Core values

As they try to round up enough votes to pass a healthcare reform bill, congressional leaders have been forced to make concession after concession on provisions sought by liberal Democrats -- the lawmakers who’ve been the driving force behind the effort to remake the U.S. healthcare system. The proposed government-run “public option” for uninsured individuals was weakened, then restricted, then all but abandoned in the Senate to appease moderate Democrats and independent Joe Lieberman of Connecticut. An alternative that would have given uninsured individuals ages 55 to 64 the option to buy into Medicare was dropped when Lieberman complained that it was no better to his mind than the public option. Senators also have rejected a proposal to help consumers obtain less expensive prescription drugs from Canada and Western Europe, and the House overrode a provision that would have allowed individuals who received government subsidies to buy policies that covered most abortions.

The news media’s focus on these debates made them seem pivotal and cast the concessions as major retreats. But as much as we may have liked some of the provisions that have been jettisoned (and disliked others), their loss doesn’t gut the legislation. The core of the healthcare reform effort remains intact. Either the House or the Senate version of the bill would bring about a historic improvement in our healthcare system. The bills aren’t perfect; each has shortcomings, some of them serious. But the legislation is getting better in important ways as it inches toward the finish line.

From the start, the primary purpose of the healthcare reform effort has been to accomplish three interrelated goals. The first and most pressing of these is to rein in costs, which have significantly outpaced inflation and economic growth. For taxpayers, the looming disaster is Medicare’s hospital trust fund, which analysts predict will become insolvent by 2017. Over the next decade, the cost of private health insurance is expected to double. The skyrocketing cost of insurance is one reason the ranks of the uninsured are burgeoning, with thousands of Americans losing their coverage daily.

The second goal of the legislation is to extend coverage as broadly as possible, by mandating insurance coverage for all Americans and providing subsidies to help some afford it. The third is to improve the quality of care, which should also help slow the rise in costs.

None of these objectives is easy to achieve; in fact, Congress has repeatedly rejected ambitious efforts to reform the healthcare system. The difference this time was the widespread support from the healthcare and insurance industries. The year began with doctors, hospitals, drug manufacturers, insurers, business organizations and consumer groups agreeing on the problems and committing to support a reform effort. Although the agreement frayed as lawmakers started proposing specific solutions, much of the friction has been around the edges of the bill, not its central elements.

The public option -- now reduced in the Senate bill to a government-managed plan offered by private, nonprofit insurers -- is a good example. It’s just one piece of the effort to expand coverage. Both bills would create a radically different approach to selling insurance, one that would let individuals and small businesses shop for policies through state or national exchanges. Insurers could not turn anyone away, and they wouldn’t be able to charge higher rates based on customers’ preexisting conditions. At the same time, low-income workers would be eligible for subsidies to buy insurance, and Medicaid would be expanded to cover more of the poor. Compared to the benefits these changes would bring, the public option just isn’t that important.

The potential benefits of the legislation for those who already have insurance are more speculative. The House and Senate versions include numerous demonstration projects to explore ways to make Medicare and Medicaid more efficient. These include efforts to better coordinate care, promote the use of the most effective treatments and give doctors and hospitals more incentives to keep patients healthy. The hope is that successful strategies will spread from those programs into privately funded care. At the very least, the changes should prod primary care doctors, specialists and hospitals to coordinate and speed the flow of information through the healthcare system, which would lead to better care. The Senate also has added several amendments in recent weeks that aim to slow the rise in private insurers’ premiums and give certain workers more choices for coverage.

Again, the current versions of the legislation aren’t ideal. The House would pay for its bill in part with a hefty surtax on the wealthy, and the Senate in part by taxing the most expensive health insurance policies. We’d prefer a broader-based approach, such as a reduction in the tax exemption for employee health benefits. The House proposes too large a tax on employers that don’t provide health insurance, while the Senate’s penalties for those who don’t obtain insurance seem too weak to force compliance. And both bills could do more to bring about the cost savings that various industry groups pledged to achieve as part of the reform. Even with these flaws, however, the legislation would lay the foundation for a system that makes medical care more available, affordable and effective. Those are the right goals, and there’s no reason to give up on them now.