As I’ve made clear on a couple of occasions, I think there has generally been too much panic over the process of getting a health care reform bill before the Congress. Given a bill as expensive and complicated as this one, and the number of disparate constituencies both within and outside the Democratic Party, it is not surprising that the details are taking some time to negotiate. Efficient negotiating processes necessarily will involve a lot of brinksmanship, necessarily will tend to be resolved at the last minute, and necessarily will have their up days and down days along the way.
The one thing that might have sent things down a different course is if President Obama had tried to preempt the negotiations by taking a more hands-on approach and placing a particular bill before the Congress. I had thought this was a good idea, although the Beltway conventional wisdom would disagree, and there would certainly be risks to the White House in trying to loop the Congress out of the process. We’ll probably never know who was right. But given that the White House didn’t take that course, everything that has proceeded since has been fairly normal.
There are also debates about health care, however, taking place outside of Washington, in living rooms and convention halls and bowling alleys all across America. These debates will come to take on more import as members of Congress return home for the August recess and begin to speak with their constituents. I do not think the Democrats have been holding their ground in these sorts of debates. In fact, I think they are losing them rather badly.
There is a long history of support for the concept of major health care reform, something that has not really changed to this day. As recently as last week, a USA Today/Gallup poll found 56 percent in support of Congress passing a “major” health care reform bill this year, versus just 33 percent opposed.
However, that does not mean the particular bills being debated by the Congress are popular. Since Memorial Day, there have been ten polls that asked whether the public supported what was identified as the Obama, Democratic, or Congressional health care “plan”. I put “plan” in quotation marks because there still isn’t “a” plan; instead the Congress is debating between several different plans. With that said, what the public thinks of as the Obama/Democratic plan has been steadily gaining opposition:
The obvious thing to point to is the increase in the number who say they are opposed to the Democratic “plan”. What may be just as important, however, is that the Democratic plan was never was all that popular to begin with. A GQR poll back at the end of May put support at only 46 percent — although then, just 33 percent were opposed. The Democrats, indeed, may not have recognized early enough that some persuasion was going to be required in order to get a majority of the public on board. And they have since lost their plurality. The support numbers have held basically steady — the problem is that virtually all of the undecideds have come around to oppose the plan.
About a month ago, Stan Greenberg and James Carville, who were bystanders in the Clinton administration when the 1993-94 health care effort failed, put out a memo outlining five things that Obama and the Democrats would have to do in order to sell health care. Let’s evaluate their performance on each of these five planks, and assign it a letter grade:
1. Voters need to hear clearly what changes health care reform will bring. Never losing health insurance when you lose a job or get sick, power shifted from insurance companies to people, reduced costs for you and your family, business and country.
The key adjective in the above statement is “clearly”. It certainly does not seem to me that there’s been much clarity in the Democrats’ explanations of what health care reform will mean for the average American — how can there have been when key elements of the plan are still being debated? Grade: F.
2. Build a narrative around taking power away from the insurance companies and giving it to people.
There’s been some of this from rank-and-file Democrats, but very little from Obama, who seems strangely resistant to populist rhetoric. I’d thought, frankly, this was one of the real advantages that Democrats had going into the legislative process: big business is very unpopular because of the economic collapse, and there might even have been some way to parlay negative sentiments about AIG — an insurance company — into skepticism about the motivations of insurers in general. But we haven’t seen very much of this from the highest-profile Dems. Grade: D.
3. The president and reform advocates have to explain concretely the changes that will mean lower costs.
There’s been a lot of assertion of this, but then, there’s that key modifier, “concretely”. And the Democrats don’t seem to be winning this argument. I know the Rasmussen polls have been pretty bearish on health care reform (and most other Democratic initiatives) in general, but their numbers on cost control are especially poor — only 23 percent expect the cost of health care to go down under the Democratic proposals, versus 53 percent who expect it to go up.
It’s not very difficult to understand why the public thinks as they do. They hear about cost control — and then, they hear that the impact on the deficit is going to be a trillion dollars. Talk about cognitive dissonance. What Obama and the Democrats probably need to do is to delineate the two parts of the proposal: acknowledge that creating a guarantee of universal coverage will cost money, and laud it as a worthy goal — a moral imperative, even. Then explain that the other parts of the bill will save money, although not quite enough to offset the costs of providing universal coverage. Maybe you need some Ross Perot-style charts and graphs to do this.
