Is the House Bill Better Than Nothing – Continued again…

 

One of my professors years ago was a round little man who liked to warn us, with a twinkle in his eye, “Making predictions is very difficult, especially predictions about the future.”  Will a bill pass, in what form, and then what will the long term implications be?  It’s hard to predict.

The incomparable Dr John Geyman, former president of PNHP, makes another strong case [below] that whatever bill this Congress is able to pass will likely set the cause of single payer healthcare back because it “would leave in place an inefficient, exploitive insurance industry that is dying by its own hand, even as [the bill] props it up with enormous future profits through subsidized individual and employer mandates.”

But below that, Sam Stein writing in the Huffington Post reveals the Goldman Sachs analysis for the health insurance behemoths is that no reform would benefit them the most, and if we end up with a version close to the House bill, that would cause the industry the most financial difficulty.

It is clear that many of the supporters and opponents of the bills, both in Congress and the general public, are clearly deluded, and single payer is what has them flummoxed.

On the Left I keep talking to supporters of the public option who claim to be “single payer at heart”, and they believe that whatever passes will be the camel’s nose under the tent, the slippery slope to single payer.  Seems delusional. If only they are right….

Speaking of the Right, many of them also believe that any bill this Democratic Congress will pass will become the same camel’s nose, the same slippery slope to socialism.  Could they be right, too?

There is still work to do. The handwriting was on the wall Saturday 10/31 when anti-abortion Democrats had enough political oomph to get their Stupid Amendment debated and passed while the Progressive Caucus couldn’t muster enough support to bring either the Kucinich or Weiner Amendments to the floor.

No matter what happens, one thing is certain:  we have to continue to build our movement.  Next time around we have to get all those Representatives and Senators who voted for reform this time, to vote for real single payer reform.  And that would prove the delusional ones were right after all.

Rob

THE AFFORDABLE HEALTH CARE FOR AMERICA ACT (HR 3962):ENOUGH REFORM TO SUCCEED?

by John Geyman

As we know, the House passed its health care reform bill on October 29, 2009  after many months of contentious debate. By a narrow margin, 220-215, the 1,990 page, almost 20 pound bill was passed. It laid out the most liberal health care reform that might be expected out of Congress this year, since any bill that may clear the Senate will certainly be more restrictive.

In order to answer our question as to the value of the House bill, we need to re-state the original major goals of reform: (1) contain skyrocketing costs of health care and health insurance; (2) expand access to care by including everyone; and (3) improve the quality of care.

At a gross cost of $1.055 trillion over ten years, the House bill would do some good things, including reduction of the uninsured by up to 30 million; helping many Americans to pay for insurance through government subsidies; helping small business to provide coverage to their employees; expanding Medicaid and community health centers; establishing a new Center for Comparative Effectiveness Research to study and recommend the most effective treatments; initiating limited reforms of the health insurance industry, such as termination (four years hence) of its common practice of denying coverage based on health status and pre-existing conditions; phasing out government overpayments to private Medicare Advantage plans; revoking a decade-old anti-trust exemption for insurance companies; and creating a new long-term care program (CLASS ACT) to supplement Medicaid and/or private long-term care insurance.

However, the negatives far outweigh the positives, and adopting this bill would delay real reform for years to come. Despite a chorus of accolades about the bill by its supporters, even comparing it with the historic importance of Social Security and Medicare, this monster bill instead bears the heavy imprint of corporate stakeholders who themselves are largely responsible for out-of-control health care costs. After months of lobbying and campaign contributions to legislators crafting the legislation, their multiple conflicts of interest and political compromises, this bill ends up being a bailout for the insurance industry and a bonanza for stakeholders in the medical industrial complex.

Here are some of the major problems with the bill:

•  It will not “bend the cost curve” for many reasons—with the exception of a provision that the government negotiate drug prices with manufacturers (as the VA does so effectively), there are no real restraints on the prices of health insurance or health care services; insurers have already warned that premiums will continue to surge in future years; perverse incentives would remain in the system to continue providing large amounts of inappropriate and unnecessary services, especially by specialists in more highly reimbursed areas; and recommendations based on studies by the new Center for Comparative Effectiveness Research could not be used to mandate coverage or reimbursement policies.

•  As the crisis in declining access to care only grows (with already 46 million uninsured and at least another 30 million underinsured), expansion of Medicaid, subsidies, and limited restrictions on insurers would not take place for four more years. And as many states struggle with their deficits during the recession, access and benefit levels available to patients on Medicaid will be seriously jeopardized in many parts of the country. Meanwhile 45,000 Americans are dying each year as a result of being uninsured—one every 12 minutes.

