The idea that Republicans haven’t had a chance to present their ideas on health care reform is a bit mind-boggling. Five separate congressional committees had hearings; each chamber had floor debates. That’s hundreds of hours the GOP had to talk about health care, all of it in public view and televised on C-SPAN. And that’s not even including all of the unofficial channels at the Republicans’ disposal. Generally speaking, the party of Rush Limbaugh and Fox Television doesn’t struggle to get across its message.

But if President Obama is determined to give Republicans one more public forum for presenting their health care agenda, as he will do when he meets with GOP leaders on Feb. 25, maybe that is just as well. For most of last year, Republicans spent their time attacking Democratic plans for reform, rather than describing their own. But now they’ve put a plan on the table. Showcasing that plan--and comparing it to what the Democrats have proposed--might help clarify a few things.

The Republican health care plan is part of the "Roadmap for America's Future." Its chief architect is Paul Ryan, ranking Republican on the House Budget Committee and a rising star in the party. Republicans boast that the Roadmap is serious plan to get the federal budget under control, which turns out to be a fairly large exaggeration. As Howard Gleckman of the Tax Policy Center has observed, the Roadmap doesn't account for trillions of dollars in lost revenue from its tax cuts. Yes, that's trillions with a "t" at the front and "s" at the back.

The health care portions of the plan, though, really would reduce what the government spends on health care. And they would do so, primarily, by extracting money from Medicare. Instead of continuing to provide coverage directly, the government would issue vouchers that seniors could use to buy private insurance. The value of the vouchers would rise far more slowly than Medicare spending is expected to grow if nothing changes.

According to the Congressional Budget Office, Medicare will soak up more than 14 percent of gross domestic product by 2080. If the Roadmap were to be adopted, CBO says Medicare would take up less than 4 percent. As Ryan explained during an illuminating interview with the Washington Post’s Ezra Klein, the hope is that converting Medicare into a voucher scheme would prod seniors to shop around to find the best value--that is, the best insurance policies, the best hospitals, the best doctors--and, in so doing, get health care that is as good if not better than they would have otherwise.

That all sounds perfectly innocuous: Who wouldn’t want seniors taking the initiative and hunting around for the best bargains? But it’s not clear how many seniors really have the ability to navigate the world of health care with the sort of sophistication to really hunt down the most cost-effective care, even if, as Ryan promises, they’d have more information at their disposal. At the very least, you'd want to give seniors ironclad protections when it comes to the design of insurance products--making sure a wide array of services were covered and that out-of-pocket spending were limited.

The Roadmap includes only vague protections along those lines. Combine that with the magnitude of the spending reductions--those cuts are very big--and it's easy to envision a world where seniors simply couldn't afford their medical care. As a preliminary (and still unpublished) analysis of the Roadmap by the liberal Center on Budget and Policy Priorities concluded, “elderly and disabled people with significant medical conditions could encounter serious difficulty securing adequate coverage.”

But wait a minute--don’t the Democratic reform plans also take money out of Medicare? They sure do. But there are several key differences. For starters, the Democrats’ reductions don't appear to be as large as what’s envisioned in the Roadmap. Also, under the Democratic plan, most seniors would still be getting their coverage directly from the government, which has lower overhead than private sector insurers. So every dollar the Democrats spend on seniors would actually go a little further.

No less important, the Democratic plans wouldn't simply slash spending and let the market sort itself out. Instead, the Medicare cuts are part of a broader package of reforms designed to change the way Medicare pays for services. These reforms are designed to reward efficiency (by, for example, paying more to doctors that join integrated group practices) while penalizing inefficiency (by, for example, paying less to hospitals with high rates of infection or, eventually, paying less money for drugs that don’t work that well). They are also designed, quite frankly, to push down the prices that providers charge.

This is a critical difference. If you simply reduce the money flowing into Medicare, relying only on the wits of beneficiaries to figure out how best to spend what’s left, seniors are bound to end up with less care. That's the Republican method. But if you also introduce system-wide changes that reward more efficient care and force down provider prices, the dollars in the program really might go farther--so that spending less doesn't always mean getting less. That's the Democratic approach.

"The slowdown in the Reid [Senate] bill is predicated on specific policies which, according to MedPAC and others, shouldn't reduce beneficiaries' access to care," says Paul Van de Water, a senior fellow at the Center on Budget. "The Ryan bill just gives every beneficiary a voucher and makes them fend for themselves in a poorly regulated private market."

The irony is that, for much of the last year, Republicans have been scaring the bejeezus out of seniors by telling them that Democrats were out to destroy Medicare. But the Roadmap makes clear that it’s not Democrats who seek massive, disruptive changes to the program. It’s the Republicans. If the coming engagement between the Republicans and President Obama help the public to understand that reality, extending the debate might actually be worth it.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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Critics of health care reform have been hammering away at its substance for months. But, since last week's election in Massachusetts, they’ve been focusing their attacks more on the way reform has come together in Congress. As the argument goes, Democrats wrote the bill on their own and in secret, producing proposals full of shady back-room deals that aren’t in the public interest. The symbol of reform’s hidden corruption is the so-called Cornhusker swindle: A promise, extracted by Nebraska Sen. Ben Nelson, that the federal government would pay the entire cost of expanding Medicaid in his state.

You can’t really defend the deal on the merits. No other state got the special treatment that Nebraska did. But if you stop and think about why Democratic leaders cut that deal, you’ll realize just how wrong-headed the broader critique of the process is. If Democrats hadn’t been so determined to reach out to Republicans--and worked so hard for an agreement that didn’t seem overly partisan--they wouldn’t have made the Nebraska bargain, or many others, in the first place.

Remember how we got to this point--and how far President Barack Obama and the Democrats have gone to accommodate Republicans and the conservatives they represent. The plan Obama outlined on the campaign trail, the one Democratic congressional leaders endorsed, called for making sure nearly every American had insurance. But accomplishing that would have cost well over $1 trillion over 10 years and, by some estimates, closer to $2 trillion. That was more than conservatives could stomach. To get the price tag down below $1 trillion, they settled on a plan that covered far fewer people.

The original Obama and congressional plans all called for creating a public insurance option, into which people could enroll voluntarily. But that proposal, too, ran afoul of more conservative sensibilities--and was summarily dropped. (The House ended up including a public plan as part of its bill, but House leaders signaled long ago their readiness to drop it in order to reach a compromise with the Senate.)

These moves didn’t make health care reform more popular. If anything, they had the opposite effect. A plan that spent more money would have required finding more offsetting revenue or savings. But it also would have provided clearer, quicker benefits for middle-class people--many of whom now fear the bill does too little to improve their lives. As for the public plan, poll after poll has shown that it is popular. And the really crazy thing is that the Democrats might have been able to keep both features--with, at most, minimal compromises--if only they’d been willing to go it alone, the way the critics insist they did.

