Backroom deals on health care

As the Senate tackles the health care bill that may be its most important domestic legislation in a generation, you might have expected thousands of citizens to descend on Capitol Hill to demonstrate, for or against. But the streets outside — and even the Senate floor — aren't where the action is. The important parts of this debate have moved into the Senate's back rooms.

The great health care debate hasn't been a triumph of mass politics on either side. Congress isn't being stampeded by the public into passing a bill — and it's not being stopped by the public from passing one either.

Instead, the debate has turned out to be a battle of old-fashioned special interests and parochialism. The most important players have been the insurance industry, the American Medical Association, labor unions and AARP, the senior-citizens lobby. As for parochialism, last week's most blatant action may have been Senate Majority Leader Harry Reid's insertion into the bill of a $100 million Medicaid bonus for Louisiana, whose senior senator, Mary Landrieu, has been one of the holdouts.

One reason for this resurgence of backroom politics is simple: Polls show the public to be fairly evenly divided on health care reform and understandably confused by its details. But there's also a deeper reason. In modern American politics, with its professional lobbyists and millions of dollars in campaign advertising, public opinion isn't always the most important thing.

"Evidence doesn't support the precept that public opinion sways Congress," said Lawrence R. Jacobs of the University of Minnesota's Humphrey Institute of Public Affairs. "Winning public opinion is not the secret of legislative success. You want to hold your own in the court of public opinion, sure. But members of Congress have to worry more about what interest groups are going to do." For members of Congress who anticipate tough re-election campaigns, what's most important is not what voters think of health care proposals today, but which interest groups will spend money in their states to shape voters' perceptions next year. Groups on both sides, from the U.S. Chamber of Commerce to the unions, have already announced millions of dollars in planned advertising spending to do just that.

When he ran for president last year, Barack Obama said he'd try to change that system, in part by keeping his gigantic grass-roots network of campaign supporters together as a new, populist force in the legislative battles to come.

But that's not what happened. Members of Congress and their aides say the Obama organization, re-christened Organizing for America (OFA), after the campaign, has had negligible effect on the debate.

For most of the year, the group was hobbled by the fact that Obama didn't have a clear proposal for it to support, beyond a general commitment to (almost) universal health insurance. It did make sure that reform supporters turned out for town-hall meetings over the summer, and it's running some ads attacking Republican House members in districts that Obama won.

But doing much beyond that has proved difficult, primarily because the most important debate over health care is not between the two parties — Republicans decided early that their goal was simply to stop a bill — but among Democrats. And OFA, now a wholly owned subsidiary of the Democratic National Committee, has carefully refrained from criticizing any Democratic incumbents. One of its biggest efforts this fall, instead, was organizing rallies and letter-writing campaigns to say "thank you" to House members who voted in favor of health care reform — lobbying with all the bite of a Hallmark greeting card.

OFA was also undercut by Obama's own strategy for winning health care reform, which began by cutting deals with the most important interest groups — including, initially, the health insurance industry — not by mobilizing public pressure.

"This is not being fought by the White House as a grass-roots campaign," Jacobs noted. "Civic engagement at the community level has largely been bypassed. ... The Obama strategy has been to neutralize the stakeholders so they don't block a bill — so they don't pull a Harry & Louise," a reference to the insurance industry advertising campaign that helped sink then-President Bill Clinton's health care reform proposal in 1994.

Obama's choice of strategies may well turn out to have been good politics, especially on an issue as complex as health care.

Well-funded, well-focused interest groups often wield power more effectively than the general public, even though the public has more at stake.

That's not a new phenomenon in American politics, but it's one Obama told his followers he wanted to change. If the president wins a health care bill, it will be a major victory. But he will have won the old-fashioned way, not by reinventing American politics. It will be evidence that Obama, an untraditional candidate, has turned out to be a very traditional president.

McManus is a Los Angeles Times columnist. He can be reached at