•  Because of a number of small-print provisions in the bill, bought by industry interests and crafted by their representatives, we would see a growing epidemic of underinsuranceamong the newly insured. These are some of the reasons: low requirements for actuarial value, the proportion of health care costs that insurers are required to pay for care (probably ending up as low as 65 or 70 percent when further compromises are made with the Senate); restricted levels of benefits to be covered (the minimal essential benefits package would be in four tiers, has yet to be developed, and we can expect that it will fall far short of all necessary care); in a last-ditch effort to pass the bill and assuage pro-life legislators, new anti-choice language was added by the Stupak amendment that would deny coverage of abortion care to millions of women; and coverage shortcomings of private plans already in force will be grandfathered in without reform.

•  Even after the expenditure of more than $1 trillion, the bill would still leave some 18 million Americans uninsured.

•  The public option, diminished as it has been to the point where it could only include 2 percent of Americans by 2019, would not have enough market clout to “keep the insurers honest.” The Congressional Budget Office (CBO) has already concluded that the public option would not offer real competition to private insurers, and that its premiums would even have to be higher than private premiums. It would not be available until 2013 through the new Health Insurance Exchange, and then only to the uninsured and some employees of small businesses without coverage. Moreover, such Exchanges have no track record of success. After 15 years of experience in California, that Exchange failed, mostly due to lack of pricing power and adverse selection by attracting sicker enrollees.

•  The CBO has projected that rising insurance costs could mean that middle-income families would spend 15 to 18 percent of their income on premiums and co-payments.

This bill would not reverse the unraveling of the employer-sponsored insurance system because of rising health care costs that outpace the rest of our economy; despite subsidies to small business, employer-sponsored insurance would remain unsustainable.

This bill would only add to the already large burden of complexity and bureaucracy, together with their additional costs. At the same time, it would forego savings of some $400 billion a year that could otherwise be achieved through a simplified, more efficient single-payer system.

So in sum, this bill, while well intentioned, is fatally flawed. It would not effectively address the three major system problems demanding urgent reform, and would delay real reform by letting much of our population falsely think that reform is at hand. It would leave in place an inefficient, exploitive insurance industry that is dying by its own hand, even as it props it up with enormous future profits through often subsidized individual and employer mandates.

The most fundamental single question about how to reform our health care system should be whether or not we abandon our multi-payer, mostly investor-owned financing system or move to a not-for-profit single-payer system, Medicare for All, which this year’s political process has carefully kept off the table. The lesson of history in this country tells us that, as long as we retain private health insurance at the core of our health care system, we can never achieve universal access to affordable, comprehensive high-quality care.

John Geyman, M.D. is Professor Emeritus of Family Medicine at the University of Washington, past President of Physicians for a National Health Program, author of a number of books on health policy, and a member of the Institute of Medicine.

Goldman To Private Insurers: No Health Care Reform At All Is Best

Sam Stein
First Posted: 11-12-09 05:12 PM   |   Updated: 11-13-09 12:02 AM

A Goldman Sachs analysis of health care legislation has concluded that, as far as the bottom line for insurance companies is concerned, the best thing to do is nothing. A close second would be passing a watered-down version of the Senate Finance Committee’s bill.

A study put together by Goldman in mid-October looks at the estimated stock performance of the private insurance industry under four variations of reform legislation. The study focused on the five biggest insurers whose shares are traded on Wall Street: Aetna, UnitedHealth, WellPoint, CIGNA and Humana.

The Senate Finance Committee bill, which Goldman’s analysts conclude is the version most likely to survive the legislative process, is described as the “base” scenario. Under that legislation (which did not include a public plan) the earnings per share for the top five insurers would grow an estimated five percent from 2010 through 2019. And yet, the “variance with current valuation” — essentially, what the value of the stock is on the market — is projected to drop four percent.

Things are much worse, Goldman estimates, for legislation that resembles what was considered and (to a certain extent) passed by the House of Representatives. This is, the firm deems, the “bear case” scenario — in which earnings per share for the top five insurers would decline an estimated one percent from 2010 through 2019 and the variance with current valuation is projected to be negative 36 percent.

What the firm sees as the best path forward for the private insurance industry’s bottom line is, to be blunt, inaction.

The study’s authors advise that if no reform is passed, earnings per share would grow an estimated ten percent from 2010 through 2019, and the value of the stock would rise an estimated 59 percent during that time period.