Under Senate procedures, the Democrats had the option of passing health care reform, or at least many of its elements, through what’s called the reconciliation process. In reconciliation, a simple majority of senators can pass a bill, without the threat of a filibuster. Rules limit what can and can’t be considered during the process, so it has definite drawbacks. But if Democratic congressional leaders were determined to pass something on their own--the way, say, Republican congressional leaders were frequently during the Bush years--they could have gotten much and maybe most of what they wanted.

But they didn’t--in no small part because they didn’t want to act in such a blatantly partisan way. Whether that was a matter of principle (i.e, they really believed bipartisanship is important) or a matter of perception (i.e., they thought voters would get mad), it ended up constraining them all year long. Instead of wrapping up negotiations and passing bills before the summer was over, the process dragged into the fall and winter. Over and over again, Democratic leaders (particularly Senate Finance Chairman Max Baucus) reached out to Republicans, only to be rebuffed. When that didn’t work, they were left trying to deal with the most conservative members of their own caucus--culminating in the negotiations with Nelson and the promise to cover his state’s Medicaid expansion. If Senate Democrats hadn’t needed Nelson’s vote to break the expected Republican filibuster--if they could have passed health reform with a “mere” 59-vote majority--they could have told Nelson to take a proverbial hike.

The same, by the way, goes for all of the other back-room deals made to pass this bill. If Obama and his supporters had a greater margin for error--if they could have passed health care reform with a simple majority of votes, instead of the 60-vote supermajority forced by the threat of Republican filibusters--they wouldn’t have had to make so many concessions to special interests that wield influence over the Congress.

But every special interest knew that the Democrats had a razor-thin margin for success--and that gave them maximum leverage. They understood early on that, by trying in good faith to reach deals with Republicans and conservatives, Democrats were falling into a trap--the one that’s ensnaring them now.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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When the Democrats announced that they would be forgoing conference committee proceedings and negotiating a final health care reform bill informally, critics pounced on President Barack Obama for violating his promise of greater transparency in government. And I, for one, had no great urge to defend him.

As a presidential candidate, Obama had not merely promised to introduce more transparency to government. He had very specifically, and very repeatedly, promised to conduct deliberations over health care “in front of the cameras on C-SPAN.” Although I never took the pledge literally--clearly, you can’t negotiate an entire bill in public view--plenty of voters did. Now Obama was paying a political price for the boast. I figured it was punishment for rhetorical hubris.

But then, on Wednesday, a press release from the Republican National Committee came across my desk. It contained a statement by Rep. Tom Price, Ga., chairman of the Republican Study Committee. “If the Democrats aren’t engaging in more nefarious backroom deal-making, why do they refuse to pull back the curtains and let the public see what’s going on?” Price said. “What are they doing that they don’t want us to see?”

To call that statement priceless is not just a bad pun. It’s a gross understatement. As you may recall, the previous administration--that is, the very Republican George W. Bush administration--had its own problems with transparency. Perhaps most famously, Vice President Richard Cheney convened a task force to help the administration design energy policy. People were naturally curious about what this task force was doing, particularly given the administration’s close ties to the petroleum industry, but Cheney wouldn’t even reveal who was on the task force, let alone open its proceedings to the public.

If Republican leadership was in high dudgeon then, I must have missed it.

The energy task force episode was emblematic of the Bush administration’s approach to transparency. And that approach has changed pretty radically in the last year. According to Ellen Miller, president of the Sunlight Foundation, the Obama administration has made “enormous strides” towards open government. The record is “not perfect,” she says, but “no White House has been more open.”

One sign of this progress is the decision to make public the names of all visitors to the White House. Want to know how frequently Billy Tauzin, the former congressman who now lobbies for the drug industry, visited 1600 Pennsylvania Avenue? You can look it up at www.whitehouse.gov. There’s even a handy search tool.

Of course, if you do that search, you’ll see that Tauzin visited the White House 11 times last year--which is not unrelated to the fact that his organization, the Pharmaceutical Research and Manufacturers of America, struck a deal with the administration over health care reform. In a nutshell, PhRMA agreed not to fight reform and the administration, with Senate Finance Chairman Max Baucus, D-Mont., as a partner, agreed it wouldn’t seek changes that reduced drug industry revenues by more than $80 billion. While the existence of a deal was no secret--the administration itself announced it, as a sign of legislative progress--the details only came to light later on, in reports that appeared in the New York Times and Huffington Post. Those details suggest the industry will make out rather well.

Still, everything is relative. The health care industry seemed to have even more influence in 2003, when the Bush administration worked with the Republican congress to create a drug benefit for Medicare. The role of lobbyists in that episode was so obvious and the resulting giveaways to industry so egregious that it disgusted even some Republicans--like Rep. Walter Jones, R-N.C., who told “60 Minutes” that “the pharmaceutical lobbyists wrote this bill."

Nor did the Bush administration and its allies seem particularly concerned with transparency during that fight. On the contrary, when the chief actuary for Medicare concluded that the drug plan would cost more than its proponents were predicting, an administration official ordered the actuary to say nothing--to the point where the actuary believed his job was in jeopardy. That same actuary, Richard Foster, has spent much of the last year issuing (somewhat) critical projections about Obama’s reforms. But neither the president nor his allies have tried to squelch Foster. Instead, they’ve been content to argue their case, in public, on the merits.

One more fact to consider is that Obama and his supporters are pushing reforms that will, on their own, advance the cause of transparency--not transparency in government, mind you, but transparency in health care. When insurance carriers make decisions about what services or treatments to cover, they often do so in secret--and leave beneficiaries no legal recourse for challenging those decisions. Reform would create a standard set of benefits, to be determined by democratically accountable officials, that all insurers must cover. It would also create binding legal processes, through which patients could challenge decisions they thought were unfair.

Could Obama be doing more to bring health care--and its policy work--out into the open? Without a question. But he could also be doing a lot less. That's worth something.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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Over the next few weeks, as the House and Senate forge a compromise between their respective health care reform bills, most of the attention will be on the high-profile issues like abortion and taxes. But there are myriad other issues that, although less visible to the public, could go a long way towards determining the success of health care reform--and the health care system more generally. High on this list is the seemingly technical question of what Medicaid pays primary care physicians.

To understand why this issue is so important, you first need to know a little about Medicaid’s history. The program was created in 1965, as part of the same law that created Medicare, but it evolved very differently. Medicare grew out of an intense, highly public debate that stretched back to Harry Truman’s efforts at national health insurance more than a decade before. Its creation reflected an emerging national consensus that government, and society as a whole, had an obligation to make sure every person over 65 had health insurance.

