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By Jay Cost

« The Pivotal Politics of Health Care Reform, Part I | HorseRaceBlog Home Page | Mike Murphy's Strange Math »

The Pivotal Politics of Health Care Reform, Part II

Yesterday I drew on Keith Krehbiel's Pivotal Politics to outline a basic structure of the health care reform fight. Today, I want to continue this discussion by reviewing some of the specific elements of the upcoming battle. I'll still be drawing on Krehbiel's basic structure - although this will be more my interpretation of the current situation than a recitation of his work.

Ideally, I would have liked to integrate the following considerations into a single argument. As the battle lines are drawn, I think that will become possible. But we're still very early in the process - so for now, the points that follow basically stand on their own.


Krehbiel's theory highlights the importance of the "filibuster pivot," the marginal legislator in the Senate who determines whether a filibuster will be sustained. The President and congressional Democrats have indicated a willingness to use budget reconciliation, which would eliminate the filibuster pivot and allow for a much more narrow voting coalition.

In theory, this would ease passage - as it would reduce the number of pivots the overhaul has to pass through. In practice, however, this could be troublesome.

First, in The Audacity of Hope, the President blasts his predecessor for precisely the same technique. Can he legitimately engage in the same practices he opposed? Maybe. On the one hand, the public doesn't usually get worked up over process. There was no outcry last summer when he abandoned his promise to pursue public financing, for nakedly political reasons. Plus, there's a certain allowance we're all prepared to give politicians when it comes to reconciling campaign rhetoric and governing reality. On the other hand, he'd be pursuing a legislative tactic he once vociferously decried to transform a large part of the economy via a narrow majority. This could be a stretch.

Second, if budget reconciliation is used to pass health care - it will probably be due to the fact that at least some Democrats would join in a filibuster. The more Democrats who would join a filibuster, the more problematic reconciliation becomes as a strategy. If Ben Nelson and Mary Landrieu are the only Democrats on the outside looking in - then I think it would be doable. But what if it's seven or eight? That's another matter.

Third, as David Gratzer of the Manhattan Institute notes, reconciliation might be a double-edged sword. It would free congressional Democrats in the key committees to write a bill that could be quite far to the left. Will they do this? If they do, will the final product be something the public would support?

Can a Consensus Be Found?

Generally speaking, the key players recognize the need for some reform of the health care system. This is necessary, but far from sufficient for passage of the bill. Following what we reviewed yesterday - what also matters is how the alternative compares to the status quo. Historically speaking, this is what trips reformers up.

My sense of things is that there are at least three potentially nettlesome points that could preclude a consensus forming for an alternative: the scope of reform (universal or something less?), the content of reform (a public insurance option or not?) and how to pay for it.

The latter two seem at this point to be the most prominent disagreements. Mary Landrieu has already come out in opposition to a public insurance option, and many Blue Dogs in the House have expressed concern with it. If a public option is deemed unacceptable to these Democrats, but still included in the bill - they will vote in favor of the status quo, even if they disapprove of it generally. Additionally, the public financing option is starting to crack the veneer of consensus. The New York Times reports that the American Medical Association has come out against a public financing option. It agrees that reforms are necessary - just not this one. This is exactly the problem that has sunk many big reforms: everybody agrees that the status quo stinks, but not enough people or groups agree that any given alternative is an improvement.

Paying for it also appears to be a big challenge at this point. This week, Bloomberg reported that the President wants Congress to reconsider limiting tax deductions for the wealthiest as a way to pay for the bill. However, CQ reported that this option remains deeply unpopular with members of Congress. This is not a huge surprise. Playing around with tax deductions is a key way members of Congress satisfy their constituencies. Limiting deductions for the wealthy reduces their ability to satisfy certain electorates (especially the ones with money to donate to reelection efforts). Senate Democrats seem partial to a tax on health benefits, but House Democrats on the Ways and Means Committee are much less so. Will the President - for the sake of compromise - support such a tax? Maybe. Of course, he campaigned against McCain on this issue, and promised that 95% of the public would have a tax cut, not an increase, under his watch. That would give the opposition some ammunition. Plus, labor unions are opposed, as some of their benefits might be made taxable. And of course Ways and Means Democrats might not go for it.

All in all, there are a lot of potential complications - yet notice who I haven't mentioned: the Republicans! Disagreements about financing this overhaul could induce a significant inter-branch, inter-chamber conflict, one that's fought entirely on the Democratic side. That's happened before. Again, what we have to look for here is not just whether everybody dislikes the status quo - we know they do. We also have to look for whether they can find some alternative to the status quo - including how to pay for it.

Public Opinion Will Matter

On low-salience issues - congressmen typically have a freer hand to vote as they like. But on issues that capture the public's attention - their positions are constrained. This could make a difference in the search for a compromise.

The chart I presented yesterday might give the false impression that the preferences of legislators are formed via purely philosophical considerations. They are not. Instead, they depend heavily on public reaction. Legislators are strategic seekers of reelection, after all.

This adds a twist to the search for compromise. Suppose, for the sake of discussion, Ohio congressman Zack Space is believed by the bill writers to be the median legislator. If he votes yes, the bill passes. No, and it fails. So, they go to Mr. Space and ask him what he thinks of the bill.

