I think Greg Sargent captured the significance of yesterday’s big vote better than anyone I’ve yet read:

Last night’s big health reform victory made history in many ways, but in hard political terms perhaps the key one is this: This is the first landmark piece of reform that passed over the unanimous opposition of one major party.

Both Social Security and Medicare had bipartisan support. While they were both the achievements of Democratic presidents, there isn’t a clear sense in the public mind that it was entirely the work of one party over the implacable opposition of the other one.

Now an achievement of equal magnitude—health care reform, which will dramatically reshape a vital aspect of American life—is about to pass into law as the work of one party and one party alone. The other party emerges from this battle defined entirely by its unanimous opposition to it.

This could have more dramatic repercussions than any of us know right now, perhaps helping define the differences between the two parties for years, in a way that no other major political battle has.

Republicans say—publicly—that this will play in their favor, and claim the public will reward them for showing the fortitude to stand firm against a far-reaching expansion of government into a deeply personal aspect of our lives. Democrats counter that Americans will realize that the dreaded government takeover warned against by reform foes is a caricature—and that once they do, it will reinvigorate the pact between government and the American people.

All this is to say that the real argument underlying this fight—this chapter in the larger ideological showdown over the proper role of government in our lives, an argument that has taken mutiple forms throughout our history—is only beginning. There will now be an actual law that frames and defines this debate. And the fact that each party placed all its chips on competing visions dramatically ups the stakes, with untold consequences to come—not just for the parties, but for the prospects of future far-reaching legislative initiatives.

The one wrinkle he doesn’t catch is the one Jay Cost highlights:

Harold Lasswell defined politics as who gets what, when, and how. By this metric, ObamaCare is bad politics for the foreseeable future. Like any major piece of legislation, this bill assigns winners and losers. The winners will be those who today are uninsured, but who will (eventually) acquire insurance. But there will not be a major reduction in the uninsured until 2014. So, the actual winners are going to be pretty few in number for some time.

Meanwhile, the losers begin to feel the effects immediately. Between now and the next presidential election, ObamaCare is going to pay out virtually zero dollars in benefits, but it will take billions out of Medicare. This is bad for seniors. They have an incentive to oppose portions of this bill (while supporting others, like the closing of the “Doughnut Hole,” which Republicans will never repeal). While the Democrats will claim that this reduction in benefits will have no effect on the quality of their care, CBO is much less certain . . .

After decades of developing a reputation for defending the interests of senior citizens, the Democrats have put it in serious jeopardy with this legislation. And they’ve done so right at the moment when demographic shifts are making the senior population more powerful than ever.

How will it all play out? Only time will tell.

We human beings have the tendency to forget that we exist within systems of relationships, which are themselves part of larger systems, and that anything we do causes ripple effects. The consequence of this is that we tend to assume that we can change this one thing over here without changing all the other parts of our lives, because everyone else’s behavior will remain the same. Life doesn’t work that way, but we never seem to remember that. This is, I think, the biggest single reason for the Law of Unintended Consequences (which states, in its simplest form, that whatever you do will always produce consequences which you neither intended nor foresaw; Murphy’s codicil to that is that those consequences will usually be negative): we fail to consider that other people will adjust to the changes we make, and thus don’t stop to think about how they are likely to do so.

This is, of course, true on a national and global scale as well as on a personal and local one; and we’ve just gotten a pretty big red flag regarding the possible unintended consequences if ObamaPelosiCare passes. To wit, a survey taken by a leading medical search and consulting firm and reported in the New England Journal of Medicine found this:

The poll finds 46.3% of primary care physicians (family medicine and internal medicine) feel that the passing of a public option will either force them out of medicine or make them want to leave medicine.

Doctors also seem to understand the impact that will have as 72% of physicians feel that a public option would have a negative impact on physician supply, with 45% feeling it will “decline or worsen dramatically” and 27% predicting it will “decline or worsen somewhat.”

Why would they feel this way? Consider:

62.7% of physicians feel that health reform is needed but should be implemented in a more targeted, gradual way, as opposed to the sweeping overhaul that is in legislation.

The respected medical journal also found 41% of physicians feel that income and practice revenue will “decline or worsen dramatically” and 30% feel income will “decline or worsen somewhat” with a public option.

Just 28.7 percent of doctors support the pro-abortion health care bill pending in the House

The assumption tends to be that if doctors and others in health care don’t like the changes the government wants to make, they can just lump it; but that fails to take into account that they do in fact have another option: they can stop seeing patients. Or, alternatively, they can stop seeing some patients (as many doctors and hospitals already restrict the number of Medicare patients they’ll take on), or see them on a different basis.