Medicaid had no such consensus behind it. Nobody had gone around the country promising to create a huge new program to cover low-income Americans exclusively, even though that’s precisely what Medicaid was. That left the program at the mercy of a political undertow that would grow over the years.

State and federal lawmakers were constantly seeking to expand the program’s reach, since more and more Americans were losing their private coverage and in need of a public alternative. But finding the money to pay for these expansions was an ongoing struggle, since its constituency--low-income Americans--didn't have much in the way of political clout.

As a result, Medicaid became gradually more underfunded over the years. And that showed up in what the program paid doctors. Today, for example, Medicaid pays primary care doctors, on average, 66 percent of what Medicare does, according to a 2009 Urban Institute study. (It’s an average because each state sets its own rates.) That’s particularly worrisome when you consider that Medicare itself pays less than private insurance.

This isn’t just a problem for doctors. It’s also a problem for patients, since doctors inevitably respond to the low Medicaid payments by seeing fewer Medicaid patients. The great irony of Medicaid is that while its beneficiaries have a more generous set of benefits than most people with private insurance, they often have a harder time taking advantage of them because fewer doctors will see them.

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When lawmakers in the House sat down to write a health reform bill this year, they understood this--and decided to do something about it. Their bill decrees that Medicaid pay primary care doctors the same rates that Medicare will. Experts hailed the move, not only because it would help low-income Americans get access to care but also because it’d give an extra financial boost to primary care physicians, who desperately need it. (The relatively low pay for primary care docs is widely considered the major reason the U.S. has a shortage of them right now.)

But, as you might expect, this sort of change doesn’t come cheaply. The Congressional Budget Office estimated that the increase in Medicaid payments would cost around $57 billion over the next ten years. And, as you also might expect--at least if you’ve been following the ups and downs of the legislative process--that was $57 billion the Senate decided not to spend, in order to reduce the overall outlays of the bill.

In an ideal world, the House version would simply prevail in negotiations. But this is not an ideal world. It’s a world in which the Senate holds more political leverage--and the decisive votes, like those from Joe Lieberman and Ben Nelson, seem contingent on keeping the bill’s price tag more or less as it was when it passed the Senate. To the extent House negotiators can pry more money out of their Senate colleagues, they have other priorities to consider--like strengthening the protection against out-of-pocket costs or moving the startup date from 2014 to 2013.

Still, higher Medicaid reimbursements ought to be the sort of change that the Liebermans and Nelsons of the world support, at least in theory. Remember, they opposed creating a stand-alone public insurance option for non-elderly Americans precisely because they feared it wouldn’t pay providers well enough. Increasing the reimbursements in an existing public insurance program that already underpays doctors and hospitals would seem like a no-brainer--which, as it happens, it is, for a great many reasons.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

For more TNR, become a fan on Facebook and follow us on Twitter.

Health care reform looks like it’s finally ready to pass the Senate, now that the Democrats have 60 votes in hand. But here on the left, not all of us are jumping for joy. Some think the Senate bill is just barely better than nothing. Others think it’s worse than even that.

As this argument goes, health care reform won’t do all that much to help people who need it. Insurance will still be expensive and even people who have coverage will discover they owe significant out-of-pocket expenses once they get sick. A public insurance option might have made this tolerable, since it would have provided better, cheaper coverage. Without it, many of us are arguing, reform is just a big giveaway to the insurance industry--one that produces little social progress.

It’s certainly true that, under the terms of the Senate bill, insurance would cost more and cover less than many of us would prefer. But would it really produce little social progress? Is it really worse than nothing?

One way to answer this question is by comparing how a typical family would fare with reform and without. At my request, MIT economist Jonathan Gruber produced a set of figures, based on official Congressional Budget Office estimates. (Click here for a closer look at the impact reform would have, in dollar terms, on families of different incomes.)  The results tell a pretty compelling story, particularly when put in human terms.

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Let’s imagine it’s 2016 and you are an administrative assistant, a garage mechanic or perhaps trying your hand at consulting for the first time. You’re married, just turned 40 and have two kids to feed on a household income of around $50,000. You want to buy health insurance, but can’t get it through an employer. How much will it cost? And how much--or how little--protection will it provide?

If reform doesn’t pass, according to Gruber’s figures, the average premium for the non-group market--that is, the market for people buying coverage on their own--will be around $12,000 a year. Right off the bat, you’re spending a fifth of your income on health insurance.

But what does it cover? Policies in the non-group market are notoriously spotty and unreliable. And benefit requirements vary enormously depending on the state. Many allow considerable, sometimes unlimited, out-of-pocket expenses. For the sake of comparison, though, let’s assume you have a policy with a deductible no higher than that allowed for a Health Savings Account. According to Gruber’s projections, that would mean you’re on the hook for--wait for it--another $12,000, plus a few hundred in change.

Put it altogether and that’s a total liability of around nearly $25,000--about half of your income.

That may actually be a best-case scenario in one sense. If you’re going to hit that high deductible, chances are pretty good that someone in your family has a chronic medical condition. And if you or your family member has had that condition all along, insurers might not even sell you a policy. Maybe you have diabetes. Or you’re married to a cancer survivor. Maybe one of your kids has asthma. Whatever the case, chances are you can’t get health insurance at all. Your total risk of loss would be, well, every single penny you have.

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So what happens if reform does pass? For starters--and this is no small thing--the insurance company will have to sell you a policy, no matter what pre-existing conditions your family brings to the table. And you’ll know from the start that the policy will cover basic services because the government will be defining a basic benefits package. That package is going to include a broader range of services than the typical non-group policy would without reform. So when your doctor recommends a standard test or procedure, you won't have to panic it falls into some hidden policy loophole.

But what will that coverage cost? The basic premium is roughly the same, according to Gruber’s calculations that he extrapolated from official Congressional Budget Office estimates. But that $50,000 income means you’re also eligible for federal subsidies. Large federal subsidies. In fact, the government will cover about two-thirds of the price, so that you’re left owing just $3,600.

Now, you could end up spending a lot more on medical care if you or someone in your family gets sick. But here, too, the federal government would step in to help. Under the reforms, the government would limit out-of-pocket spending to around $6,000 per year. Combined with the premium, you’re on the hook for around $10,000 total, or about a fifth of your income.

That’s not pocket change, for sure. A family making $50,000 will have to make serious sacrifices to find $10,000. But it’s better--light years better--than finding $25,000 or more. It’s potentially the difference between having to give up your home, get an extra job or declare bankruptcy. Just knowing the bills that could come will be the difference between getting care you need--and skipping it, at grave risk to your health.

