Slouching Toward Health-Care Reform.

"Don't make the perfect the enemy of the better," says the president and congressional insiders when confronted with the sorry spectacle of a health-care bill whose scope and ambition continue to shrink, and whose long-term costs to typical Americans continue to grow. They're right, of course. But by the same logic, neither the White House nor congressional Democrats will be able to celebrate the emerging legislation as a "major overhaul" or "fundamental reform." At best, it's likely to be a small overhaul containing incremental reforms.

Real reform has moved from a Medicare-like public option open to all, to a public option open to 6 million without employer coverage (still in the House bill), to a public option open only to those same people in states that opt for it, or about 4 million (the original Harry Reid version of the Senate bill), to no public option but expanded Medicare (the Senate compromise) to no expanded Medicare at all (the deal with Joe "I love all the attention" Lieberman).

In other words, the private insurers are winning and the public is losing.

Pharmaceutical companies are winning as well. Yesterday, proposals to allow U.S. pharmacies and wholesalers to import prescription drugs from Europe and Canada were defeated in the Senate. No matter that American consumers pay up to 55 percent more for their prescription drugs than Canadians, or that the measure would have saved the government at least $19.4 billion over 10 years (according to the Congressional Budget Office). Big Pharma's argument that the safety of such drugs couldn't be assured was belied by the defeat of another proposed amendment that would have allowed drug imports only if their safety and economic benefits were certified by the Secretary of Health and Human Service.

Doctors and hospitals are also winning. More and more of the putative "savings" from health-care reform ("savings" should really be understood as projected costs that are under the wildly-escalating costs projected without such savings) rely on constraints on future Medicare spending. But the details of such constraints keep vanishing, while ever more of the messy work of coming up with them is assigned to a so-called Medical Advisory Board that will supposedly recommend them later on. What no one wants to admit is that Congress never actually implements promised Medicare savings. When crunch time comes, it caves in to the AMA and the AARP. In a few years time, when boomers swell the ranks of seniors, and the political power of the AMA and AARP together rival that of Wall Street, the cave-ins will be boggling.

Meanwhile, opponents of abortion are winning, too. Ben Nelson (a Nebraska Democrat who enjoys being the spoiler even as much as Joe Lieberman) is holding out for even more restrictions.

More about the political reality after the jump.

--Robert Reich

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