I think the public is sophisticated enough to comprehend this argument, and I think that it might be a winner. In this month’s Kaiser Foundation tracking poll, 45 percent started out saying that $1 trillion is “about the right amount” or “too little” to be spending on health care, versus 42 percent saying “too much”. When, however, Kaiser stipulated that “spending this amount would mean nearly everyone in the U.S. would have health insurance coverage”, support rose to 57 percent. This argument was more persuasive to people than a another one Kaiser advanced about reducing long-term costs.
The White House clearly concluded somewhere along the way that arguments about cost containment were more persuasive than arguments about universal coverage. The problem, again, is that the arguments about cost containment won’t make any sense to people unless you’re also selling the arguments about universality — not when the bill has a $1 trillion price tag. Grade: F.
4. Show all voters and seniors that there are benefits for them, including prescription drugs.
This probably has to count as another failure. Plans for health care reform are not very popular with seniors. Obama has talked in passing about closing the Medicare Part D “donut hole”, but it hasn’t been a central focus of the debate, nor is it clear if this will be addressed in whatever bill ultimately comes out of Congress. Having some kind of “prize” to show to seniors could be a big help. Grade: D-.
5. All of these points should be made with the dominant framework that continuing the status quo is unacceptable and unsustainable.
This is the argument we’ve heard most frequently from Democrats and one that they’re probably winning. Indeed, all the Republican talk about the need for “bipartisan” reform somewhat reinforces this point: there are very few people will to go on record describing the status quo as acceptable.
However, none of this will necessarily encourage the public to have much confidence in the particular solution to the status quo that the Democrats are advancing. Winning this point, in other words, is a necessary condition for the passage of health care reform, but hardly a sufficient one. With that said, Democrats should probably be making more of the fact that Republicans have yet to offer their own version of health care reform. Grade: B.
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Overall, that works out to a grade point average of1.06, or a letter grade of a straight ‘D’. And that frankly seems generous when looking at the situation more holistically. If this were a pass-fail class, the Democrats would probably deserve a failing grade.
The strategy from here, at least, seems relatively clear (although “clear” is not the same thing as “easy”). Firstly, the Democrats need a plan that will be the focal point of their sales efforts. It doesn’t necessarily need to be the plan that will eventually be voted upon by the Congress, but it does need to have specific answers on key details like the public option, the employer mandate, and the funding mechanism. Until the Democrats have a plan, they are unlikely to gain ground with the public on health care reform. This, by the way, is why it is potentially a significant setback if the House in fact does not vote on health care before the August recess — far more so than if the Senate hadn’t voted. If the House approved a health care bill, that would give Democrats a plan to talk about through the recess, regardless of what the Senate chose to do later on. But without either chamber having approved a plan, they’ll continue to be drowned in a sea of process stories.
If and when the Democrats are at the stage where they have a plan to frame the discussion, then President Obama needs to give a speech. Not a town-hall forum, and not a press conference. And not multiple speeches. A speech. A “big” speech, and probably a somewhat long speech. A make-or-break speech in prime time on a busy television night. Preferably one from the Oval Office, or perhaps in front of a joint session of Congress — not some bullsh*t at a steel mill in Toledo. This is not as risky as it sounds, since the President is very good at delivering big speeches. But he’s probably only going to get one shot.
Until then, I don’t think Obama can go completely into hiding, but there is definite risk of overexposure. The President is not as popular now as he was a few months ago, and he’s being associated with a still-unformed health care “bill” that definitely isn’t all that popular and in fact may be dragging his numbers down. It might be better for the President to preserve some of that political capital and to rely on some of the more persuasive members of Congress, Joe Biden, Katheelen Sebelius, and under ideal circumstances the Clintons, to do his bidding for him in the meantime, in conjunction with a some grassroots action and a robust advertising effort.
The best thing that health care has going for it is that it doesn’t necessarily need to be all that popular to pass. Congressional Democrats will simply have to acknowledge that, while the passage of a bill might not do them any favors in the near-term, its failure would almost certainly be much, much worse. But I’m not sure that Democrats had to find themselves in this lose-lose position in the first place. And I’m not sure that they can’t find their way out of it, if they start to take more heed of what the public really needs to hear about their health care bill.