It’s a difference you’d feel at other income levels, too. If your family of four makes more money--say, around $75,000--your premiums and out-of-pocket expenses will be higher, but still a few thousand less than it’d be without reform. If you make less money-- $35,000--the savings would be much larger. (If you make less than that, you'll probably be on Medicaid, which offers even more protection.)

Could the deal be better still? Of course it could. The House bill, for example, offers substantially better protection from out-of-pocket expenses.

That's an argument for improving the Senate bill in conference committee, when its members meet with their House of Representatives counterparts, and for improving the law if and when it goes into effect. Those of us on the left can, and should, fight for both.

But we should also recognize the Senate bill for what it is: A measure that will make people's lives significantly better. Surely that's worth a little enthusiasm.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

For more TNR, become a fan on Facebook and follow us on Twitter.

On Monday morning, a week ago, the Congressional Budget Office predicted that, for most people, insurance would cost the same or less if the Senate's health care reform bill passes. By the afternoon, critics of health care reform rushed to the microphones, claiming vindication. CBO, these critics insisted, had determined reform would mean higher costs!

What happened? The simple answer is that the critics were being deliberately deceptive. And they almost certainly were. But there's also a more complicated answer. The critics were taking advantage of widespread confusion over the definition of cost--a confusion that has been hanging over this debate for the last few months and is continuing to distort it.

Until now, the CBO, which is Washington's official scorekeeper, has been assessing reform proposals largely on the basis of how they would affect the federal budget. And whenever CBO has issued one of its assessments, critics have focused largely on CBO's estimates of government outlays--that is, the amount of money a bill would require Washington to spend on expanding government health insurance programs or providing people with financial assistance to buy insurance.

These numbers inevitably sound big. Most of the bills CBO has analyzed have called for outlays in the neighborhood of $1 trillion over 10 years. And while that figure represents just a fraction of the total federal budget--government outlays for the same period will be more than $40 trillion--it still represents an increase in what Washington will be spending. That's bound to upset anybody whose primary concern is the size of government.

But sometimes government needs to grow, in order to take on responsibilities the private sector can't handle on its own. And when that's the case--as it seems to be with health care--the only relevant question is whether an initiative adds to the federal deficit. Here, the news has been largely good. The bill before the Senate now would raise some tax revenue while finding savings in other government programs. The net result, according to CBO, would be lower deficits overall. (It reached a similar conclusion about the House bill.)

Of course, that's not the end of the story. The most important issue for most Americans isn't what the government spends on health care. It's what they, as individuals and families, spend on health care. That's the question the CBO finally addressed this week--although the findings were, in fairness, a bit hard to follow.

The vast majority of Americans with private insurance get coverage through employers. For these people, CBO predicted, premiums would stay about the same or come down a bit if the Senate bill became law. That wouldn't be the $2,500 in annual savings that President Obama famously promised during the campaign. But it also wouldn't be the huge hike in premiums critics had been predicting.

Where the price of health insurance would start to change radically is in the non-group market--that is, for people who buy on their own, as individuals, rather than through an employer. Premiums for these people, who number a little more than 30 million, would tend to go up. That's one of the points reform critics seized upon in their press conferences.

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But the more interesting and relevant story was why CBO expected premiums to go up. For the most part, CBO found, it was because people would be getting health insurance that provided more benefits and covered medical bills more completely--coverage that often wasn't available to people in the non-group market before. In many cases, CBO determined from its economic models, people would actually opt to buy more expensive insurance than necessary simply because they valued the added protection.

In addition, CBO noted, while premiums in the non-group market would rise, the majority of people buying insurance on their own would simultaneously become eligible for federal subsidies. For the majority of these people, the subsidies would more than offset the increase in premiums, so that they'd end up paying less--even as they were getting better coverage.

To be sure, not everybody would be so lucky. People making more than four times the poverty line, or $88,000 a year for a family of four, wouldnt be eligible for subsidies. They'd end up paying more. So would some, although not all, people who now have cheap insurance because they are young, healthy, and have minimal benefits. They'd be a small minority of the total U.S. population, but still a few million people. They, too, figured prominently in last week's anti-reform propaganda.

But it's virtually impossible to design a reform scheme that doesn't, in the early stages, involve at least some transfer of money away from the healthy and wealthy. The point of insurance is to pool risk, bringing in contributions from relatively healthy people, so that medical bills don't fall too heavily on the sick. And if government is going to offer subsidies to the poor and middle-class, it's bound to finance those subsidies through taxes on the wealthy.

Keep in mind that CBO is very skeptical about reform's ability to make medical care itself less expensive. If it turns out that better use of information technology, more scrutiny of treatments, and other innovations reduce the incidence of wasteful medical treatments--as many experts believe will happen--then it's possible everybody, even the very healthy and very wealthy, would end up spending less on health care, at least in the long term.

And if not? Then even those few people who do end up paying more for their insurance would still gain something: The peace of mind that they'll still have coverage even if they suddenly stop making a lot of money, as well as the knowledge that insurance will meet their needs if they get sick. That's something worth celebrating, even if the reform critics don't agree.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

For more TNR, become a fan on Facebook and follow us on Twitter.

Health professionals spend many thousands of hours training to cure disease. But they can learn how to stop the spread of deadly hospital infections in just a few minutes, by learning five steps for putting lines (that is, tubes) into patients’ bodies.

Wash your hands. Clean the patient’s skin with chlorhexidine, a special antiseptic. Cover the patient fully in sterile drapes. Don full protective gear, including mask and gown. Add a sterile covering to the site afterwards.

In a now-famous study of Michigan hospitals, a physician named Peter Pronovost was able to reduce the rate of in-hospital infection nearly to zero, simply by creating a checklist with these steps and then having hospitals empower nurses to enforce it. The reduction took place in big hospitals and small ones, urban and rural, famous teaching institutions and obscure community establishments. In short, the strategy worked everywhere, which means it ought to work anywhere.

These sort of hospital infections kill as many as 20,000 people a year. And they cost a lot of money to treat. Each episode requires about $45,000 in overall spending, which adds up to more than $2 billion a year by some estimates. Getting doctors and hospitals to adopt the anti-infection strategy should be, as Atul Gawande has observed in the New Yorker, a “no-brainer.”

Listening to the health care debate, you might think that Congress agrees. The proponents of reform talk all the time about improving the quality of care, both to save lives and make it less expensive, and frequently cite hospital infections to make their point. (Even opponents of reform have been known to agree on this front.) And the bills they’ve moved through the legislative process supposedly follow through on this.

But if you look closely at the legislation, you’ll see that the proposals fall a bit short on that promise. The bill that passed the House of Representatives last month does have a section on reducing infections--and, smartly, it applies not only to hospitals but also to out-patient clinics, which are prone to the same problems. But the House bill requires only that hospitals and clinics report the incidence of disease. The bill doesn’t attach financial rewards or penalties to the results.