The next best thing for the insurance industry would be if the legislation passed by the Senate Finance Committee is watered down significantly. Described as a “bull case” scenario — in which there is “moderation of provisions in the current SFC plan” or “changes prior to the major implementation in 2013” — earnings per share for the five biggest insurers would grow an estimated ten percent and the variance with current valuation would rise an estimated 47 percent.

The report, a Goldman official stressed, was analytic not advocacy-based. Their job was to provide a sober assessment of the market realities facing private insurers under various versions of health care reform.

Story continues below 

“If no reform at all happens you would see the largest rise in EPS,” a Goldman official acknowledged. “But what we are doing is just analyzing what the stocks would do under different scenarios.”

The study does note on the front page that the firm “does and seeks to do business with companies covered in its research reports.” Those companies include Aetna, Wells Point and United Health.

In the context of the current health care debate, the findings provide a small window into the concerns that have driven the private insurance industry’s opposition to reform legislation. Simply put: health care reform is going to hurt their bottom line. No less a prestigious voice than Goldman Sachs is telling them so.

Some insurers, in the end, will be hit harder than others. CIGNA is the lowest of the big five, for instance, because it does little business providing insurance plans to Medicare patients, individuals and families buying health plans directly, or small employers that offer health plans to their workers.

In addition, some reforms are going to hurt the industry more than others. Regulatory changes — such as prohibiting the prejudice against consumers with pre-existing conditions — will have an impact across the board, as will the funding cuts to Medicare Advantage.

Overall, Goldman calculates the probability of reform passing Congress at 75 percent. Though the limitations of Goldman’s political prognostications were on full display earlier in the document:

By mid-late October, we expect a cloture vote (60 votes) to bypass a potential filibuster followed by several weeks of debate over proposed amendments on the Senate floor (with a similar process under way in the House). If both the Senate and House are able to pass legislation (perhaps before the Thanksgiving recess), a House-Senate conference negotiation should produce combined legislation for final approval (perhaps by mid-December).

 

Advertisements

Is the House bill better than nothing (continued)

 

More comments from worthy commentators – Jonathan Cohn, a highly respected single payer advocate and writer, in The New Republic writes about why we should support the bill and urge its passage in the Senate, and Dennis Kucinich discusses why he voted against the House Bill.  For commentary from HCHP’s own Dr Aaron Carroll, check out his blog http://mdcarroll.com/.

The House Bill Is “Worse Than Nothing”? Really?

  • Jonathan Cohn November 9, 2009 | 1:47 pm
    Marcia Angell, M.D., is one of the nation’s most well-respected experts on health care issues. And with good reason. A board-certified pathologist who also trained in internal medicine, she’s a former editor of the New England Journal of Medicine and senior lecturer at Harvard Medical School. Her writing credits include The Truth About Drug Companies and an award-winning article at TNR on the same subject. (She co-wrote that with Arnold Relman, a distinguished physician, writer, and intellectual in his own right.)

Angell is a well-known advocate for single-payer health care: If it were up to her, she’d simply expand Medicare to cover everybody. This is not, of course, the kind of health care reform we’re going to get this year. Instead, we will–if we are lucky–get something that looks like the bill that passed the House of Representatives on Saturday night.

Angell is not impressed, as she explains today at the Huffington Post:

Is the House bill better than nothing? I don’t think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we’ve tried health reform and it didn’t work. But the real problem will be that we didn’t really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.

I’m a longtime single-payer supporter myself. If Angell could get her way, I’d be thrilled. But Angell can’t get her way.

Blame the composition of the U.S. Senate, where North Dakota has the same representation as California. Blame the power of special interests like the drug industry, which virtually own large swaths of Congress. Blame public opinion, which remains stubbornly skeptical of big government even as it cherishes programs like Medicare. Or blame somebody else. The numbers in Congress simply don’t provide enough support for anything remotely approaching single-payer. Just look at how hard it is to pass a scaled-back public insurance option.

To Angell–and to others on the left, as my colleague John Judis notes today–this is reason for ditching the whole effort. But what, really, would that accomplish? The immediate impact would be to undermine Obama and his allies in Congress, creating the (accurate) impression they are incapable of passing major legislation. The Democratic Party would lose seats at the midterms and then, quite possibly, suffer even bigger setbacks two years hence. That’s not exactly a recipe for progressive revival.

