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Jacob Hacker: Obama's Almost Perfect Strategy

Jacob S. Hacker is co-director of the Center for Health, Economic, and Family Security at U.C. Berkeley, and a fellow at the New America Foundation. He recently edited Health at Risk: America's Ailing Health System--and How to Heal It. We hope he will be contributing to The Treatment on a regular basis.

Like others obsessed with health reform (such as, say, Jon and Jon), I have been frenetically sifting the Obama administration's pronouncements. The debate has shifted so fundamentally in just the last few days that it is hard to step back and see the administration's plans in their larger strategic context. But let me try to paint that bigger picture, drawing on a piece I wrote a few weeks ago for the Christian Science Monitor outlining how I thought the administration should proceed politically. Much as I admire the CSM and hope it is strengthened by its new Web-only approach, I doubt anyone outside my immediate family read my op-ed (and maybe not even them). Nonetheless, the administration has so far played its cards just as I thought they should--with one crucial possible exception.

Here were my four big recommendations:

1. Use the budget. The budget cannot be filibustered by an obstructionist Senate minority of 41, so the worry expressed by Jon O. about attracting Republicans in the Senate is pretty much moot when it comes to the President's tax plans (as was largely true for President Bush when it came to attracting Senate Democratic support for tax cuts for the rich). While not everything can be done in the budget, "the key features of reform can and should." Clearly, Obama gets this.

2. Move it or lose it. It may be cliche to talk about a presidential "honeymoon," but political scientists have repeatedly shown that Presidents generally get more of what they want in their first year than at any other time in their presidency. The last epic battle over health reform is equally prescriptive: President Clinton's plan, which was delayed until late 1993, went down in flames for many reasons, but "it didn't help that members of Congress had stopped worrying about the 1991 recession and started worrying about the 1994 midterm elections." Obama has learned this lesson, too. By far the most important development in the health care debate this year is that he is pushing forward with reform now.

3. Make Congress own it. Clinton's other big political mistake was to craft his 1,342-page bill within the White House and executive agencies, rather than move quickly to spearhead congressional action." Obama is not going to make the same mistake. He will supply the vision; Democrats in Congress will write the legislation.

4. Keep it simple. Finally, I argued that "the vision should be simple and unthreatening. Clinton's plan had too many moving parts and too many red flags." By contrast, the reforms that Obama called for during the campaign had just three key elements: (1) lowering the cost of health insurance for workers who have it, so employers continue to provide good job based benefits; (2) creating a new national insurance pool ("Exchange") that allows those without such benefits to buy coverage as good as that received by members of Congress, with contributions to the cost of that coverage required of employers that don't now provide insurance; and (3) the creation of a new public plan modeled after Medicare that would be offered within this pool to provide a secure guarantee of coverage for those who now lack it and to drive down costs while improving quality.

I believe that Obama and his key advisers still believe in these three elements, but--and this is a big "but"--they are reluctant to make the case for any of them right now, thinking it best to wait until congressional bargaining begins to press for even these broad policy mechanisms. After all, it was not only the public health insurance plan that was left out of the list of principles, as Jon notes, but also the new national insurance Exchange and the required contributions by employers-each of which is arguably just as crucial. (Without employer contributions for firms that don't provide insurance, employers will just stop providing coverage and dump their workers in the pool. Without an Exchange, there is no way to adequately regulate private insurance or connect people with good group health plans.)

It makes sense to keep the targets for political attacks hidden for as long as possible, but that does not mean that Obama and his advisers should start dropping key priorities-priorities that they have already articulated and defended-before the debate begins. For if there is a final lesson from the Clinton reform debacle, it is that the President's power is greatest as an agenda setter rather than a legislator. Obama should make sure the agenda is set correctly.

So when the administration presses its agenda to leaders in Congress, it shouldn't sweat the details. But it should make clear that the big three-employer contributions, an Exchange, and a public health insurance plan aren't details. They are the essence of Obama's vision of a transformed system.

--Jacob S. Hacker