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The Senate bill Majority Leader Harry Reid just introduced is a bit better on that front. It establishes a monetary penalty designed to prod hospitals in the right direction: Medicare would reduce payments to hospitals whose infection rates put them in the worst quartile nationwide. But the penalty is tiny: Just one percent. And, unlike the House, the Senate chose not to extend the penalty to outpatient clinics.

Who stood in the way of doing more? Depending on who you ask, it was hospital lobbyists, career bureaucrats reluctant to tinker with Medicare, ideological opposition to aggressive regulation of medical care, or--most likely--some combination of all three. And, sadly, the same set of forces seem to have successfully undermined other, similarly inspired efforts at what’s come to be known as “delivery reform.” Remember the proposal to reduce preventable re-admissions? The policy applies only to a handful of conditions. And the commission to recommend Medicare payment changes? By law, the commission couldn’t touch doctors, hospitals, or hospices until 2019.

It’s important to keep these shortcomings in perspective. They don’t, for example, affect the Congressional Budget Office estimates of the bills’ costs, since CBO never gave them much credit anyway. (CBO has predicted reform will pay for itself largely because of tax increases and separate Medicare changes.) And if the measures in the law don’t go as far as they should, they would move our health care system in the right direction -- ideally, making possible more sweeping changes in the future.

But when it comes to making medical care not only cheaper but also better, reducing hospital infections is among the easiest changes to make--something reform really should be able to do, even in this political universe of such limited possibility. It’s an almost perfect test case of whether reform can, in fact, change medical care for the better. “If we can’t eliminate [hospital infections], we will never have a system that works for people,” says Harvard economist David Cutler. But if reform does eliminate (or even reduce sharply) the infections, Cutler goes on to explain, “it shows the government, providers, and taxpayers that we can do this.” No doubt something on this front is better than nothing. But we can still do a lot better than something.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

Exclusive: Click here to see slides from the McKinsey report. 

Ask doctors, hospitals, drugmakers, or insurers for their opinion of President Obama’s health care proposals, and you’ll likely get an earful about how reform will severely hurt their bottom line. Ask many liberals, and you’ll hear the opposite complaint: that the current incarnation of reform won’t affect these industries enough to significantly alter their behavior.

Now there’s a document that suggests both sides are wrong: The medical-care industry would need to make significant, and socially beneficial, changes in response to the bills currently moving through Congress; but such changes won’t come remotely close to destroying the industry’s profitability. Of course, reports on health care come out all the time. But this one deserves special attention--because it was prepared by the nation’s most famous consulting firm and was never meant to see the light of day.

Sometime in August, McKinsey & Company created a PowerPoint document called “Health Care Reform and Implications for Key Stakeholders: What this Could Mean for Client X.” Over the course of 44 slides full of charts and graphs, the firm examines the potential impact of reform on insurers, doctors, hospitals, and the drug industry. McKinsey tells Client X that the presentation’s purpose is to “help inform your understanding of the broader healthcare system impact and what this might mean for your key customers and Client X going forward.” After a source supplied me with the document--which is marked “confidential”--I contacted McKinsey. A spokesperson told me that “Client X” is not a particular company. Instead, he explained, the document is a broad overview of how McKinsey expects health care reform to play out. (It also appears to be a presentation that McKinsey consultants could adapt based on a client’s particular situation.)

Although legislation has evolved, McKinsey’s predictions about reform’s basic design and scope seem right on target, which is no small achievement. Remember that, in August, it seemed entirely possible Congress would pass no health care reform at all. But McKinsey identifies as the “most probable outcome” passage of a bill with somewhere between $750 billion and $1.05 trillion in federal outlays, a functional insurance exchange, a possible cap on the employer tax benefit, some cuts in reimbursements, and a severely watered-down public option. That outline describes, with uncanny precision, the bill Congress will probably pass sometime in the next two months.

But it’s the forecasts about what reform will mean afterward that matter to McKinsey’s clients. And perhaps the most surprising element of McKinsey’s analysis is its prediction that legislation really will force the medical-care industry to change its ways.

The bills moving through Congress use a number of strategies to induce such change. On the one hand, there are relatively heavy-handed efforts that would simply cut (or attempt to cut) the sheer volume of cash flowing into health care: reduced fees to insurance companies that offer private coverage to Medicare enrollees, a tax on the most expensive health insurance plans that would prod employers and individuals to buy cheaper coverage, and a dramatic strengthening of the commission that recommends changes in Medicare payments.

At the same time, the bills include more narrowly focused reforms. There would be bonuses for doctors who organize into integrated group practices, which tend to foster better care. There would be penalties for hospitals that have high rates of avoidable readmissions. And there would be funding for studies of which drugs work better than others, so that Medicare and insurers could stop paying for the less effective alternatives.

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McKinsey seems convinced that this entire package of reforms will influence behavior. Over and over again, it tells Client X that the world is changing. Hospitals, McKinsey says, will face “increased requirements to coordinate care across system/care continuum,” “significantly more value-conscious consumer decision-making,” and “intensified focus on performance measurement and improvement.” It has even starker warnings for the drug industry: “Big Pharma faces the largest potential revenue risk,” the document predicts. Partly that’s because of existing trends in the drug industry. But it’s also because studies of comparative effectiveness are sure to reduce the sale of drugs that don’t work as well. McKinsey suggests that the drug industry can survive and even thrive in this environment “by focusing on ‘productive’ innovation (supported by strong evidence), collaborating with payors and providers in new ways, and revamping commercial and R&D models to significantly improve effectiveness and efficiency.” 

These are precisely the sorts of changes that the architects of reform want the drug industry--and, more broadly, the entire health care sector--to make. “One generally comes away with the sense that [McKinsey] sees reform as changing incentives, first more modestly and then, potentially, in a more fundamental way in later years,” says Larry Levitt, vice president for special projects at the Kaiser Family Foundation, who reviewed the document at TNR’s request. “That’s a good sign.”

Meanwhile, McKinsey’s analysis suggests that--as long as they adjust to the new incentives--doctors, hospitals, and insurers will be just fine. While predictions carry uncertainty, McKinsey states, “it appears that providers overall (both hospitals and doctors) and payors may be largely unharmed (but with lots of variation across them).” “One comes away with the impression that this is also very manageable for the various sectors and, at least in the case of hospitals, maybe a net positive,” Levitt says.

To be sure, McKinsey’s recommendations track closely with the firm’s self-interest. As a consultant that sells strategic advice on how to adapt to changing markets, McKinsey wants companies to believe, on the one hand, that dramatic changes are coming--but, on the other hand, that they can still prosper if they follow McKinsey’s advice.

