On their way to Washington last week, Tea Party activists stopped in Lansing, Michigan. And among the officials who addressed them was Mike Cox, the state’s Republican attorney general. Cox recently announced he would be among more than a dozen state officials filing lawsuits challenging the constitutionality of health care reform. And, at the rally, he whipped the conservative crowd into a frenzy: “Can’t you just see them running around (Washington) D.C. saying, ‘So much to spend, so much to spend, so little time to spend it’?”

Most legal experts seem to think the lawsuits won’t succeed. Among other things, it turns out that the U.S. fought a large war, about a hundred and fifty years ago, in order to settle the issue of state nullification. But if the officials filing these suits seem not to understand that history--or at least, not to care about it--their opposition to the Affordable Care Act, like their supporters’, seems genuine. If they had their way, their states really would reject the new health care law.

Imagine for a moment that you work in a hospital emergency room. And just outside the door, a man has collapsed from a heart attack. Inside the facility, literally feet away from where he lies, are the equipment and knowledge to save his life. But this man doesn’t have health insurance.

Would you treat him anyway? Or let him die?

If you think the way the vast majority of Americans do, you’d choose to save the man. Whatever your political attitudes, the thought of withholding life-saving treatment from somebody because of ability to pay seems too cruel.

And that’s fine. I’d make the same decision! But if you believe that, then you should also support what remains one of the most controversial elements of health care reform, even after its enactment. That element is the individual mandate.

An individual mandate is a requirement that everybody carry health insurance. Such requirements are a feature of every universal health care system in the world. And, under the recently passed Patient Protection and Affordable Care Act, they’d be a feature of America’s health care system as well. Starting in 2014, Americans who don’t obtain coverage either through a government program, through an employer-sponsored private policy or through a plan purchased directly through the new insurance exchanges would be subject to financial penalties.

Back in 2007 and early 2008, during the campaign for the Democratic presidential nomination, the mandate became a focus of dispute between the two front-runners, Hillary Clinton and Barack Obama. Clinton supported the mandate while Obama opposed it. But after becoming president and consulting with his advisers over how best to design a plan, Obama changed his mind and indicated he would support the idea.

Obama would end up arguing for the mandate largely on the same grounds that Clinton had: It was necessary, he said, in order for the rest of the insurance system to work. A major goal of health reform is to make sure everybody, even people with pre-existing medical conditions, can get coverage. To accomplish that, you have to require that insurers offer policies to everybody, without discriminating against them based on health status. But imposing such a requirement would allow people to game the system: They could wait until they get sick and then buy coverage. The only way to avoid this problem is to make everybody carry insurance even when they are healthy.

It’s a technical argument more than a moral one. And it happens to be correct. For proof, one need look only at states that have imposed community rating (the requirement that insurers charge the same rates to people in different health conditions) and/or guaranteed issue (the requirement that insurers gives policies even to people with medical problems) without a mandate. The requirements have made coverage more available to people in poor health, but only by raising premiums substantially, as insurers anticipate healthy people will opt out of coverage until they need it.

Still, there are other reasons to support a mandate. One is explicitly about redistribution—from the medically lucky to the medically unlucky. At any one time, only a very small percentage of the population will have major health problems. The rough rule of thumb is that 20 percent of the people are responsible for about 80 percent of the costs in the system. But fortune (and misfortune) plays a huge role in determining who ends up as part of that 20 percent—all it takes is contracting a serious disease, having a debilitating accident or developing an acute condition. Rather than force this unlucky 20 percent to bear the burden of their medical expenses alone, you can ask everybody else—the people lucky enough to be in good health—to help shoulder that burden.

When you phrase it that way, the argument for a mandate sounds awfully liberal. But there is a third argument for the mandate—related, but from a different philosophical point of view. That’s where the dying man outside the emergency room comes in.

The fact is that, even before the Affordable Care Act passed, the U.S. guaranteed health care in life-threatening situations. Under the Emergency Medical Treatment and Active Labor Act, which the Democratic Congress passed and President Ronald Reagan signed in 1986, providers of medical care must give stabilizing care to people who need it, regardless of ability to pay.

The law is hardly a substitute for universal coverage: It doesn’t require that providers offer preventive or follow-up treatment and it allows them to collect huge bills afterwards. But, in practice, many doctors and hospitals will end up providing quite a lot of charity care. And while they can pay for at least some of that out of their own revenues, they inevitably pass a portion of those bills onto everybody else, in the form of higher insurance premiums and higher taxes.

But some uninsured people who end up getting charity care could afford to pay for insurance premiums—or, at least, pay some portion of them. It might not be enough to offset the entire cost, but it’d be enough that they were making a reasonable contribution to the cost of their own care. And there’s no reason they shouldn’t. As one mandate supporter explained a few years ago, “for people who can afford to buy insurance, it's time for them to step up to the plate and buy that insurance.”

Does that sound like a conservative argument? That’s because it is. The quote is from a Fox News interview with former Massachusetts Governor Mitt Romney, in 2006, not long after he signed into law that state’s universal coverage scheme. Romney, of course, is a Republican. The Massachusetts system closely resembles the one the U.S. will get under the Affordable Care Act, complete with an individual mandate.

Today, Romney denounces the Affordable Care Act as an unconscionable government takeover of health care. And he is just one of many conservatives who supported the individual mandate before it became part of “Obamacare.” But don’t be fooled. If Romney and fellow Republicans weren’t so determined to tarnish the Affordable Care Act politically, they’d acknowledge what they said before: The individual mandate makes perfect sense.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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“There’s no fixing the government health care takeover Democrats forced through on Sunday. It must be repealed.”

So said Jim DeMint, the Republican senator and presidential hopeful, speaking one day after health care reform passed the House of Representatives, clearing the final legislative hurdle to enactment. And it’s a sentiment you hear a lot on the right these days. Over the last week or so, as passage seemed ever more likely, Republicans moved from denial to anger: If they couldn’t stop this bill from becoming a law, they would stop the law from taking effect.

