul.
“My own personal view is that those three Republicans won’t be there to vote for it out of committee when it comes right down to it,” said Finance member John D. Rockefeller IV of West Virginia. “So this will have all been a three- to four-month delay game, which is exactly what the Republicans want.”