Perhaps Angell and those who agree with her that this would be a constructive failure–that eventually growing frustration with our health care system will help us elect even more progressives and pass more ambitious reforms. Well, maybe. But that’s an awfully big chance to take. Progressives said the same thing when the Clinton health care plan failed and, before that, when efforts to pass universal coverage under President Richard Nixon collapsed. If anything, the conversation about health care reform has drifted the opposite direction over that span of time. You could plausibly claim that the reforms on the table today are more or less what moderate Republicans were proposing under Clinton, just as the Clinton reforms were not that far removed from what Nixon himself wanted in the early 70s.

And what would happen in the meantime? According to the Congressional Budget Office, the House bill would mean about 36 milion people get health insurance, reducing the number of uninsured by around two-thirds. People who had pre-existing medication conditions would, finally, have the ability to get insurance just like the employees of large companies do. The insurance would not always be as generous as it should be, but the government would prohibit lifetime caps, place some limits on out-of-pocket spending, and establish a basic benefits package that makes sure all policies cover a broad range of services.

The studies–which, I know, Angell has seen–suggests tens of thousands of people* die or go bankrupt every year because they can’t afford to pay their medical bills. Countless more suffer. The House bill wouldn’t stop such hardship altogether. But it would reduce it significantly–arguably, by as much as any single piece of domestic legislation since the Great Society. Surely that qualifies as something more than “a few improvements around the edges.”

The House bill would do many other things, too, familiar to the readers of this space–from the creation of a public plan to the creation of pilot programs that would begin to change the way we deliver medical care. And while it wouldn’t do nearly enough to make health care less expensive–the drug industry, among others, remains a source of untapped savings–the House bill certainly wouldn’t cause the cost of medicine to go up even more quickly. If anything, it’ll cause the cost to go up a bit more slowly.

As I’ve argued repeatedly, the House bill is not close to perfect. Neither is its Senate counterpart. But we don’t pass perfect laws in the U.S. We pass imperfect ones and then do our very best to improve them over time.

It happened that way with Social Security and Medicare. It can happen that way with comprehensive health care reform, too. But only if we do something, rather than nothing.

*Note: I originally wrote “millions” of people die or go bankrupt every year. That’s rather overstated. It would be more accurate to say “tens of thousands,” as I’ve now rewritten, although one could plausibly argue it’s more like “hundreds of thousands” depending on your definition of “medical-related bankruptcy.” In any event, thanks to reader “adsprung” for correcting my error–and for reminding me that I should read over my blog entries a little more carefully before hitting “publish.”

***********************************************************************************

Congressman Kucinich addresses vote on H.R. 3962

Congressman Dennis Kucinich after voting against H.R. 3962 addresses why he voted NO, stating:

“We have been led to believe that we must make our health care choices only within the current structure of a predatory, for-profit insurance system which makes money not providing health care. We cannot fault the insurance companies for being what they are. But we can fault legislation in which the government incentivizes the perpetuation, indeed the strengthening, of the for-profit health insurance industry, the very source of the problem. When health insurance companies deny care or raise premiums, co-pays and deductibles they are simply trying to make a profit. That is our system.”

“Clearly, the insurance companies are the problem, not the solution. They are driving up the cost of health care. Because their massive bureaucracy avoids paying bills so effectively, they force hospitals and doctors to hire their own bureaucracy to fight the insurance companies to avoid getting stuck with an unfair share of the bills. The result is that since 1970, the number of physicians has increased by less than 200% while the number of administrators has increased by 3000%. It is no wonder that 31 cents of every health care dollar goes to administrative costs, not toward providing care. Even those with insurance are at risk. The single biggest cause of bankruptcies in the U.S. is health insurance policies that do not cover you when you get sick.”

“But instead of working toward the elimination of for-profit insurance, H.R. 3962 would put the government in the role of accelerating the privatization of health care. In H.R. 3962, the government is requiring at least 21 million Americans to buy private health insurance from the very industry that causes costs to be so high, which will result in at least $70 billion in new annual revenue, much of which is coming from taxpayers. This inevitably will lead to even more costs, more subsidies, and higher profits for insurance companies – a bailout under a blue cross.”

“By incurring only a new requirement to cover pre-existing conditions, a weakened public option, and a few other important but limited concessions, the health insurance companies are getting quite a deal. The Center for American Progress’ blog, Think Progress, states, ‘since the President signaled that he is backing away from the public option, health insurance stocks have been on the rise.’ Similarly, healthcare stocks rallied when Senator Max Baucus introduced a bill without a public option. Bloomberg reports that Curtis Lane, a prominent health industry investor, predicted a few weeks ago that ‘money will start flowing in again’ to health insurance stocks after passage of the legislation. Investors.com last month reported that pharmacy benefit managers share prices are hitting all-time highs, with the only industry worry that the Administration would reverse its decision not to negotiate Medicare Part D drug prices, leaving in place a Bush Administration policy.”

