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Health Care Reform: Sifting Through the Suboptimal Solutions

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If the fight over health care reform has proven anything, it's just how broken our system has become -- from the crippling influence of money on our politics to the way the modern misuse of the filibuster has taken away the power of the duly elected majority and handed it to a handful of bought-and-paid-for senators (yes, I'm talking about you Joe Lieberman).

This disturbing and destructive state of affairs has created a country that is, in the words of Tom Friedman, "only able to produce 'suboptimal' responses to its biggest problems."

And that's where we find ourselves on health care as we head towards the legislative end game. The big optimal solutions have all been gutted -- and we are left to pick through the patchwork of suboptimal ones.

What makes this exercise harder is that the details seem to change form more frequently than the characters in Twilight. At the moment, and while we are waiting for the latest CBO score, "the whole town," as Mike Allen puts it, "is talking about a proposal that few have seen, and none understand."

One by one, Congressional leaders who said they would not support a bill without a public option have come to the conclusion that, on second (or third or fourth) thought, they actually will. Leaving aside what this does to the already tattered trust the public has in their representatives, is a progressively watered-down public option preferable to a Medicare expansion combined with a national non-profit insurance plan similar to the one offered to federal employees, regulated by the Office of Personnel Management?

Bernie Sanders, one of the leading advocates of the public option, is now arguing that these proposals combined "may be stronger than the very weak public options that both the House and the Senate have already passed."

Jacob Hacker, the godfather of the original public option concept, also approves of the proposed expansion of Medicare, calling it an "enormous positive development."

Of course, expanding Medicare by allowing those 55 to 64 to buy into the program won't be subsidized for the first three years and therefore may end up being prohibitively expensive, especially if it ends up being an expansion of Medicare not tied to Medicare rates.

Amidst the tea leaf reading and jockeying for political position (at least among Democrats; Republicans are united in their commitment to kill reform) it's important not to lose track of the things that absolutely have to be included in any health care bill for it to deliver reform in more than name only.

It has to expand access to include as many of the 46 million uninsured Americans as possible. Both the House version and the current incarnation of the Senate bill go a long way to meeting this goal.

It has to create competition and reduce costs. In the end, it doesn't matter if this is accomplished by creating a government-run non-profit insurance provider (the so-called "public option") or by adopting a national privately run system that is heavily regulated by the federal government, and allowing those 55 to 64 the "option" of buying into the Medicare program. It's not the label we give these that matters, it's the end result: competition and cost reduction. The current bill mandates that most Americans get insurance coverage, creating 30 million new customers for the insurance industry. These new customers have to have options -- especially less expensive options -- or this will be a massive windfall for insurance companies.

The best way to provide more choices for consumers is through the latest incarnation of Sen. Ron Wyden's Free Choice Act, which he is offering as an amendment to the health care bill. The provision would give employees the ability to choose their own insurance plans within the insurance exchange -- instead of having to accept the plan chosen by their employer, as is the case in the bill Harry Reid brought to the floor of the Senate.

To qualify as real reform, the bill also needs to give Congress the ability to negotiate with the drug companies over Medicare prescription drug prices. The White House cut a deal with PhRMA taking away this ability to negotiate. That agreement is still part of the Senate bill but not part of the House bill -- and should not survive the conference process.

And, knowing how quickly things can get slipped into bills, or carved out of bills, in the dark of night, we have to ensure that the positive elements of the current bill don't suddenly vanish -- especially the provisions that keep insurance companies from denying people coverage on the basis of pre-existing conditions or dropping customers when they actually become sick.

If the final bill contains all these elements, it will be a suboptimal solution worth supporting.

Then we can move on to the business of fixing our broken system, so we can get back to being a country able to produce optimal responses to our biggest problems.