A historical precedent for repeal exists. In 1988, President Ronald Reagan and the Democratic Congress passed the Medicare Catastrophic Coverage Act. The bill promised to fill in some key gaps in Medicare coverage, chief among them an overall limit on benefits and a lack of prescription drug coverage. But the bill proved unpopular. Only a tiny fraction of seniors ever experienced catastrophic expenses that surpassed the Medicare limits; the drug benefit, although helpful, didn’t start right away. To pay for the benefit, the act raised taxes on wealthy seniors. Conservatives attacked that future mercilessly, implying (wrongly) that many more seniors would end up paying the tax. The public turned sharply against the act and, within a year, Congress had repealed it by an overwhelming margin.

Democrats complacent about their victory this week should remember that example and remember it well. But they should also take comfort in the fact that the situation is different in several key respects. Although most of health care reform’s benefits won’t begin until many years from now, the architects of the bill understood what happened with Medicare Catastrophic. That is why they front-loaded the bill with a handful of tangible benefits. Seniors will get additional assistance buying drugs, young adults under 26 will get to stay on their parents’ policies, the government will prohibit annual and lifetime limits on benefits and insurers will be prohibited from rescinding policies without good cause--all within the first year.

The politics have changed too. Precisely because Medicare Catastrophic was a bipartisan act, passed by a Democratic Congress and signed by a Republican president, neither party really took political ownership of it. Neither Reagan nor congressional Democrats had made it a defining issue of their previous campaigns and after enactment, neither was going to expend huge political resources defending it.

The situation today could not be more different. President Barack Obama and his allies made health care reform a centerpiece of the 2008 campaign. And over the last year, they’ve made it the signature cause of Obama’s first term. Their political survival depended on its passage and, now, their political survival depends on its implementation. In short, they are going to keep fighting for it.

Of course, the prospect of yet more fighting over health care won’t excite most Americans, who at this point just want to move on to other matters. (Heck, even some of those who write about health care for a living are eager for something new.) But there’s nothing wrong with fighting about--or, at least, debating about--health care. It’s an argument about how we, as a nation, want to set priorities. It’s a discussion we’ve been having for decades--over everything from Medicare spending to insurance regulation--and it’s a discussion we were bound to keep having, no matter what happened to reform.

What’s changing this week, with the enactment of the Democrats’ bill, is the boundaries of that discussion. All societies have to make decisions about how to allocate resources. Broadly speaking, there are two ways to make those decisions. A society can make those decisions collectively, through government, by imposing regulations and spending taxpayer dollars. And a society can make those decisions individually, through the market, by simply allowing individuals to spend money according to his own preferences and means.

It’s not a stark, either/or choice. Instead, each nation finds its own middle ground between the two extremes. And, historically, the U.S. middle ground has been closer to the market side. Unlike in the rest of the developed world, government didn’t guarantee access to coverage, although it subsidized it for some people who couldn’t afford it. Government didn’t set overall budgets for health care spending, although it would limit the money its own programs spent for treatment.

For a long time, Americans were comfortable with that approach. But, over time, it caused more and more people to struggle. Millions had no health insurance; millions more had either insurance that was too expensive or insurance that didn’t cover enough.

Health care reform promises to shift the middle ground between government and market, modestly, but in a way that will have far-reaching effects. Now government will guarantee that all (or most) people have the ability to get insurance that will actually meet their needs. It won’t do so by taking over the insurance business--even if, truthfully, that’s what some of us would prefer. Instead, it will do so by setting rules for how the insurance industry behaves. And it won’t make insurance free for all people. But it will provide financial assistance, enough so that people of limited means won’t have the same high exposure to medical costs they do now.

Minutes after the House finished passing health care reform, Obama described the bill as a major, but not a radical, reform. That about sums it up. It will change the way people live far more than it will change the principles by which we govern.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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When Alma Dickson slipped on an icy sidewalk in Dallas, Texas, she knew she was hurt. But she wasn’t sure that she could pay for the medical care she needed. The year was 1929 and Dickson, a schoolteacher, didn’t make enough money to pay for x-rays and treatment on her own. But Dickson had recently signed up for something new: A plan under which she paid a monthly premium in exchange for a promise of care at a local Dallas hospital. Dickson went, had her broken ankle set, and left without paying a penny.

February 26, 2010

President Barack Obama

Senator Harry Reid Majority Leader

Senator Max Baucus, Chairman, Committee on Finance Senator

Tom Harkin Chairman, Committee on Health Education Labor and Pensions

Congresswoman Nancy Pelosi Speaker of the House of Representatives Congressman

Charles Rangel Committee on Ways & Means

Congressman Henry A. Waxman Committee on Energy and Commerce

Congressman George Miller Committee on Education and Labor

Dear Mr. President, Congressmen and Congresswomen

Our health care system is in crisis. America has higher per-capita medical spending than any other industrial democracy, Health care spending continues to increase, and is projected to reach $3.3 trillion by 2019. Health insurance premiums are rising rapidly, particularly within individual and small group markets. Meanwhile, the financial security traditionally offered by health insurance continues to erode, with rapid increases in out-of-pocket spending. Rising public health care program costs are driving large, ultimately unsustainable state and federal budget deficits. It is likely that more than 50 million Americans are now uninsured, with more losing coverage every day due to the twin challenges of deep recession and rising health care costs. Although this country has some of the best medical technology in the world, the quality and effectiveness of medical care often falls short of what every American deserves.

This week, the President put forth a proposal for finishing the job of enacting comprehensive health care reform with which Congress has struggled for the past year. Yesterday the President, House, and Senate leaders from parties spent much of the day in a nationally televised health care summit. This meeting identified areas of bipartisan agreement—many of which are already included in pending legislation. It also identified areas where future bipartisan agreement might be possible, such as malpractice reform. Yet the meeting also underscored the profound differences that separate the leadership of the two parties. Most notably, the President's proposal would cover 30 million people who would otherwise remain uninsured. The Congressional Budget office reports that Republican proposals would only expand coverage to 3 million.

