The moment of decision on health-care reform is arriving for progressives in Congress. Some of them have insisted they will refuse to vote for any bill without a public option, and that is now the only bill that has any chance of passing. If they hold to their position, the most significant social reform on behalf of low-income Americans in 40 years will go down to defeat.
It should hardly be surprising that we have come to this point. The requirement for 60 votes in the Senate to pass ordinary legislation was always going to empower the most conservative members of the Democratic caucus or the few moderate Republicans who might support a bill. For a while this past week, it seemed as though a provision to allow 55- to 64 year-olds to buy in to Medicare might provide an acceptable alternative to the public option and secure the 60th vote for the bill. But when both Joe Lieberman and Olympia Snowe said they wouldn't support a Medicare buy-in, that hope dissolved.
None of this, however, affects the central provisions of the legislation, which would extend health coverage to an estimated 33 million of the uninsured, raise standards of protection for millions whose coverage is limited, eliminate some of the most hated abuses of the insurance industry, and create a new system of insurance exchanges that would enable people who buy policies individually or through small groups to get new choices and better prices for coverage.
Yet these provisions of the legislation -- which would go a long way toward relieving one of the greatest injustices in our society -- are poorly understood by the public, including many of those who would benefit from the changes. And they are poorly understood in part because the supporters of reform have been fixated on one goal -- saving the public option, which, according to the Congressional Budget Office's analysis of Majority Leader Harry Reid's bill, would have enrolled less than 2 percent of the population and probably would have had higher premiums than private insurance plans.
Strategists will argue about whether it ever made sense to include a public option in the bill, given the low probability it had of being enacted in a strong enough form to be significant and sustainable. If it turns out to have been useful, it was precisely because it could be dropped in the end and serve as evidence that moderate Democrats had won concessions. But the attention lavished on the public option meant that pressure from the left did not come to bear on other provisions of the legislation such as the slow timetable for implementation (under the Senate bill, most of the extension of coverage would not occur until 2014). The danger now is that some liberals in Congress may not be able to shift gears and vote for something they earlier pledged to oppose. Some of the Democratic base may also become demoralized about reform because it lacks a provision they were mistakenly told was essential.
If things go as well as may be realistically expected, the Senate will pass a bill no later than January. Under normal circumstances, a House-Senate conference would then write a final bill, which would have to be approved by each house. But because of the difficulty in keeping all 60 votes in the Senate, congressional leaders may have to weigh another option: just putting the Senate bill up for a vote in the House.
If that approach proves necessary, there should be one last effort to incorporate some of the stronger provisions from the House in the final Senate bill. The House bill would create a national program with clear federal regulatory authority, while the Senate bill would probably result in an uneven patchwork of state programs. The House has also set an early date for the extension of coverage -- Jan. 1, 2013, which would make the reforms a fait accompli if a new administration takes office later that month.
Liberals in Congress should also recognize that with either a 2013 or 2014 date for implementation, there will be time enough to revise the program before it goes into effect (indeed, time enough for the opponents to roll it back). Many of the specifics, such as the level of subsidies, almost certainly will be changed in the intervening years. And many of those specifics can be changed through budget reconciliation, which requires only 51 votes to pass the Senate.
Sen. Lieberman's influence is at its maximum in passing health-care legislation now, and some of those provisions will be hard to change. But if Democrats succeed in getting a bill through Congress in the next several weeks, they can return to some of the issues in the reconciliation process next year. And at that point they won't necessarily need to have Lieberman on board.
If progressives in Congress can see that far ahead, they'll see their way to vote for a compromise.