Still, McKinsey’s report struck me as well-reasoned, and the conclusions themselves are hardly outlandish. Moreover, everyone--from McKinsey to the Congressional Budget Office to think tanks--has biases, and no one is operating with perfect information. So I don’t think McKinsey’s conclusions can be dismissed out of hand. And if they’re right? Then it’s decent news for Client X, and better news for the rest of us.

Jonathan Cohn is a senior editor of The New Republic.

Polls show that Americans are confused about what health care reform means. And, if you listen to members of Congress on television, you get the impression that some of them aren’t certain, either. But figuring out what health care reform entails isn’t hard. All you have to do is look at Massachusetts.

Almost three years ago, the state introduced an ambitious initiative designed to make sure nearly all residents have health insurance. Under this scheme, the state requires employers to contribute toward the cost of covering workers, while requiring individuals to get insurance. It sets up regulated marketplaces, through which individuals and small businesses can obtain insurance, and it forbids insurers from denying coverage, or charging higher rates, because of preexisting conditions.

These are the same key elements you’ll find in the reform bills moving through Congress--which is precisely what has a lot of people worried, on both ends of the ideological spectrum. Conservatives tend to see Massachusetts as a classic case of government run amok. Liberals, although more sympathetic to the basic idea, say the reforms have provided too little coverage for too much money. There’s even one argument on which critics from both sides agree: Massachusetts hasn’t figured out a way to restrain the overall growth in health care costs. If national health care reform fares no better, the country could be in serious fiscal trouble.

The critics have some valid points, particularly on the question of costs. And, with key details about national health care reform still unresolved, understanding the shortcomings in Massachusetts could help lawmakers make the right choices. But the more significant story about Massachusetts is the one that gets told too rarely: the story of what’s gone right. If Massachusetts offers a preview of where we are headed nationally, then Americans can look forward to a health care system that, however imperfect, will be vastly better than the one we have now.

Health care reform in Massachusetts was actually the product of a long struggle that dates to the 1980s, when the state passed a law requiring employers to offer coverage to their employees or contribute toward the cost of covering uninsured workers. It was an ill-fated, if noble, effort: Before the law took effect, employers won repeal of its central provisions. Chastened, lawmakers in the ensuing years focused on incremental reforms, such as expansions of public programs for children and the restructuring of a fund to help subsidize charity care. The initiatives helped, but plenty of residents still struggled to find affordable medical care--either because their insurance was inadequate or because they were among the 10 percent of residents who had no coverage at all.

In 2006, though, reform advocates finally got a chance to try something big again. It was all thanks to a fortuitous political circumstance--one that spawned an unlikely alliance between Republican Governor Mitt Romney and Democratic leaders in the legislature. The Bush administration had decreed that it would not renew a special “Medicaid waiver,” under which Massachusetts channeled some federal money to large safety-net hospitals, unless the state redirected the money toward expansion of insurance coverage. Compelled to act, Romney and the legislature agreed on a scheme that blended ideological approaches and demanded compromise from both sides. There would be insurance for everybody, but everybody would have to pay what they could for it. Liberals wouldn’t get a single-payer plan or anything close to it; conservatives would have to put up with a large expansion of government, even by Massachusetts standards. Fittingly, Senator Ted Kennedy--who’d helped orchestrate the deal from Washington--appeared alongside Romney at the signing ceremony in Boston’s historic Faneuil Hall. 

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Three years later, that system remains in place, and Massachusetts residents deal with health insurance in virtually the same way that all Americans would if Congress were to pass health care reform. By law, anybody living in Massachusetts must obtain health insurance or face a penalty, which this year will be as much as $1,068. For the majority of people, who work for large companies, that means buying the coverage their employers make available. For those who don’t have insurance through a large employer, that means using the “Connector,” a regulated market administered by state-appointed officials.

The goal of the Connector is to give everybody the same sorts of choices people working for large employers already have. It screens insurance plans to make sure they meet basic standards, like covering all essential care and limiting out-of-pocket expenses to $10,000 per family. Because buying insurance can be expensive--Massachusetts has the nation’s highest premiums, at more than $13,000 a year for the average family policy--the Connector also makes subsidies available. Money for the subsidies comes from a variety of sources, including (token) contributions from medium and large employers who choose to pay a fee rather than provide health benefits for employees.

There’s no disputing that the reforms have expanded coverage. During a period in which the proportion of Americans without health insurance has remained stuck at more than 15 percent, the proportion of Massachusetts residents without coverage has fallen dramatically, to below 3 percent, according to official figures. That is by far the lowest percentage of any state.

Of course, coverage by itself is meaningless if it doesn’t translate into more access to medical care or less financial hardship because of medical bills. And there is evidence, mostly anecdotal, that some people are really struggling under the new scheme, either because it’s tough to pay the insurance premiums or because, even with coverage, their medical bills are a burden. But the overall picture looks encouraging. According to a study that two Urban Institute researchers published this spring, the number of working-age adults reporting that they skipped care because of high costs fell from 17 percent to 11 percent in the first two years after the law took effect. The gap was even more dramatic among those eligible for subsidized insurance through the Connector--that is, people making less than three times the poverty line, or around $66,000 per year for a family of four. Among those people, the proportion skipping care because of cost fell from 27 percent to 17 percent. And that’s despite a rough leveling-off in the second year, most likely due to the fact that the recession meant lots of people were out of work and counting their pennies. When the economy rebounds, the number should decline even more.

Still, there is the problem of overall cost. The new rules for the individual insurance market have brought down premiums for people buying coverage on their own, which is no small feat. But the Massachusetts reforms haven’t brought down prices on the whole. In fact, premiums for people who get insurance through employers are rising a tad faster than they are in the country at large. If costs continue to skyrocket, the state’s health care reforms will become unsustainable, requiring either large cuts or tax increases.

Then again, until recently, Massachusetts hadn’t seriously tried to reduce costs. The goal was simply to expand coverage and, perhaps, deal with costs later--which seems to be what’s happening now. In July, a special task force recommended far-reaching changes in the way insurance pays for medical care, by, for example, paying physicians an annual fee per patient rather than a fee for every additional service. For years, experts have said such reforms could save money. But these arguments are only now getting political traction, and many in Massachusetts credit the reforms. As this argument goes, the new system, by giving the state a greater stake in health care costs, has focused public attention on the problem and provided the government with more leverage to solve it. The left also seems more invested in the cost issue now, if only because it recognizes that controlling costs is necessary to sustain the recent coverage expansions.

