Unlike so many, I find myself being more impressed each time I delve into the new law. This is, ultimately, a piece of legislation that WILL achieve many stated and even unstated objectives:

1. It will extend the Medicare Part A trust fund for just long enough to allow BOTH sides to discuss meaningful reforms to make it truly sustainable.
2. It provides a real commitment to our nation's poor; and strengthens Medicaid at the same time. Here, too, there are opportunities for additional reforms, but this makes clear what our priorities are; and, importantly, demonstrates our national humanity and compassion for those less fortunate.
3. It dramatically reforms our understanding of and right to health insurance. We have never had a federal definition of health insurance and this begins that discussion in a meaningful way.
4. It is financially sustainable, as long as our elected officials do not undo the tax and revenue-generating items.

What do we need to wait for and hope for?
1. Tort reform and/or Malpractice reform. This should have been firmly part of this law, but will have to wait.
2. Sustainable Growth Rate legislative reform: This is universally recognized as necessary and putting it off, even for a few months, is a big disappointment.
3. Implementation of insurance regulation and insurance exchange regulation will be the first real tests of the success of the law.
4. Taking the Medicare savings and law changes as a first step; and not ignoring the very real legacy costs that we still have to address. AND working with the private (for-profit and not-for-profit) sector to develop a structure and process for improving the delivery of high-quality health care with consideration of cost.
5. Revisiting the notion of better patient education and not being scared off by hateful rhetoric. Discussions around end-of-life and compassionate care should not be politicized or used for pure political gain.

I remain very optimistic about this country and about seeing our elected officials, of both parties, come together around common goals and purposes. In the mean-time, I am proud of the many elected individuals (and their staffs) for having stood behind their promises and made this a reality.

It's better to take more time rather than rush through a Pandora's box of perverse incentives like the 1,900-page House bill (HR 3962). The quality of the reform is far more important than the date of enactment. At the same time, that doesn't mean it's OK to kick back and relax for another 15 to 20 years.

Open the House bill and out flies a menagerie of stinging things: Job-killing employer mandates, payroll taxes and surtaxes. Hazy market rules to be set and re-set by a powerful "Health Choices Commissioner." A public option menacing private markets and amplifying the financial disasters of Medicare and Medicaid. Onerous red-tape and reporting requirements for firms and individuals. Dozens of new government agencies. New incentives for lawsuits. And a staggering price tag, according to the nonpartisan Centers for Medicare and Medicaid Services (CMS) and the Lewin Group (which analyzed an earlier, but similar, version of the bill).

Reform that improves on the status quo must meet several conditions: Lower costs over the long haul. No damage to the quality of health care. No bureaucrats interfering with doctor-patient decisions about care. Easier shopping for health insurance. And above all, no threat to Americans' financial security.

HR 3962 fails on these counts and more. Far better to tear off a few more calendar pages than to rush through a destructive assault on one-sixth of the U.S. economy. No segment of society needs reform more than small business does. Millions of independent firms and their employees have struggled with suffocating costs and administrative burdens for nearly a generation. The status quo is unacceptable, but the House bill shows how to make things even worse.

So what's the ideal pace for the Congressional proceedings? The actual pace seems to alternate Waiting for Godot (talk, talk, talk) and Lucy and Ethel in the chocolate factory (1,900-page dump-and-vote). Something in the middle would be nice.

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(NOTE: At this writing, the new Senate bill isn't out yet.)

My spirits tend to sag a little bit at this time of the year. I'm pretty sure it's a sunlight/Vitamin D deprivation sort of thing. But the health-care non-reform legislation coming down the pike has me dragging even more than normal compared to the typical Wisconsin November. We've read proposed legislation from the House of Representatives that expands access to care dramatically (with an expanded price tag to boot) while doing nothing to rein in wasteful spending nor drive towards health. In its present state it's just another deferred tax for our children and their children and their children's children to pay. So where's the health-care delivery transformation in the bills being bandied about in Congress? Where's the waste removal effort going to come from? Certainly not from government. And that's why my biggest beef is with the weak employer non-penalties for non-participation.

It's a very simple formula, folks. Public option + weak employer penalties = socialized medicine.

Why do I want to see employers retain responsibility for providing health-care? Because employers -- not government -- will drive accountability, innovation and value in ways that government simply will not.

Can Congress present something by year's end to President Obama? Is it feasible or even necessary? In its present form, I certainly think not. It seems that the House passed its legislation, packed as it is with bogies, knowing that in reconciling their bill with the Senate many of the more left-leaning pieces would be shot down when the moderates finally flex their muscles. At least I hope that will prove to be the case.

I've lived and worked in the United Kingdom and received care in both the public National Health Service and the private sector. As a health economist and management consultant, I've worked with clients in other European countries' health systems along with Canada's.

There is no Nirvana, no Hope-in-a-Health-System pill for us to swallow. The American health system reform challenge won't and can't be solved by importing any single nation's health system into U.S. borders.

