History Will Ignore Much of Today’s Health Care Reform Headlines

Living through historical moments can seem far less grandiose than reading about it. In the day-to-day grind of making history the big picture can get lost. Little issues take on huge proportions while overarching themes are hidden in the maelstrom. Historians get to step back, find the threads that build tension, create a narrative, and set-up the pay-off.

So it is – and will be – with health care reform. There have been a lot of distractions. For instance, critics of the Obama Administration have been pounding away at HR 3200, the House version of health care reform legislation. That legislation makes great fodder for 24-hour news channels and partisans across the spectrum. The bill offers something for everyone to demagogue. The fact that, in the end, HR 3200 – America’s Affordable Health Choices Act of 2009 – won’t have served as anything more than a lightening rod hardly matters.

The same can be said of the Senate Health, Education, Labor and Pensions Committee’s proposal. The Senate HELP Committee’s and the House health care plans gave liberals something to cheer about and conservatives something to attack. My guess is history will show that was its greatest contribution to the debate. Yes, elements of these bills will be included in the legislation that will be signed into law by President Barack Obama later this year. But that’s because there’s always been a broad consensus concerning health care reform. It’s the 25 percent or so of the issue on which there is disagreement that is causing all the ruckus. And at the end of the day, I’ve longed believed it will be moderates who resolve the contentious health care reform issues.

And those moderates are almost ready to make their positions known. Senate Finance Committee Chair Max Baucus has promised to unveil a formal proposal Tuesday or Wednesday. While it’s not certain that any Republican Senators will sign-on to the proposal, what Senator Baucus will propose will be far more moderate than the current alternatives. According to the Associated Press, Senator Baucus and the other five Senators negotiating a bi-partisan bill have made progress on several controversial items, “including health insurance for the poor, restrictions on federal funding for abortions, a verification system to prevent illegal immigrants from getting benefits, and ways to encourage alternatives to malpractice law suits.”

If compromises have been reached on these issues, HR 3200 and the Senate HELP Committee’s proposal will have played an important role. By being the most extreme bill available to critics during August it flushed out their attacks. This, in turn, made it easier for moderates to indentify the hot buttons they needed to address. A Washington Post story describing some of the solutions being developed by the Senate Finance Committee’s so-called “Gang of Six” underscores this. (The Gang of Six are Democratic Senators Baucus, Jeff Bingaman, and Kent Conrad along with Republicans Mike Enzi, Charles Grassley and Olympia Snowe). For example, illegal immigrants will be specifically prevented from obtaining any benefits from the insurance exchanges being contemplated. A government-run health plan – the means leading to a government takeover of health care according to critics – will not be missing from the proposal.

For the past few weeks, Republicans have associated President Obama with HR 3200 and the liberal Senate HELP Committee proposal. Yet he has embraced neither. Instead, he is has set the stage for circling the wagons around whatever moderate proposal emerges from the Senate Finance Committee. And Senator Baucus and the others are working hard to make that possible. For example, President Obama embraced a Bush Administration proposal to permit states to test approaches to medical malpractice reform. According to the Washington Post article, such a provision will be in the Senate Finance Committee’s bill.

Liberal critics of President Obama will accuse him of capitulating to conservatives on many of these issues, especially abandonment of a public option. Conservatives will say he’s proven himself to be a liberal tax-and-spender and government-expander (the proposal is expected to cost around $880 billion over 10 years). In the short term there will be much sound and fury over such issues by both sides. If the compromise health care reform solution put forward by Senator Baucus and his colleagues becomes law, however, history will little note nor long remember such histrionics. (Which, for those paying attention to the clichés in this paragraph would tend to prove that Abraham Lincoln trumps William Shakespeare).

So long as the outcome meets President Obama’s general principles for the health care reform the White House will declare victory. History will relegate talk of death panels, cries of socialism, and demands that government get out of Medicare (along with other government-sponsored programs) to footnotes, if that.

