Obama’s Health-Care Gamble

President Barack Obama begins and ends each workday at the White House by going over a to-do list with his chief of staff, Rahm Emanuel. The two were reviewing things recently when Emanuel reminded him of the sheer size of the administration's workload, which includes fending off the Great Recession and dealing with terrorists in Iraq, Afghanistan, and now, evidently, Yemen. "You know, Mr. President," Emanuel said, "Franklin Roosevelt had eight years to deal with the economy before he had to lead a war. You have to do it all at once."

Nothing unusual about a little fawning in the Oval, but it prompts questions. Given the urgency of those challenges, underscored by the Nigerian bomber, was it wise for the president to spend most of his first year and political capital on a monumentally complicated overhaul of the nation's health-care system? And will the results of that gamble—not fundamental reform, but rather an expensive set of patches, bypasses, and trusses bolted onto the existing system—improve the lives of Americans enough to help him or his fellow Democrats politically?

Put me down as skeptical.

Perhaps not since the New Deal has a new president made such a massive bet on a single domestic initiative. I think I understand Obama's reasoning. It did not take him long (probably after the first round of CIA briefings) to realize that he was not going to be able to satisfy his liberal base on intractable, unwinnable foreign and security policy. It's easier to make history on the home front. And Obama was genuinely moved by the heart-wrenching health-care stories he heard on the campaign trail. So he sought—and may well get—things to brag about. The legislation will extend coverage to at least 30 million of the uninsured, and it will end, or at least limit, some of the insurance industry's most predatory practices.

But the crusade that is dragging itself toward the finish line doesn't quite feel like a triumph, let alone the launch of a new New Deal. The reasons offered for the undertaking have been ever-shifting. In the campaign, it was about rationalizing the system and saving federal cash; then it was about protecting coverage of the middle class; then about the moral duty to cover the uninsured. By the time Bill Clinton met privately with Senate Democrats on Obama's behalf, it was (in his telling) primarily about the political optics: the need to pass something, anything, to avoid defeat.

The effort to jam the bill through Congress made the public dubious. Most Democrats voted for a version of the bill on the first round without having read, let alone digested, its thousands of pages. As the Christmas Eve vote approached, desperate last-minute stocking stuffers appeared in the small print, such as a $1.2 billion payoff to the state of Nebraska that secured Sen. Ben Nelson's reluctant vote. Obama had promised us a transparent "Google Government," but now we know what Obama government actually looks like: ambitious and generous, perhaps, but also secretive, Chicago-style, and way too complicated. Fewer than half of voters now support the legislation, murky as it still is to them. Crucially, support has cratered among independents.

The result is a 10-year, trillion-dollar contraption full of political risk and unintended consequences for a health-care system that constitutes one sixth of the economy. Many of the people who will benefit directly from the reforms, the uninsured, don't vote. Insurance premiums will continue to shoot up for most of us; Democrats fret that they will be blamed for those increases in the 2010 elections. Some regulations on the industry kick in immediately, but most don't begin until at least 2013. And yet, to allow the bill to "save" money in the first decade, most new taxes and fees go into effect immediately. "We're collecting money before we're giving all the benefits!" lamented a Democratic senator facing reelection. "That is a political disaster."

Maybe for that guy and his congressional colleagues, but what about Obama? For now, he is safely behind a blast wall, since many of the law's features wouldn't come into play until his second term, if he has one. But if he's lucky enough to get that far, he will discover that even simple things in government never go as planned; a project as large and complex as his health-care "fix" is certain to be more costly and disruptive than anticipated, and in ways no one can predict. "Never allow a crisis to go to waste," Emanuel declared a year ago. "They are opportunities to do big things." Yes they are, but Obama has to hope he's not creating another crisis in the process.