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Playing Health Care PoliticsReform may depend on Obama's ability to mend fences in his own party.

By John DickersonUpdated Tuesday, Sept. 29, 2009, at 5:29 PM ET

Barack Obama. President Barack Obama Sen. Max Baucus, D-Mont., has taken a lot of heat from both left and right ever since he unveiled his health care reform bill two weeks ago. The latest attack comes from the left: A new political ad accuses him of caring more about campaign contributions from insurance companies than a constituent with a serious heart defect but no insurance.

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Why? He's not supporting a government-backed insurance option. [Update, 4:50 p.m.: Baucus voted against it twice on Tuesday in the finance committee hearing, arguing inclusion would kill health care in the Senate. "My goal is to get a bill out of this committee that gets 60 votes," he said.] Liberal groups, like those that paid for the ad (they call themselves the Progressive Change Campaign Committee and Democracy for America, if you're keeping score at home), say that only a public option will create true competition with insurance companies and thus lower costs. Ostensibly, since President Obama supports a public option, these groups are his allies. But Max Baucus is also his ally. As chairman of the Senate finance committee, he has fashioned a bill Obama is relying on to advance his health care reform plans.

So liberals who helped Obama get elected to end the influence of special interests are now attacking Obama's key man in the Senate for being so influenced by special interests that he's killing a top Obama priority. Objections to reform from Republicans or free-market conservatives are at least expected and (relatively) straightforward. As we approach the end game on health care reform, Obama's more delicate task will be managing opposition from within his own party.

The ad won't influence the debate. There's not much money behind it, and it comes too late in the process. (It was just unveiled yesterday, and the Senate finance committee will vote on amendments to include a public option today. [Update: The committee voted down two versions of a public option today, 15-8 and 13-10.]) But the fracas is significant in a larger sense—as the latest salvo in a battle among factions in the Democratic Party over the shape of health care reform. And it will be the task of the president, who is leader of the party, to get everyone in line.

In the ad, Bing Perrine, one of Baucus' constituents, describes how last year he collapsed because he has congenital heart disease. As a result, his medical costs have skyrocketed. A public option would help hold down those costs, Perrine explains, and then asks: "Senator Baucus, when you take millions of dollars from health and insurance interests that oppose reform and oppose giving families like mine the choice of a public option, I have to ask: Whose side are you on?"

The message is pretty tough: Baucus is so craven he doesn't care about sick people. But the message is also muddled. The ad makes a point about the public option, but Perrine's plight could just as easily be used to illustrate the need to prohibit insurance companies from rejecting people who have pre-existing conditions. Perrine says he owes $100,000 because he couldn't get insurance, but if the Baucus bill (or any of the others) passed, insurance companies would have to cover him. In fact, regardless of what happens with the public option—and there are still three chances it could become a part of health care reform—under any of the bills now being considered in the House or Senate, insurance companies would not be allowed to deny Perrine coverage.

In his joint address to Congress on health care, the president vowed, "If you misrepresent what's in this plan, we will call you out." He's not about to do that here. Nor is he (or a White House aide) likely to stand up for Baucus, who is working hard to carry the president's water. He could easily argue that, given opposition in the Senate to the public option, progressives should rally around building support for fights that are winnable, such as increasing subsidies for working families or making sure insurance companies cover pre-existing conditions. That last option might be a nice thing to do. But it could be costly. Liberals don't think the public option is dead. They point to public polls that regularly show support for such a plan. Plus, fundraising for the ad has been brisk and spiked after Tuesday's finance committee votes against the public option. If the president appeared to take Baucus' side, he would unnecessarily inflame passions in a sizable bloc of his party.

At any rate, administration officials argue this ad and other efforts to target Democrats are mostly the kind of thing that concern party elites, not regular people. The president will have a lot of disputes to adjudicate as this legislation reaches its final stages. Why expend political capital now? Better to let liberals blame conservative Senate Democrats instead of President Obama for killing the public option.

The president has never worked too hard to stop these intraparty attacks, and he's not about to start now. He's asked that liberal groups not attack their own. Chief of staff Rahm Emanuel has, too. The groups haven't listened. This isn't the first of these ads. Moveon.org and the Progressive Change Campaign targeted Democrats and earlier this month organized to put pressure on the White House. Perhaps none of the outside groups are afraid because there's not that much pressure. Arshad Hasan, executive director of Democracy for America, says no one from the White House or Obama's political group, Organizing for America, has ever directly asked them to stop.

Staying out of the fight not only preserves the president's political capital; it also gives him room to maneuver. He gains with moderate Democrats by making public comments calling for liberals to lay off. But he also benefits by having liberal noise makers. He can point to them as evidence for the need for concessions like increased subsidies or some kind of public-option-like instrument—ideas that he supports anyway.

Whether the president's hands-off approach has worked will be determined in the coming weeks. With nearly all Republicans opposed to the president's plan, the last stages of negotiations will be among Democratic factions. Obama came into office promising to bridge the partisan divide in Washington. But the outcome of the health care debate may depend more on his ability to bridge the divides in his own party.

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John Dickerson is Slate's chief political correspondent and author of On Her Trail. He can be reached at . Follow him on Twitter.

photograph of Barack Obama by Olivier Douliery-Pool/Getty Images.

COMMENTS

We all know that Medicare and Medicaid are running out of money. There is no "magic bullet" that can insure all people, and anyone with a brain knows that insurance reform technically cannot be done through "reconciliation". So, that boils down to needing 60 votes to overcome a filibuster. The Democrats, unlike the Republicans of the previous administration, actually listen to their constituents, and a lot of rank and file Democrat voters don't want a public option. There are enough votes to pass serious insurance reform, and there is NOT enough to pass the public option. So, as Obama has said many times, "don't let the good be defeated by the perfect". Insurance reform is needed now - healthcare is bankrupting our government and our citizens. We can start with serious insurance reform. That will alleviate many problems for millions of Americans. Yes, the public option would have been great, but if we don't pass reform because of that then Democrats will prove to America they are incapable of governing, and suffer HUGE losses in 2010.

-- moderate001
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Meaningful healthcare reform would have to include protection from arbitrary cancellation or denial of coverage and it would have to preclude denial for pre-existing conditions. OK. A healthcare insurance reform law could require those protections... BUT, without price controls it would be meaningless. Insurers will certainly cover you in spite of pre-existing conditions -- if they're allowed to charge you thousands per month to do so.

How, then, do we force price controls on the for-profit healthcare industry? The most simple and obvious way is to introduce serious competition to them. This is precisely what the public option is. A less direct way would be to impose some standardization of coverage agreements and then to open up all parts of the country to all potential insurers. And to have some legal safeguards against collusion and price-fixing among them.

Remember, for decades, rightwingers have been preaching the gospel that "the marketplace" will ALWAYS be more efficient than any government enterprise. OK... then why are they afraid of the competition from government?

-- EbenCooke
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