We commend the President’s pursuit of bipartisan solutions. Yet the summit made plain that it is now time to move decisively and quickly to enact comprehensive reform. We believe that the only workable process at this point is to use the President's proposal to finish the job. After long debate, the House and Senate have passed two similar bills that do crucial things to improve US health care. All that needs to happen, if Republicans insist on blocking final improvements, is for the House and Senate to make the required adjustments and to pass these bills by majority vote in both houses. Given the likelihood of a filibuster, this legislation will likely require the majority-vote reconciliation process. Reconciliation has been used by both Democrats and Republicans to enact welfare reform, Reagan and Bush-era tax cuts, the state children's health insurance programs (SCHIP), and other key legislation. Reconciliation is an appropriate and justified mechanism to secure an up-or-down vote on this critical bill.

The President's proposal incorporates many of the best ideas proposed by Democrats and Republicans, patients, clinicians, and researchers. It combines and strengthens many elements of the House and Senate bills and repairs their deficits. It offers a strong foundation for comprehensive reform. Fully implemented, the President's proposal would:

• Cover more than 30 million people who would otherwise go uninsured.
• Provide financial help to make coverage affordable for millions of working families.
• Strengthen competition and oversight of private insurance through insurance exchanges and increased regulation of private insurers and their rates
• Provide unprecedented protection for Americans living with chronic illnesses and disabilities
• Make significant investments in community health centers, prevention, and wellness.
• Increase financial support to states to finance expanded Medicaid insurance coverage
• Eliminate the Medicare prescription drug "donut hole"
• Eliminate objectionable provisions such as special funds for Nebraska's Medicaid program
• Reduce the federal budget deficit over the next ten years and beyond.
• Provide a platform to improve the quality and economy of the health care system and to slow future growth of health expenditures.

We, the signatories of this letter, come from different perspectives. Some of us are long-standing advocates of progressive causes. Some of us are nonpartisan or identify as political moderates. From these differing perspectives, we agree on one thing: After months of extensive debate, expert analysis, and the historic passage of House and Senate bills, it is time to pass a final bill. The President's proposal provides a foundation for finishing this work -- and for future steps to build on this foundation..

It may be possible, as the President suggested, to incorporate proposals put forth by the Republican leadership. This proposal already incorporates many traditional Republican ideas for health reform, such as tax credits to help middle-income Americans pay for health care, organizing markets through health insurance exchanges, and creating a regulatory structure that allows insurers to sell coverage across state lines.

Time is short, however. If Republican leaders do not promptly offer constructive proposals in the context of comprehensive legislation that has already passed both the Senate and the House, Congress must move forward. It is time to act.

Sincerely,

Henry Aaron, Brookings Institution
Emily Abel, UCLA
Ronald Andersen, UCLA
Dean Baker, Center for Economic and Policy Research
Ronald Bayer, Columbia
Linda Bergthold, Independent Consultant and Health Policy Researcher
Linda Blumberg, Urban Institute
Peter Bourne, Health Policy Advisor, President Jimmy Carter
Richard Brown, UCLA
Anna Burger, Secretary-Treasurers, SEIU
Deborah Burnett, University of Chicago
Paul Cleary, Yale University
David Cutler, Harvard University
Stephen Davidson, Boston University
Linda Degutis, Yale University
Judith Feder, Georgetown University
Eric Feldman, University of Pennsylvania
Brian Flay, Oregon State University
Lawrence Gostin, Georgetown University
David Grande, University of Pennsylvania
Tim Greaney, Saint Louis University
Colleen Grogan, University of Chicago
Jonathan Gruber, MIT
Jacob Hacker, Yale University
Mark Hall, Wake Forest University
Helen Halpin, University of California, Berkeley
Bradley Herring, Johns Hopkins University
Diana W. Hilberman, UCLA
Jim House, University of Michigan
Jill Horwitz, University of Michigan
William Hsiao, Harvard University
John Jacobi, Seton Hall University
Peter Jacobson, University of Michigan
Timothy Jost, Washington and Lee University
Daniel Kahneman, Princeton University
Rosalie A. Kane, University of Minnesota
George Kaplan, University of Michigan
Jerome Karabel, University of California, Berkeley
Eleanor Kinney, Indiana University-Indianapolis
Mark Kleiman, UCLA
Gerald Kominski, UCLA
Karl Kronebusch, Baruch College, City University of New York
Paula Lantz, University of Michigan
Miriam Laugesen, Columbia University
Robert Leflar, University of Arkansas
Arleen A. Leibowitz. UCLA
Carol Mangione, UCLA
Willard Manning, University of Chicago
Wendy Mariner, Boston University
Ted Marmor, Boston University
Jerry Mashaw, Yale University
Timothy McBride, Washington University
Michael Millenson, Northwestern
Farideh Motamedi, USC
Fitzhugh Mullan, George Washington University
Jack Needleman, UCLA
Len Nichols, George Mason University
Jonathan Oberlander, University of North Carolina
Gilbert Omenn, University of Michigan
Alexander Ortega, UCLA
David Orentlicher, Indiana University-, Indianapolis
Kevin Outterson, Boston University
Frank A. Pasquale, Seton Hall University
Mark Peterson, UCLA
Phillip Pizzo, Stanford University
Harold Pollack, University of Chicago
Daniel Polsky, University of Pennsylvania
Ninez Ponce, UCLA
Marc Rodwin, Suffolk University
Victor Rodwin, New York University
Sara Rosenbaum, George Washington University
Meredith Rosenthal, Harvard University
Lainie Friedman Ross, University of Chicago
William Sage, University of Texas
Jim Scott,, George Washington University School of Medicine and Health
Sciences
Mark Schlesinger, Yale University
Steven Shortell, University of California, Berkeley
Theda Skocpol, Harvard University
Barbara Starfield, Johns Hopkins University
Paul Starr, Princeton University
Rosemary Stevens, Cornell University
Katherine Swartz, Harvard University
Donald H. Taylor, Jr., Duke University
William Terry, Brigham and Women's Hospital
James Toole, MBA Actuaries
James Tulsky, Duke University
Alexander Wagenaar, University of Florida
Rachel Werner, University of Pennsylvania
Celia Wcislo, SEIU
Joe White, Case Western University
Elizabeth Yano, UCLA
Fred Zimmerman, UCLA

(Titles and degrees omitted.  Institutional affiliations for identification
only)

The Obamas are worried about their daughters getting fat. In November 2008, Barack got a promotion and mentioned to the media that, a couple years earlier, he was concerned that Malia had become “a little chubby.” A later visit to a pediatrician convinced Michelle that both Malia and her  sister Sasha needed to slim down.