As with any major reforms, history will also likely show that the historic health care bill to come will accomplish less than its critics fear or than its advocates claim while at the same time bringing forward unintended consequences of significant proportion. But those problems will be a challenge for a future Congress and Administration. History, after all, is made one step at a time.

Obama Speech Accomplishes Much, But It’s Only a Start

Agree with him or not, President Barack Obama knows how to deliver a speech. Anyone free of Pavlovian conditioning against the man would admit his address to Congress Wednesday night was powerful and at times moving. The question is, of course, what does it mean? (For those interested in reading along, here is the prepared text of President Obama’s health care reform speech).

First, it signals President Obama’s intent to shape not just the Congressional and public debate, but health care reform legislation itself. He repeatedly sprinkled variations of “under my plan” when discussing proposals. Whereas in the past he was content to lay out general principles to guide the reform process, this phrasing signals he is now taking ownership of the legislation. That alone will change the course of the legislative process.

Second, he gave Senator Max Baucus and the Gang of Six the cover they need to negotiate bi-partisan health care reform. As discussed in earlier posts, the Senate Finance Committee Senator Baucus chairs will take up legislation next week. The path they are headed down, as outlined in the Framework for Comprehensive Health Reform, disappoints many liberals. President Obama could have left them out on a political limb. Instead he embraced several of their proposals and, by refraining from declaring a government-run health plan a necessary component of reform, gave the negotiators the space they need to deliver a moderate package. Based on the President’s speech, there is little if anything in the Framework he would not accept. What this means is that the legislation produced by the Senate Finance Committee could serve as the foundation upon which the President can build his own, detailed proposal.

Third, the President, after the requisite insurance industry bashing, focused on constraining health care costs. Whether his proposals go far enough to “bend the cost curve” as the Administration is fond of saying, is open to legitimate challenge. But by elevating the need for controlling medical costs to the top of the health care reform discussion, the President makes it more likely cost containment will be part of the final package.

Fourth, President Obama made clear he would no longer tolerate lies and half-truths about his health care reform package. He called those who claim he would establish death panels liars. He rebuked those who claim illegal aliens would be eligible for federal premium subsidies. He rejected charges that he would be cutting back on Medicare benefits. There are those who will continue to make these charges, but the President made clear their claims would be repudiated quickly, loudly and sharply.

Fifth, President Obama called for a more robust Health Insurance Exchange than some moderates have been considering. He noted an exchange available to individuals and small businesses would mean “these customers will have greater leverage to bargain with the insurance companies for better prices and quality coverage. the same clout large employers enjoy when negotiating rates.” This implies the exchange would do more than simply present information to consumers, but would define benefits and seek bids from carriers wishing access to these markets. Whether or not such an exchange would be successful is open to debate. A similar approach was taken in California as part of its small group reform in the 1990’s. That legislation, AB 1672 is generally considered to have been very successful. The purchasing pool it created, however, has long been out-of-business, unable to compete with the private market.

Sixth, the President put forward his pragmatic side. He wants a government-run health plan to compete with private carriers, but he didn’t declare such a public plan was critical. Instead he said, the impact of a public option “shouldn’t be exaggerated – by the left or the right or the media. It is only one part of my plan ….” In other words, it’s a part of his plan he’d like to see in whatever legislation passes Congress, but it’s not an absolute requirement. Another example of his pragmatism trumping partisan ideology: the President reached out to Republicans by adopting some of their proposals, including those concerning malpractice reform. Yes, there was red meat for liberals, but there was plenty for moderates and even some conservatives to cheer about in his speech.

