With bitter pills, Obama gets his health vote

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Barack Obama is set to become the first U.S. President to extend access to health-care insurance to virtually all Americans, now that laborious Democratic deal-making in the snowed-in U.S. capital has won over the last hold-out senator.

With Senate passage of the health-care package expected on Christmas Eve, Mr. Obama is on track to sign a final bill into law within days of the Jan. 20 anniversary of his inauguration.

The milestone would significantly enhance his record of first-year achievements and earn him the distinction of accomplishing what all of his Democratic predecessors since Harry Truman tried but failed to do: ensure that all U.S. citizens and legal immigrants are able to get health insurance.

That is a singular achievement and the second in as many days for the President, who also extracted a commitment from developing countries to join the fight against global warming. But in both so-called successes, Mr. Obama acted as a broker of deals rather than a principled idealist. As such, he risks alienating his most fervent supporters.

The Senate compromise, reached at the White House's prodding, was most ferociously attacked not by Republican opponents, but by Mr. Obama's once most enthusiastic backers on the U.S. left. They denounced the strict conditions governing insurance coverage of abortions and the absence of a public health plan that would compete with private insurers.

For core Democrats, the deal to win Nebraska Senator Ben Nelson's vote was the second bitter pill Mr. Obama has asked them to swallow in recent days, after he returned from last week's United Nations summit on climate change in Copenhagen with a weak agreement that he nevertheless called "an unprecedented breakthrough."

 The less-than-promised outcomes on two of the signature issues of Mr. Obama's campaign have provoked intensive soul-searching on the U.S. left about whether to work to elect Democrats in next year's mid-term elections, which will determine whether Mr. Obama's party holds on to its majorities in the House of Representatives and Senate.

"There are a lot of progressives who worked very hard to get the President elected who are disappointed," Timothy Jost, a law professor at Washington and Lee University and a leading proponent of public health insurance, explained in an interview.

Instead of earning praise for advancing a cause the U.S. left has championed for decades, commentators spent most of Sunday criticizing the President for putting deal-making before principles.

"This is not insurance or health-care reform. … It's allowing more people, 30 million people, to buy into the existing broken system," Markos Moulitsas, editor of the Daily Kos blog considered a bellwether of progressive opinion, said on Meet the Press .

"Well, he's made a lot of people with insurance stock a lot richer," MSNBC host Joe Scarborough mused on the same program.

The principal gripe is that the plan precludes the creation of a government-run insurance plan, forcing Americans to rely instead on the private U.S. insurance industry that is widely decried for gouging Americans on premiums, denying them coverage when they need it most, and making insurance unattainable for 47 million legal and illegal U.S. residents.

Instead, the plan would provide low- and middle-income earners subsidies to buy insurance from private providers on "exchanges" set up in each of the 50 states. Coverage would be mandatory, with fines for not being insured.

Mr. Obama has promised tougher regulations on the industry. The Senate bill and legislation adopted last month in the House would, for the first time, both ban insurers from denying coverage to those with pre-existing conditions and, eventually, prevent companies from slapping limits on how much Americans could claim in medical costs.

Nebraska's Mr. Nelson, who hails from a staunchly conservative jurisdiction that has previously elected only Republicans to state-wide office, only agreed to support the bill after amendments allowed individual states to prohibit insurers from covering elective abortions altogether. In states that do allow abortion coverage, individuals could not use subsidies to buy plans that cover the procedure. The other concession Mr. Nelson won would ensure that Nebraska - and only Nebraska - would be able to count on full federal funding for the Medicaid expansion.

"A number of states are treated differently from other states. That's what this legislation is all about - compromise," reasoned Senate majority leader Harry Reid, who negotiated the deal with Mr. Nelson.

Despite the bill's perceived flaws, Prof. Jost was more positive about its contents than most of his fellow proponents of a strong public option. He noted that it would establish a number of pilot projects aimed to improve care while containing costs.

Many of the programs would involve replacing the system under which doctors and hospitals are paid for every procedure they perform with new methods of remuneration. The fee-for-service system is often criticized for encouraging quantity over quality and is one of the reasons the U.S. spends far more on health care as a proportion of its economy than any other country.

"This is far more revolutionary than anything I've seen in Canada in 20 years," Prof. Jost said of the experimentation with health-care delivery proposed in the Senate bill.

Still, only time will tell whether dejected Democrats will forgive Mr. Obama his political compromises enough to turn out for their party next November. Participation is particularly crucial in determining winners in mid-term elections, when typically as few as a third of Americans exercise their franchise. And recent polls show a widening "enthusiasm gap" between Democratic and Republican supporters.

"What this bill is going to do for conservatives is elect a lot of conservatives," Mr. Scarborough predicted on Meet the Press. "Democrats are depressed right now."