He might have to equivocate. Space is from Ohio's 18th Congressional District - which went for Bush twice, then McCain. So, his voters might be disinclined to the bill after it gets a full airing. Plus, Space is just a sophomore legislator - meaning that he probably has not built up the kind of credibility and trust that helps create a "personal vote." In other words, Space would have to wait and see how his constituents react. There's probably little information he could provide beyond generalities about the mood of his constituents.

But there are so many polls out there - isn't it easy to gauge public opinion? No. In fact, the polls can contribute to the false sense that public opinion is firmly established. On a subject like health care - it's potentially malleable.

Recently, Rasmussen found:

Sixty-three percent (63%) of voters agree with the core objective of providing affordable health care for 'every single American'.

Overall, just 35% rate the U.S. health care system as good or excellent. That suggests plenty of room for improvement. The biggest challenge to any reform proposal, however, is that 70% of insured rate their own health insurance coverage as good or excellent. This means that any proposal that would force people to exchange their existing plan for something new is a non-starter. In fact, only 25% would support a reform proposal that required a change in their own coverage.

This suggests public uncertainty about what to do. People want affordable care for everybody, but they don't want their plan changed. They think the whole system is bad, but they like their own place in the system. That gives both sides at least a toehold with public opinion.

The NBC/Wall Street Journal poll suggests that while the public may be more convinced that health care is a problem, they have not broken decisively toward any particular solution. In 1993, it found that 66% of the public would be willing to pay more in taxes for the sake of universal health insurance. It asked the same question this February, and found just 49% willing to sacrifice. Relatedly, in 1999 it found that 43% thought government should be primarily responsible for health care coverage, compared to 28% favoring employers, and just 17% favoring individuals. In February, those numbers shifted rightward - with 36% favoring government, 24% employers, and 31% favoring individuals.

This sort of ambivalence implies that the fate of any reform proposal will depend on how well each side argues its case. One way in which this battle is bound to occur is via euphemisms. Democrats like to call one program "a public choice option" to facilitate "universal care." Republicans call the same program "bureaucrat-run socialized medicine." My hunch is that if you offered the Democratic language to the public, it would support the bill. Offer the Republican language, it would oppose it. This suggests that the actual political fight could be determinative.

In the meantime, legislative drafters will have to engage in some guesswork on whether a given proposal can attract enough votes for passage. Nobody can be sure - as it depends on how the public eventually views the bill. So, while the pivotal politics theory is scientific - its application by legislative leaders is more artistic, depending heavily on hunches and intuitions about what can be sold and what can't.

Bringing Tactics Back In

I opened this series suggesting that while legislative tactics are important, they need to take a back seat to structure. Having now given structure its due - I want to offer some thoughts on Obama's tactical approach.

It's easy to be critical of Clinton's top-down strategy in 1993 because his bill failed. But, in light of the generally dismal track record of such reforms, we shouldn't be overcritical. In fact, I think Obama's bottom-up approach has some risks, too.

Congress is simply not well suited to designing comprehensive laws like this. As Professor Charles O. Jones once said: "Congressional decision making sometimes resembles a meat slicer, reducing public problems to a series of discrete, unrelated, and often contradictory tidbits of policy." We saw something like this with the stimulus bill. We're seeing it again with the Waxman-Markey climate bill. Each bore the stamp of congressional particularism. Rather than having been constructed to tackle the problem in the most efficient way - they appeared cobbled to together to satisfy the constituencies whose support was critical for passage.

Promoting a bottom-up health care reform runs the same risk. The big question is, what happens if this process produces a bill that reads like an endless set of unconnected rules and regulations, adding up to an unintelligible jumble? This might scare the public off.

This question becomes even more pertinent if the Obama Administration's insistence on the need for speed goes unheeded. Both Senators Grassley and Enzi have complained this week about the President's push for a quick timeline. Speed helped salvage the stimulus bill - as the vote was taken before the opposition could fully communicate the inefficiencies of the bill. However, speed was justified then because the economy was supposedly on the line: "crisis could become catastrophe," and so on. That's a much tougher case to make here. Speed is necessary only for political purposes - namely, to get the bill passed before the President's honeymoon ends and/or the opposition discovers a weakness that it can exploit. If the Obama administration cannot move this quickly through the legislature, the congressional "meat slicer" might produce a bill that the public will have time to consider, then reject. In that case, the status quo wins.


The point of these essays has not been to assign odds to the probability of health care reform passing this year. That's well outside my scope. Instead, there are two modest lessons to walk away with.

First, it's good to cruise up to 30,000 feet for a while to get a lay of the land. This is easy to miss, given that press reports provide fragmentary information focused on the day-to-day maneuvers of this committee or that interest group. What I wanted to do here is outline a basic structure for understanding the upcoming battle, as well as some very general considerations of what to look for as we move forward.

Second, it's clear that the chances of a major overhaul are at their greatest point in at least sixteen years - maybe longer. Yet we need to recognize that: our system does not often allow substantial changes to pass through; previous Democrats from Truman to Clinton have failed at precisely what President Obama intends to do; and there are potential obstacles to passage.

Regardless of what happens, this should be a fascinating process to watch - and an excellent civics lesson on how our system works. Either it will be one of those rare instances when there is a major policy breakthrough, or it will be another case of lofty ambitions being thwarted by our complicated, Madisonian system.

-Jay Cost