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That doesn’t mean Massachusetts will succeed. Many experts, in fact, think only the federal government has the power to make serious changes in the way medical care is financed and, as a result, practiced. But there are signs that such changes may be coming. President Obama and his allies have focused on costs in ways that the Massachusetts reformers never did. Many experts believe that the most aggressive measure on the table, the Senate Finance Committee bill, would, over time, reduce the annual increases in health care spending.

Of course, every cost-cutting measure offends at least one powerful interest. Already, groups representing doctors, hospitals, device-makers, and the drug industry have been striking deals with the White House or congressional committees--deals designed to shield their members from changes that hold out promise for long-term spending reductions. But, if Massachusetts proves anything, it is that you don’t have to get everything right on the first try. Simply by addressing the coverage problem, you create political conditions for addressing the cost problem. And, in the meantime, you’ve put access to affordable health care within reach of nearly the entire population. It wouldn’t be everything reform could be. But it would be a historic accomplishment all the same.

Jonathan Cohn is a senior editor of The New Republic.

When conservatives scream about socialized medicine and death panels, you should tune them out. But lately conservatives have been making an argument you should hear. It's about whether we can believe Congress when it promises to raise taxes or cut spending--and, as such, whether we can believe that health care reform can actually be fiscally responsible.

As you may know, many promoters of health care reform say that the proposals in Congress will pay for themselves and, over the long run, actually reduce what we spend, as taxpayers and as a society. As proof, they point to (among other things) a series of changes in the way Medicare pays for services--changes that would, over time, pay the providers of medical care less and, accordingly, restrain the growth in overall Medicare spending. They also cite a reduction in the tax subsidy for the most generous health job-based insurance policies, or so-called "Cadillac plans." Experts believe this will induce employers and employees to seek out cheaper, more efficient insurance arrangements.

The Congressional Budget Office agrees that these measures would save the government money. (CBO doesn't predict the effect on health care spending overall, but it's a reasonable inference.) Still, the CBO delivered that judgment with a caveat: Cost control will only work if future lawmakers let those changes take effect. As CBO noted--and as conservatives have been arguing, in some cases very loudly--that's hardly a sure thing.

A big reason for doubt is the fate of a law called the "Sustainable Growth Rate." SGR is basically an effort to set a hard budget on physician payments in Medicare. After any year when Medicare reimbursements grew more quickly than the SGR, the government is supposed to cut those payments back. But thanks in no small part to physician lobbying, Congress has in recent years flinched at letting the cuts go into effect, instead passing yearly "postponements."

You can see where this argument is going. If politicians in Washington aren't willing to let the SGR take effect, why should we believe they'd be willing to let the planned Medicare reductions and insurance taxes take effect? It's a good question. But, it turns out, there are some good answers, as well.

For starters, the policies are structured differently. The SGR is a cut, plain and simple, that would affect physicians no matter how they changed their behavior. The planned Medicare reductions are part of a broader package, full of financial incentives that should, at least in theory, reward more efficient care. There would be bonuses, for example, that would reward the formation of integrated groups that deliver more coordinated chronic care. Similarly, both employers and employees would be able to avoid paying the Cadillac tax by shifting to plans that don't cost as much.

Severity and timing of the changes is another distinction. At least today, SGR is a joke because--if it went into effect--the reduction in physician payments would be a highly disruptive 20 percent. The adjustments in the new reform law would be less stark and, in the case of the insurance tax, less direct. The Cadillac tax falls on the insurer, not the individual. That ought to soften the political blow--not entirely, for sure, but perhaps enough to make a difference.

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Keep in mind that, notwithstanding the SGR experience, lawmakers in Washington have--from time to time--stuck by decisions to impose higher taxes or hold the line on Medicare spending. It happened in 1990, when President George H.W. Bush and a Democratic Congress agreed to raise taxes; it happened in 1993, when President Bill Clinton and a Democratic Congress agreed to raise taxes again; and it happened in 1997, when Clinton and a Republican Congress agreed to cut Medicare and Medicaid spending, although it later backed off some of the cuts.

Decision-makers in Washington stood by those changes because, during those periods, there was political will to reduce budget deficits. The same seems to be true today. President Obama has insisted reform be fiscally neutral, forcing Capitol Hill to reduce significantly the benefits reform will offer. Just two weeks ago, an effort to wipe out the SGR forever collapsed because, without offsetting revenues or savings, Congress itself was unwilling to authorize the extra money.

That doesn't mean the will to maintain fiscal balance will prevail throughout the next decade, or beyond, as the planned Medicare changes and insurance tax take full effect. But health care reform, done right, should make it easier to maintain that discipline in the future--not only by putting cost-saving measures on the books, putting the onus of action on those who wish to cancel them, but also by getting everybody covered.

For reasons that have as much to do with politics as policy, it's simply easier to control the cost of medicine if most people have insurance. As proof, just look at Massachusetts, where--three years after extending coverage to include 97 percent of the population--the state is looking seriously at truly sweeping changes in the way medical care is organized.

To be clear, a lot of reform advocates--this writer included--would support expansions of coverage even if it didn't reduce the deficit, purely on moral principle. And the case that health reform, as currently written, will actually pay for itself is a lot stronger than the case that health reform will restrain future medical spending. When it comes to the actions of future politicians, there are never guarantees.

But that's not a reason to oppose health care reform. It's a reason to push even harder on cost control--now, while lawmakers are still writing legislation, and in the future, when they have opportunities to improve upon it. Instead of ignoring complaints about cost control, reform advocates should answer them.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

The insurance industry did itself no favors last week when it released a report purporting to show that health care reform would cause insurance premiums to skyrocket. The report focused on only a few specific changes contained in the various reform bills, rather than the bills in their entirety. And the report came out just a day before the Senate Finance Committee, the last of five congressional panels with jurisdiction, was scheduled to vote on a bill. Most of Washington interpreted the report as an effort to delay, if not derail, the reform debate--which it almost surely was. The industry quickly found itself on the defensive. And the Senate Finance Committee pressed ahead, passing a bill just as it was expected to do.

But buried inside the insurers' new piece of propaganda were two perfectly valid arguments--arguments that advocates of reform would be foolish to ignore.

The first of these arguments is about what's come to be known as the individual mandate. A central element of every reform bill that's gone through committee is a requirement that everybody obtain insurance. 

There's a moral argument for the mandate: We want a system that includes everybody, and that means everybody paying what they can for coverage.  There's also a more practical rationale. Without a mandate, young and relatively healthy people might decide not to buy insurance, because they figure they're unlikely to have high medical expenses. (Insurance only works when there's a large number of people paying in, so there are enough contributions from the majority who are healthy to offset the costs of those who are sick.) Besides, even young and healthy people can end up with high medical expenses, from an accident or a serious disease. Forcing them to get insurance is actually in their own interest.

