Health care debate: A long way to go

The Senate negotiations that resume this week on the overhaul of the health care system are about many things — Medicaid spending levels, taxes, the opioid drug crisis, the number of Americans who will be uninsured. But this fight is only marginally about health care. It’s really about power and politics and the presidency.

Certainly the substance of the bill that emerges from the Senate — if one does emerge — is not insignificant. That bill will shape, though not determine, the profile of health care in the United States. But what is occurring in Washington this week is (and this should not astonish you) more about profile than anything else.

Here’s why. The Senate bill will differ from the legislation the House passed this spring, almost certainly in major ways.

The two competing bills will go to a House-Senate conference committee, which operates under rules that are prescribed but not always applied. The result will be a compromise bill that will go to both chambers. That is when you should start paying close attention.

The unwritten but indispensable, immutable rule about lawmaking: Congressional legislation is like an NBA playoff game. You can pretty much ignore the first three quarters, and maybe part of the fourth quarter. It is the final few minutes that count. That’s when the game is won or lost.

In the meantime, much of what is going on is posturing. The theatrics, to be sure, have been compelling: closed-door negotiations by a committee not exactly marked by gender or ideological diversity, feverish lobbying, a rush to judgment.

And there are innumerable, sometimes irreconcilable, motives in motion. Some have to do with health care, but these merely make up the platform on which other forces are at play. Indeed, we know what really matters in the next week or so. This is the playbook:

The president. For Mr. Trump, the substance of health care legislation doesn’t matter so much as the fact of having overturned Obamacare.

The Republican lawmakers. They ran on repealing Obamacare, and many of them have voted more than five dozen times to eliminate the Affordable Care Act — in roll calls that were meaningless because of the assurance that President Barack Obama would have vetoed the legislation.

Now that the GOP controls the White House and both houses of Congress, they must make good on their promise.

The Democratic lawmakers. Twice in nearly a century — during the Franklin Roosevelt and Barack Obama years — the Republicans have become the “Party of No,” defining themselves as being against pretty much everything the Democrats favored. Now, Democrats are playing that role, providing a united front against just about everything the Republicans and the president support. The Democrats’ dreary role here is to say no and then to bray to their supporters that they fought the good fight and kept the faith.

Next come the two unknowns that could define this era and actually shape the contours of the American health care system.

The first is whether the president and Senate Majority Leader Mitch McConnell of Kentucky employ the tactic of winning support from Senate skeptics by understanding the NBA rule and saying to their wavering Republican colleagues: Vote for this bill in the full knowledge that it’s not the final product.

Help get this bill to conference, where the real work occurs and where you may get your way.

The second is whether the bill fails and the Senate is forced to do what it is supposed to do, and what the Democrats who created Obamacare failed to do: Craft bipartisan legislation to address the crisis of health care while minimizing the number of uninsured and preserving Americans’ sense of health security.

The first time a modern political party put country ahead of party was in 1935. That year, 81 House Republicans and 16 Senate Republicans — ardent foes of FDR, who was so odious to them that many of them would not even speak his name — nonetheless voted to create Social Security.

Who says history doesn’t have lessons for the present, and who says history cannot repeat itself?