President-Elect Obama and Senator McCain set perfect tones for the governance we need in their gracious speeches last night. Both emphasized healing and working together. These are two concepts that presidential candidates understand uniquely, having seen and navigated the profound diversity of people and views that comprise our nation. Their call for cooperation and bipartisanship will prove vitally necessary in the quest for health reform—real health reform, not lowest common denominator milquetoast. 

Part of the need for bipartisanship is simple math. Whatever the final makeup of the Senate (and we may not know for a while), we know that neither the Democrats nor the pro-reform camp will reach the magic, filibuster-proof 60-vote threshold.  Furthermore, there is no guarantee that Democrats will unite unanimously in favor of any legislation, especially legislation as complex as health reform. Therefore, especially given the leadership displayed by both McCain and Obama last night, we view the potential composition of the Senate as an opportunity far more than a challenge.

We have an opportunity to build a health reform package that can cover all Americans, kick-start the delivery system toward efficiency and sustainability, and earn the trust of the American people through a bipartisan legislative process.  A Democrat-only strategy, as some Obama supporters may be tempted to pursue, risks driving the stakeholders we need (the ones who will make reforms smart and implementable and therefore sustainable) to a monolithic Republican camp of opponents. In other words, if the initial proposals have nothing in them for Republican champions to rally around, we could lose those Republicans who are interested in real reform. Some of these Republicans have already made their preferences and commitment public and some have even supported comprehensive legislation. Yet, if we do not engender the cooperation of willing Republican negotiators, we will provide a safe haven for stakeholders and advocacy organizations opposed to reform.

A far better strategy would be to take the spirit of Obama’s eloquence last night literally. We do not need a “Blue” health plan or a “Red” health plan, but rather a plan for the United States of America. Congressional Democrats and the White House will need to listen seriously to those who voted against Obama, as the president-elect promised. They need to build into the plan enough market forces and budget constraints that can make reasonable Republicans—not those trapped in ideology—as comfortable with the plan as conservative Democrats. That will enable the American people to feel comfortable and supportive of the final legislation as well, rather than succumbing to fear of change that helped sink previous reforms. Enemies of reform will spend millions trying to scare the people, and bipartisan tableaux will be crucial to counteracting that old but wickedly effective tactic.

This will appropriately take some time; not forever, but surely most of the first session of the next Congress. It is perfectly reasonable for the Obama Administration to lead with economic and energy initiatives before we settle on the details of a coverage expansion and delivery system reform proposal that can pass and be signed by the President. Unlike the 1993-94 experience, the next White House is not likely to draft a 1,300 page bill and send it down Pennsylvania Avenue for perusal. As we all recall, that didn’t work out very well. What we may not recall so clearly, however, is that President Clinton also had large Democratic majorities in Congress (258 in the House and 57 in the Senate) similar to what President Obama will have come January 2009.  I expect that this time the new President will make his priorities clear in a variety of ways, but that the committees will drive the legislative process from hearings to the Senate floor to a conference committee.

Leadership will be more important than some policy details. Political leaders, health system stakeholders, employers, labor, consumers, the media and civil society all have vital roles to play in this important opportunity. A few policy details are essential: for Rs there must be private insurance markets and a central role for individual choice, and for Ds we must make health insurance and quality care affordable for everyone, and we must provide enough good information to make individual choice meaningful. The rest, as they say, is commentary. That commentary, however, will be scrutinized quite intensely, as it should be. I could not be happier or more optimistic about the upcoming debate.