Health care financing and delivery in the U.S. has morphed into the oxymoronic "system" it is due to its historic roots based in World War II era wage controls. Sixty years later, a holey, patchwork quilt of incentives has driven stakeholders -- providers, payers, suppliers, and patients -- to our current state of high-cost, low-value, resource-wasting dissatisfaction.

Improving the U.S. system will require us to learn from the best practices of our peer-developed countries' systems; the recipe would include:

- The equity of the United Kingdom's NHS ushered in through the Beveridge Report in 1948
- The satisfied physicians of France
- The mixed public/private system of Switzerland
- The electronic health infrastructure of Denmark.

Furthermore, we'll usher in a new era of participatory medicine where health citizens collaborate in their own care with providers. Today's launch of the Journal of Participatory Medicine formalizes this movement.

With greater involvement of American health citizens, ours will be a uniquely American system that will move the U.S. up from our position as No. 37 on the World Health Organization's global league table of health nations.

I'll defer to National Federation of Independent Business (NFIB's) official statement, from Susan Eckerly, Senior Vice President:

"Today's Finance Committee vote is pivotal as we evaluate the future of comprehensive health-care reform. NFIB appreciates the many provisions in this package that reflect small businesses' needs, which are rooted in approaches that aim to lower cost, increase coverage options and provide real competition in the private marketplace.

"We commend committee members for ensuring that an employer mandate and public option were excluded from the revised package. While NFIB greatly appreciates efforts to hold the line on these issues, we have strong concerns that, moving forward, attempts will be made to weaken the framework established by the Finance bill. We deeply believe that if any of those attempts are successful, they will derail health-care reform altogether.

"This is the only comprehensive health-care reform bill that provides a meaningful pathway to achieve the goals long supported by NFIB, including:

-- Individual and Small Group Market Reforms - Federal rating reforms in the individual and small group markets are essential to any reform effort, and must include protections against pre-existing conditions. It is imperative that the variation for age, geography, family composition and personal behavior are preserved or strengthened, but not lowered, as this legislation moves forward.

-- Health Insurance Exchange - An exchange modeled on provisions under the SHOP legislation (S. 979) will improve competition, allow small businesses and individuals a broader choice of plans and create a simpler and more efficient way to purchase insurance.

-- National Plans/Interstate Sale of Insurance - Allowing national benefit plans to be purchased across state lines can and will produce competition. The interstate purchase of insurance has been proven to foster competition in the marketplace, and gives additional options to consumers.

"NFIB has been a constructive participant in the health-care debate and has spent more than a decade voicing our need for reform. As floor debate begins, small business must weigh the benefits of reform against the potential new costs of doing business. Small businesses will have a difficult time supporting a final health reform package if its long-term costs outweigh the benefits we have worked to secure.

"NFIB remains committed to supporting reform efforts that provide more affordable and accessible health-care options for small employers and their workers. It is essential that a final bill makes their core needs and common-sense solutions a priority."

Sen. Baucus may have won a hotly contested playoff game, but a tougher divisional match and ultimately the championship still lie ahead. In the weeks and months to come, what the House and Senate produce will say as much about President Obama's political game and the legislature's resolve as it will about the fundamental American ethos. Since its inception and the framing of the Constitution, the American republic has been rooted in John Locke's theory of individual rights and shaped by competing Federalist views. We've espoused the mantra of limited government but with bipolar tendencies toward expansive federal programs (i.e., Social Security and Medicare). Historically, we've tolerated government incursions in health care but only when it concerned the purview of the deserving poor, disabled or the elderly.

On the other hand, our individualism has been tempered by a righteous sense of empathy and social fairness. Even so, the question lingers: are we ready to climb that proverbial Mount Everest of ideological shifts? Will we foray into that cultural tempest of universal coverage? Or will the heavy burden of government-sponsored anything scare us back into the arms of familiar traditions? At stake, will be a broken system and the millions of uninsured.

Indeed with the Finance Committee's 14-9 vote, the Congress undoubtedly inched closer to advancing what has been an arduous path to reform. Odds are some form of health legislation will pass, but whether the final incarnation represents substantive change, however, remains to be seen. The Baucus bill, the least politically offensive, won the coveted moniker of bipartisan, though barely. In exchange for a lone Republican vote and in the hopes of assuaging more conservative Democrats, Senator Baucus abandoned the public option. Instead he pegged health-care cooperatives and insurance exchanges as a viable alternative. These approaches, inherently weaker in nature, will unlikely wield enough leverage against an insurance industry, which in recent days has proved onerous and sadistic.

If individuals will be mandated to purchase health insurance then the public should be offered meaningful competition, which is best achieved through a more muscular government-backed option. The insurance industry and many others in the health-care sector are poised to reap an influx of potential customers. The Finance Committee proposed safeguards to protect ordinary citizens. It ensures guaranteed issue and caps annual out-of-pocket expenses. Rather, it concedes variations in premiums based on age, family composition and tobacco use. Ultimately, it leaves open the door for consumers to be bullied by gluttonous industry practices.

Throughout history we've acted out-of-character. Nixon, a limited-government Republican, proposed employer-mandated coverage in addition to a form of public option. Likewise, both Republican and Democratic administrations have tolerated a "backdoor approach" to universal coverage with incremental expansions of Medicaid. But yet again history is calling. And, if we follow the leads of FDR and Johnson we may be able to do something bold and characteristically American.