Seventh, President Obama’s speech was, well, presidential. Republican behavior was a bit childish. When President Obama stated that “the reforms I’m proposing would not apply to those who are here illegally” Representative Joe Wilson achieved a new low in politics by shouting out “You lie!” Even when President Bush was arguably shredding the Constitution and, intentionally or not, misstating the facts, Democrats still treated him with respect when he appeared before Congress. Many Americans will see Representative Wilson’s outburst as a sign of partisan passions coming to rule the GOP. (Representative Wilson later apologized for his “lack of civility,” but the damage was done). Meanwhile, Republican House members were shown on television waiving paper at the President. Apparently these were copies of the GOP health care reform plan and their presence at the speech was meant to demonstrate that the Republicans were more than just the party of “no.” Unfortunately, the television audience wasn’t in on the symbolism. It just looked strange and undignified. Again, like Representative Wilson’s behavior, these antics may play well to the base, but it does nothing to expand that base.

Eighth, the President made clear the status quo is untenable. However, this message was simply part of a 45 minute presentation, dampening the impact. Change scares people. President Obama needs to prove his message that change is needed. If the Administration wants to reposition the debate to require opponents of health care reform to defend the status quo, he will need to devote at least one political event to this topic.

President Obama accomplished a great deal in his address to Congress, but at the end of the day, it was just one speech. Now comes the tough part, tying together the elements of a package that can make it’s way through Congress, while at the same time justifying the reform effort. Given the passions surrounding the health care reform issue, this will be no easy task.

Obama’s Health Care Speech a Beginning, Not an End

Whether you support President Barack Obama or not, his address tonight on health care reform to a joint session of Congress is a major event. American want reform, but are increasingly wary of the what they are hearing is likely to emerge from Washington. Of course, much of what they hear about what’s being considered is wrong or concern proposals that no one expects to reach the President’s desk, but the public’s unease is troubling for reformers nonetheless.

A well established political law holds that it is easier to attack than to propose and promote change. Reformers, consequently, are always at a disadvantage. The White House has seen the tenor and substance of the debate hijacked by charges both serious and silly. Worse, from their perspective, President Obama is being tied to reform bills he has neither endorsed nor blessed. The media and voters describe Congressional proposals as those of the Administration even though the President has stated only principles for reform, not details.

That changes tonight. Or at least, it starts to change tonight. President Obama is going to step into the health care debate over the next several weeks in a far more forceful fashion than before. While it’s unclear how specific he will get tonight, there is little doubt that he will be very clear about what he wants in a health care reform bill – and what he does not – over the next several days. My guess is he will use the introduction of mark-up of legislation by the Senate Finance Committee, expected to begin as early as next week, as his foundation. But whatever vehicle he commandeers (to mix metaphors), we are very close to moving past accusations concerning what Obamacare is to seeing what actually what the President’s plan actually looks like.

And this process begins with tonight’s speech. The folks over at Politico have a good “what to look for” post. Among the most significant items:

  1. Will President Obama keep it simple – and, consequently, comprehensible?
  2. Who will serve as the President’s foil? (My guess – insurance companies).
  3. Where does President Obama stand on a government-run insurance plan? We know he wants one, but will he threaten to veto a bill without a public plan?

Here’s some other questions to keep in mind while watching the President’s speech:

  1. Is the President specific about ways of reducing medical costs?
    Health insurance premiums reflect the underlying cost of health care. So does the burden of public programs like Medicare and Medicaid. Will President Obama make this clear? And will he have ideas for dealing with them?
  2. How will the President frame the rationing issue?
    The spurious fear mongering around death panels not withstanding, the public has legitimate concerns about what reform will mean to their own access to health care. There is rationing of care under the status quo (based primarily on the quality of one’s health insurance), but it’s mostly hidden and subtle. Every health system rations care in some way. How explicit will the President be about the inevitable rationing resulting from his plan?
  3. What type of Health Care Exchange does the President support?
    Does he see these exchanges as bringing together information or are they actively negotiating with carriers concerning rates and benefits? Will they replace brokers or supplement them?
  4. How does President Obama describe the efforts in the Senate Finance Committee to shape bi-partisan reform?
    Does he describe their efforts as central to health care reform legislation or as just one of many sources? Does he give its chair, Senator Max Baucus, political support and cover or leave him to fend for himself? As regular readers know, I’m one of those who believe the bill the Senate Finance Committee produces will be close to what eventually emerges from Congress. Part of my reasoning has been that President Obama wants reform legislation . Which brings us to …
  5. Does President Obama show more interest in practical results or partisan purity?
    Will he seek to please the liberals or the moderates? Will he show a willingness to accept less than a full loaf or will he insist a host of specific elements be included in the reform bill?
  6. Will President Obama succeed in making the status quo unacceptable?
    The devil known is always more welcome than the unknown variety. Right now those attacking reform have the easier task. The President needs to reverse the argument, putting the burden on his critics to demonstrate that the current system is worth preserving – or that it can be preserved. If he fails, the Administration will remain on the defensive. Not a fatal setback, but a serious problem.