If this bill passes, will it really mean that nearly half of our primary-care physicians will leave practice? I’m sure it won’t; but will it mean that some leave, and some work fewer hours, and some retire early, and that in general, the availability of doctors drops? For my part, I saw enough “reduced activity days” (read: one-day strikes) by doctors while we were in Canada that I have no doubt it will. How is that going to improve health care?

Proponents of socializing our medical system need to take this very seriously. As the managing partner of the firm that conducted the survey wrote,

Many physicians feel that they cannot continue to practice if patient loads increase while pay decreases. The overwhelming prediction from physicians is that health reform, if implemented inappropriately, could create a detrimental combination of circumstances, and result in an environment in which it is not possible for most physicians to continue practicing medicine.

Health-care reform and increasing government control of medicine may be the final straw that causes the physician workforce to break down.

We human beings have the tendency to forget that we exist within systems of relationships, which are themselves part of larger systems, and that anything we do causes ripple effects. The consequence of this is that we tend to assume that we can change this one thing over here without changing all the other parts of our lives, because everyone else’s behavior will remain the same. Life doesn’t work that way, but we never seem to remember that. This is, I think, the biggest single reason for the Law of Unintended Consequences (which states, in its simplest form, that whatever you do will always produce consequences which you neither intended nor foresaw; Murphy’s codicil to that is that those consequences will usually be negative): we fail to consider that other people will adjust to the changes we make, and thus don’t stop to think about how they are likely to do so.

This is, of course, true on a national and global scale as well as on a personal and local one; and we’ve just gotten a pretty big red flag regarding the possible unintended consequences if ObamaPelosiCare passes. To wit, a survey taken by a leading medical search and consulting firm and reported in the New England Journal of Medicine found this:

The poll finds 46.3% of primary care physicians (family medicine and internal medicine) feel that the passing of a public option will either force them out of medicine or make them want to leave medicine.

Doctors also seem to understand the impact that will have as 72% of physicians feel that a public option would have a negative impact on physician supply, with 45% feeling it will “decline or worsen dramatically” and 27% predicting it will “decline or worsen somewhat.”

Why would they feel this way? Consider:

62.7% of physicians feel that health reform is needed but should be implemented in a more targeted, gradual way, as opposed to the sweeping overhaul that is in legislation.

The respected medical journal also found 41% of physicians feel that income and practice revenue will “decline or worsen dramatically” and 30% feel income will “decline or worsen somewhat” with a public option.

Just 28.7 percent of doctors support the pro-abortion health care bill pending in the House

The assumption tends to be that if doctors and others in health care don’t like the changes the government wants to make, they can just lump it; but that fails to take into account that they do in fact have another option: they can stop seeing patients. Or, alternatively, they can stop seeing some patients (as many doctors and hospitals already restrict the number of Medicare patients they’ll take on), or see them on a different basis.

If this bill passes, will it really mean that nearly half of our primary-care physicians will leave practice? I’m sure it won’t; but will it mean that some leave, and some work fewer hours, and some retire early, and that in general, the availability of doctors drops? For my part, I saw enough “reduced activity days” (read: one-day strikes) by doctors while we were in Canada that I have no doubt it will. How is that going to improve health care?

Proponents of socializing our medical system need to take this very seriously. As the managing partner of the firm that conducted the survey wrote,

Many physicians feel that they cannot continue to practice if patient loads increase while pay decreases. The overwhelming prediction from physicians is that health reform, if implemented inappropriately, could create a detrimental combination of circumstances, and result in an environment in which it is not possible for most physicians to continue practicing medicine.

Health-care reform and increasing government control of medicine may be the final straw that causes the physician workforce to break down.

which doesn’t happen all that often anymore; but he’s really sounding like he’s been mugged by reality when it comes to the whole health care debate:

Barack Obama campaigned offering a new era of sane government. And I believe he would do it if he had the chance. But he has been so sucked into the system that now he stands by while House Speaker Nancy Pelosi talks about passing health care via “deem and pass”—a tricky legislative device in which things get passed without members having the honor or the guts to stand up and vote for it. . . .

Yes, I know Republicans have used the deem and pass technique. It was terrible then. But those were smallish items. This is the largest piece of legislation in a generation and Pelosi wants to pass it without a vote. It’s unbelievable that people even talk about this with a straight face. Do they really think the American people are going to stand for this? Do they think it will really fool anybody if a Democratic House member goes back to his district and says, “I didn’t vote for the bill. I just voted for the amendments.” Do they think all of America is insane? . . .

Yes, my own view may be distorted by the fact that I’m disappointed in the health care bill. But at least I violently opposed the nuclear option when the Republicans tried it a few years ago. I don’t think it is mere partisanship that makes me believe that representatives should have the guts to actually vote for the legislation they want to become law.

Either this whole city has gone insane or I have or both. But I’m out here on the ledge and I’m not coming in the window. In my view this is no longer about health care. It’s just Democrats wanting to pass a bill, any bill, and shredding anything they have to in order to get it done. It’s about taking every sin the Republicans committed when they were busy being corrupted by power and matching it with interest.