Trouble is, individual mandates are not necessarily popular. Just ask President Obama, who exploited that fact during his presidential campaign. Remember, Hillary Clinton was the Democrat proposing a mandate; Obama attacked her for it. As the Senate Finance Committee deliberated over its version of reform, it decided to weaken its version of the mandate. It made it easier for people to opt out of the requirement, by demonstrating that buying insurance would be a hardship. It also reduced the penalty that people would face if they didn't comply. 

Neither effort was particularly controversial, although both should have been. At some point, if the mandate becomes too weak, it ceases to be effective. People ignore it and then we're back to the problem of young, healthy people opting out of the system. It's not clear whether the reductions the Senate Finance Committee proposed went that far; experts offer different opinions. But the weakening of the mandate is, at the very least, risky.

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The senators eager to scale back the mandate, including Democrat Charles Schumer and Republican Olympia Snowe, defended their moves on the grounds that it was unfair to make people pay for insurance that's not affordable. And it's hard to argue with that kind of logic. But that merely gets to the second problem that the insurers rightly cited in their flawed report: The bills in Congress don't do enough about the cost of coverage.

In theory, reform can reduce insurance premiums in a number of ways. It can wring out waste, by creating standard methods of billing and creating electronic medical records to reduce duplication of services. It can focus payment on treatments--and methods of care--that actually make people better. It can change the tax treatment of health insurance, a move most economists believe will encourage people to seek out more efficient policies. And it can leverage government pricing power, by setting hard caps on premiums or creating a public insurance plan that could help drive down prices. 

Most of the bills in Congress take some of these steps. But they don't take all of them. And even the cost-cutting reforms the bills do include could stand to be stronger. The Finance Committee, for example, cut a deal with both the drug industry and the hospitals under which the industries agreed to put up with relatively modest cuts in exchange for a promise to face no further reductions. Those industries, and other sectors of the health care system, could stand to give up a lot more. The House and Senate Health, Education, Labor and Pensions Committee bills both include a public insurance option. But even the House version--the stronger of the two--wouldn't save as much money as possible. To be sure, there's reason to think that the cost-cutting measures still in the bills will do at least some good. But it's clear they could go a lot farther.

Unfortunately, the insurance industry hasn't been entirely helpful in making such improvements. The insurers oppose not just a public option but, it turns out, changes to the tax treatment of benefits. They have come out for a strong individual mandate, but, of course, that's an idea that quite obviously helps their bottom line. (The more people who have to buy insurance, the more money for them.) And while they've called for stronger cost control, they haven't gone after groups like the drug makers or hospitals publicly. Instead, they've concentrated their fire on the public plan and, now, reform as a whole. 

The insurance industry, in short, has done nothing but look out for itself, much as it always has. But a bill that's bad for insurers could be bad for the rest of America, as well. The insurers don't deserve to get their way. But we might be better off if they did, at least on these two key issues.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

President Obama and his allies in Congress are doing everything they can to rally 60 senators behind health care reform. But, for one red-state senator, even 60 "yes" votes won't do. It has to be 65. "I think anything less than that would challenge its legitimacy," he said in late September. It's a ludicrously high standard for passage--the sort you'd expect from a Republican opponent. But this comment came from Democrat Ben Nelson. And, while Nelson may be an extreme case who revels in opportunities to buck his party, he's not the only conservative Democrat arguing that health care reform--even the scaled-back version moving through the Senate Finance Committee--may be too much, too fast.

Even though the bill, as constructed, would leave millions uninsured and millions more with scant coverage, several of Nelson's Democratic colleagues have talked about weakening the bill even more, by further reducing its funding. They say they're worried about controlling the cost of medical care, and yet, they've eschewed obvious ways to cut costs, such as taking more money from the drug or hospital industries. And they oppose a voluntary public insurance plan, which is among the most efficient ways of delivering affordable, reliable coverage.

What are their motives? The charitable explanation is that Nelson and his allies are acting out of principles they come by honestly--that they simply can't abide even this modest expansion of government. But sincerity does not guarantee good public policy. And, in this case, their opposition wouldn't seem to serve their constituents well: 12.8 percent of Nelson's Nebraska constituents lack health insurance, as do 17.5 percent of Blanche Lincoln's in Arkansas and 20.2 percent of Mary Landrieu's in Louisiana. Many additional people in those states are "underinsured," meaning their coverage doesn't meet their needs. Because the Senate Finance bill does not offer financial assistance to people making more than three times the poverty line--and because the insurance it guarantees is less protective than what other, more expensive versions of reform would require--many of these people will remain exposed to the severe financial, not to mention medical, risks of inadequate coverage. More generous reform would ameliorate that problem, and few of its beneficiaries would bear the price, since the money to pay for it would likely come from taxes on the rich and on expensive benefit plans.

A less charitable explanation for the obstructionism of red-state Democrats is that they are trying to curry favor with health industry interests that help finance their campaigns. (Nelson has always been a favorite candidate of the health insurance industry, for example.) But there's a political cost to watering down reform: It might produce a bill that voters don't like. A reform crafted to appease the health care industry would extract minimal concessions from it: It would let drugmakers and hospitals get off with minimal sacrifice, even as both stand to gain the business of millions of new customers. Such reforms would do little to tamp down the skyrocketing prices of drugs and hospital stays (and, for that matter, the prices of devices and doctor visits). Insurers would have more leeway to raise their own prices and treat their sicker patients badly. Employers would continue to operate with minimal interference, which would mean fewer guarantees for Americans who get insurance through their jobs. By insisting that reform conforms to the interests of these groups, conservative Democrats can perhaps secure their campaign contributions--but only at the risk of alienating constituents. Lincoln will have Wal-Mart. But will she win her next election?

To be fair, Nelson, Lincoln, and others do have constituencies that express some seriously right-wing views. And, while polls sometimes show that conservatives support reform, voters in these states may well be skeptical. Perhaps what these senators need is a clever way out of their political dilemma--a way to produce change without supporting reform that is perceived as too liberal. Fortunately, the procedures of the Senate allow for just such a convoluted arrangement. Obama and his allies are focused on getting 60 votes because that's what it takes to break a filibuster. But a senator can vote to break a filibuster without voting for the bill being filibustered. Nelson and others can simply support cloture and then vote "no" on the final bill (or merely abstain). As long as Democrats have 50 "yes" votes--and they almost surely do--the bill will pass.

This approach would let an important bill come to a full vote and would allow a simple majority to pass the legislation. It's more democratic than allowing a minority inflated by the over-representation of small states to block the newly elected president's central domestic policy promise. Surely that's enough legitimacy for Nelson--particularly when it's also the right thing to do.