Looking back over the past year of health-care legislation, I would make the following observations:
• The Obama Administration made remarkable progress on health information technology, prevention and wellness and health-care quality in the February 2009, stimulus legislation.
• Although the House and Senate health-care reform bills were not bipartisan and some of the compromises were not particularly good ones, I am pleased that the Senate discarded the public option, the logic for which was never compelling.
• Relative to what the bills attempted to accomplish, the goal of enabling universal health insurance would be achieved. However, there are some structural flaws in the design of the insurance systems that, if not corrected, will put our country at serious financial risk.
• Structural health-care payment and delivery reform could avoid a financial crisis, but it is not clear that any level of government has the political will to tackle these issues, and they were addressed in these bills. Raising taxes to fund health insurance will cripple the economy, and cutting Medicare payments in our existing flawed system will simply drive doctors and other providers out of the system, which will create shortages. At this stage, it is unclear how we will create universal insurance that is affordable and financially sustainable.
• I commend Senators Harkin and Dodd and their colleagues for some excellent work on prevention and wellness. I also believe that the foundation has been laid for supporting more community health centers, a vital tool for health care delivery. Nevertheless, the good pieces of the legislation are relatively under-developed nuggets, not full-blown health care transformation solutions.

Politically, this legislation went as far as Congress could probably go, but much remains to be done.

Former Secretary of Health and Human Services Donna Shalala, now president of the University of Miami, has often told me that for major legislation to pass there must be consensus on the problem and the solution. In health care, most people agree on the problems: the U.S. health care system is too expensive, leaves too many Americans uncovered and fails to achieve its potential in quality.

As for the solution, a consensus remains elusive. For liberals, reform entails a public option, a Medicare and Medicaid expansion and government subsidies for low-income Americans. For conservatives, the solution calls for the development of an individual insurance market with purchasing across state lines, medical malpractice reform and the expansion of health savings accounts. Some liberals may have believed that a Democratic caucus with 60 members would thwart the need for consensus. However, centrist Senators, who represented votes 55 to 60, quickly ended those notions.

In any negotiation, the power lies with the coveted undecided. Without the counter-balance of major conservative ideas to court Republican votes, it is no surprise that many liberal ideals have been stricken from the bill. While this compromise has produced a bill that leaves both liberals and conservatives wanting, no single bill would ever have done everything for everyone. Health-care reform will be a continuous process of learning and adaptation with many opportunities in the future. Given the lack of consensus, for a bill to exist, compromise was necessary.

Compromises are inevitable in any complex piece of legislation. Those that address the unique needs of particular communities and increase the degree to which the legislation meets its fundamental goals are good compromises. Those unrelated to the purpose of the legislation turn the legislative process into a power game in which the strong prey upon the weak.

The decisions to drop the public option and the Medicare eligibility of 55-64 year olds were sensible. Once the Senate required insurers to cover everyone who applied, prohibited coverage limitations based on pre-existing conditions, provided subsidies for those who could not afford insurance, and created national exchanges to insure competition, the primary reasons for having a public option or for expanding Medicare melt away.

I liked the tanning salon tax, because salons probably increase the risk of skin cancer. I was disappointed that the Senate deleted the cosmetic surgery tax. Many plastic surgeons game the insurance system and Medicare by coding cosmetic surgery as reimbursable reconstructive surgery. While some cosmetic surgeries have medical and psychological benefits, the health benefit of others is marginal at best, and risky at worst. Anything that forces a more thoughtful decision on such surgeries would have been beneficial.

I am disappointed that the legislation did not more aggressively address health-care access, quality, and cost issues. As a piece of legislation designed to make health insurance universal, it is relatively good. However, the ultimate problem with mandatory universal health insurance remains how to pay for it without creating other problems. The penalty for young, healthy people who choose not to get insurance is too low, and the subsidy for the older, less healthy people is too generous. If either the House or Senate legislation gets enacted, we will have serious financial problems we will eventually have to address.

Under normal laboratory conditions, adult fruit flies have an average lifespan of seven days. The average fruit fly would have therefore outlived the tentative Medicare buy-in compromise presented by the gang of 10 Senators this last week.

