Could This Be What He Planned All Along?

By  |  September 11, 2009 | 

A conventional look at the The Speech: Obama over-learned the lessons of Hillary-care; he gave Congress too long a leash; he lost control of the message; the wacko’s attacked with a barrage of Socialist/Nazi/Plug-Pulling-on-Grandma-isms; not only was health reform on the ropes but the entire Obama Presidency was in danger of imploding (taking the Dems down with him in the mid-terms); Obama had his back against the wall, a make-or-break moment. Then last night, the President gave a great speech that staked out a thoughtful middle ground; Joe Wilson went rogue, horrifying nearly everyone; this led to real sympathy for Obama and the Dems and a shift in the political landscape. In the end, a mild version of health reform – with nearly-universal coverage, some regulatory protections against the most heinous insurance practices, fee hikes to pay for it all, and a little movement toward improving quality and efficiency – passes.

Another look at The Speech: Obama, a student of history, realizes that health reform is a near-impossible sell since every special interest will come out swinging; he gives Congress the ball knowing that whatever plan emerges from their sausage factory will simply be red meat for demagoguing Republicans and special interests worried about preserving their Gravy Train; Congress obliges by developing plans that overpromise and under-resource, or that push predictable hot buttons (immigrant coverage, palliative care); the Right and its attack dogs go berserk throughout the Wacko Days of August; the left hunkers down, drawing a line in the sand on the Public Option, kyboshing malpractice reform, and avoiding the hard questions about financing. Then last night, Obama gives a superb speech that positions him as the only grown-up in the room, one offering a reasonable, pragmatic, middle-of-the-road solution to some real problems; the Republicans look like sunburned sourpusses (John Boehner), texting teenagers (Eric Cantor), or immature louts (Joe Wilson). The President’s approval ratings skyrocket; he uses this political capital to whip his party in line, finds a couple of centrist Republicans who can read tea leaves, and health reform passes.

Scenario 1, the reactive one, is what you’d go with if you thought the President was a normal politician. Scenario 2 is the one you’d favor if you thought Obama (and Axelrod and Emanuel) were superb chess players, thinking 10 moves ahead. And (to mix sports metaphors), if you believed that they were expert in the art of political jujitsu.

Of course, Obama couldn’t have prepared for his two biggest breaks: Ted Kennedy’s death (sorry if that seems insensitive, but there’s no question that the tragedy enhanced the prospects for reform) and Joe Wilson’s folly. But chance favors the prepared mind, right.

So those are the two scenarios that could explain the painful road to health reform. Which one do you think is right?

(If you need a hint as to my guess and you’re over 18, click here to see a poster, created during other [similarly] perilous moments during the campaign).


  1. Tom Murin September 11, 2009 at 2:03 pm - Reply

    The answer is clearly # 1. You give Obamo too much credit.

    Also, I don’t believe the”breaks” will add up to much, if anything. Wilson shouldn’t have shouted out, but the facts seem to be on his side concerning coverage for illegals – provision to confirm legal residency were defeated. So if there is no way to confirm compliance – how will the provisions be enforced?

    I’m for healthcare reform, but we need to know what the plan is before it is voted on. Something this important should not be rushed through congress.

  2. Brad September 11, 2009 at 2:48 pm - Reply

    Regardless of your political stripes, one can certainly entertain the possibility that Congressmen Wilson should have considered an alternate venue to express his feelings. While sitting in Congress, in front of a national audience, he will not engender the good will of many by his outburst. Some traditions of respect need following–and that goes for Democrats as well.

    This letter in todays NYT sums it up (if Obama could only wish for a do over):

    To the Editor:

    It would have been audacious but, nevertheless, a teaching moment had President Obama called Representative Joe Wilson, who heckled him during his address to Congress, to the well, like a teacher calling an errant child to the front of the class, asked him his name, asked him what state he came from, asked him to repeat his remark, asked him to explain why he called him a liar, straightened him out, then told him to sit down.

    Richard Rosenthal
    New York, Sept. 10, 2009

  3. Bob Wachter September 11, 2009 at 2:58 pm - Reply

    Thanks, Brad. That reminds me of something my favorite president of all time once did to take down a disrespectful zealot. Worth a look (clip is about 3 minutes long).

  4. menoalittle September 12, 2009 at 3:19 am - Reply


    Good speech, good blog coverage and perspective.

    I was looking forward to hearing O’Bama provide an HIT update and its meaningfully useful status, saving billions of dollars to pay for health care reform. As someone said someplace, the silence was deafening.

    Could it be that while on the “yard”, he listened to doctors who have had the misfortune of having to work extra hours to protect patient safety from HIT gone bad? Did he speak with Secretary Sibelius and realize that the FDA has to approve these devices that thus far, had slipped under the radar? Did he hear about the experiences of patients whose care was neglected as the computers needed to be fixed?

    He was particularly complimentary to the doctors doing tonsillectomies and tests not knowing results of CER. He said nothing. Smart move.

    There was a bonus for the past maligning. Tort reform.

    He got some messages and reacted after the en passant nipped his pawn and Emanuel and Axelrod said, omg, we forgot about that move.

  5. DSL September 12, 2009 at 5:58 am - Reply

    Funny, I had the same thought, referring to it in conversation with my friends as aikido-politics.

    On the one hand I hesitate to give the administration too much credit, but on the other hand they did admit to calculatingly taking advantage of Rush Limbaugh’s divisiveness when he wished out loud for Obama to fail. In light of that clever move, it seems entirely plausible to me that they expected special interests and obstructionists huff and puff to blow the house down in August, all the while keeping an eye on the principles of reform that everyone can agree on. Now we just have to wait and see if he can corral congress in order to “carry the day” with a meaningful bill by the end of the year.

  6. Bob Wachter September 14, 2009 at 11:00 pm - Reply

    On the Health Affairs blog, the always insightful and amusing Uwe Reinhardt grades Obama’s speech (here). While giving the Prez thumbs up for style, he thinks the Princeton poli sci department would give higher grades than the econ department because some of the numbers don’t quite add up. In particularly, Uwe provides a realistic appraisal of just how hard cost control will be to accomplish. (For example, what makes us think the newfangled “public plan” can cut costs when Medicare hasn’t been able to?) The piece is provocative and well worth a read.

  7. MKirschMD September 25, 2009 at 12:17 pm - Reply

    The speech was well crafted and executed. The teleprompters performed flawlessly. As a physician, I thought it was absurd that the president stated that defensive medicine ‘may’ increase costs. Reality check in order.

  8. JackLounge January 19, 2010 at 5:03 am - Reply

    Interesting read. The comments caught my attention. The lastest one September 15th 2009. Here it is January 18th 2010 and the vacant senate seat from Mass. is to be filled in 24 hours. The chaos is fascinating.
    A new image for law making. It is sometimes like making sausage as the article reads. On this occasion,though, it is more like making scrapple. No one really wants to know what is in it.
    There is no chess game going on here.

  9. JackLounge January 19, 2010 at 5:03 am - Reply

    Interesting read. The comments caught my attention. The lastest one September 15th 2009. Here it is January 18th 2010 and the vacant senate seat from Mass. is to be filled in 24 hours. The chaos is fascinating.
    A new image for law making. It is sometimes like making sausage as the article reads. On this occasion,though, it is more like making scrapple. No one really wants to know what is in it.
    There is no chess game going on here.

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About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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