Health Reform Future: Obama, Democrats Are on Their Own for Final Push

The seven-hour Blair House Project, starring Barack Obama, served its purpose. It showcased democracy in action, clarified where both parties stand in the health care debate, and cleared the decks for everyone to move on. And that includes our passive-aggressive community organizer-in-chief.

"We cannot have another yearlong debate on this," Obama said. If there's no significant progress toward a bipartisan bill in the next few weeks, he said, "we've got to go ahead and make some decisions and then that's what elections are for. We have honest disagreements about the vision for the country and we'll go ahead and test those out over the next several months till November."

Bland words, delivered more in pensiveness than with partisan resolve, but the message came through: One way or another, the end is near. Obama even signaled his willingness to use "reconciliation" -- a Senate procedure that can't be filibustered -- to finish the job on health care. To which I can only say, thank you, Mr. President.

The summit appeared to be modeled on Obama's community organizing background, with a relentless and ultimately futile focus on finding areas of agreement. Republicans didn't buy the common ground approach, anyway. Their leadoff speaker, Sen. Lamar Alexander of Tennessee, shot right out of the cannon, telling Obama and his party to scrap their bills and start over.

The wind is blowing in the other direction. There have been a slew of stories recently about all the reconciliation-enabled programs of the past, most of them passed by Republicans. Reconciliation is the reason many jobless people are continuing to get health insurance under their old employer-sponsored group plans. It passed in 1986 as part of COBRA -- an increasingly familiar acronym that stands for the Consolidated Omnibus Budget Reconciliation Act.

Reconciliation is being bandied about now as a fancy word for majority rule. In the Senate, where 60 votes are required to break a filibuster, that's considered cheating by whichever party is in the minority. In this case, it's worth pointing out that the Senate passed its initial health bill by 60 votes. That bill is the basis for the final package Democrats are crafting; reconciliation may be called into service to tweak it.

It's also worth noting that of the Senate's 41 Republicans, 20 of them come from the nation's 20 least populous states. So when they say they know what America wants, as several did Thursday, they may be operating on partial evidence. Rep. Charles Rangel (D-N.Y.) was put out enough to reassure fellow New Yorkers about where they stand in the life of the nation. "I would want them to know that they are Americans, and we do listen to them, and that the states that oppose this great plan (don't) speak for all of America," he said at the summit.

Republicans, who seemed unprepared for their impromptu Q-and-A with Obama earlier this year in Baltimore, this time fielded an impressive lineup of doctors and fiscal experts as well as party leaders. Democrats had more people and fewer experts -- no doctors, for a start, though Sen. Tom Harkin of Iowa said he had sold insurance as a young man and Sen. Dick Durbin of Illinois said he had defended and prosecuted hospitals and doctors in malpractice suits. But it didn't much matter because this was an Obama production. A GOP memo helpfully quantified to what extent -- congressional Republicans talked for 110 minutes, congressional Democrats for 114 minutes and Obama for 119 minutes.

The Obama-centrism may have been deliberate, given that Obama's 50 percent approval rating is much higher than either congressional party. Alternatively, Obama may have been reacting to an aggressive Republican game plan that not only challenged the substance of his proposals but also ignored the order in which he wanted to discuss them.

The president was most combative and pointed during the three-hour, pre-lunch session. He correctly guessed that the pile of paper in front of House Minority Whip Eric Cantor was the 2,400-page Senate bill and said without a smile that "props like this ... are the kinds of things we do that prevent us from having a conversation." When Sen. John McCain, his 2008 rival, went off on a trademark rant about deal making and a backroom process, Obama cut him off. "We're not campaigning anymore. The election's over," he said. "We were supposed to be talking about insurance."

The afternoon session found Obama more mellow, perhaps after eating lunch or being advised to stop biting people's heads off. He even acknowledged that McCain made a good point about the unfairness of letting 800,000 Floridians -- and no one else -- stay on more expensive private insurance plans within Medicare. Obama also got more backup from his fellow Democrats, particularly in defense of their plan to regulate insurance policies in a new exchange where consumers could comparison shop, as they do for hotels and flights on Web sites like Expedia.

Durbin said the exchange is modeled on the government-run marketplace used by federal employees and members of Congress. "If you think it's a socialist plot and it's wrong, for goodness sakes drop out of the Federal Employees Health Benefit Program," Durbin said. "But if you think it's good enough for your family, shouldn't our health insurance be good enough for the rest of America?"

Republicans as a team sounded knowledgeable, but there was no getting around two central points: Their incrementalism wouldn't fix the major problems of the current system, such as cruel insurance rules and 46 million without insurance, and they came off sounding cold and uncaring about people who don't have coverage or a lot of money. Right after Sen. Patty Murray of Washington state told a tragic story about a single mother of three who got sick, missed work, got fired, lost her health insurance, couldn't see a doctor and died, Sen. Tom Coburn of Oklahoma -- an obstetrician -- came back with this: "The key goal is to reconnect purchase and payment so we become good purchasers."

The idea of the "prudent shopper," as Rep. Henry Waxman (D-Calif.) sarcastically phrased it, came up often as a GOP solution to rising costs, wasteful spending and even covering the uninsured. Individual patients could personally make their own choices "with the asset value" we already have from wasteful health care spending, Coburn said.

Sen. John Barrasso of Wyoming, an orthopedic surgeon, said sometimes people with catastrophic coverage "ask the best questions, shop around, are the best consumers of health care" because their plans don't cover routine procedures. He gave an immediate "yes" when Obama asked him if Congress should have bare-bones catastrophic coverage instead of the broader minimum benefit now set by the federal government. "We'd have more skin in the game," Barrasso said.

"Would you feel that way if you made $40,000?" Obama asked. "Because that's the reality for a lot of folks ... They're not premiers of anyplace. They're not sultans from wherever. They don't fly into Mayo ... They're folks who are left out. And this notion somehow that for them the system was working and that if they just ate a little better and were better health care consumers they could manage, is just not the case."

Covering the uninsured was the last topic of the day and it was compressed into a relatively small amount of time, but it is the heart of the matter. "The other side may feel, 'you know what, it's just not worth doing that,'" Obama said as the discussion began. He was right. The other side, with a plan that covers only 3 million more Americans, doesn't feel the urgency of people who have no net. Among the many things the summit made clear is that in this, as in so much else these days, Democrats are on their own.