The New Republic

President Obama and his allies in Congress are doing everything they can to rally 60 senators behind health care reform. But, for one red-state senator, even 60 "yes" votes won't do. It has to be 65. "I think anything less than that would challenge its legitimacy," he said in late September. It's a ludicrously high standard for passage--the sort you'd expect from a Republican opponent. But this comment came from Democrat Ben Nelson. And, while Nelson may be an extreme case who revels in opportunities to buck his party, he's not the only conservative Democrat arguing that health care reform--even the scaled-back version moving through the Senate Finance Committee--may be too much, too fast.

Even though the bill, as constructed, would leave millions uninsured and millions more with scant coverage, several of Nelson's Democratic colleagues have talked about weakening the bill even more, by further reducing its funding. They say they're worried about controlling the cost of medical care, and yet, they've eschewed obvious ways to cut costs, such as taking more money from the drug or hospital industries. And they oppose a voluntary public insurance plan, which is among the most efficient ways of delivering affordable, reliable coverage.

What are their motives? The charitable explanation is that Nelson and his allies are acting out of principles they come by honestly--that they simply can't abide even this modest expansion of government. But sincerity does not guarantee good public policy. And, in this case, their opposition wouldn't seem to serve their constituents well: 12.8 percent of Nelson's Nebraska constituents lack health insurance, as do 17.5 percent of Blanche Lincoln's in Arkansas and 20.2 percent of Mary Landrieu's in Louisiana. Many additional people in those states are "underinsured," meaning their coverage doesn't meet their needs. Because the Senate Finance bill does not offer financial assistance to people making more than three times the poverty line--and because the insurance it guarantees is less protective than what other, more expensive versions of reform would require--many of these people will remain exposed to the severe financial, not to mention medical, risks of inadequate coverage. More generous reform would ameliorate that problem, and few of its beneficiaries would bear the price, since the money to pay for it would likely come from taxes on the rich and on expensive benefit plans.

A less charitable explanation for the obstructionism of red-state Democrats is that they are trying to curry favor with health industry interests that help finance their campaigns. (Nelson has always been a favorite candidate of the health insurance industry, for example.) But there's a political cost to watering down reform: It might produce a bill that voters don't like. A reform crafted to appease the health care industry would extract minimal concessions from it: It would let drugmakers and hospitals get off with minimal sacrifice, even as both stand to gain the business of millions of new customers. Such reforms would do little to tamp down the skyrocketing prices of drugs and hospital stays (and, for that matter, the prices of devices and doctor visits). Insurers would have more leeway to raise their own prices and treat their sicker patients badly. Employers would continue to operate with minimal interference, which would mean fewer guarantees for Americans who get insurance through their jobs. By insisting that reform conforms to the interests of these groups, conservative Democrats can perhaps secure their campaign contributions--but only at the risk of alienating constituents. Lincoln will have Wal-Mart. But will she win her next election?

To be fair, Nelson, Lincoln, and others do have constituencies that express some seriously right-wing views. And, while polls sometimes show that conservatives support reform, voters in these states may well be skeptical. Perhaps what these senators need is a clever way out of their political dilemma--a way to produce change without supporting reform that is perceived as too liberal. Fortunately, the procedures of the Senate allow for just such a convoluted arrangement. Obama and his allies are focused on getting 60 votes because that's what it takes to break a filibuster. But a senator can vote to break a filibuster without voting for the bill being filibustered. Nelson and others can simply support cloture and then vote "no" on the final bill (or merely abstain). As long as Democrats have 50 "yes" votes--and they almost surely do--the bill will pass.

This approach would let an important bill come to a full vote and would allow a simple majority to pass the legislation. It's more democratic than allowing a minority inflated by the over-representation of small states to block the newly elected president's central domestic policy promise. Surely that's enough legitimacy for Nelson--particularly when it's also the right thing to do.

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