“During the debate, when the interests of insurance companies would have been effectively challenged, that challenge was turned back. The ‘robust public option’ which would have offered a modicum of competition to a monopolistic industry was whittled down from an initial potential enrollment of 129 million Americans to 6 million. An amendment which would have protected the rights of states to pursue single-payer health care was stripped from the bill at the request of the Administration. Looking ahead, we cringe at the prospect of even greater favors for insurance companies.”

“Recent rises in unemployment indicate a widening separation between the finance economy and the real economy. The finance economy considers the health of Wall Street, rising corporate profits, and banks’ hoarding of cash, much of it from taxpayers, as sign of an economic recovery. However in the real economy – in which most Americans live – the recession is not over. Rising unemployment, business failures, bankruptcies and foreclosures are still hammering Main Street.”

“This health care bill continues the redistribution of wealth to Wall Street at the expense of America’s manufacturing and service economies which suffer from costs other countries do not have to bear, especially the cost of health care. America continues to stand out among all industrialized nations for its privatized health care system. As a result, we are less competitive in steel, automotive, aerospace and shipping while other countries subsidize their exports in these areas through socializing the cost of health care.”

“Notwithstanding the fate of H.R. 3962, America will someday come to recognize the broad social and economic benefits of a not-for-profit, single-payer health care system, which is good for the American people and good for America’s businesses, with of course the notable exceptions being insurance and pharmaceuticals.”

Is the House Health Care Bill Better than Nothing?

What to make of the health care bill passed late in the night on 11/7?

Below are two (long) commentaries by writers I greatly respect.  Marcia Angell is the iconic former editor of the New England Journal of Medicine and a stalwart single payer advocate.  Maggie Mahar is a thoughtful non-single-payer healthcare writer, the author of Money Driven Medicine, and someone I admire although don’t always agree with.  It’s worth the time to read both of these as we figure out where we should go from here.

– Rob

Is the House Health Care Bill Better than Nothing?

By Marcia Angell, M.D.Physician, Author, Senior Lecturer, Harvard Medical School  November 8, 2009 08:02 PM

Conservative rhetoric notwithstanding, the House bill is not a “government takeover.” I wish it were. Instead, it enshrines and subsidizes the “takeover” by the investor-owned insurance industry that occurred after the failure of the Clinton reform effort in 1994. To be sure, the bill has a few good provisions (expansion of Medicaid, for example), but they are marginal. It also provides for some regulation of the industry (no denial of coverage because of pre-existing conditions, for example), but since it doesn’t regulate premiums, the industry can respond to any regulation that threatens its profits by simply raising its rates. The bill also does very little to curb the perverse incentives that lead doctors to over-treat the well-insured. And quite apart from its content, the bill is so complicated and convoluted that it would take a staggering apparatus to administer it and try to enforce its regulations.

What does the insurance industry get out of it? Tens of millions of new customers, courtesy of the mandate and taxpayer subsidies. And not just any kind of customer, but the youngest, healthiest customers — those least likely to use their insurance. The bill permits insurers to charge twice as much for older people as for younger ones. So older under-65’s will be more likely to go without insurance, even if they have to pay fines. That’s OK with the industry, since these would be among their sickest customers. (Shouldn’t age be considered a pre-existing condition?)

Insurers also won’t have to cover those younger people most likely to get sick, because they will tend to use the public option (which is not an “option” at all, but a program projected to cover only 6 million uninsured Americans). So instead of the public option providing competition for the insurance industry, as originally envisioned, it’s been turned into a dumping ground for a small number of people whom private insurers would rather not have to cover anyway.

If a similar bill emerges from the Senate and the reconciliation process, and is ultimately passed, what will happen?

First, health costs will continue to skyrocket, even faster than they are now, as taxpayer dollars are pumped into the private sector. The response of payers — government and employers — will be to shrink benefits and increase deductibles and co-payments. Yes, more people will have insurance, but it will cover less and less, and be more expensive to use.

But, you say, the Congressional Budget Office has said the House bill will be a little better than budget-neutral over ten years. That may be, although the assumptions are arguable. Note, though, that the CBO is not concerned with total health costs, only with costs to the government. And it is particularly concerned with Medicare, the biggest contributor to federal deficits. The House bill would take money out of Medicare, and divert it to the private sector and, to some extent, to Medicaid. The remaining costs of the legislation would be paid for by taxes on the wealthy. But although the bill might pay for itself, it does nothing to solve the problem of runaway inflation in the system as a whole. It’s a shell game in which money is moved from one part of our fragmented system to another.

