03/18/2010 05:12 am ET Updated May 25, 2011

What Should Progressives Do?

Not surprisingly, progressives are disappointed at the turn the battle over health care reform has taken. The Senate is considering a bill that is much watered down even from the House-passed bill, which also left a lot to be desired.

While both would add 30 million or more Americans to the roles of the insured, provide subsidies to make coverage affordable for many of them, and prohibit insurers from discriminating against people with pre-existing conditions, they don't do much to keep down the costs of either insurance or medical care.

Some see it as a windfall for private insurers who, not satisfied with the revenues from those 30 million new customers, have lobbied hard to limit their exposure for the cost of care. The result is that, for some plans, the insurer will be on the hook for only 60% of the cost of care, leaving the policyholder responsible for a whopping 40%.

Since those are the only policies many of the new customers will be able to afford, we are in danger of creating a new cohort of underinsured Americans - mandated by the federal government. We already know what will happen to them because many of today's underinsured cannot afford the out-of-pocket costs and decide to forgo services they need. And they are people who, despite their limited incomes, value insurance enough to have purchased it.

So, given this situation, progressives are, not unreasonably, disappointed. Should they, therefore, do as Howard Dean recommends and reject the current bills in the hope of electing more progressives in the midterm elections and starting again? My answer is no, and here is why.

First, having studied the history of past reform attempts for my new book, Still Broken: Understanding the U. S. Health Care System," (due out in the spring), I may be more aware than most of the enormity of the political accomplishment to date. Less than a year into President Obama's term, a bill has already passed the House and there is at least a fair chance that the Senate will pass one, too.

Harry Truman, John Kennedy, and Bill Clinton were not even able to get floor votes on their reform proposals. Only Lyndon Johnson, in the wake of both President Kennedy's assassination and his own landslide victory in 1964, was able to accomplish that. Even with those favorable conditions, however, it took the exercise of his formidable legislative skills for him to induce the Congress to enact Medicare and Medicaid. Not only do those conditions not obtain now, but also the Congress is a vastly different place today. Close may only count in horseshoes, but the events to date argue for trying to get as good a bill as possible, and then, passing it.

Secondly, it is extremely risky to think that the midterm elections will produce a stronger Democratic majority in the Senate than the present one. If it happens, that result will differ from the norm in which the majority party loses seats in midterm elections.

Third, if the Democratic majority does not increase, how soon will another president want to make the effort given how hard it has been to get even this far?

Fourth, we must not ignore the nature of the legislative process in the Senate. Last week, with the Medicare buy-in for 55-year-olds and a weakened public option, the leadership was only 2 votes shy of the 60 - not 51 - needed to pass the bill. Given a process dominated by the threat of a filibuster, those last 2 senators - whoever they are - have enormous influence.

There are at least 2 reasons to work to improve this bill, and then to vote for whatever version is on the table. One is the undeniable good the bill will do. It may not be as much as we would like, but it is real nonetheless. And given the history, it needs to be recognized as a substantial accomplishment.

The second reason is that the new law may change the politics of reform in ways that could make a better bill possible in the future. The key to real reform is finding a way to mobilize public opinion to counter the power of special economic interests as well as the narrow political interests of a Republican opposition determined to kill any reform.

The new law will create a group of 30 million or more who will buy coverage they did not have previously because the law requires them to do so. Then, imagine how they will feel when, having laid out some of their limited funds for insurance premiums, they discover that they must also pay out-of-pocket 40 percent of their medical bills. They will be ripe for organizing by a group which, like AARP does for Medicare beneficiaries, focuses on issues of great concern to them and can bring the influence of those 30 million people to bear until their representatives improve the law.

Add to Medicare beneficiaries and the 30 million newly underinsured the millions of others who fear change today because they are afraid of losing the coverage they have. A much more concerted effort is needed to persuade them that they are operating under an illusion. Even if they expect to retain coverage because they work for a large employer, they need to be reminded of the extent to which that coverage has already been weakened by recent increases in out-of-pocket costs and the imposition of more administrative hurdles before the insurers will pay their doctors for services rendered.

So, we should see this episode as part of a continuing saga, rather than as a process that ends with the President's signature on a new law enacted by this Congress. This is a bill worth supporting. Then, on the day after it passes, begin to organize to make it better.