Left Flank

I voted for Barack H. Obama for one reason: enacting universal health care reform. Congress and the Obama campaign have laid the foundations for health care insurance that take the Clinton follies into account.

But not everybody thinks 2009 has to be a repeat of 1994. Since June, staff members from three key Senate committees--Budget, Finance, and Health, Education, Labor, and Pensions--have been meeting regularly to map out a health care strategy for the coming year. They've formed three working groups: one focused on expanding insurance coverage, one focused on improving the system's functioning, and one focused on financing a new initiative. They've also been meeting with officials representing almost every key stakeholder involved in the health care debate, from doctors to insurers to consumer advocates to employers. The goal of these meetings has been to develop a common vision among Senate Democrats for what universal health care should look like--and how to pass it. Although the discussions still have a ways to go, a rough consensus is starting to take shape.

According to multiple participants in the process, the final proposal will probably resemble the initiative Obama touted on the campaign trail. People who like their insurance could keep it; others could buy coverage through a cooperative, like the one federal employees use, in which insurers couldn't exclude people with pre-existing conditions. There would be subsidies, so that everybody could afford a plan, plus serious efforts to restrain future growth in health spending so that the actual price of insurance would start to come down.

Agreement is also emerging over a roll-out strategy. It would kick off as early as this month, when Max Baucus--whose reputation for bipartisan compromise makes him an unlikely vessel for liberal ambition--introduces a white paper outlining reform options for universal coverage. Afterward, if all goes well, he and Ted Kennedy--who helped drive the process from Massachusetts, where he is receiving treatment for brain cancer--will craft a full-fledged bill. The idea, according to a senior staffer, would be to introduce the measure early next year, after the inauguration: «We intend to push for health care out of the box,» the staffer says.

Of course, drafting a proposal is relatively easy. Passing one--well, that's another story. But Baucus himself confirms what staffers have been saying for months: Assuming Senate Democrats can find some common ground on reform, they would consider using the budget reconciliation process to enact it.

This is a crucial development. The rules of reconciliation limit debate, restrict amendments, and prohibit filibusters. It's the one time a simple majority of 50-plus-one votes--rather than the 60 it takes to break a filibuster--can definitively pass legislation. It's a brass-knuckles way to move legislation and, as such, nobody's first choice. But, if the Republicans won't negotiate, Baucus has told me, the Democrats might have to use it. «My first preference is always to work together with my [Republican] colleagues to get legislation done,» Baucus says. «When that's not possible, I'll find another way.»

None of this makes universal coverage a done deal. The emerging consensus over principles and strategy could still break down over details, such as how to pay for the subsidies or whether to create a new public insurance program, modeled on Medicare, into which anybody could enroll. Baucus and Kennedy would also have to find common ground with colleagues who are supporting an alternative, bipartisan bill Oregon Democrat Ron Wyden has spent the last two years promoting. And that's just in the Senate. Over in the House, discussions are more embryonic and scattered; although traditional champions of reform like John Dingell, Pete Stark, and Henry Waxman are ready to go, Nancy Pelosi and her leadership team may not be.

But Obama can push them, and he would be well advised to do so. Notwithstanding all the knee-jerk pessimism, the environment for health care reform is a lot more favorable than it was in 1994. And, while taking on health reform in the first year would still pose political risks for the Obama administration, so would delaying it.

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