Will Health Care Reform be Scott Brown's legacy?

If Senator Scott Brown represents Massachusetts for decades he will have an opportunity to forge his own legacy as a Senator, but if he is voted out of office in 2012 the health care reform bill passed this week will be his legacy. The bill--especially the House provisions included in the reconciliation package--would not have become law without him.

If you go back to the first of January, the question was whether or not the House would accept the Senate bill as it was written and whether the Senate would approve any changes the House might propose. Because there had been 60 votes for the Senate version, the Senate held all of the cards in that negotiation. Majority Leader Harry Reid had worked like crazy to get a bill that could hold together 60 votes. He was not going to compromise with the House and risk losing his super-majority. At the time there were three options:

1. The House would pass the Senate bill as is, making the Senate bill the law of the land and shutting out House provisions.
2. The House and Senate would try to find a solution in conference that would keep all of the House votes and not lose even one Senate vote.
3. The two chambers could not come to an agreement and the bill would die.

In reality, the only way health care reform was going to be passed was with option 1. Even at that, the Senate bill was unacceptable to the pro-life Stupak group and was also opposed by liberal House members who didn't think it went far enough in it's provisions. Any change to make it more pro-life would have lost liberal votes in both chambers. Any change to make it more pro-choice would have shut out the Sutpak bloc. Any liberalization of the terms of the bill would have lost votes in the Senate.

With the landscape as it was in January, it was going to be either the Senate bill or no bill at all.

But as we know, everything changed on January 19. With Scott Brown's election, Senate Democrats no longer had 60 votes. That meant leadership also didn't have any leverage with the House. If there was going to be health care reform, it would have to go through a reconciliation process that only required a simple majority.

That change put the ball squarely in Nancy Pelosi's court. Now the House had the upper hand in negotiations. It didn't matter anymore what conservative Democratic Senators like Ben Nelson an Blanche Lincoln thought about the bill because their votes wouldn't matter anyway. Pelosi realized that this was her chance to enhance the bill is whatever way she needed to get House Democrats behind it. As long as it was palatable enough for 51 senators, it would work out.

So Pelosi crafted a sidecar bill that made the final product more progressive. The reconciliation bill increases premium subsidies to low- and middle-income families, expands Medicare payroll taxes to capital gains and dividends, closes the prescription drug "donut hole" for Medicare recipients, eases the excise tax on high-cost "Cadillac" insurance plans, and strengthens efforts to move Medicare reimbursement money away from for-profit Medicare Advantage plans and back to doctors and hospitals where it belongs.

The result is that the bill is more progressive than it ever would have been if Martha Coakley had been elected.

If Scott Brown is unlucky enough to take to the floor of the Senate on January 2, 2013 to give his farewell speech, he'll talk about what he has done for Massachusetts. But he won't mention his greatest legacy: ensuring that the Health Care and Education Affordability Reconciliation Act of 2010 became the law of the land.