Watching the spin doctors go to work on the speech will be a fascinating lesson in politics. Watching them will also be annoying. One can predict what Fox News and MSNBC will be saying, but they don’t really matter. They preach primarily to established constituencies. The public that still has an open mind on the issue will be tuned to the networks, CNN and waiting for their morning paper.

As you listen to the reaction, keep in mind that tonight’s speech is only the beginning of the Administration’s final push for health care reform.  The game isn’t over tonight. It’s just beginning.

Senate Finance Health Reform Framework Creates Context for President’s Speech

In yesterday’s post I described some highlights of a draft health care reform proposal being circulated in Washington by Senate Finance Committee Chair Max Baucus. Yesterday all I could find were news stories about the proposal. Today the full text of what is called the “Framework for Comprehensive Health Reform” is available.

There’s a lot of interesting details in the proposal. It would dramatically change the way health insurance is priced, purchased and administered. It brings together several proposals to reduce the underlying cost of care (although it fails to bring them together into a single section – a political error in my view). It offers subsidies to make coverage more affordable. requires individuals to obtain coverage, and penalizes businesses of more than 50 workers who fail to offer its employee’s insurance. It does not include a government-run plan, but does create state-level health insurance exchanges and authorizes health insurance co-operatives.

The document is only 18 pages and well worth the reading. Because what is significant about the framework is its embodiment of the more moderate ideas under serious Congressional consideration. The framework is not legislation and the Finance Committee is likely to make significant changes to various aspects of the proposal. But if the legislation that emerges from the committee is anything like what’s being circulated by Chairman Baucus, it is the vehicle for reform that has the best chance of capturing any Republican support and of attracting moderate and conservative Democrats. It is also the legislative package destined to be the target of liberal wrath.

Which is another reason the Senate Finance Committee’s Framework is significant. The proposal is being circulated just before President Barack Obama’s address to Congress on health care reform. In his speech President Obama will be creating the context for the final push toward comprehensive health care reform. Previously the debate had focused on the only proposals on the table – the liberal bills passed by the Congressional committees. You were either for them or against them. The Framework being considered by the Senate Finance Committee brings forward a new option, a more moderate option. It won’t attract the support of conservative Republicans – nothing Democrats propose could. But it may attract some GOP votes and it certainly will bring along many moderate and conservative Democrats.

I have long maintained that health care reform would be decided by such moderates. But it is up to President Obama to make this possible. His speech will either strengthen or weaken Senator Baucus’ proposal. His address is expected to clarify what provisions he considers crucial to reform and which he simply prefers and encourages. If he stakes his position firmly in the liberal camp the chances of moderates prevailing is greatly reduced. If, however, he embraces some of the provisions put forward by Senator Baucus, the debate will shift considerably toward the middle. And the legislation likely to emerge from Congress will look substantially like the Framework.

In other words, President Obama is coming to the health care reform arena with no intention of sitting on the sidelines. Now that there are two teams on the field, he needs to make clear which one he’s on.

