Veterans of health reform battles know all too well that enacting health reform is as challenging to the nation’s political system as it is important to the nation’s well-being. We also know that perseverance pays off. Despite several dips in the legislative roller coaster over the past 12 months, we greeted the new year having passed historic, transformative legislation in both houses of Congress. The fact that we still need a little heavy political lifting to take it over the finish line would hardly surprise Sen. Edward Kennedy, whose death ironically set in motion the political obstacles we now face. But he wouldn’t tolerate our giving up.
We know too much to be distracted by calls to “start over” or “go small.”
For one thing, small steps will fail to bring the cost and coverage reforms we need. And from a political standpoint, they’re hardly any easier to achieve than full-scale reform. The choice is clear: either we move forward to enact the Senate bill with modifications or we quit—knowing we won’t be returning to meaningful reform any time soon. Anyone serious about health reform, regardless of party affiliation, should recognize that the legislation simply has too much to offer to believe for a minute that doing nothing is the better choice.
Based on experience to date, I doubt that many—or any—Republicans will let this simple truth outweigh political concerns. But it saddens me that too many Democrats seem not to grasp the choice before them. Progressives in the House seem preoccupied with the Senate’s unwillingness to exert sufficient public leadership to rein in insurers and make health care truly affordable. Moderates in both bodies seem to fear that government has gone too far. To state the obvious: the Senate bill, even with some improvements from the House, is a political compromise. But for both camps, it’s a compromise worth making.
Progressives are understandably disappointed that this legislation will not deliver universal health insurance coverage. But covering over 30 million people who now lack insurance is a giant step forward, at least on a par with the passage of Medicare and Medicaid 45 years ago. And at least half of the newly insured would be covered by a Medicaid expansion that will include all people with incomes below 133 percent of the federal poverty level—finally ending the distinctions between “deserving” and “undeserving” poor and the unconscionable failure to cover low-wage adults who aren’t disabled or parents of dependent children.
And while progressives worry that the bill provides insufficient subsidies and inadequate coverage, moderates can take heart in the modest coverage the bill actually guarantees and requires most people to buy. Far from promoting “Cadillac” insurance plans, the Senate bill–even with improvements pushed by House progressives—simply assures people the basic protection that even the new Republican senator from Massachusetts believes everyone should have.
Next is insurance reform—curbing the unacceptable insurance practices that discriminate based on preexisting conditions and rescind benefits just when we need them. When it comes to holding insurers accountable for covering us when we’re sick, the Senate bill is hardly the government takeover some critics have claimed. Moderates who favor minimal regulation can take heart in the flexibility this bill allows: industry can offer a variety of benefit packages, (including the high deductible plans favored by Republicans) and operate outside as well as inside exchanges.
Progressives worry that these provisions leave far too much room for “innovative” insurer behavior at consumers’ expense. But progressives should recognize that the bill establishes not only significant limits on insurer behavior but requirements for transparency that are key to stronger oversight and enforcement. The Senate bill–like its House companion–also requires new, higher minimum loss ratios, or the percent of premium dollars insurers spend on medical care, for insurance companies. This measure of a policy’s efficiency will force insurers to trim overhead and profits, assuring better value for our health insurance dollar.
Turning now to cost containment, or the measures to slow the health care cost growth that is killing both affordable coverage and a productive economy. It’s true—the Senate bill has a tax on high cost insurance plans that progressives see as more a threat to benefits than a goad to efficiency. And it does not have a public plan, without which, progressives fear, private insurers will have insufficient pressure to contain costs. In both respects, the bill reflects moderates’ goals—and will do so even with modifications to the tax that mitigate the negative impact progressives fear.
And both moderates and progressives can take credit for the Senate legislation’s provisions requiring Medicare to lead all payers in putting pressure on costs by replacing rewards to volume of services, regardless of their health benefits, with rewards to efficiently provided, coordinated care that promotes health. For progressive and moderate Democrats—and even Republicans—adopting effective accountable payment mechanisms isn’t about being “left” or “right;” it’s about our only option. Either we get our health care costs under control or affordable coverage goes down the drain.
In short, on the big three of coverage, insurance reform and costs, a slightly modified Senate bill, would, after decades of failure, establish a public/private framework to assure all Americans affordable quality health care—and, perhaps most importantly, it would establish federal responsibility to make sure that goal is achieved.
The framework is not simple and we’ll be perfecting it for a long time to come. But after decades of trying and failing, hoping and waiting, can anyone who truly values reform say no to this opportunity to get to work? To me, that would be unconscionable.