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Should We Blame Health Care Reform if Republicans Win in 2012?

President Obama faces a knife fight for reelection next year. Of course, the catastrophic economy poses his greatest political challenge. He also faces implacable Republican opposition, two difficult wars, and a host of other toxic foreign and domestic legacies of the Bush administration. Have I mentioned that he is still African-American and has a funny name?

The president has created some problems for himself, too. He has struggled to combine the inside and the outside political game. During his first two years, his central strategy was to negotiate what had to be done to win passage of the stimulus, health reform, and other specific legislative measures. Passing bills is important, but other things matter, too. Loudly proclaiming victory for items such as a too-small stimulus has created more serious long-term vulnerability than the White House seemed to know.

With beautiful exceptions, the president has struggled to present a broad progressive message that extends beyond his personal appeal and political fortunes. He’s struggled in crafting a politically and programmatically effective response to the foreclosure crisis.

He too-often negotiates with himself, allowing Republicans to pocket preemptive concessions while paying little political price for their implacability. President Obama couldn’t stop Senator Richard Shelby from delaying and then thwarting the appointment of Nobel Prize economist Peter Diamond to the Federal Reserve Board. The president couldn’t stop Republicans from undermining the appointment of the distinguished health care delivery expert Donald Berwick to lead the implementation of health reform. What’s frustrating is that he hasn’t found a way to make Republicans pay a higher political price for their extreme partisanship—extremism that now seeks to hold hostage the full faith and credit of the United States.

There’s even a meme going around that health reform was actually the central strategic error of the early Obama presidency. On this view, it was a mistake to spend so long waging trench warfare to pass the Affordable Care Act. For example, Time’s Joe Klein believes that President Obama misread his mandate:

In 2008, Barack Obama wins a smashing electoral victory, largely because the public believes he’s a calm, cool adult who can lead the country out of an economic crisis. But for some crazy reason, he decides to focus much of his attention on passing a universal health care plan that has been the long-term dream of his party. This, despite polls that indicate nearly 80% of the public are satisfied with the health care they already have. The plan passes, but it’s so complicated, the public isn’t sure what’s in it (and is wondering why the President hasn’t focused similar attention on the economy), and Obama’s party is clobbered in the 2010 elections.

Klein personally supported health reform. So this indictment has added sting.

It’s not a stupid argument. Americans were baffled and dismayed by the prolonged sausage-making required to get ACA passed. Democrats made tactical errors within a sclerotic Senate process that left little margin for error. Health reform could have been more intimately linked in the public mind with the realities of a recession that was hammering state budgets and further unraveling employer-based health coverage.

Politically and substantively, the worst aspect of health reform is simply the long time-lag between the bill’s passage and the on-the-ground help ACA will eventually provide in millions of lives. ACA has already helped many people—those with preexisting conditions, young adults covered under their parents’ employer-based policies, for example. Yet of course most Americans don’t know what’s in the bill. Many key provisions have yet to kick in. ACA expenditures were back-loaded to meet a rather arbitrary budget target. It would have been better to have front-loaded things, to make more of an immediate difference for more people, and to bolster a faltering economy.

Regular readers of this space know many substantive reasons why health reform was both deeply necessary and deeply difficult to accomplish. If one believed health reform is important, 2009 was a unique historical moment to get this done. The process and the end product weren’t always pretty. Yet ACA will provide health insurance to an estimated 32 million Americans who would otherwise go uninsured. It addresses insurance company abuses and will reduce the number of Americans who contract cancer and thus lose their homes. It will provide $200 billion per year in economic help to low- and moderate-income families.

Health care reform was a central issue in the 2008 presidential campaign. Despite all the difficulties and the occasional errors, President Obama believed in this and put himself on the line to get it done. Its passage marked a historic promise kept to millions of needy people. I believe the president was both smart and courageous to do so.

I’m not convinced that his political fortunes would be brighter had he postponed the health care issue to attack some ostensibly more feasible alternative political agenda. The economic and fiscal crisis would have been just as bewilderingly complex. Republicans would have been just as implacable, just as resolute in opposing the centerpiece efforts of an Obama presidency. The administration’s political strategies and private negotiating posture would have the same characteristic difficulties. The president’s difficulties with his own political base would have been rightly magnified by his failure to follow through on a matter of central concern to so many people.

I am convinced that the moment to address the central gap in American social insurance could easily have been lost. Some of the same people who now lament the president’s decision to focus on health reform might instead be lamenting the president’s lack of boldness in missing the once-in-a-generation opportunity to assist tens of millions who are now uninsured.

President Obama must raise his game to win reelection, and to make his presidency as worthy and effective as it can be. His committed pursuit of health reform was not the problem. We’ll see soon enough whether health reform helps him win a second term. It certainly made him more deserving of one.