Outlines of Senate Finance Committee Health Care Reform Plan Emerges

Senator Max Baucus of the Senate Finance Committee is circulating a draft health care reform proposal that could form the basis for whatever reform package emerges from Congress. If there is going to be bipartisan health care reform legislation, this is it.

The draft reflects ideas from six members of the Congressional panel who have spent months trying to find common ground – Democratic Senators Baucus (Montana), Jeff Bingaman (New Mexico) Kent Conrad (North Dakota) and Republicans Mike Enzi (Wyoming), Charles Grassley (Iowa), and Olympia Snowe (Maine). The group, often referred to as the Gang of Six, has been working under tremendous pressure. Democrats have been pushing for action and liberals are concerned about giving up on, among others, provisions for a government-run health plan. Republicans have been equally vociferous on their three colleagues, some arguing that the GOP should seek to defeat any health care reform plan in order to deliver a political blow to President Barack Obama and others opposed to specific elements such as how to pay for insuring the uninsured. Rumors of the gang’s failure have been constant and consistent fodder for bloggers, talk shows and news programs, yet they keep on moving forward. The draft proposal is the most concrete evidence yet that these rumors are unfounded.

As reported by the Associated Press, the plan circulated by Senator Baucus includes a fee on insurance companies to help fund coverage for the uninsured, enabling non-profit co-operatives to compete with carriers, authority for health insurance exchanges (note: there would be more than one) to help individuals and small business purchase coverage, expansion of Medicaid, tax credits to help low- and middle income Americans buy private coverage, and a requirement for insurers to disclose their administrative costs and profits.

The Wall Street Journal describes Senator Baucus’ plan as requiring “most Americans to carry health insurance” and, in addition to a fee imposed on all insurers, would include a tax on “insurance companies when they offer particularly generous health insurance plans.”  The Journal describes the exchanges as providing “standardized information on insurance plans and pricing." The article also makes explicit what is generally assumed to be a part of any health care reform plan: carriers will no longer be able to exclude coverage for pre-existing conditions; drop insureds who become ill; and will cap out-of-pocket medical expenses.

Bloomberg reports that Senator Baucus’ proposal “works to reduce Medicare costs by rewarding doctors based on the quality of care provided, not the number of treatments or tests administered.”

The cost of the proposal is estimated to be $900 billion over ten years. The Senator is emphasizing that what he is circulating is only a draft and subject to change. However, he warned Senate Finance Committee members that they would need to suggest ways to pay for any provisions they suggest that increases the cost.

So what does all this mean? Well let’s get the obvious elements out of the way: the devil is in the details; it’s unclear how well the proposal goes after medical cost containment because the media tends to focus on what’s easier to understand (insurance reform) – the good news is there are indications reducing health costs is significant part of the package.

It’s also clear the proposal will be unacceptable to both liberals and conservatives. No problem, the more ideological on both ends of the political spectrum would be unhappy with any reform Congress is capable of passing. Liberals will complain because it doesn’t give government enough control over the nation’s health care system; conservatives because it gives government too much control over the nation’s health care system.

However, ideologues don’t pass much legislation, moderates do. And the Senate Finance Committee’s is apparently getting ready to pass legislation far more moderate than what has already been approved by the Senate Health Education Labor and Pensions Committee or by the three House Committees with jurisdiction.

Which means if the Senate Finance Committee actually moves forward something along the lines of the package being circulated by Senator Baucus, for better or for worse, what passes for moderate health care reform legislation is more likely to become a reality sooner rather than later.

Obama Openness to Compromise Should Be No Surprise

Negotiators on the Senate Finance Committee are expected to put forward their compromise health care reform proposal on or before September 15th. President Barack Obama is not waiting to see what they produce. Instead he’s likely to provide some helpful hints during an address to a joint session of Congress on September 9th.  The speech will not lay out legislative language, but is likely to put forward the President’s prescription for change in far greater detail than has previously been the case. And liberals are nervous.

