Pulling it Together: A Note on Presidential Leadership Strategy
In inside circles of the health reform debate there has been criticism of the President for not weighing in earlier and publicly on the details of health reform legislation. Does he want the Senate’s approach to employer obligations, or the approach taken in the House? What form of public option does he want: a robust one, a trigger, an opt-in, an opt-out, or none at all? What level of premiums and cost sharing is he willing to see people pay? With financing looming as a make-or-break issue, does he want a tax on insurance companies offering “Cadillac plans,” or does he want a surtax on wealthy Americans? Other than laying down general goals the President has not taken a position on any of these choices—at least not yet. Is this punting to the Congress, or is this a smart strategy?
For one thing, the moment the President takes a specific position on any of these issues it immediately becomes a magnet for media coverage and the target for all opposition attacks. It also makes it more difficult for others within his party to offer their own proposals, and trickier for the President to compromise to get a law passed without appearing to reverse his original stance. Until now, the President’s lack of specificity on key details has kept a much broader coalition of groups in the debate than has ever before been the case in health reform. With the shape of a potential compromise still somewhat unclear and vote counts fluid, the President’s stance may still be the right strategy for now.
Although the President’s strategy left many of the tough tradeoff decisions to the leaders on Capitol Hill, it may have also encouraged buy-in on Capitol Hill. One of the reasons health reform failed last time around was the lack of ownership of the legislation by leadership in Congress. A benefit of the strategy this time is that the leadership is fully engaged. And powerful committee chairs have put aside turf considerations in unprecedented ways—although clearly there will be heavy lifting ahead to blend House and Senate bills together.
Presidential authority, though formidable, is not unlimited. It is always partly real—tangible carrots and sticks a President can wield—and partly the perception of authority. It needs to be husbanded and used judiciously. The decisive moment for public leadership in this debate will likely come when there is a bill in conference; then again when that bill moves from conference to the floor of the House and the Senate and is the focus of intense lobbying and national debate. At that stage the President will need to become not just a health reform advocate-in-chief, but chief sponsor of the legislation itself, embracing its key details. The President will need to save some of his authority for that critical stage in the debate when he will be the only effective counterweight to the opposition to health reform, especially with the public. This is the point in the process when the inside and the outside games come together, and key details are debated not only on Capitol Hill, but in the news media and around the country.
It is obviously important that the President’s staff work behind the scenes to make sure that his goals are protected in the bills that emerge from the House and the Senate; from financing to coverage and affordability, to cost containment and now abortion, and more. That process is, by its nature, opaque and hard to follow from the outside. Sometimes, judiciously, the President will need to send public signals and weigh in as the end game nears.
But it is not self-evident, as the conventional wisdom seems to hold, that it would have been the best strategy for the President to have taken clear positions on all the big health reform issues early on. It would certainly have satisfied the media to have the President’s position, issue-by-issue, to dissect every day. It may have made the leadership’s job on Capitol Hill easier for the President to declare himself earlier on key details of the legislation so they weren’t faced with so many of the tough decisions on their own. But it might also have slowed legislative progress and eroded influence and maneuvering room the President will need when the health reform process reaches its critical final rounds very soon.
also of interest
- Visualizing Health Policy: Health Coverage Under the Affordable Care Act (ACA)
- How Five Leading Safety-Net Hospitals Are Preparing For The Challenges and Opportunities of Health Care Reform
- Summary of Coverage Provisions in the Patient Protection and Affordable Care Act
- Explaining Health Care Reform: Questions About Health Insurance Subsidies