Do it first, don't write a bill, and let someone else take the credit.

Repairing some of the worst Bush administration screw-ups.
April 3 2008 6:58 AM

Health Care Policy

Do it first, don't write a bill, and let someone else take the credit.

With President Bush's approval rating hovering in the 30s, just about everyone has an opinion on what George W. has done wrong in the past seven years. But not everyone can explain what the next president must do to fix it. So we've called in some experts to tell us. Fixing It is a 10-part series to be published over the course of the week by some of our favorite writers, offering detailed policy prescriptions for the next president, whoever that may be, on how to quickly undo some of the damage that's been wrought. One of our contributors wryly describes the series as "News You Can Use. If You Happen To Be President." Read the other entries here.

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Let someone else take the credit. In part, the 1994 effort was foiled by simple Republican intransigence. Bill Kristol, then a Republican strategist, wrote a famed memo titled "Defeating President Clinton's Health Care Proposal," in which he warned, "Any Republican urge to negotiate a 'least bad' compromise with the Democrats, and thereby gain momentary public credit for helping the president 'do something' about health care, should be resisted." Similarly, Bill McInturff, a Republican pollster, advised that the party's midterm hopes relied on "not having health care pass."

Cynical? Sure. But Kristol and McInturff were responding to very real electoral incentives. Much of the electorate still considers health care a Democratic issue. This is particularly true when the reform charge is led by a Democratic president and named after him or her. For Republicans to assist in passing health reform, then, would be to give Democrats a massive accomplishment they can take with them into the election. If the next president to try ambitious heath reform is to succeed where the last failed, he or she will need to hang back a little bit and change the political incentives. Let the congressional process work, and allow the bill to be named after two powerful senators—one of whom should be a Republican looking for a legacy. He can pull in a few of his powerful colleagues who also see themselves as historic legislators, and you'll be closer to your majority. And don't worry: Even if the bill is called Baucus-Grassley, you'll still be the one signing it.

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Have a political strategy.Health care is complicated. Voters are afraid of losing what they have. The electorate has a lot of status quo bias. Powerful stakeholders will oppose the final bill. So the next president needs to deploy an aggressive communications strategy from the first day. The commander in chief will need to make sure that his or her allies are well-funded and ready to rebut attacks; that the war room is well-staffed with a powerful set of talking points; and that the various stakeholders know that attempts to kill reform will not only lead them to be written out of this bill, but to seeing their own political priorities impeded in the future. Remember when Teddy Roosevelt said, "Speak softly and carry a big stick?" Well, by letting Congress write this bill, you're speaking softly. The political strategy is your big stick. In the past, the executive branch has been so concerned with creating a bill, they've forgotten to sell it. By outsourcing the creation to Congress, you can free up resources for the PR blitz.

Have principles more than a policy. Don't take the above to mean you should go into the reform process without any idea of what you want. It's just that what you want shouldn't be too specific. Health reform is meaningless if it isn't actually universal, if it doesn't make the system more seamless and integrated, and if it doesn't reform the insurance industry so it can begin competing on price and quality rather than risk-shifting and denials of coverage. Optimally, you'll also break the link between employers and health insurance and create a public plan that can compete with private plans, so consumers can choose between health insurance that seeks profit and health insurance that seeks health. So those should be your principles: universality, integration, insurance industry reform, a transition away from employer-based insurance, and public-private competition. You can advocate for those things without getting too hung up on the details. Rather than being dogmatic about policy and agnostic about politics, as your predecessors were, you should be dogmatic about politics and, if not agnostic about policy, more focused on ends than means.

Ezra Klein is an associate editor at The American Prospect. His blog contains much health care wonkery.

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