What a difference a week makes.

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Last week, many commentators (including me) saw the Graham-Cassidy bill as abit of Hail Mary legislating, a last desperate stand againstObamacare. This week, it started to look as if it might actuallyhave some chance of passage. The legislative math remains daunting; the parliamentary obstacles high. But the status ofRepublican health-care efforts has moved from “flatline” to “stillbreathing, barely.”

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The situation is so fluid that I don’t want to make predictions,other than to say that the chances of passage are still south of 50percent. But as long as it’s a live possibility, we have to thinkabout what passage might mean. I think that one of the mostinteresting, and least explored, questions is what our health-carepolitics would look like if this thing managed to pass.

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Why is that an interesting question? Because before 2008, webarely even had anything that people in other Western democracieswould recognize as health-care politics. In most such countries,the health minister is one of the most important government jobs --far more important, in many places, than heading a tiny andtoothless defense ministry. And debates over the nationalhealth-care program, whatever its design, are major issues inelection after election.

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In the U.S., before 2008, Democrats would complain about thecost of our health-care spending, and then perform ritual obeisanceto some never-never national health-care program. Republicans wouldlargely ignore the issue while mouthing the words “block grants” --code for taking money and power from the federal government andgiving it to states via discretion over Medicaid. Noone would talk much about all the spending we were alreadydoing on programs like Medicare, Medicaid and the VA. Every fourelections or so, Democrats might get close to some sort of nationalhealth-care scheme, but they always found that in the end, whilevoters might like the idea of guaranteed health care, they suredidn’t like the taxes needed to pay for it, or the changes thatwould have to be made in their own very satisfactoryarrangements.

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It took the worst financial crisis in 70 years to alter thatdynamic, along with a bout of mass delusion among moderateDemocrats, who somehow convinced themselves that voting to passObamacare wouldn’t end their political careers. Whatever else thoselegislators gave us, good or ill, they also gave us a more “normal”health-care politics, in which both the electorate and the electedspend immense amounts of time quibbling over health-care policy,even to the exclusion of other things they’d really like to getdone.

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Continued on page 2 >>>

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If Graham-Cassidy passes, it will return us to something morelike the health-care politics of yore, because the federalgovernment will be (mostly) out of the health-care-program business(with the huge and growing exception of Medicare). Feds willprovide much of the funding. But the states will be the onesin charge of deciding what the system in their state will looklike.

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Of course, Democrats can one day undo what Republicans aredoing, just as Republicans are planning to undo the work of theDemocrats. The left can pass another Obamacare, or some different,more expansive plan. But to do so, they will have to go through thewhole painful process of passing Obamacare all over again: sootheor pay off all the anxious interest groups; find the extra taxdollars to fund it; reassure voters who have good insurance thatthey will not lose by the new plan.

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This task will be immensely harder in Round 2 than it was in2010. By the time they get around to it (in 2020, soonest),Democrats will be forced to scavenge for new sources of funding atthe same time as every predator on K Street is scouring thelandscape to feed our existing defense commitments and rapidlygrowing entitlement burden.

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They will also be trying to whip up support from a publiclargely exhausted by the last decade of wild promises andunderwhelming delivery from both sides of the aisle. Thanks to theexperience of Obamacare, that public will be inclined to disbelieveany assurances about how splendid this will be for folks whoalready have insurance they like. And Democrats will somehow haveto overcome all these political obstacles without aonce-in-a-lifetime financial crisis handing them unnaturally largecongressional majorities.

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It is more likely that health-care politics in America willmostly move down to the states, permanently, where they will becomevigorous and perennial. This will mean the end of wall-to-wallmedia coverage of that politics, because the media isnationalizing, while state and local outlets keep dwindling, and itis too hard to get people in California interested in theblow-by-blow details of something happening in Georgia. It willalso mean the end of the Democratic dream of a nationalsingle-payer system. It will probably mean the end of the dream ofsingle-payer, period, because the obstacles to single-payer at thestate level are simply too enormous; it is too hard to controlpayment when people often cross state borders to seek treatment,and too hard to finance, when states have to run budgets that areat least nominally balanced.

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And yet, this could still be very good news for the DemocraticParty.

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Democrats have a strong natural advantage in health-carepolitics: They have cared about it for a very long time. They havepoured a lot of time and money into developing the policyinfrastructure to design health-care plans and get them passed.Republicans have not done that work, as a party, though there arecertainly many smart individuals working on the issue. With 50states exploring custom health-care programs, Democrats have achance to ride in waving all that expertise, and reverse some oftheir devastating losses at thestate and local level.

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Democrats need to regain some of those seats, not just becauseit will give them more power over state policy, but because thosestate-level offices are where most people begin their politicalcareers. The fewer of them your party holds, the fewer chances youhave to discover a future star.

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Can Democrats win back states they’ve lost by marching into 50capitols and proposing single payer? Certainly not. But they may beable to win back those states by designing local solutions that fitthe local politics, economy and cultural values, while pushingthose places a little closer to progressive ideals. And in theprocess, they might bring some political diversity into their ownparty, which would be good for Democratic electoral fortunes, andgood for America.

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If that sounds a little optimistic -- well, perhaps so. Butthen, the optimists aren’t always wrong. Just ask anyone whothought that Graham-Cassidy would never even come this close to avote.

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