She banned the girls from watching television on weekdays, put them on low-fat milk, replaced sugary drinks with water, largely eliminated hamburgers from their diet, and monitored portion sizes at meals carefully. The next time she took them to the doctor, she reports, he was amazed. “What on Earth are you doing?” he asked.

It’s a good question.

What Michelle Obama is doing this week is launching the next big government “war” on a supposed social crisis. On Tuesday, President Obama signed an executive order directing government agencies to work with private industry to combat “childhood obesity.” The First Lady took to the airwaves, issuing dire warnings that one third of America’s children are dangerously fat, while launching a website which makes the alarming claim that, “for the first time in our history, American children may face a shorter expected lifespan than their parents.” The goal of the campaign, Mrs. Obama emphasized, is to “eliminate this problem of childhood obesity in a generation.”

All this is dangerous nonsense. Let’s start with the Obamas’ goal of trying to produce an America with no fat kids. Consider what we even determine to be “fat.” In recent years, government panels decided to define “overweight” and “obesity” as the 85th and 95th percentiles of body mass on the height-weight growth charts for children. According to someone heavily involved in the process, they did this quite arbitrarily, without any evidentiary justification, other than a vague sense that increasing weight among children was a problem that required some definitional markers.

Now, the statistically curious might wonder how, given this definition, it’s possible for one-third of America’s children to be too fat. The answer is that federal public health agencies have decided to use data from the 1960s and 1970s to define the 85th and 95th percentiles. In other words, when Michelle Obama claims a third of our children are too fat, what she’s really saying is that what was the 85th percentile on the height-weight charts 40 years ago  is about the 67th percentile today.

Is this a problem? Some might note that, by every objective measure, including life expectancy, and rates of chronic disease and disability, American children, like American adults, are both bigger and healthier now than they were a generation ago. (Despite claims to the contrary, Type II diabetes among children remains quite rare.) Obesity panic-mongers reply that, although the health of our children is admittedly better than ever, this trend is going to be reversed by a growing epidemic of fatness (hence claims about a generation of children that will not live as long as their parents).

In fact, a new comprehensive meta-analysis of data from more than a dozen countries, including the U.S., reveals that, for a decade now, obesity rates all over the world among both adults and children have been largely flat or actually declining. The study points out that alarmist claims from public health officials about an “obesity epidemic” are all explicitly based on the mistaken assumption that obesity rates are continuing to rise.

In particular, the claim that life expectancy in America is going to decline is unsupported by any demographic or epidemiological evidence. (This widely repeated claim can be traced to some data-free musings in a New England Journal of Medicine article five years ago, from which the authors subsequently backed away.)

The choice of weaponry in this unnecessary war is also unfortunate. The Obamas want to improve the nutritional value of school meals, help children become more active by making urban areas amenable to physical activity, improve labeling on food products, and decrease the number of “food deserts”–areas where it’s difficult and expensive for people to buy fresh fruits and vegetables.

These are all laudable goals in and of themselves, but it’s a terrible mistake to pursue them  in the name of getting rid of fat kids. First, numerous studies indicate that, just as with adults, improving children’s nutrition and activity levels is beneficial to their health, but usually produces little or no weight loss (which is all the more reason to focus on health rather than weight). Nor are thin children in any less need of good food and healthy activities than fat ones. Indeed, over the past 20 years, extensive research has demonstrated that, when studies control for factors such as physical activity levels, weight simply ceases to have any meaningful correlation with health.

Second, a rich literature on stigmatization shows that the health costs of social stigma are high. I don’t believe Michelle Obama wants to stigmatize fat kids, but a campaign dedicated to eliminating them is guaranteed to do so in a profound way.

On that same theme, one wonders if the First Lady has considered that putting her pre-teen daughters on diets is far more likely to make them eating disordered rather than permanently thin. (If the kind of obsessive monitoring of food and activity choices Obama recommends to parents actually “worked,” there would be almost no fat kids in America today, at least in the middle and upper class families where Obama’s anxieties about her daughters’ weight are all too common). And does she really think it’s a good idea for her husband to make negative comments about his daughter’s body to the nation’s media?

Everyone should support reasonable attempts to make it easier for all children to enjoy a healthy balance of foods and the pleasures and benefits of physical activity. Trying to do so by stigmatizing the bodies of one out of every three American kids is a horrible idea.

Paul Campos is a professor of law at the University of Colorado. He is the author of The Obesity Myth. 

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The idea that Republicans haven’t had a chance to present their ideas on health care reform is a bit mind-boggling. Five separate congressional committees had hearings; each chamber had floor debates. That’s hundreds of hours the GOP had to talk about health care, all of it in public view and televised on C-SPAN. And that’s not even including all of the unofficial channels at the Republicans’ disposal. Generally speaking, the party of Rush Limbaugh and Fox Television doesn’t struggle to get across its message.

But if President Obama is determined to give Republicans one more public forum for presenting their health care agenda, as he will do when he meets with GOP leaders on Feb. 25, maybe that is just as well. For most of last year, Republicans spent their time attacking Democratic plans for reform, rather than describing their own. But now they’ve put a plan on the table. Showcasing that plan--and comparing it to what the Democrats have proposed--might help clarify a few things.