Here is my program for real reform:

Recommendation #1: Drop the Medicare eligibility age from 65 to 55. This should be an expansion of traditional Medicare, not a new program. Gradually, over several years, drop the age decade by decade, until everyone is covered by Medicare. Costs: Obviously, this would increase Medicare costs, but it would help decrease costs to the health system as a whole, because Medicare is so much more efficient (overhead of about 3% vs. 20% for private insurance). And it’s a better program, because it ensures that everyone has access to a uniform package of benefits.

Recommendation #2: Increase Medicare fees for primary care doctors and reduce them for procedure-oriented specialists. Specialists such as cardiologists and gastroenterologists are now excessively rewarded for doing tests and procedures, many of which, in the opinion of experts, are not medically indicated. Not surprisingly, we have too many specialists, and they perform too many tests and procedures. Costs: This would greatly reduce costs to Medicare, and the reform would almost certainly be adopted throughout the wider health system.

Recommendation #3: Medicare should monitor doctors’ practice patterns for evidence of excess, and gradually reduce fees of doctors who habitually order significantly more tests and procedures than the average for the specialty. Costs: Again, this would greatly reduce costs, and probably be widely adopted.

Recommendation #4: Provide generous subsidies to medical students entering primary care, with higher subsidies for those who practice in underserved areas of the country for at least two years. Costs: This initial, rather modest investment in ending our shortage of primary care doctors would have long-term benefits, in terms of both costs and quality of care.

Recommendation #5: Repeal the provision of the Medicare drug benefit that prohibits Medicare from negotiating with drug companies for lower prices. (The House bill calls for this.) That prohibition has been a bonanza for the pharmaceutical industry. For negotiations to be meaningful, there must be a list (formulary) of drugs deemed cost-effective. This is how the Veterans Affairs System obtains some of the lowest drug prices of any insurer in the country. Costs: If Medicare paid the same prices as the Veterans Affairs System, its expenditures on brand-name drugs would be a small fraction of what they are now.

Is the House bill better than nothing? I don’t think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we’ve tried health reform and it didn’t work. But the real problem will be that we didn’t really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.

*********************************************

Why Congress’ Health Care Bills Are Better Than You Think

By Maggie Mahar, Health Beat. Posted November 6, 2009.

Many progressives are expressing deep disappointment with the health reform legislation now moving through Congress.

Some suggest that some legislators made deals with lobbyists and let them write the bills. Others complain that both the subsidies and the penalties are too low. Still others don’t like the fact that states can “opt out” of the public insurance option and decide not to offer “Medicare E” — Medicare for everybody.

Finally, many ask: “Why can’t everyone sign on for the public plan in 2013? Why do we have to wait until 2013? Why can’t they roll out universal coverage next year?”

Normally, I would be among the first to critique the bills. By temperament and training, I’m both a skeptic and a critic.

But in this case, I think it is important to recognize that we cannot expect this first piece of health reform legislation to be anything but wildly imperfect. In fact, I’m impressed by the progress Washington has made in just 10 months.

I’ve been watching the struggle for health care reform since the early 1970s, and compared to what has happened over the past 39 years, this is mind-boggling.

I also believe that those who favor overhauling our health care system should send a strong signal to legislators: We support you for having come this far. We realize that you have three years to strengthen, change and refine the plan before rolling it out in 2013.

What Has Been Accomplished So Far: Affordability

What is astounding is that this Congress has made as much progress as it has. We may have a new administration in the White House, but we do not have a brand-new group on the Hill.

The majority of our legislators are moderates; many are conservatives. Nevertheless, a sufficient number have found the will to stand up and back changes that would make health care affordable for millions of poor, working-class and middle-class Americans.

For example, under the House bill, a family of three making $32,000 a year would pay $1,360 in annual premiums for good, comprehensive coverage; under the Senate Finance Committee bill, that family would be asked to lay out $2,013. Today, without reform, if that family tried to buy insurance, it would find that the average plan costs $13,500. For this household, the current legislation makes all the difference.

Too often, the press suggests that such a family would be expected to pay $10,000 out of pocket to cover co-pays and deductibles. That just isn’t true.

Even if the entire family were in an auto accident and racked up $200,000 in medical bills, at their income level, the House bill caps out-of-pocket expenses at $2,000 a year. Under the Senate Finance bill, the family would have to pay $4,000.

