Harry, Louise, and Barack

What are our fondest hopes and worst fears for the health legislation now slouching towards the president's desk? On the plus side, it will cover slightly more than half of America's uninsured, qualify more of the near-poor for Medicaid, and it may lead to some greater rationalization of health outlays, though exactly how remains to be seen.

On the minus side, the plan leaves most people dependent on employers for health coverage and reinforces the political and economic power of the private insurance industry. It subsidizes insurers with more than half a trillion public dollars over 10 years, mainly using tax credits. And it gets most of that money by requiring savings in Medicare and other federal health programs of about $400 billion and by taxing so-called Cadillac insurance policies -- many of which are actually Chevrolets that cost a bundle because of the present system's inefficiency and tendency to penalize older and sicker policyholders.

Largely missed in the debate is the fact that the plan doesn't address the problem of unraveling coverage for people who are insured -- some 86 percent of the population. According to a Commonwealth Fund study, there were 25 million underinsured Americans in 2007, meaning that high deductibles and co-pays and uncovered treatments or services left them nominally insured but often unable to get the care they needed. That's a 60 percent increase since 2003, and nothing in the bill prevents this crisis from worsening.

In short, the plan has reasonably good safeguards for the new subsidized policies for the currently uninsured, but it leaves intact the problems afflicting the rest of the system. The government won't use its power to negotiate wholesale drug prices; insurers are free to keep increasing premiums, deductibles, and co-pays at will. The bill does help the uninsured, but the basic flaws remain in the existing system for the rest of us.

These weaknesses are the consequence of the Obama administration's political calculation that it was bet-ter to have the insurance industry's Harry and Louise supporting the president than opposing him. But that was a political choice, not an inevitability.

The road not taken was a tough reform campaign pitting the citizenry against a widely resented industry. Instead, the right has deftly turned much of the resentment against President Obama, using the Medicare savings to make bogus claims about death panels for Grandma (when it's actually private insurers that cause suffering and even death by denying necessary care). A reform that should have been a big winner for Obama will be a political wash, at best. Ironically, the supposedly supportive insurance industry, resentful that the drug companies and hospitals got an even better sweetheart deal, has begun publicly criticizing the bill.

By working with rather than against the insurers, the administration denied itself not just a worthy target but the kind of cost savings achievable from more systemic reform. The best strategy was an expansion of Medicare to the working-age population. That idea, which survived in truncated form as the public option, was first put forward in 2001 by the political scientist Jacob Hacker, who proposed that non-elderly people could have the option to join what he called Medicare-Plus. Hacker wrote, "Approximately 50 to 70 percent of the non-elderly population would be enrolled in Medicare Plus" -- more than 130 million Americans.

In 2008, The Lewin Group calculated that such a program would cost about $49 billion in the first year but produce a net savings of a trillion dollars over a decade because of its efficiencies and bargaining power. The campaigns of Hillary Clinton, John Edwards, and Obama all embraced versions of Hacker's idea.

But this plan was anathema to Obama's partner, the insurance industry, and the "public option" was quickly reduced to a token. Even in the House bill, the plan would cover only 11 million or 12 million people, not 130 million, and would have no significant effect on costs, according to Congressional Budget Office Director Doug Elmendorf. In Sen. Max Baucus' version of the bill, the public option is further reduced to a system of "co-ops." CBO says these "are unlikely to establish a significant market presence in many areas of the country or to noticeably affect federal subsidy payments."

It takes a huge leap of faith to believe that this measure is a good incremental strategy to achieve secure health care for Americans and a more just and efficient allocation of health resources. The long-term struggle for health reform doesn't end with this bill. In the next round, Harry and Louise should accurately be identified as the problem, not the partners.

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