The Republican health care plan is part of the "Roadmap for America's Future." Its chief architect is Paul Ryan, ranking Republican on the House Budget Committee and a rising star in the party. Republicans boast that the Roadmap is serious plan to get the federal budget under control, which turns out to be a fairly large exaggeration. As Howard Gleckman of the Tax Policy Center has observed, the Roadmap doesn't account for trillions of dollars in lost revenue from its tax cuts. Yes, that's trillions with a "t" at the front and "s" at the back.

The health care portions of the plan, though, really would reduce what the government spends on health care. And they would do so, primarily, by extracting money from Medicare. Instead of continuing to provide coverage directly, the government would issue vouchers that seniors could use to buy private insurance. The value of the vouchers would rise far more slowly than Medicare spending is expected to grow if nothing changes.

According to the Congressional Budget Office, Medicare will soak up more than 14 percent of gross domestic product by 2080. If the Roadmap were to be adopted, CBO says Medicare would take up less than 4 percent. As Ryan explained during an illuminating interview with the Washington Post’s Ezra Klein, the hope is that converting Medicare into a voucher scheme would prod seniors to shop around to find the best value--that is, the best insurance policies, the best hospitals, the best doctors--and, in so doing, get health care that is as good if not better than they would have otherwise.

That all sounds perfectly innocuous: Who wouldn’t want seniors taking the initiative and hunting around for the best bargains? But it’s not clear how many seniors really have the ability to navigate the world of health care with the sort of sophistication to really hunt down the most cost-effective care, even if, as Ryan promises, they’d have more information at their disposal. At the very least, you'd want to give seniors ironclad protections when it comes to the design of insurance products--making sure a wide array of services were covered and that out-of-pocket spending were limited.

The Roadmap includes only vague protections along those lines. Combine that with the magnitude of the spending reductions--those cuts are very big--and it's easy to envision a world where seniors simply couldn't afford their medical care. As a preliminary (and still unpublished) analysis of the Roadmap by the liberal Center on Budget and Policy Priorities concluded, “elderly and disabled people with significant medical conditions could encounter serious difficulty securing adequate coverage.”

But wait a minute--don’t the Democratic reform plans also take money out of Medicare? They sure do. But there are several key differences. For starters, the Democrats’ reductions don't appear to be as large as what’s envisioned in the Roadmap. Also, under the Democratic plan, most seniors would still be getting their coverage directly from the government, which has lower overhead than private sector insurers. So every dollar the Democrats spend on seniors would actually go a little further.

No less important, the Democratic plans wouldn't simply slash spending and let the market sort itself out. Instead, the Medicare cuts are part of a broader package of reforms designed to change the way Medicare pays for services. These reforms are designed to reward efficiency (by, for example, paying more to doctors that join integrated group practices) while penalizing inefficiency (by, for example, paying less to hospitals with high rates of infection or, eventually, paying less money for drugs that don’t work that well). They are also designed, quite frankly, to push down the prices that providers charge.

This is a critical difference. If you simply reduce the money flowing into Medicare, relying only on the wits of beneficiaries to figure out how best to spend what’s left, seniors are bound to end up with less care. That's the Republican method. But if you also introduce system-wide changes that reward more efficient care and force down provider prices, the dollars in the program really might go farther--so that spending less doesn't always mean getting less. That's the Democratic approach.

"The slowdown in the Reid [Senate] bill is predicated on specific policies which, according to MedPAC and others, shouldn't reduce beneficiaries' access to care," says Paul Van de Water, a senior fellow at the Center on Budget. "The Ryan bill just gives every beneficiary a voucher and makes them fend for themselves in a poorly regulated private market."

The irony is that, for much of the last year, Republicans have been scaring the bejeezus out of seniors by telling them that Democrats were out to destroy Medicare. But the Roadmap makes clear that it’s not Democrats who seek massive, disruptive changes to the program. It’s the Republicans. If the coming engagement between the Republicans and President Obama help the public to understand that reality, extending the debate might actually be worth it.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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Critics of health care reform have been hammering away at its substance for months. But, since last week's election in Massachusetts, they’ve been focusing their attacks more on the way reform has come together in Congress. As the argument goes, Democrats wrote the bill on their own and in secret, producing proposals full of shady back-room deals that aren’t in the public interest. The symbol of reform’s hidden corruption is the so-called Cornhusker swindle: A promise, extracted by Nebraska Sen. Ben Nelson, that the federal government would pay the entire cost of expanding Medicaid in his state.

You can’t really defend the deal on the merits. No other state got the special treatment that Nebraska did. But if you stop and think about why Democratic leaders cut that deal, you’ll realize just how wrong-headed the broader critique of the process is. If Democrats hadn’t been so determined to reach out to Republicans--and worked so hard for an agreement that didn’t seem overly partisan--they wouldn’t have made the Nebraska bargain, or many others, in the first place.

Remember how we got to this point--and how far President Barack Obama and the Democrats have gone to accommodate Republicans and the conservatives they represent. The plan Obama outlined on the campaign trail, the one Democratic congressional leaders endorsed, called for making sure nearly every American had insurance. But accomplishing that would have cost well over $1 trillion over 10 years and, by some estimates, closer to $2 trillion. That was more than conservatives could stomach. To get the price tag down below $1 trillion, they settled on a plan that covered far fewer people.

The original Obama and congressional plans all called for creating a public insurance option, into which people could enroll voluntarily. But that proposal, too, ran afoul of more conservative sensibilities--and was summarily dropped. (The House ended up including a public plan as part of its bill, but House leaders signaled long ago their readiness to drop it in order to reach a compromise with the Senate.)

These moves didn’t make health care reform more popular. If anything, they had the opposite effect. A plan that spent more money would have required finding more offsetting revenue or savings. But it also would have provided clearer, quicker benefits for middle-class people--many of whom now fear the bill does too little to improve their lives. As for the public plan, poll after poll has shown that it is popular. And the really crazy thing is that the Democrats might have been able to keep both features--with, at most, minimal compromises--if only they’d been willing to go it alone, the way the critics insist they did.