Moreover, under both bills, there are no co-pays for primary care. Even private insurers cannot put a $25 barrier between a family and preventive care.

Moving up the income ladder, a median-income household earning roughly $55,000 would pay premiums of $4,300 to $6,500 — depending on whether the Senate Finance bill or the more generous House bill sets the terms.

Without legislation, they too would face a $13,500 price tag — and that is if they could get a group rate. If they are buying insurance on their own, coverage could easily cost $16,000.

For self-employed workers, early retirees and those who work for (or own) a small business, the legislation offers major savings.They will be able to buy coverage on the Insurance Exchange, where they would suddenly become part of a group — which makes their premiums much lower.

Whether rich or poor, this is great news for anyone who works for himself, retired early (voluntarily or involuntarily) or is part of a small firm.

Granted, the legislation now on the table still doesn’t make insurance affordable for many Americans at the upper edges of the middle class — or the upper class. They don’t qualify for subsidies. But, as I discuss below, the legislation does point the way to lowering their premiums.

Before reform becomes a reality in 2013, I am convinced that this will happen, in part because it must. We can no longer ignore the waste, inefficiency and pure fraud in our health care system. There is absolutely no reason why we should pay so much more for health care than any other nation in the developed world.

And at least the current legislation protects these more affluent households from medical bankruptcy. No matter how much a family earns, they cannot be asked to pay more than $10,000, out of pocket, in a given year. For households that have savings and property to protect, this means that they don’t have to worry about being wiped out by a medical disaster.

Even if you and your family are in that car accident that leads to $200,000 in doctors’ and hospitals bills, you will owe only $10,000. In that situation, doctors and hospitals will let you pay off your bills over time, because they know you can. You won’t be forced into bankruptcy court. This represents an enormous step forward.

In addition, under reform, private insurers will not be able to put a cap on how much they will pay out to you and your family, over the course of a year or over a lifetime. If tragedy strikes and a child needs six or seven years of cancer treatments, your insurance will not “run out.”

For some families, this one provision will mean the difference between being able to care for their child and financial ruin (coupled with the suspicion that, if they had just had more coverage, they might have been able to save their child).

Moreover, in the very first year of reform, the public plan will offer less expensive, higher-quality coverage to uninsured Americans, the employees and owners of small firms, and those who now buy their own insurance in the private sector.

Congressional Budget Office Director Douglas Elmendorf has been spreading misinformation about the government plan, asserting that only 20 percent of those who are eligible for the Exchange will choose it. His offers no evidence for this claim — just a string of “probablies.”

He then argues that despite the fact that its administrative costs will be far lower than those of private insurers, the public plan will cost more than comprehensive private insurance. This theory is based on the unfounded assumption that only one-fifth of Exchange shoppers will pick the government option, coupled with speculation that those running the public plan will make no effort to control costs and utilization.

For peculiar reasons that I don’t fully understand, progressives have been listening to Elmendorf’s numbers. They seem to forget his past: He was mentored by Martin Feldstein, known as the dean of conservative economists. Elmendorf first made his mark in Washington by helping to quash the Clintons’ hopes for health care reform.

Coverage Denial Is Forbidden

Finally, under the House and Senate reform bills, insurers will no longer be able to deny coverage, or charge a customer more, because of a pre-existing condition.

If you’ve begun to take that idea for granted, keep in mind that the Republican’s recent 11th-hour proposal for reform “gives the insurance industry more leeway” as the Wall Street Journal put it yesterday. (Media Matters points out that this WSJ story disappeared from the paper’s Web site sometime last night.) Under the Republican proposal, insurers would be able to take pre-existing conditions into consideration.

House Speaker Nancy Pelosi’s health care reform fact sheet offers two outrageous examples of just how easy it is for insurers to deny coverage today:

Peggy Robertson: The Colorado mother of two was denied health coverage because she had a C-section in 2006. The insurance company told her if she got “sterilized” she would be eligible for coverage.

Christina Turner: After being sexually assaulted in Florida, Turner followed her doctor’s orders and took a month’s worth of anti-AIDS medication as a precautionary measure. She never developed an HIV infection. Months later, when shopping for new health insurance coverage, Turner was repeatedly denied coverage because of the precautionary anti-HIV treatment she received after being raped.

Today, in most states, this could happen to anyone. (I am fortunate to live in New York, where we have community rating, so I don’t have to worry about pre-existing conditions. My employer provides excellent insurance, with no annual or lifetime caps, so the current reform legislation would probably have no immediate effect on my life.) We all should recognize that the bills on the table would change the lives of millions of Americans, giving them the security they don’t have today.