Mandates, whether for individuals or employers, are one of the most critical issues in the reform debate. Republicans fear employer mandates will impose significant financial burdens on companies and put them out of business. Democrats argue that employers have to take responsibility for the health of their workers. Both have a point.

Is it realistic to believe that if employers were not required to contribute funds to employees' health plans, they would reinvest that money into salaries? These days, sadly not. It follows that many businesses, fighting to stay alive in a global downturn, may choose the path of self-preservation and least expense. And if that path leads to a fine, management may very well choose it.

That's probably true in many, if not most, cases. Fortunately, there are a few notable and laudable exceptions in the business community. Starbucks, for example, is a successful American company that provides health benefits to all of its full and part-time employees. They serve as the example that comprehensive employee coverage and success in business aren't mutually exclusive.

On the other hand, if we legislatively compel employers to contribute to workers' health plans and the costs put them out of business, unemployment rises and with it, the ranks of the uninsured. And then we're back at square one because we'll be worse off than we currently are.

Rather than becoming mired in a debate about the means, let's focus on the desired end: How do we ensure that workers have good, reliable and continuous coverage without breaking the backs of America's small businesses?

For the past 50 years, Americans have looked to their employers for their health care. This has been so prevalent that most Americans have not even considered looking elsewhere for health care coverage until recently. Employer health plans are no longer the solution as these same plans have contributed to the downfall of many of those companies that offered them. In Michigan, the big three cite the costs to carry those plans as a factor in their inability to be competitive with imports made by companies that don't have to factor in exorbitant health care plans -- competitors whose employees for the most part have universal health care coverage.

Employers, like everyone in America, need to be part of sweeping health care reform. They need to contribute in the form of a tax or partial contribution to employee premiums. This will help offset the cost of covering everyone while still relieving major companies of high costs associated with employer plans. We can't lose sight of the goal: to provide affordable and equal coverage for all Americans. With or without mandates, the current proposed plan still falls far short of that goal.

The Finance Committee was right to keep an employer mandate out of health reform. It's a bad idea in good times. It is a really bad idea during a deep recession and has no place in health-care reform.

An employer mandate (or equivalent payroll tax or play-or-pay) is inefficient for several reasons: It doesn't reduce health-care costs and, instead, substitutes a hefty and direct penalty on the very people struggling to pay for insurance. It does nothing for the unemployed, self-employed or early retirees. It harms small and vulnerable firms, ultimately costing the economy jobs and revenue, which is particularly destructive in the current economic environment where hiring is stagnant and unemployment is climbing to nearly 10 percent.

There is consensus among most economists that an employer mandate is ultimately a tax on low-income workers, depressing the wages of some and throwing others out of work. In fact, Obama adviser Larry Summers explained how employer mandates cause unemployment among low-wage workers. Employer mandate advocates defend their position as "shared responsibility," an argument eloquently refuted by Obama adviser Ezekiel Emanuel and Victor Fuchs in "Who Really Pays for Health Care?: The Myth of Shared Responsibility":

"Employers do not bear the cost of employment-based insurance; workers and households pay for health insurance through lower wages and higher prices. ... Failure to understand that individuals and households actually foot the entire health care bill perpetuates the idea that people can get great health benefits paid for by someone else. It leads to perverse and counterproductive ideas regarding health care reform."

An employer mandate would do its worst to small-business owners and employees. A 2009 NFIB study (and summary) predicted that an employer mandate could destroy 1.6 million jobs (over five years), around one million of them in small firms. An employer mandate is especially devastating for the newest and most vulnerable businesses. Mandates lay heavy burdens on small firms, increasing their administrative loads and causing additional cash-flow problems, especially during their first five years. A mandate gives employers strong incentives to cut wages, replace full-time employees with machines or exempt part-timers, or to turn to foreign outsourcing.

Forcing small businesses to provide a benefit they and their employees can't afford won't solve the problems of our health-care system.

The employer mandate is a distraction in the health-care reform debate. Most Americans favor universal coverage regardless of employment. However, no one is sure how this will be funded. Meanwhile, those with insurance are defending their positions. The seniors do not want to lose Medicare benefits while those with employer coverage want to preserve it.

Sadly, both government and industry have poor track records in health care. Companies can no longer afford escalating health costs, particularly in a global economy. The auto industry has already buckled under such pressures. The federal government is destined for the same fate. Without additional tax revenue or reduced spending, Medicare will be insolvent within 10 years.

We need to return to fundamentals. The principle of universal coverage is that everyone contributes to this common good. This means a shared view of its value, and its affordability. We are a long way from that enlightened perspective. Health care has become a free-market circus, tying our political process in knots and confusing the American public. Because of this, we are mired in details like the employer mandate.

The founders of our country understood the value of aligned public interest. It started with the early settlers' notion of the "common", a public grazing ground shared by all. That same philosophy led to broader public interests like national defense and public education, which American taxpayers value and support.

The time has come for health care to be treated in the same way.