Senator Lieberman was the immediate and proud killer. Yet as Amy Goldstein makes plain, other assassins waited in the wings, including physician groups, community hospitals, otherwise-progressive senators from rural states. There is a useful lesson here. Democrats have cast insurers as the all-purpose villain in health care reform. There are sound political reasons to do so. Particularly in the non-group market, the industry certainly lives down to its villainous stage role.

We should recognize, however, that strategic imperatives and message discipline can cloud analytic clarity. Virtually the entire supply side of the medical economy has a strong economic interest in constraining the growth and bargaining power of Medicare. This includes traditional targets of liberal wrath such as big Pharma and device manufacturers. It also includes warmer and fuzzier constituencies, too: community hospitals, the Mayo Clinic, academic medical centers and many others. Effective cost control requires us to stringently bargain with these institutions. They will resist efforts to strengthen government's bargaining leverage to accomplish this task. As we saw in the demise of this modest but worthy Medicare compromise, our failure to confront this political fact brings real human and financial costs.

A few words about the substance. Near-seniors age 55-64 face serious risks that make them a natural constituency for health reform. Too young for Medicare, but old enough to face marked health risks, this group includes the most immediate victims of preexisting condition exclusions, large medical expenses and accompanying bankruptcies, chronic illness and disabilities. Not surprisingly, then, polls indicate that this group ranks among the most enthusiastic supporters of health reform. Equally unsurprising, support for health reform plummets at age 65, once seniors secure Medicare coverage.

Based on what we know, the proposed Medicare buy-in would have been helpful, but it would have had a very small immediate effect. Over the next several years, the main beneficiaries would apparently have been a small population of men and women with chronic illnesses eligible for high-risk pools, who suffer costly conditions and who have been uninsured. High-risk pools can be a useful stop-gap. They are not an effective or humane long-term policy. We don;'t know enough details to evaluate Medicare buy-in as a specific policy. Over the long-term, liberal hopes matched provider and conservative fears about where this might head. These possibilities were enough to prove fatal in a world in which reform requires 60 Senate votes.

Now that the buy-in is dead, those who favor reform should move on to address the serious problems millions of near-seniors face, and would have faced even if the buy-in had become law. Near-seniors need strong regulation to prevent insurer discrimination on the basis of illness or disability. They need generous affordability credits and better protections against high out-of-pocket costs, particularly for those with incomes around 300 percent of the poverty line. They need rapid implementation of health insurance exchanges, which are several years off.

The buy-in deserves an honest obituary. We should mourn its quick death and what might have been. It's now time to pass the bill, and to focus on essential details that remain to be done. In doing so, we should remember who killed the buy-in, and others who were happy to see it dead. As we move to secure the rudiments of universal coverage, we can't wage every fight. When the current health reform is done and we look more seriously to control costs, we'll be fighting other battles soon enough.

The bill needs to be amended to eliminate any opportunity for states to opt out of a public option; it has to once and for all cover all Americans. The bill also needs to be amended to remove any language about gun possession, since it gives health insurers targets for denial. We don't need any amendment to make it tougher on employers -- we need a strong public option. It will take courage and commitment, but I am banking on the majority of senators to realize that most Americans don't have the Cadillac health-care coverage that they enjoy and is paid for by tax-payer dollars and many of those Americans would settle for the smart car version.

The health-care bills introduced by the House and now the Senate are the products of long, exhaustive and complicated political efforts. What has become clear is that our leaders are not showing any strength, courage or commitment to the American people. I have been writing about health-care reform for the past three years in my breast cancer blog and I have received hundreds of comments from people without health care who are desperate for answers. These are mostly women diagnosed with breast cancer. Several ask what their options are for an easier death since they cannot afford treatment. These are the stories we are not hearing when these bills are introduced. These are the families that need a public option.

As debate begins surrounding Reid's bill, even liberal senators are now shying away from a public option and several are putting emphasis on states being able to opt out. Joe Lieberman cites the economic crisis as the reason to leave many people without a government provision for health care when in fact it is because we are in such a dire economic crises that people are now looking to their government for health care. They are all disregarding polls that show most Americans now want a public option.

