Health Care Reform: A Peek Behind the Curtain

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People often talk dismissively of “process stories” and the media’s obsession with “inside baseball” in Washington. But sometimes, these stories give us a real window on how decision-making really works. I’ve written here before about how much I admire the work that the New Republic’s Jonathan Cohn has done in explaining this nation’s health care system. (And his book “Sick” remains at the top of my recommended reading list for anyone who wants to understand, in human terms, how truly broken the system is.) Today, he takes us behind the scenes with an inside look at the White House debate over how aggressively to pursue reform amid all the other crises that are demanding the country’s attention and its resources. There were those who had their doubts, Cohn reports:

Axelrod’s anxiety hadn’t dissipated since the election. And now he had a new ally in Larry Summers, whom Obama had appointed to head the National Economic Council. One concern for Summers was the diversion of presidential and staff attention from other issues, like the economy. Mostly, though, Summers worried about money. Experts generally believe it will take years before better use of information technology, more preventive care, and other reforms start to yield serious savings. At least in the short run, health care reform is therefore likely to add to the government’s financial burden–during a time of rising deficits. This made Summers uncomfortable.

But one particular senior Administration official held firm. And that senior official happened to be the President of the United States. Cohn tells us:

Repeatedly, the president made clear that he was not abandoning health care reform. There was the meeting in early January where he expressed disappointment with the budget numbers his advisers were showing him. And there was the Sunday after the inauguration, when Daschle found himself in the White House to meet with Rahm Emanuel. Daschle had requested the get-together in order to clarify the president’s intentions on health care. During the meeting, which took place in Emanuel’s office, Obama himself stopped by and reiterated to Daschle what he’d been saying in public: He was doing health care this year.

That decision to pursue so much, of course, continues to be the subject of a lot of second-guessing. But, as Cohn concludes:

Whatever the fate of health care reform, though, the debate does tell us something about the way Obama plans to manage his presidency. Obama has long struck many observers as an extremely cautious politician, and his handling of the banking crisis and the economic stimulus bill has tended to reinforce that perception. The trajectory of the health care debate inside his administration, however, suggests that Obama is not always as cautious as he might seem. He can think big. He can take risks. And he can bring his advisers to him–rather than the other way around.