Under Senate procedures, the Democrats had the option of passing health care reform, or at least many of its elements, through what’s called the reconciliation process. In reconciliation, a simple majority of senators can pass a bill, without the threat of a filibuster. Rules limit what can and can’t be considered during the process, so it has definite drawbacks. But if Democratic congressional leaders were determined to pass something on their own--the way, say, Republican congressional leaders were frequently during the Bush years--they could have gotten much and maybe most of what they wanted.

But they didn’t--in no small part because they didn’t want to act in such a blatantly partisan way. Whether that was a matter of principle (i.e, they really believed bipartisanship is important) or a matter of perception (i.e., they thought voters would get mad), it ended up constraining them all year long. Instead of wrapping up negotiations and passing bills before the summer was over, the process dragged into the fall and winter. Over and over again, Democratic leaders (particularly Senate Finance Chairman Max Baucus) reached out to Republicans, only to be rebuffed. When that didn’t work, they were left trying to deal with the most conservative members of their own caucus--culminating in the negotiations with Nelson and the promise to cover his state’s Medicaid expansion. If Senate Democrats hadn’t needed Nelson’s vote to break the expected Republican filibuster--if they could have passed health reform with a “mere” 59-vote majority--they could have told Nelson to take a proverbial hike.

The same, by the way, goes for all of the other back-room deals made to pass this bill. If Obama and his supporters had a greater margin for error--if they could have passed health care reform with a simple majority of votes, instead of the 60-vote supermajority forced by the threat of Republican filibusters--they wouldn’t have had to make so many concessions to special interests that wield influence over the Congress.

But every special interest knew that the Democrats had a razor-thin margin for success--and that gave them maximum leverage. They understood early on that, by trying in good faith to reach deals with Republicans and conservatives, Democrats were falling into a trap--the one that’s ensnaring them now.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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When the Democrats announced that they would be forgoing conference committee proceedings and negotiating a final health care reform bill informally, critics pounced on President Barack Obama for violating his promise of greater transparency in government. And I, for one, had no great urge to defend him.

As a presidential candidate, Obama had not merely promised to introduce more transparency to government. He had very specifically, and very repeatedly, promised to conduct deliberations over health care “in front of the cameras on C-SPAN.” Although I never took the pledge literally--clearly, you can’t negotiate an entire bill in public view--plenty of voters did. Now Obama was paying a political price for the boast. I figured it was punishment for rhetorical hubris.

But then, on Wednesday, a press release from the Republican National Committee came across my desk. It contained a statement by Rep. Tom Price, Ga., chairman of the Republican Study Committee. “If the Democrats aren’t engaging in more nefarious backroom deal-making, why do they refuse to pull back the curtains and let the public see what’s going on?” Price said. “What are they doing that they don’t want us to see?”

To call that statement priceless is not just a bad pun. It’s a gross understatement. As you may recall, the previous administration--that is, the very Republican George W. Bush administration--had its own problems with transparency. Perhaps most famously, Vice President Richard Cheney convened a task force to help the administration design energy policy. People were naturally curious about what this task force was doing, particularly given the administration’s close ties to the petroleum industry, but Cheney wouldn’t even reveal who was on the task force, let alone open its proceedings to the public.

If Republican leadership was in high dudgeon then, I must have missed it.

The energy task force episode was emblematic of the Bush administration’s approach to transparency. And that approach has changed pretty radically in the last year. According to Ellen Miller, president of the Sunlight Foundation, the Obama administration has made “enormous strides” towards open government. The record is “not perfect,” she says, but “no White House has been more open.”

One sign of this progress is the decision to make public the names of all visitors to the White House. Want to know how frequently Billy Tauzin, the former congressman who now lobbies for the drug industry, visited 1600 Pennsylvania Avenue? You can look it up at www.whitehouse.gov. There’s even a handy search tool.

Of course, if you do that search, you’ll see that Tauzin visited the White House 11 times last year--which is not unrelated to the fact that his organization, the Pharmaceutical Research and Manufacturers of America, struck a deal with the administration over health care reform. In a nutshell, PhRMA agreed not to fight reform and the administration, with Senate Finance Chairman Max Baucus, D-Mont., as a partner, agreed it wouldn’t seek changes that reduced drug industry revenues by more than $80 billion. While the existence of a deal was no secret--the administration itself announced it, as a sign of legislative progress--the details only came to light later on, in reports that appeared in the New York Times and Huffington Post. Those details suggest the industry will make out rather well.

Still, everything is relative. The health care industry seemed to have even more influence in 2003, when the Bush administration worked with the Republican congress to create a drug benefit for Medicare. The role of lobbyists in that episode was so obvious and the resulting giveaways to industry so egregious that it disgusted even some Republicans--like Rep. Walter Jones, R-N.C., who told “60 Minutes” that “the pharmaceutical lobbyists wrote this bill."

Nor did the Bush administration and its allies seem particularly concerned with transparency during that fight. On the contrary, when the chief actuary for Medicare concluded that the drug plan would cost more than its proponents were predicting, an administration official ordered the actuary to say nothing--to the point where the actuary believed his job was in jeopardy. That same actuary, Richard Foster, has spent much of the last year issuing (somewhat) critical projections about Obama’s reforms. But neither the president nor his allies have tried to squelch Foster. Instead, they’ve been content to argue their case, in public, on the merits.

One more fact to consider is that Obama and his supporters are pushing reforms that will, on their own, advance the cause of transparency--not transparency in government, mind you, but transparency in health care. When insurance carriers make decisions about what services or treatments to cover, they often do so in secret--and leave beneficiaries no legal recourse for challenging those decisions. Reform would create a standard set of benefits, to be determined by democratically accountable officials, that all insurers must cover. It would also create binding legal processes, through which patients could challenge decisions they thought were unfair.

Could Obama be doing more to bring health care--and its policy work--out into the open? Without a question. But he could also be doing a lot less. That's worth something.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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Over the next few weeks, as the House and Senate forge a compromise between their respective health care reform bills, most of the attention will be on the high-profile issues like abortion and taxes. But there are myriad other issues that, although less visible to the public, could go a long way towards determining the success of health care reform--and the health care system more generally. High on this list is the seemingly technical question of what Medicaid pays primary care physicians.