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.

This bill is only a start to health-care reform. The token Republican senator who voted for the bill proves that both parties are beginning to listen to the needs of their constituents. The discussion surrounding the passage of this bill however seems more designed to promote Sen. Olympia Snowe than to promote real health-care reform. The bill itself is a compromise seriously lacking in appeal. Without a public option, it is not what can be called reform. If the democrats continue to woo Snowe and her cohorts it is clear we won't see a public option in any final reform either. Furthermore, I find it very concerning that this bill outlines cutting future Medicare spending and taxing higher-end plans as viable means to pay for health care. I thought the idea was to relieve the burden health-care costs are putting on Americans.

While I applaud Snowe for her courage to break with her party on this issue, there are reasons Americans voted for Democrats and health care is one of them. Maybe someone should remind the Democrats of that.

The President was exceptionally eloquent in his grounding of health-care reform on moral arguments. He did many things very well:

• He made a persuasive case that, while the percentage of Americans completely without insurance coverage is relatively small, the percentage of Americans persistent insecure about health insurance is very high.
• He also made a cogent argument that when health care costs grow fast and crowd out other spending, we lose economic competitiveness.
• He stated his goals with great clarity. While I am disappointed that he did not focus on health improvement and health-care quality, his prioritization was a welcome contrast to his muddled messages over the last several months.
• His outreach to opponents on issues such as medical malpractice and low-cost coverage for the seriously ill were also welcome.

The proposed prohibitions on lifetime and annual coverage limitations, on denials of coverage for pre-existing conditions, and on terminations of coverage after someone becomes ill and the requirements for individuals to buy health insurance made sense, although an unintended consequence of a badly-designed employer mandate could be the destruction of even great employer-based health plans.

His case for the public option was flawed. State government regulation is the cause of lack of insurance competition. A public option does not create fair competition; it either creates unfair competition or it is ineffective. Nevertheless, I appreciated his message that achieving affordable coverage and care were more important than the litmus test of a public option.

He tread on dangerous ground when he spoke about financing. It's easy to talk about spending cuts, but brutally difficult to make them happen. When he speaks about "waste and abuse," he does not mention that one person's waste is another person's livelihood. There is a way to achieve these cuts, but the political challenges are enormous. The lack of specificity on how to pay for his proposals is the most serious issue in the speech.

Only time will tell whether his speech succeeded, but it was well-crafted and well-delivered.

In hopes of extinguishing concerns of a government takeover and reducing the political risk for moderate senators, health-care co-ops have emerged as a compromise solution to the highly-contested public option. Ezra Klein is correct to point out that co-ops materialized as a necessity for the politics of health care, not as a first line answer to a health policy conundrum. As a result, the effectiveness of health care co-ops must be measured by their impact on policy (reducing costs and increasing insurance competition) and their impact on politics (increasing the prospect of passing health care reform).

The structure of health-care co-ops remains ill-defined. In order to have any impact, co-ops would have to achieve economies of scale- - a success that will hinge on their ability to attract a sufficient number of members, predicted at 500,000 customers, to negotiate competitive rates. Yet state or regional level organization may be more likely since attempts of organization at the national level would only recreate the political problems of a public plan; not only disappointing those on the left who view the public option as a necessity, but also reigniting cries of a government takeover. With national organization, conservative replays of Senator Reid's comments, "We're going to have some type of public option, call it 'co-op', call it what you want," would only gain more traction.

On a policy level, these co-ops most likely will lack the negotiation power of Medicare, reducing their ability to dramatically cut premiums. Yet, with the expected $6 billion dollars of seed money, co-ops could successfully emerge as an alternative to insurance monopolies in certain markets. Politically, this dissociation from the government buffers moderate Senators from political retribution by undermining suggestions of socialized medicine and bolsters President Obama's claim that if you like your health insurance, you can keep it.

Co-ops cannot be the major lever of cost control for health care; their existence will not alleviate the acute need to re-examine the health care finance and delivery systems or reshape preventive health. They may, however, provide President Obama the best opportunity to fulfill his desire of increasing choice, while avoiding the major government intervention that seems to ratchet up anti-reform dialogue.