That last sentence is the key, I think. The Republican Party doesn’t have clean hands on this, though they’ve yet to do anything that took quite as much gall as what the Democrats are doing here; the GOP abandoned its principles and supporters both for the siren song of the pleasures of power, and they quite rightly got kicked to the curb by the voting public for it. They deserved the losses they took, and if the political pendulum swing that looks like it’s coming in November in fact materializes, it will happen despite the fact that the GOP, quite frankly, still doesn’t deserve it.

That said, whatever the Republican Party might be guilty of, the Republican base still has the right to be heard from, and we are not happy with what the Democrats are doing; and who else ise going to represent us than Republican politicians? Joe Conason can ding Republicans all he wants for hypocrisy in their newfound concern for proper process, and I won’t defend them—but wrong is no less wrong because it’s pointed out by a hypocrite. Fundamentally, “you do it too” isn’t an argument (except for electing people like Sarah Palin who are outsiders to the Washington mindset). Rep. Steny Hoyer (D-MD) can insist until he’s blue in the face that Americans don’t care about process, but he’s wrong; and quite frankly, to the extent that he’s right, we as Americans need to change that. Something I learned from math class and relearned from studying baseball is that good process is important, because doing things the right way is a better predictor of good future results than good current results; until we get the political process right in this country, we’re going to keep on fouling ourselves up.

If you listen to the news, you probably know that both the House and the Senate have passed health care bills; that the two bills differ; that the Senate Democrats no longer have a filibuster-proof majority; and that rather than allowing even the slightest bit of Republican input to revise the bill—just enough to pick up one Republican vote—the administration and the Democratic leadership on the Hill have opted to use the budget reconciliation process to solve the problem. There’s been a fair bit of handwringing over that, but it’s ostensibly what they’re going to do.

“Ostensibly” being, I think, the key word, because I’m not sure it’s ever going to happen, even if the House passes the Senate bill (which is far from assured at this point). Jeffrey Anderson laid out the reasons why two weeks ago, though most people don’t seem to have caught on:

Senators want nothing to do with “reconciliation”—whether politically or for what it would do to their chamber—and they already like their own bill (which the House would then already have passed) just fine. The President would then already have gotten a bill through both chambers, and while House members would complain powerlessly, he would dip his pen in the ink and visualize himself in the history books. He might even try to score a few extra political points by saying, As you know, we intended to use the reconciliation process to make a few small changes to the Senate bill. While I know that there was some disagreement from some people, I think that that process would have been entirely appropriate to pursue. But some people are uncomfortable with it, and I think that’s a legitimate concern. It’s important to remember that our democratic institutions deserve the benefit of the doubt. Also, the American people understandably think that we’ve been focused on health care long enough. So that’s why I am making the decision not to pursue “reconciliation.” Instead, I am moving on to a jobs bill. . . .

House members would be left holding the bag. Target squarely on their chests, they would now get to face their fuming constituents after having passed a $2.5 trillion bill that would allow public funding of abortion, would send $100 million to Nebraska, $300 million to Louisiana, $100 million to Connecticut, would exempt South Florida’s Medicare Advantage enrollees from annual $2,100 cuts in Medicare Advantage benefits, would raise taxes, raise deficits, raise health costs, empower Washington, reduce liberty, politicize medicine, and jeopardize the quality of health care. Most of all, they would feel the citizenry’s wrath for having voted to pass a bill that only 25 percent of Americans support.

Anderson’s argument was only strengthened when the Senate parliamentarian ruled that not only must the House pass the Senate bill as is before reconciliation could be used to amend it, the President must sign it into law. That sounds more than a little fishy to me, but there it is: if the House passes the Senate bill, it will have to become law before anything can be done to change it. Figure the odds, at that point, that either the President or the Senate lifts a finger to do so. Why should they? The Senate Democrats, as noted, are content with their bill, the President will be content to have signed sweeping health care legislation, and both will want to put the whole long, bruising slog behind them; why reopen the battle unnecessarily to consider making changes Senate Democrats won’t vote for anyway?

For all the talk about trust, there’s no doubt in my mind: if the House passes the Senate bill, that’s the end of it. If House Democrats get hung out to dry for it, as far as the Senate and the White House are concerned, that’s just the price of victory.

In the most recent posts on his HorseRaceBlog, Jay Cost analyzes the legislative process that the Democratic leadership will have to use to bring the Senate health care bill to final passage of both houses of Congress, and then the political context in which they will be trying to do so, and concludes that it’s possible but will be a very long row to hoe. If you want to understand the fight that’s ahead, read his posts; they are, as usual from Cost, meticulous, well-informed, and insightful pieces of analysis.