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By Jay Cost

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Five Questions on Health Care

The Democrats in Congress have reconvened to continue work on health care. Their ultimate success or failure will hinge on how several questions are answered. Here are five that I'll be asking.

1. How will the legislative math work? I have yet to see a proposal that unites the various factions of the Democratic Party in the Congress, so the question becomes how can party leaders get the 218 votes in the House then 60 in the Senate? The fact that there is still no clear signal on reconciliation, the principal benefit of which would be to reduce the burden from 60 to 51, is an indication that the leadership itself does not quite know how the votes will line up.

As of now, the conventional wisdom among the punditocracy is that the public option will be dropped as a way to pick up party moderates, under the assumption that the progressive caucus will go along for the ride. But will they? It is highly unlikely that all of them will. Most of them would presumably be willing to grant at least some small concessions to add votes - but how far are they willing to go? That depends upon individual legislators themselves, which means that - until you get to 218 in the House and 60/51 in the Senate - every concession the leadership makes had better add more moderates than it loses progressives. This is when legislative calculus begins to look like actual calculus!

There are indications that a compromise will be a hard pill for many progressives to swallow. This is Representative Raul Grijalva (D-AZ), co-chair of the House Progressive Caucus, on the compromise coming out of the Senate Finance Committee:

I think the product that has come out from [Max Baucus's] committee and himself, I really believe that it has no legitimacy in this debate. It's an insider product. It's there to protect the industry. It is not there to try to look for that middle ground. He is key in holding up deliberations, has been key in trying to work on a consensus, but everything you see in his legislation had to be approved by the industry before it became part of the plan...I consider Senator Baucus's proposal to be essentially an insider trader move to protect an industry and really doesn't have validity at all, both political validity or content validity.[Emphasis Mine]

This is not the first time I have seen a progressive House member blast Baucus. John Conyers took a shot at him a few months ago, and Baucus does not appear to be terribly popular on the progressive sites.

The progressive caucus is going to do a head count this week to find out how many members agree with Grijalva on the following point:

And, you know, this political line in the sand that we have drawn is not a gimmick. We feel very strongly about it. We believe that it's not only good public policy that we're advocating, it's good political policy, because our base really needs to see its party and its leadership come through with a commitment that was made in this era of change. And this is one of them. Health reform is the biggie. And I think the progressives, while there will be an effort to label us, I think we're going to work hard these next two weeks to build not only the internal support that we need for the public plan, but, more importantly, the external support to also put pressure on our colleagues. [Emphasis Mine]

The House leadership can afford to lose about 40 of their members before a bill fails in the lower chamber, assuming no Republican votes (which at this point seems reasonable). Recently, 57 members of the House Progressive Caucus indicated that they would not vote for a bill that lacks "a robust public option". The big question is: how many of those members are making a credible threat? That the White House is sending the President out to campaign strongly for the public option just this weekend is a sign that the answer to this question is not as obvious as it might seem.

2. What's the common ground on the public option? Like the last query, I do not think the answer to this question is as obvious as it first appears. We might initially think it is something like Baucus's Senate Finance plan, but I would refer again to the progressive reaction to the Baucus plan. Grijalva goes out of his way there to suggest that the Baucus plan is not common ground.

In general I am not sure how progressives are going to view any kind of compromise bill that attracts the moderates. Their attitude seems to be one of deep suspicion of the for-profit health industry. Take away the public option, but retain employer and/or individual mandates, and that looks like a big boon to the insurance companies. They might consider that an outright defeat. In that case, the normal calculations of compromise - you get half a loaf versus a whole loaf, but you're still better off - would not apply. Progressives might think they have not gotten even half a loaf at all!

This points to one big problem with doing comprehensive reforms like this. Different factions have different diagnoses for what ails the system - and when a comprehensive bill is introduced, it inevitably favors one view over another. If the progressives' view is on the losing end, they might think the bill does not do much of anything. And remember: the President wants to be the "last" to tackle this issue - meaning that the stakes are very high. So, if the progressives think the bill will further solidify the insurance industry's hold over health care, they might bolt.

3. Can the party come together around a cost estimate? Obama's speech last week helped to unite the party, but it was a campaign style speech that did not even try to resolve the issues that have actually divided it (and forced the President to make the speech in the first place!). The public option is such an issue, but it is just one part of a broader divide among the various factions in the caucus.

Another issue is the price tag, and relateldy how it is funded. Can the leadership put together a bill that accomplishes policy goals to the progressives' satisfaction without exploding the deficit, which will drive away moderates? The first attempts at this - the House tri-committee bill and the Senate HELP committee bill - were unsuccessful. Again, progressives seem not to like the Senate Finance Committee outline, either. So, the search for a Goldilocks-style compromise - neither too hot nor too cold, but just right - continues.

4. How much work is left to be done? Last week, the President repeated the oft-quoted notion that there is agreement on 80% of an overhaul. That may be so, but it does not really answer the question. Historically speaking, the Democrats can always agree on the initial 80%; it's that final 20% that tends to trip them up!

Intra-party disagreements almost always happen behind closed doors; their public pronouncements tend to be little more than spin, so I don't even have a sense on this one. Here are things I am wondering. What items do they need to find agreement on? Do they at least have basic ideas about how to get to an agreement? How much from the original bills can be salvaged? Have they made positive progress on that 20%, or have they spent the last few months merely learning what will not work? Above all, can they get it done "in time?"

"In time" is in scare quotes because it's a purely political concept, which means the leadership might redefine it as it sees fit. Indeed, the timeline has already been altered once - there were no votes taken in July, as was initially demanded. The new deadline is Thanksgiving. There might be too much work left to do to meet that deadline, which in turn would suggest it might have to be pushed back again. Can it be? That would put the vote for passage in the second session of the 111th Congress, during the midterm election year. That could be dicey, which means the answer to this question is a politically consequential one.

5. How will the public react, and how will legislators react to that reaction? Clearly, the public response to the House tri-committee bill and the Senate HELP committee bill was less than positive. The town hall protests reflected the strong opposition of the right, and the President's sagging poll numbers indicated that the broad middle had its doubts, too. How will the public react to the new proposal, once it is actually produced? That's uncertain, to say the least. Few people expected the reaction we saw this summer, so who knows what will come next. Additionally, will moderate legislators want an opportunity to take the new bill back to their districts to gauge public reaction? Will the leadership give them an opportunity?

Relatedly, how will the right respond? It has essentially been shut out of this process - that agreement on 80% is agreement among Democrats to the exclusion of Republicans - but conservatives have nevertheless found ways back into the public debate. This weekend's "tea party" protest in Washington indicates at the least that the right is worked up enough to take to the streets - something that historically is a hallmark of leftwing activism. So, it will be interesting to see how the right attempts to inject its views into the process, and what result that will produce.

Final point on this. When gauging the legislative reaction, it's important not to commit a fallacy of division. For instance, if support for the bill is split 50-50 in a national poll - then you can probably expect that more Louisianans oppose it than favor it. This will affect the political calculations of Senator Landrieu and Representative Melancon, inclining them against the bill. Generally, the strong Democratic presence in red state Senate seats means that 50-50 might actually mean something less when it comes time to tally up the votes in the upper chamber.

-Jay Cost