Last Call

Nate "The Numbers" Silver games the numbers on Obamacare and comes up with four scenarios on how Obamacare might pass with benefit of a public option attached.

1. Whip Democrats Into Submission. This is probably the closest thing to the default approach. So long as there are a dozen or a half-dozen different iterations of health care floating around Capitol Hill, individual Democratic Congressmen can afford to bargain for their preferred version. "Progressive" Democrats from rich districts can object to the plan of raising taxes on the very wealthy to pay for expanded coverage. Labor-backed Democrats can try and play hardball on any proposal to remove the benefits tax exemption. The Blue Dogs can howl at the moon for whatever it is they want -- probably some kind of sweeteners for rural districts, like the ones given to farm-state Democrats on the climate bill. And advocates of the public option can continue to treat it as a sine qua non and threaten to oppose any bill that doesn't include one.

Once a particular bill is put up to a vote, however, the overwhelming majority of Democrats are going to have a difficult time voting against it. Health care reform remains quite popular in theory and at least marginally popular in practice. It will probably do the most good for those districts where conservative Democrats tend to reside.

And then there is the oldest motivator of all: survival. The failure of health care reform in 1994 may have damaged Bill Clinton -- but it really damaged the Congressional Democrats, who lost 54 seats in the House and another 8 in the Senate. Of the 36 incumbent Democrats who lost that year, only four (North Carolina's David Price, Ohio's Ted Strickland and Washington's Maria Cantwell and Jay Inslee) would ever return to the Congress (whereas Clinton, of course, was re-elected). Any Democrat who votes against health care, moreover, can expect to be permanently shut off from the Obama-run DNC and from most or all grassroots fundraising drives, and many of them can probably expect a primary challenger.

There are probably some Democrats who would be better off if health care went away. But once it comes up to vote, I'd imagine there will be very few who are actually better off voting against it.

2. Reconciliation. This is not necessarily mutually exclusive with the other scenarios, but Obama could try and use the reconciliation process to pass health care, which would mean Republicans would lose the ability to filibuster in the Senate and Democrats would need only need 50 votes for passage. This is risky: the extent to which the bill remained intact would depend upon the rulings of the obscure Senate Parliamentarian, and going through reconciliation would cause mayhem on the Hill with somewhat unpredictable political consequences. And it would certainly look overtly partisan -- especially now that Democrats have gained their 59th and 60th seats in the Senate. But if Obama decides that health care is too big to fail, reconciliation is an option.

3. Wyden-Bennett and Other "Bipartisan" Approaches.. I don't see any particular reason why the Administration couldn't press the reset button and push for a different sort of health care bill -- particularly Ron Wyden's, which already has a half-dozen Republican supporters. In fact, it might make Obama look somewhat good to "acknowledge the political realities" (yadda yadda) and adopt a more "bipartisan" approach. A lot of Republicans claim to support health care -- just not the particular approach being put forth by the Democratic Congress. Shifting gears, particularly to a bill like Wyden-Bennett that is strong on cost containment, would reveal many of them to be hypocrites, but probably also secure enough of their votes to make passage a likelihood.

4. Hope the Economy Gets Better (or Some Other Secular Change in Momentum). In general, I'm pessimistic about the state of the economy insofar as it will affect Obama's political capital. Even if the economy formally pulls out of a recession -- some economists think we're already out of the recession -- it will take some time before the employment picture turns around. The past week, however, has brought some relatively good economic news and the Dow is now hovering at about 8,800 points, around its 6-month highs. If the next monthly jobs report is better than expected, if the Dow somehow rallies past 10,000, or if the recession is declared over, that might give Obama a little bit of actual momentum which may be amplified by the Washington press corps, which by that point will have tired of the "Obama is melting!" storyline and may be looking to describe his "comeback" instead.

Of the four scenarios, #1 is clearly the approach Obama needs to take, especially the hardball approach to Democrats. Once a bill is put up to vote, Democrats who vote against it need to be shown the door. All the debate and amendments and riders aside, when the final bill comes up for a vote, every Democrat needs to back it. If not, Obama needs to make it clear that there will be consequences, and dire ones...and follow up on them.

#2 is something of a last resort. It would make the health care bill vulnerable to a five year sunset period, like No Child Left Behind. It would have to be constantly renewed, and there will come a time when the Republicans will be less stupid and have more power than they have now. That's dangerous, far too easily screwed with by the GOP, and may cut off millions of people at a time they need the program the most. Too risky.

#3 is the least desirable idea. The bottom line is while Wyden-Bennett does have some great things going for it (portability, a health insurance exchange) it still doesn't have a public option, and without one, it's not going to happen. It's still one of those Judd Gregg-type plans where we force everyone to buy health insurance from the insurance companies, and the kind of coverage they are going to get is going to be high deductible "catastrophic only" coverage where one hospital stay will still bankrupt a person. We wouldn't have 50 million uninsured, we'd have 50 million underinsured. It would also remove the tax deduction for employers, causing most of them to stop offering insurance, putting a hell of a lot of Americans on the self-insured path. Without some sort of union/group/co-op to go with this, we'd have 300 million self-insured, most likely underinsured people. Sure, you couldn't be denied coverage for a pre-existing condition. You'd just have to pay three times as much in premiums as the next guy. No, #3, a Republican plan with no public option and mandates, means a big fat gift of 50 million new customers to the country's health insurance giants and no incentive to compete. What are you going to do, offer the guy with cancer a lower premium, just so you can have the honor of covering his chemo? There's no profit in that. And insurance companies are in business to make profit. Obama will never sign it, and it's moot because it'll never pass.

#4, the economy getting better? Not anytime soon. We're going to be in double digit unemployment well into 2011. Any prediction the economy is getting better will be only a temporary thing. The Dow may be up a bit right now based on stellar bank earnings, but the reality is our economy is badly wounded. Not enough to hope for, but it could be a wild card down the road.

In order of probability, I'd have to go with 1, 2, 4, 3. Obama would have to completely lose the narrative for #3 to happen, which is why opponents are pushing for a fatal delay to 2010. Should that be the case, you can bet #3 will be back on the table as "the only alternative" in 2011...minus all the Democrats who got zapped for not coming through on health care in 2009. It just exists so the Republicans can say they have a health care plan (massive subsidies to Big Pharma and the insurance giants), much like they had a stimulus package (TAXEN CUTTEN UBER ALLES), a budget plan (TAXEN CUTTEN UBER ALLES) and a climate change plan (massive ethanol subsidies to farm states.)

We'll see how this plays out.