The looming 2012 health care battle

National Journal's Ron Brownstein makes an important point about health care -- even if the Democratic reform bill is signed into law, Republicans are likely to try to repeal it if they take back the White House in 2013:

If Obama does sign a reform bill, which appears more likely than not, Republicans will face a momentous choice between consolidation and repudiation -- between accepting the new program and seeking to dismantle it. The alternative paths are neatly captured by the GOP's contrasting reactions to the two central cords of America's existing social safety net. After FDR got Social Security approved in 1935, Alf Landon, his Republican challenger in 1936, denounced it as "unjust ... stupidly drafted [and] ... folly." Roosevelt's landslide victory over Landon (and subsequent re-elections) provided Social Security the time to build impregnable support. But many congressional Republicans kept fighting the program until President Eisenhower, a Republican, declared a truce after his election in 1952.

By contrast, Republicans largely accepted Medicare soon after President Johnson signed it into law in 1965. Although conservative Republicans such as Barry Goldwater and Ronald Reagan had fiercely condemned the program before its creation, Nixon during the 1968 campaign spared Medicare from his criticism of the Great Society's cost. Once elected, he quickly "became a strong supporter of Medicare" and effectively ended challenges to its existence, Morone notes.

Which path might Republicans follow if Obama signs universal health care? Several factors point toward confrontation. The GOP accepted Medicare so quiescently partly because the program began dispensing benefits just one year after passage and rapidly became too popular to assail. Social Security, though, was phased in over many years--as health care reform is slated to be. Such delay can invite "fierce and protracted ... guerrilla war," notes Harvard sociologist Theda Skocpol.

Also encouraging confrontation is the breadth of Republican opposition. Almost all House Republicans at the time voted to derail Medicare and Social Security by "recommitting" the bills to committee. But once those challenges failed, about half of House Republicans backed Medicare on final passage and four-fifths supported Social Security. House Republicans last week voted 176-1 against the health care bill.

Some senior House Republicans have already pledged to repeal any health care bill if they regain the majority. And many GOP challengers in 2010 will surely echo them. But with Obama holding a veto pen, Republicans probably couldn't mount a real threat unless they won the White House in 2012. One top adviser to a possible 2012 GOP presidential contender says that, given the GOP base's hostility to the reform plan and independents' unease, it is likely that "most potential [Republican] candidates will argue for wholesale replacement with their own version of health care reform."

If Obama passes health reform and Republicans then seek its repeal, the next presidential election could lastingly redefine America's social safety net. Like 1936 and 1968, 2012 looms as a crossroads in the relationship between Americans and their government.

Specifically, the bill defers the insurance subsidy system and the health insurance exchange until 2013, From a political perspective, it would presumably make more sense to deliver all of the bill's benefits before the election that could decide its fate. So why is the bill structured this way? Here are a few possible reasons:

1. Deferring implementation until 2013 limits the costs of the bill under Congressional budget rules.

2. It avoids embarrassing implementation problems taking place during the campaign.

3. Setting up the health insurance exchanges is technically difficult and will take several years.

4. Despite the plan's bad poll numbers, Democrats want the 2012 election to be about health care (a traditionally favorable issue).

In any case, even if Republicans gain ground in Congress and take back the White House in 2012, they would still have to defeat a Democratic filibuster in the Senate to repeal the bill. The odds of all those things happening aren't especially high. But given the strength of the conservative base, we should expect a long GOP guerrilla war to try to weaken and undermine the program if it does in fact pass. This issue isn't going away any time soon.

Update 11/17 12:46 PM: Matthew Yglesias clarifies an important point that I wasn't clear about -- a GOP effort to "repeal" health care reform wouldn't necessarily eliminate every provision of the enacted legislation. However, from the standpoint of Democrats and advocates of reform, the changes Republicans are likely to propose would almost surely be seen as gutting the legislation.

Update 11/18 5:16 PM: The Kaiser Family Foundation has posted a useful summary of the House bill that includes implementation dates for key provisions.

Comments

[Rob]

Brendan's comments are sensible, but his penultimate sentence is a textbook example of the heavy-handed use of loaded terminology, more worthy of a political partisan than a neutral commentator. Why is it that when Democrats seek to roll back tax cuts, they're being true to their principles, whereas if Republicans seek to roll back an ill-conceived restructuring of American health care, they'd be waging "a long GOP guerrilla war to try to weaken and undermine the program"?

Try to see it this way, Brendan. For Republicans, the work goes on, the cause endures, the hope still lives, and the dream shall never die.

[daniel rotter]

Why is it that when Democrats seek to roll back tax cuts, they're being true to their principles, whereas if Republicans seek to roll back an ill-conceived restructuring of American health care, they'd be waging "a long GOP guerilla war to try to weaken and undermine the program?"

Putting aside the "ill-conceived" editorializing (which I disagree with), that's because Democrats' attempts to roll back tax cuts have never been a long-term goal, while the Republicans' efforts to repeal the health care plan very likely will be.

[David]

Brendan's prediction seems as likely as any, although, as Rob points out, it's written from a Democrtic POV. Here's a re-statement of Brendan's four reasons for the structure from a Republican POV:

1. The Dems finagled the budgeting process to make an unaffordable plan score as affordable.

2. The implementation in 2013 will be a disaster, but voters won't know that when they re-elect Dems in 2010 and 2012.

3. The exchanges won't work. Medical care will be screwed up for years until the exchanges are straightened out or eliminated.

4. The Plan may be very expensive and provide lousy health care, but it will be a success if it helps elect Democrats.

[daniel rotter]

2. The implementation in 2013 will be a disaster, but voters won't know that when they re-elect Dems in 2010 and 2012.

Here's my Democratic POV of David's Republican POV of Brendan's Democratic POV as it relates to the above: When it comes to the issue of the health care bill at issue, voters who re-elect Dems in 2010 and 2012 are uninformed idiots.

[Jinchi]

1. Deferring implementation until 2013 limits the costs of the bill under Congressional budget rules.

Bingo. Gaming the numbers is a pretty common tactic among politicians. Bush did the same thing when he put an expiration date in his tax cut plan.

Having decided that the plan must fall below (arbitrary number X) the easiest way to maximize the plan is to delay it's implementation by several years.

4. Despite the plan's bad poll numbers, Democrats want the 2012 election to be about health care (a traditionally favorable issue).

This point makes no sense to me. The 2013 phase in date guarantees that Democrats will be fighting "death panel" style accusations for the next 3 years, not to mention multi-million dollar "repeal the bill" campaigns funded by the insurance industry. They'd in a far better position defending health care coverage that millions of Americans would actually have (with slogans like "Republicans want to cancel your health care coverage - Vote Democratic").

And despite David's paraphrase, it was the conservative Democrats who pushed both the arbitrary budget number and the delayed implementation. Liberal members wanted universal coverage "on day one". Which leads to an explanation you didn't offer.

5. There are a number of Democrats in Congress who want health care reform to fail