As reported by the Associated Press and elsewhere, the White House is signaling that President Obama’s intends to offer common ground for moderates, but not much red meat for liberals (to mash two unrelated metaphors). Senior advisor David Axelrod, for example, is quoted as saying that the president “believes in ‘fundamental principles’ about overhauling health care … but ‘he’s not dogmatic about how we get there.’”

This type of talk infuriates liberals who are adamant that a government-run health insurance plan – an anathema to conservatives and many moderates – be included in the final reform package. The Congressional Progressive Caucus has directly lobbied President Obama by letter and phone to include a public plan and its members are threatening to vote against any bill without one.

During the phone call the President did not reassure the liberals, but promised to continue to communicate with them. Meanwhile, the White House was signaling a willingness to accept a so-called “trigger” for a public health plan in lieu of launching a government insurance plan on Day One of reform. The trigger concept is being pushed by Senator Olympia Snowe, one of the Republican senators working on the Senate Finance legislation. She has proposed what the Associated Press describes as nonprofit agencies offering health coverage “only if private insurers could not cover 95 percent of the people in their regions with plans costing no more than about 15 percent of the person’s or household’s annual income.” (While an uninsured rate of five percent might sound like a high hurdle meet, other countries have significantly lower rates. (In Germany the uninsured rates is roughly 0.2 percent; in the Netherlands approximately 1.5 percent. Both countries have private insurers).

If on Wednesday the President fails to insist on a government-run health plan liberals will be outraged, but they should not be surprised. President Obama has been totally forthcoming concerning his pragmatic approach to politics and legislating. In a speech to Families USA in January 2007 – even before he announced his presidential campaign – then Senator Obama declared that while it was critical to achieve health insurance for all Americans, it was important to be “agnostic in terms of how to achieve those values.” Throughout the current debate he has constantly repeated his three guiding principles for reforms and, while stating his preferences, has made clear everything is on the table.

The fact is, and this will shock many, Congressional Democratic are not a monolithically liberal group – and as a whole they are certainly less liberal than their leadership. Some liberals seem to think that all members of the Democratic caucus need to think like and, more importantly, vote like, Speaker Nancy Pelosi and Senate Majority Leader Harry Reid. Such delusions are at best naive and at worst dangerous. Congress should represent a broad spectrum of opinion and their voting should reflect that diversity. In fact, one of the strengths Democrats have among the electorate is the perception they are more open to and tolerant of diverse opinions than the GOP.

Only rarely, and then usually as the result of a national calamity, do the extremes of a party pass legislation. Usually the heavy lifting is done from the center. This goes back to the importance of the final vote (in the Senate the 60th vote; in the House the 218th). As explained in a previous post, their tolerance for change has a great impact on what winds up in any particular bill. In the Democratic party, these votes are far closer to the political center than it is to the ideology of the Congressional Progressive Caucus. This doesn’t make these moderates unfaithful to the Democratic party. On the contrary, it helps define that party.

Liberals seeking health care reform need to acknowledge this reality. President Obama has long made clear he does. Like his mentor Senator Edward Kennedy, President Obama appears more interested in passing legislation than he is in maintaining the purity of his ideological positions. And like the liberal Senator Kennedy, President Obama appears willing to accept a portion of the loaf if, in doing so, he improves the lives of those he champions.

Liberals may be unhappy with this pragmatism, but in doing so they ignore the reality of the 2008 election: the Democratic Party and the independent voters they won over last November may be left of center, but like President Obama, they are more pragmatic than ideological. They seek change not purity. Unlike the true believers, they are agnostic in terms of how to achieve desired results. If that means compromising on issues like a government-run health plan, then compromise is what they, and their President, will do.

Health Care Reform News versus Entertainment

There’s news and then there’s The Daily Show, hosted by Jon Stewart. Mr. Stewart is clear his is not a news show. He is an entertainer. His show is, after all, on Comedy Central. Yet his insights on the health care reform are far deeper than anything you’ll find on CNN, Fox or MSNBC. While clearly liberal, Mr. Stewart has the smarts to be an equal opportunity lambaste-er.