To understand why this issue is so important, you first need to know a little about Medicaid’s history. The program was created in 1965, as part of the same law that created Medicare, but it evolved very differently. Medicare grew out of an intense, highly public debate that stretched back to Harry Truman’s efforts at national health insurance more than a decade before. Its creation reflected an emerging national consensus that government, and society as a whole, had an obligation to make sure every person over 65 had health insurance.

Medicaid had no such consensus behind it. Nobody had gone around the country promising to create a huge new program to cover low-income Americans exclusively, even though that’s precisely what Medicaid was. That left the program at the mercy of a political undertow that would grow over the years.

State and federal lawmakers were constantly seeking to expand the program’s reach, since more and more Americans were losing their private coverage and in need of a public alternative. But finding the money to pay for these expansions was an ongoing struggle, since its constituency--low-income Americans--didn't have much in the way of political clout.

As a result, Medicaid became gradually more underfunded over the years. And that showed up in what the program paid doctors. Today, for example, Medicaid pays primary care doctors, on average, 66 percent of what Medicare does, according to a 2009 Urban Institute study. (It’s an average because each state sets its own rates.) That’s particularly worrisome when you consider that Medicare itself pays less than private insurance.

This isn’t just a problem for doctors. It’s also a problem for patients, since doctors inevitably respond to the low Medicaid payments by seeing fewer Medicaid patients. The great irony of Medicaid is that while its beneficiaries have a more generous set of benefits than most people with private insurance, they often have a harder time taking advantage of them because fewer doctors will see them.

When lawmakers in the House sat down to write a health reform bill this year, they understood this--and decided to do something about it. Their bill decrees that Medicaid pay primary care doctors the same rates that Medicare will. Experts hailed the move, not only because it would help low-income Americans get access to care but also because it’d give an extra financial boost to primary care physicians, who desperately need it. (The relatively low pay for primary care docs is widely considered the major reason the U.S. has a shortage of them right now.)

But, as you might expect, this sort of change doesn’t come cheaply. The Congressional Budget Office estimated that the increase in Medicaid payments would cost around $57 billion over the next ten years. And, as you also might expect--at least if you’ve been following the ups and downs of the legislative process--that was $57 billion the Senate decided not to spend, in order to reduce the overall outlays of the bill.

In an ideal world, the House version would simply prevail in negotiations. But this is not an ideal world. It’s a world in which the Senate holds more political leverage--and the decisive votes, like those from Joe Lieberman and Ben Nelson, seem contingent on keeping the bill’s price tag more or less as it was when it passed the Senate. To the extent House negotiators can pry more money out of their Senate colleagues, they have other priorities to consider--like strengthening the protection against out-of-pocket costs or moving the startup date from 2014 to 2013.

Still, higher Medicaid reimbursements ought to be the sort of change that the Liebermans and Nelsons of the world support, at least in theory. Remember, they opposed creating a stand-alone public insurance option for non-elderly Americans precisely because they feared it wouldn’t pay providers well enough. Increasing the reimbursements in an existing public insurance program that already underpays doctors and hospitals would seem like a no-brainer--which, as it happens, it is, for a great many reasons.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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Health care reform looks like it’s finally ready to pass the Senate, now that the Democrats have 60 votes in hand. But here on the left, not all of us are jumping for joy. Some think the Senate bill is just barely better than nothing. Others think it’s worse than even that.

As this argument goes, health care reform won’t do all that much to help people who need it. Insurance will still be expensive and even people who have coverage will discover they owe significant out-of-pocket expenses once they get sick. A public insurance option might have made this tolerable, since it would have provided better, cheaper coverage. Without it, many of us are arguing, reform is just a big giveaway to the insurance industry--one that produces little social progress.

It’s certainly true that, under the terms of the Senate bill, insurance would cost more and cover less than many of us would prefer. But would it really produce little social progress? Is it really worse than nothing?

One way to answer this question is by comparing how a typical family would fare with reform and without. At my request, MIT economist Jonathan Gruber produced a set of figures, based on official Congressional Budget Office estimates. (Click here for a closer look at the impact reform would have, in dollar terms, on families of different incomes.)  The results tell a pretty compelling story, particularly when put in human terms.

(click to enlarge)

Let’s imagine it’s 2016 and you are an administrative assistant, a garage mechanic or perhaps trying your hand at consulting for the first time. You’re married, just turned 40 and have two kids to feed on a household income of around $50,000. You want to buy health insurance, but can’t get it through an employer. How much will it cost? And how much--or how little--protection will it provide?

If reform doesn’t pass, according to Gruber’s figures, the average premium for the non-group market--that is, the market for people buying coverage on their own--will be around $12,000 a year. Right off the bat, you’re spending a fifth of your income on health insurance.

But what does it cover? Policies in the non-group market are notoriously spotty and unreliable. And benefit requirements vary enormously depending on the state. Many allow considerable, sometimes unlimited, out-of-pocket expenses. For the sake of comparison, though, let’s assume you have a policy with a deductible no higher than that allowed for a Health Savings Account. According to Gruber’s projections, that would mean you’re on the hook for--wait for it--another $12,000, plus a few hundred in change.

Put it altogether and that’s a total liability of around nearly $25,000--about half of your income.

That may actually be a best-case scenario in one sense. If you’re going to hit that high deductible, chances are pretty good that someone in your family has a chronic medical condition. And if you or your family member has had that condition all along, insurers might not even sell you a policy. Maybe you have diabetes. Or you’re married to a cancer survivor. Maybe one of your kids has asthma. Whatever the case, chances are you can’t get health insurance at all. Your total risk of loss would be, well, every single penny you have.

So what happens if reform does pass? For starters--and this is no small thing--the insurance company will have to sell you a policy, no matter what pre-existing conditions your family brings to the table. And you’ll know from the start that the policy will cover basic services because the government will be defining a basic benefits package. That package is going to include a broader range of services than the typical non-group policy would without reform. So when your doctor recommends a standard test or procedure, you won't have to panic it falls into some hidden policy loophole.

