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Task Unfinished on Health System

The health care reform bill that passed the Senate on Christmas Eve is a far sight from perfect, as was the House bill that passed previously. Both are weighed down with giveaways and trade-offs, and neither is likely to substantially lower costs for the nation or for individuals. Both would extend coverage to folks who don’t have it now, but the costs almost certainly will be crushing.

The Senate bill, on the whole, is better than the House bill, but that’s not saying much. The Senate legislation provides freedom for states and communities to test various mechanisms for providing health care, an embrace of experiments that may go far toward identifying the best way forward.

The Senate bill abandons the idea of public insurance, unwisely foreclosing one of those ways. A public option remains part of the House bill.

Neither bill seriously tries to shift from a system that pays doctors for services provided to one that pays for how healthy doctors keep you. Neither addresses the malpractice system in any substantive way. Both reforms are necessary to keeping medical costs from spiraling further.

Instead, Capitol Hill in the past few months shifted focus toward providing security — eliminating exclusions for pre-existing conditions, ensuring access to insurance for everyone — and away from making structural changes to America’s medical system.

Without doing both, however, the country is in danger of ending up with an untenable result: a health care system that more quickly bankrupts the nation. Already, medicine consumes 17 percent of the nation’s gross domestic product, a figure rising as medical costs outpace inflation, not to mention wages and production.

The current system itself is the problem.

Insurance adds costly overhead while reimbursing services rather than results, rewarding (or at least not penalizing) defensive health care and demanding that doctors and hospitals make huge investments in bureaucracy and paperwork.

That dysfunctional system won protection in the Senate, which chose to demand that 94 percent of Americans enroll in it. The Senate’s alternatives come in the form of experiments likely to begin in communities all over the nation, and in allowing Americans to buy the same insurance that lawmakers have.

The House plan — which aims to cover 96 percent of Americans — includes national and statewide insurance exchanges. It also includes the possibility of a government-run alternative.

The two diverge on how they’d pay for reform: The House bill would tax people making more than $500,000 for an individual, $1 million for a couple, and by making huge cuts to Medicare and Medicaid. The Senate’s bill would make similar cuts while raising Medicare taxes and charging new taxes on high-end health insurance.

The Senate bill would subsidize insurance for anyone making less than four times the poverty level — now just over $88,000 — and would exact a penalty from employers who don’t offer coverage. Small businesses would get financial assistance. The House bill would severely penalize employers with payrolls higher than $500,000 who don’t offer insurance.

Extending health care coverage to those who can’t afford it, or who don’t have access, is necessary, humane and long overdue. It also would be expensive. Both bills, for example, seem likely to explode Medicaid costs in Virginia, which has notoriously miserly benefits as it is. And neither bill makes any serious effort to change the systems and protocols that have allowed health care costs to rise beyond all reason.

Thankfully, both the House and Senate bills now go to a conference committee tasked with reconciling them. Given how many concessions had to be made to get a measure through the Senate, and how many ornaments were added in the House, both bills are filled with provisions superfluous to the cause of health care reform.

Whether they’re superfluous to the politics of reform is another matter. Democrats will do everything they can to craft a bill that can pass each chamber and make it to the president’s desk over nearly unanimous Republican opposition.

America has never been this close to serious reform of the health care system, even with imperfect measures like these. The nation is unlikely to get this close again for years. The campaigning for and against reform has been so dishonest and noxious, even by the standards of modern politics, no one is likely to revisit the subject anytime soon.

Still, it’s worth the effort to improve these imperfect bills as a way to start to improve our very imperfect health care system.