Now, let me say, I recognize the health care reform debate is a serious issue. One has only to read a comment left by Tracey to appreciate that. She played by all the rules (purchased coverage, paid her premiums), but her son’s coverage will soon reach it’s lifetime maximum. The substance of health care reform is literally about life and death.

The politics of health care reform sometimes loses sight of that reality. Beneath the bombast and the shrill rhetoric human lives hang in the balance. Sometimes it takes humor to put things in perspective and to get us focused on what really matters – that the status quo cannot be sustained. Change is needed and our leaders and the media need to be focused on helping us understand the tough choices we need to make. They need to be clear and articulate. They need to avoid fear mongering and hysteria. When leaders and the media fail, they need to be held to account.

Enter Mr. Stewart and his comrades in humorous arms. Take, for example, this clip in which John Stewart gives both President Barack Obama and Fox News deserved reality checks (the president at about 3 minutes and 30 seconds into the clip; Fox at about 4 minutes and 40 seconds).  Warning: The clip is PG-13 rated – at least.

In another episode, Mr. Stewart captures the absurd heights the national dialogue on health care reform reached this August, when he observes “So the debate seems to have boiled down to one side screaming so loud and so angrily that they’ve drowned out the other sides’ incoherence.”

Congress is about to convene once more and the final push for health care reform is about to begin. Next week, as you leave what I hope is a terrific Labor Day weekend behind you, keep this in mind: for entertainment masquerading as news, tune into MSNBC or Fox (depending on your predisposition). For news delivered as entertainment, keep an eye on The Daily Show. Consider it the silver lining of the political craziness we call the legislative process. And let’s hope at the end of the day the result of all this is a system that works for Tracey and the rest of us.

Vacations Almost Over – It’s Time to Get Real

The August vacation is almost over and not a moment too soon. Vacations are supposed to be a time of relaxation, recharging, maybe even contemplation. It’s a break from the norm; a chance to get a new perspective on things.

Sometimes.  Then again there’s the vacation from hell where everything goes wrong and you can’t wait to get back home. The hotel that looked pretty in pictures turns out to make the Bates Motel look hospitable. And let’s not even get into the crowded airports and late flights. Such vacations are not about rest, their about survival.

When it comes to health care reform, August was more of the vacation as disaster variety. A month of demonization (fitting, somehow, for a vacation from hell), dark fantasies, and an ever increasing lack of civility. Instead of an opportunity for all sides to present their differing perspectives and to present persuasive arguments for their point-of-view we witnessed the Outrage of 2009. Sincere people whipped into a frenzy by those who profit from conflict and fear. It was not only a bad month, it was a sad one.

But that will soon be behind us. Labor Day marks the end of summer (at least psychologically if not astronomically). It will soon be time to get serious. Here’s my take on what we have to look forward in September. Some of these items are well publicized, others guesses, and still others the result of wishful thinking. As a whole, however, I expect this list identifies much of what is to come now that we’re done “relaxing.”

