The superlatives are justified. The passage of comprehensive health care reform is this country's most momentous social reform since the creation of Medicare more than 40 years ago. And in my view the new law is at least that long overdue.
It beggars belief that a nation as rich as the United States could have tolerated for years a health care system which every other advanced economy would reject out of hand, one which left tens of millions without health insurance, and under which serious illness could very well mean financial ruin. The new law finally confronts the problem, and takes bold steps towards fixing it.
Sunday's vote is also a political triumph. Scott Brown's unexpected win in Massachusetts — a Republican in a liberal state, running against this bill — stunned the Democrats and caused many to think the effort was dead. Barack Obama bravely chose not to back down. Without that commitment, the bill would have failed. The same goes for Harry Reid and Nancy Pelosi: they did not deviate.
In parliamentary terms, the Democrats made the whole venture more dramatic than it needed to be. It is absurd that getting the Senate bill through the House should have been such a struggle. But the main thing is that they succeeded. It is a success that eluded all their predecessors. They are entitled to celebrate. They have their places in history.
Remarkable as it may be — and welcome, too, as I believe — it is nonetheless a tainted victory. Brown won in Massachusetts for a reason. The Democrats had failed to make their case for this reform to the American public. They pressed the case for some sort of reform, but that was easy: the country was already there. What the country dislikes is this particular bill, and the Democrats, intent on arguing among themselves, barely even tried to change its mind.
People struggle to understand how extending health insurance to 32 million Americans, at a cost of a trillion dollars over ten years, can be a deficit-reducing measure. If cuts in Medicare will pay for half of that outlay, as the plan intends, they struggle to see how the quality of Medicare's services can be maintained — let alone improved, as Pelosi said again in her speech on Sunday. The CBO notwithstanding, the public is right not to believe these claims.
Whether you agree with that or not, the law the Democrats just passed is unpopular. It is a far-reaching, transformative measure that in the end will affect almost everyone; it is opposed by most of the country; and it is now law. I would never have believed this possible in the United States.
I am used to explaining to foreigners that the US political system is, by design, exquisitely sensitive to public opinion, with its lower house up for election every two years. American governments cannot ignore their people, as Europe's governments can and frequently do, I used to argue. And I would cite my favorite example. Germany's government abolished its currency and forced the euro on a country that was opposed to monetary union throughout, saying, "You are wrong. We know better. We will do this regardless, and you will come to like it." Can you imagine such a thing happening in the U.S., I used to ask? Could anything be more un-American? The usual response would be laughter.
Who's laughing now? And one wonders, is this trampling down of public opinion going to be habit-forming? Recall Pelosi's recent comment that once the Democrats have "kicked through this door", they can move on to the rest of their (equally unpopular) agenda.
Thanks to the unrewarded exertions of conservative Democrats, this health care plan has moderate, centrist ambitions. It is not socialism in disguise. Shame on liberal Republicans (if there are any) for failing to support it. Even so, the Democrats' claims for the reform have been dishonest in one crucial respect, and most voters understood this. It is right to provide guaranteed health insurance, but wrong to claim this great prize could be had, in effect, for nothing. Broadly based tax increases and fundamental reform to health care delivery will be needed to balance the books. Denying this was a mistake. What was worse — an insult to one's intelligence, really — was to argue as Obama has in the past few days that this reform was, first and foremost, a cost-reducing initiative, and a way to drive down premiums.
The guarantees are so valuable that honesty about the cost was worth trying. Eventually, perhaps, the Democrats will come clean about this, though doing so before November would be a little abrupt. Between now and then, the country may come around to liking the plan anyway, as Democrats hope. As I say, the guarantees are so valuable. But obviously this could go either way.
The Republicans' dementedly fierce opposition — John Boehner called passage of the bill Armageddon — should help. This law does not mean the end of the world as we know it. It does not mean "government-run health care", either. These things will become more obvious. Also, Obama may get a boost merely from having got this big thing, whatever its merits, done.
Equally, on the other hand, the bill is only the beginning of a long and difficult process of reform. The issue is certain to remain contentious. And every problem the project encounters will be an occasion to remember the public's hostility at the outset. The reform is not going to be hailed a great success before November. The order of the day will be legal challenges, political quarreling, implementation problems, and embarrassing discoveries about the bill's innards.
Looming over all is the biggest risk for the Democrats. Albeit in a worthy cause, Obama has broken faith with American voters. He promised post-partisan leadership. He promised to moderate the warring tribes on Capitol Hill, and strive for common-sense, centrist solutions. Then, on this epic issue, he allied himself with — in fact, subordinated himself to — liberal Democrats in Congress. With help, to be sure, from a rabidly partisan Republican party, he has divided the country more deeply than ever. And he has pushed through a far-reaching measure that country does not want. In November we will find out what, if anything, it will cost his party and his presidency.