Progressives cannot let this opportunity slip through our fingers because we are so busy critiquing the legislation — and arguing with each other. The Wall Street Journal Online reports that Senate Majority Leader Harry Reid has begun to warn that the Senate may not be able to complete the legislation by the end of this year.

Given all of the criticism he has faced, Reid could be losing heart. After all, conservatives continue to argue that legislators like Reid will be punished at the polls. Congressmen who have been pushing for reform need our encouragement. Progressives should continue to make it clear that the majority of Americans want reform — and a public option — even if the legislation is far from perfect.

Next year, the 2010 election campaigns will be in full swing. Fearful of losing, some members of Congress will begin to back away from change, so it is critical that broad reform legislation is passed this year.

Over the next three years, it can be amended as the crucial details are fleshed out. Anyone who thought that Congress would be able to overhaul a $2.6 trillion industry with just one bill was, I submit, terribly naïve.

What Remains To Be Done In the Next Three Years

There is so much to be done to lay the groundwork for a reformed system — this is one reason reform cannot be implemented until 2013:

Congress must figure out how to regulate the private insurance industry. This will require enormous cunning.

Reformers will have to find a way to stiffen the penalties for those who choose not to buy insurance, without alienating young, healthy voters. This is a job for a charismatic president.

Legislators must map out how the Insurance Exchange will work.

They also will need to come up with a formula that will adjust for risk if one plan winds up with a larger share of poor and sick customers. (Some fear that this will happen to the public plan, so this, too, is a crucial detail.)

Finally, and perhaps most importantly, Medicare needs time to begin eliminating waste in the system — saving billions of health care dollars while simultaneously lifting the quality of care. In fact, while all eyes are focused on the legislation, Medicare already has begun putting its own house in order.

What the Current Proposed Public Plan Offers

What many reformers don’t seem to understand is that when the public plan begins to negotiate fees with providers in 2013, Medicare fees for some very expensive services will be significantly lower than they are today, while reimbursements to primary care doctors will be substantially higher.

Medicare already has announced plans to cut fees for CT scans and MRIs by as much as one-third and has proposed trimming fees to cardiologists by 6 percent next year. Meanwhile, it would hike fees for primary care physicians by 4 percent.

Congress has 60 days to respond, or the changes take effect Jan. 1. Over the next three years, we can expect more changes in the fee schedule. And private insurers will follow Medicare’s lead. As their representatives explained to the Medicare Payment Advisory Commission (MedPAC), they just want Medicare’s actions to provide political cover for their own.

In other words, the public plan will be negotiating fees with providers in a very different, less expensive and more rational context.

This is another reason why public-plan premiums will be significantly lower than the CBO’s Elmendorf suggests.

Over the next three years, Medicare will be realigning financial incentives to reward preventive care and management of chronic diseases, while reducing payments for overly aggressive tests and treatments that have no proven benefit — and penalizing hospitals that don’t pay enough attention to medical errors. In the process, Medicare will be conserving health care dollars while protecting patients from needless risks.

As President Barack Obama has promised, Medicare cuts can make health care safer and more affordable for everyone — including the upper middle class. Because most private insurers will mime Medicare’s efforts to reduce overpayment, the cost of care will come down for everyone.

The public health insurance plan will incorporate Medicare’s reforms, and it will have clout. Seven percent of Americans now buy their own insurance in the private sector market. Most are neither poor nor sick. (If they were, they wouldn’t be able to purchase insurance.) More than half earn over $55,000. They will be able to go into the Exchange and sign up for the public plan.

Other middle-class self-employed Americans who cannot afford to buy individual insurance will join them in the Exchange, where they will automatically become part of a group. In addition, a large share of relatively young Americans (age 25-34) are uninsured. Most are relatively healthy. No one knows how many will choose the public plan, but since it will have much lower administrative costs than private-sector plans, it will be less expensive. This should make it attractive to younger Americans.

Finally, even if the Senate’s opt-out provision for states remains in the final health care reform bill, states will not opt out. It would be too difficult for politicians to try to explain to voters why they cannot have access to a government plan that will be able to offer comprehensive insurance for less than what they pay for private insurance.

The Enemy of the Good

If there ever was a time to avoid the traps of perfectionism, it’s now. As the old saying goes, don’t let the perfect be the enemy of the good.

And there’s a lot that’s good in the bills coming out of the House and Senate. No, they’re not perfect, but they offer a path to even better reform in the future while improving the lives and health care outcomes for millions of Americans. And that is all to the good.