The black art of producing health care reform can be filed as a leadership issue -- or, perhaps more accurately, a math problem. Thinking about it in the abstract -- top down, bottom up, middle out -- obscures the real point of the exercise: to produce a piece of legislation that comes the closest to doing the most good for the most people and gets the votes needed to become law.
How do you do that -- in general? As Tom Peters wrote decades ago the answer is a combination of "loose-tight" skills. It means knowing what to insist on and what to compromise on; what to fight over and what to let go; where to specify a design precept that's non-negotiable and where to leave room for allies and enemies to work out something that is acceptable to enough people to get you the votes you need.
But the hard truth is, while it is in the end a math problem, there is no formula for getting it right or even getting it done. It takes a fine reading of the public's mood and attention span, a nuanced understanding of the individual members of Congress and their wants, needs and desires, and a command of the actual material under debate to steer a course that delivers a piece of legislation that only can get passed but also should get passed.
It's as much about personalities as it is about principles, as much about close-to-the-ground politics as it is about high-minded policy prescriptions. It's the kind of thing that leadership literature purports to define and describe -- and rarely bears much relationship to what actually happens.
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