I've always wished for more comprehensive reform than we seem to be getting. I think there's pretty good evidence that other countries achieve universal coverage with at least comparable outcomes while still managing to spend less than us. I've always been willing to talk about the sacrifices necessary to achieve similar results. But when it comes to actual policy for reform, I've always thought of it like I do anything else in medicine - in terms of benefits and harms. And, if I have to be honest, it seems like the current reform proposals are likely to do much more good than harm.
This last week, as many previous supporters of reform suddenly revolted, I've been fielding a lot of questions asking how reform proponents could have won more. How could they have gotten a public option? How could they have gotten more concessions? Why did they give up so much?
Many are screaming that President Obama should have done more. Others believe that Senator Reid could have run things better. I'm no longer sure. I've come to the conclusion that there may not be much more they could have done.
I say this as someone who believes that much more radical reform would have been preferable to what we are going to get. When we started all of this, I was told that was impossible (ironically, by many who now want to kill the bill). The votes weren't there. It couldn't happen. And I kept being told that I didn't want the perfect to be the enemy of the good, did I?
I used to dismiss such claims as weak. I thought if we just tried harder, if we just convinced more people, then anything would be possible. I still think this is true - in the House of Representatives. I no longer think it is in the Senate, however. At least not now.
For better or for worse, you seem to need 60 votes to pass significant legislation. I know that's not what it says in the Constitution. I know that's not the way it has always been. But that doesn't change the reality of today. No matter how many polls you quote or surveys you take, you need 60 votes in the Senate.
And, unlike in the House of Representatives, the Senate is not representative of the people of America. It's representative of the States themselves. And the States do not necessarily represent America. A fair number of small states (at least by population) are conservative. They just are. Even when they elect Democratic Senators, those Senators are going to be conservative. They just are.
And, because of how the Senate works, a Senator from conservative Nebraska (population 1.8 million) has just as many votes as a Senator from liberal California (population 36.8 million). In fact, the Senator from California represents more than twice the number of people than the Senators from Nebraska, Wyoming, Louisiana, Arkansas, Missouri, and North Dakota combined. It doesn't matter that way more total people support reform in California than oppose it in all those other states. In the Senate, a vote is a vote.
Moreover, you can't pressure a Senator in a conservative state from the Left. That will only drive them to the Right. That's because you don't win an election as a Democrat in a conservative state by becoming more progressive. You win by becoming more conservative.
Yes, you can make individual Senators more progressive in progressive states. You can threaten a senator from New York or California by running a more liberal person against them in the primaries. This is why Senator Spector fears a primary in (Blue) Pennsylvania. He's a conservative Senator in a more progressive state. That's why the Republican Party had so much trouble making him more conservative. That's why he eventually became a Democrat to survive.
Similarly, you can't realistically pick at a Democratic Senator in a conservative state for not being progressive. Senator Nelson is risking his election by supporting health care reform in Nebraska. For that matter, so is Senator Reid in Nevada. You can't demand that he move further from his electorate and just expect him to respond. He wasn't elected by you. He was elected by mostly more conservative people.
Sure, you could work harder to make a conservative state more progressive. I think many conservative Democrats like Senator Nelson would welcome that; it would make his life a lot easier. But the Democratic Party isn't working that hard in Nebraska. When they do - attacking him for not being progressive enough - it probably isn't resonating with a lot of Nebraskans.
You can wish the Senate were different. You can bemoan President Obama for not offering more support. You can blame Rahm Emanuel for twisting the wrong arms. You can blame Senator Baucus for taking so long with the Finance Committee bill. You can blame Senator Reid for not getting people to vote the way you want. But the likeliest reason Progressives have had to "sacrifice more" is that the Democratic Party has more leverage over Progressives. That's just the way it is.
If you disagree, if you think you really can get a more Progressive bill, I want to hear more than talking points and slogans. No "fight harder" or "do it better" or "if only so-and-so had pushed". I want to know how you deal a huge defeat to reform, and then get to 60 votes on a new bill that's more progressive than this one. How do you do that on any legislation, for that matter? There are many other things that Democrats are going to want to accomplish, including a climate-change bill, a new budget, and even, perhaps, further cost-controls in health care. What will you do to convince conservative Democrats in conservative states to become more progressive?
And if your solution to a more robust reform is to push a bill through reconciliation, why does that require killing the present bill? Why not pass it and then add in what you can through reconciliation later? That seems much less risky.
I'm not asking rhetorically. I really do wish someone would explain this to me. Answer in the comments below. Why do you think killing the bill will do more good than harm? No posturing, no name-calling, and no rhetoric. This is far too important, and real people's lives are involved.
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