  • President Barack Obama will describe ObamaCare.
    According to the Associated Press, the White House is “considering a speech to spell out more details of his goals for overhauling health care ….” My guess is he’ll have to go beyond detailing goals and dive into specific on legislation. To date the President has been content to outline a broad definition of meaningful reform. There were advantages to this approach, but the downside is rapidly overwhelming those benefits. The Administration’s vagueness kept its options open, but allowed Congressional Committees to define the President’s health care plan in the public’s mind. The bills attacked during the various town hall meetings are Congressional proposals, not President Obama’s. The Administration needs to define “acceptable compromise.”  Otherwise opponents of change will continue to savage the process of reform, killing the purpose of reform without having to engage in a debate on policy.
  • The Senate Finance Committee will meet its September 15th deadline for issuing a bi-partisan proposal, or on September 16th we’ll see a Democratic proposal emerge from the committee.
    Senator Max Baucus, Chair of the Finance Committee, and his colleagues are to be commended for seeking health care reform that can gain the support of moderates in both parties. They have spent months working through both broad policies and minute details – hard work on easy issues, a herculean task when it comes to something as complex and controversial as health care reform. The time has come, however, to move on. They have created expectations that the fruits of their labor will be made public by September 15th. That expectation needs to become a reality. To date, President Obama has given them political cover by continuing to speak of principals as opposed to specific provisions. As noted above, however, that position is too tenuous to continue. If the Senate Finance Committee fails to bring forward a compromise plan before the President begins staking out firm political and policy positions their compromise won’t matter. If the Finance Committee acts first, however, the President can elevate their approach to the first proposal among equals. The most potent ordering of things is for the Senate Finance Committee to get specific first with President Obama following suit shortly thereafter. If handled correctly it would create a strong middle ground upon which moderates could take a firm stand.
  • The political attacks will continue and become more vicious …
    The Keith Olbermanns and Glenn Becks of the world have found a ratings magnet: vilify the opposition while rejecting any possibility that opponents might have a reasonable, albeit different, position. Demonizing opponents sells to those already on your side. As cable news blabbers have no need to make policy they are free to paint the world in deepest blacks and whites and “find their audience.” At the same time partisans on both sides are reveling in the fundraising bonus blind anger generates while, at the same time, proving their bona fides to core constituencies for future political efforts. As the August press coverage demonstrates, hate, slander, lies and fear sell. And there are plenty of politicians and media outlets willing to take advantage of this ugly reality.
  • … and the political attacks will become more subtle.
    At the same time the extremists will get even more viscous, lawmakers, who operate in shades of gray, will begin to prod opponents into compromises with stilettos as well as reasoned arguments. An example: Senior White House adviser David Axelrod’s claim that Republican Senators Charles Grassley and Mike Enzi have not acted in good faith during their discussions with Senator Max Baucus and other Senate Finance Democrats to produce a bi-partisan health care reform bill. The attack by Mr. Axelrod is both a means of assuring liberals that the White House is capable of playing hardball as it is of prodding the GOP Senators to continue negotiations.
  • The Status Quo is in for a beating.
    The only way to enact substantial change is to convince people the status quo is untenable. This is good news for reformers as the health care system’s status quo is untenable. Medical costs must be constrained or state governments and private businesses alike will be bankrupt. Families cannot live in fear of facing a choice between financial and health security. The medical infrastructure of emergency rooms and pro bono care cannot continue to handle their ever increasing burden. Advocates of reform will make this case repeatedly and in the harshest of terms. The resulting cacophony will be painful in many senses of the word, but it’s an inevitable part of the process.
  • Many issues will be in play, only a few will be discussed.
    Change will come, either thoughtfully and not. All Americans will benefit from a thoughtful approach.Such thoughtful reform includes tackling medical cost containment. Health insurance premiums, after all, reflect the cost of health care. Those premiums have doubled in the past 10 years, an unsustainable rate of increase. If we’re going to “bend the cost curve” as President Obama puts it, tough decisions will be required. Making those decisions is especially difficult in an environment when consultations on living wills is construed as creating death panels, but making them is essential nonetheless. Politically, however, lawmakers need a bad guy. So the public debate will focus on market reforms (Exchanges and public plans, pre-existing conditions and mandates to buy coverage) which permit the vilification of insurance companies while, hopefully, quieter arguments focus on cost containment. Hopefully, because if health care reform is to have any long term meaning, it needs to control costs.

By the end of the year President Obama will sign into law health care reform legislation. That final package may not look much like the legislation discussed at the town hall meetings in August, but it will dramatically change America’s health care system nonetheless. And when the raucous debates, political warfare and mongering of fear is over, when the reforms are signed into law but before the long process of making them work begins, hopefully there will be time for a real vacation.