But what will that coverage cost? The basic premium is roughly the same, according to Gruber’s calculations that he extrapolated from official Congressional Budget Office estimates. But that $50,000 income means you’re also eligible for federal subsidies. Large federal subsidies. In fact, the government will cover about two-thirds of the price, so that you’re left owing just $3,600.

Now, you could end up spending a lot more on medical care if you or someone in your family gets sick. But here, too, the federal government would step in to help. Under the reforms, the government would limit out-of-pocket spending to around $6,000 per year. Combined with the premium, you’re on the hook for around $10,000 total, or about a fifth of your income.

That’s not pocket change, for sure. A family making $50,000 will have to make serious sacrifices to find $10,000. But it’s better--light years better--than finding $25,000 or more. It’s potentially the difference between having to give up your home, get an extra job or declare bankruptcy. Just knowing the bills that could come will be the difference between getting care you need--and skipping it, at grave risk to your health.

It’s a difference you’d feel at other income levels, too. If your family of four makes more money--say, around $75,000--your premiums and out-of-pocket expenses will be higher, but still a few thousand less than it’d be without reform. If you make less money-- $35,000--the savings would be much larger. (If you make less than that, you'll probably be on Medicaid, which offers even more protection.)

Could the deal be better still? Of course it could. The House bill, for example, offers substantially better protection from out-of-pocket expenses.

That's an argument for improving the Senate bill in conference committee, when its members meet with their House of Representatives counterparts, and for improving the law if and when it goes into effect. Those of us on the left can, and should, fight for both.

But we should also recognize the Senate bill for what it is: A measure that will make people's lives significantly better. Surely that's worth a little enthusiasm.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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On Monday morning, a week ago, the Congressional Budget Office predicted that, for most people, insurance would cost the same or less if the Senate's health care reform bill passes. By the afternoon, critics of health care reform rushed to the microphones, claiming vindication. CBO, these critics insisted, had determined reform would mean higher costs!

What happened? The simple answer is that the critics were being deliberately deceptive. And they almost certainly were. But there's also a more complicated answer. The critics were taking advantage of widespread confusion over the definition of cost--a confusion that has been hanging over this debate for the last few months and is continuing to distort it.

Until now, the CBO, which is Washington's official scorekeeper, has been assessing reform proposals largely on the basis of how they would affect the federal budget. And whenever CBO has issued one of its assessments, critics have focused largely on CBO's estimates of government outlays--that is, the amount of money a bill would require Washington to spend on expanding government health insurance programs or providing people with financial assistance to buy insurance.

These numbers inevitably sound big. Most of the bills CBO has analyzed have called for outlays in the neighborhood of $1 trillion over 10 years. And while that figure represents just a fraction of the total federal budget--government outlays for the same period will be more than $40 trillion--it still represents an increase in what Washington will be spending. That's bound to upset anybody whose primary concern is the size of government.

But sometimes government needs to grow, in order to take on responsibilities the private sector can't handle on its own. And when that's the case--as it seems to be with health care--the only relevant question is whether an initiative adds to the federal deficit. Here, the news has been largely good. The bill before the Senate now would raise some tax revenue while finding savings in other government programs. The net result, according to CBO, would be lower deficits overall. (It reached a similar conclusion about the House bill.)

Of course, that's not the end of the story. The most important issue for most Americans isn't what the government spends on health care. It's what they, as individuals and families, spend on health care. That's the question the CBO finally addressed this week--although the findings were, in fairness, a bit hard to follow.

The vast majority of Americans with private insurance get coverage through employers. For these people, CBO predicted, premiums would stay about the same or come down a bit if the Senate bill became law. That wouldn't be the $2,500 in annual savings that President Obama famously promised during the campaign. But it also wouldn't be the huge hike in premiums critics had been predicting.

Where the price of health insurance would start to change radically is in the non-group market--that is, for people who buy on their own, as individuals, rather than through an employer. Premiums for these people, who number a little more than 30 million, would tend to go up. That's one of the points reform critics seized upon in their press conferences.

But the more interesting and relevant story was why CBO expected premiums to go up. For the most part, CBO found, it was because people would be getting health insurance that provided more benefits and covered medical bills more completely--coverage that often wasn't available to people in the non-group market before. In many cases, CBO determined from its economic models, people would actually opt to buy more expensive insurance than necessary simply because they valued the added protection.

In addition, CBO noted, while premiums in the non-group market would rise, the majority of people buying insurance on their own would simultaneously become eligible for federal subsidies. For the majority of these people, the subsidies would more than offset the increase in premiums, so that they'd end up paying less--even as they were getting better coverage.

To be sure, not everybody would be so lucky. People making more than four times the poverty line, or $88,000 a year for a family of four, wouldnt be eligible for subsidies. They'd end up paying more. So would some, although not all, people who now have cheap insurance because they are young, healthy, and have minimal benefits. They'd be a small minority of the total U.S. population, but still a few million people. They, too, figured prominently in last week's anti-reform propaganda.

But it's virtually impossible to design a reform scheme that doesn't, in the early stages, involve at least some transfer of money away from the healthy and wealthy. The point of insurance is to pool risk, bringing in contributions from relatively healthy people, so that medical bills don't fall too heavily on the sick. And if government is going to offer subsidies to the poor and middle-class, it's bound to finance those subsidies through taxes on the wealthy.

Keep in mind that CBO is very skeptical about reform's ability to make medical care itself less expensive. If it turns out that better use of information technology, more scrutiny of treatments, and other innovations reduce the incidence of wasteful medical treatments--as many experts believe will happen--then it's possible everybody, even the very healthy and very wealthy, would end up spending less on health care, at least in the long term.

And if not? Then even those few people who do end up paying more for their insurance would still gain something: The peace of mind that they'll still have coverage even if they suddenly stop making a lot of money, as well as the knowledge that insurance will meet their needs if they get sick. That's something worth celebrating, even if the reform critics don't agree.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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