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.

Co-ops are unfortunately not the solution. Health co-ops as our only alternative to private insurers will fail to provide the level of competition and cost savings that is needed to truly reform our health system. A public option, with the stability and resources of the federal government backing it, would be a better and more formidable competitor to insurers and result in improved access to affordable care. Co-ops on the other hand, with their limited size, reach and negotiating ability, would be too weak to provide any real competition to the private insurance industry and we'd be in the same situation we are now with health-care costs spiraling out of control.

Co-ops will likely fall short in all three essential elements required of any new coverage option: cost, quality and access. Creating new co-ops will be expensive and since there will be multiple co-ops as opposed to one national plan, they can't take advantage the economy of scale of a national public option and build on the foundation that exists with other public plans. Health co-ops would lack the negotiation power of size to substantially lower prices, they would also be forced to spend a good bit of money on advertising and other administrative costs making them a poor substitute for the lower cost public plan, adverse selection for their risk pool would be a concern as well, as the co-op plan looked to ensure it had the funding to support anticipated claims for this underserved population. It remains to be seen how quickly co-ops can attract the level and quality of providers they will need to create a comprehensive plan or what the risk tolerance of providers will be to participate in a new untested system. Also, in question is the ability of these plans to keep the president's promise to allow people to keep their provider if they choose to.

Provider panels are an essential element of both quality and access, and health co-ops' capacity to ensure both in today's market is a real unknown.

The public option avoids all of these challenges and remains the best way to lower costs and improve access to care. The promise of health co-ops is an empty one that with few exceptions has gone the way of the buggy whip and carbon paper.

A non-profit co-op model health plan is worth a try particularly if it takes on some of the culture of a co-op: innovative strategies in the best interest of each individual. I think that the public plan can and should remain as a fail-safe if this does not work.

Since coverage for all is in the best interest of providers, payment for co-ops could be phased based on the cost effectiveness of regional or state provider systems with a public plan as a fail-safe.

Whether member-owned cooperatives can create an affordable health insurance option to get more Americans covered depends on a variety of factors, some of which are unrelated to the characteristics of the cooperative:
• Whether the cooperatives are required to take in anyone who applies for coverage, regardless of medical history or status (this feature is called guaranteed issue);
• Whether lower-income insured participants are subsidized in some way to make insurance affordable;
• Whether the cooperatives can define a reasonable benefit package without a lot of political interference that adds expensive, marginally-beneficial coverage mandates; or
• Whether elected officials will allow the cooperative to operate as cost-efficiently as possible, or whether they will try to impose a variety of policies on them unrelated to their core mission, such as the requirement that the cooperatives pay "prevailing wages" or requirements that they get work done via preferred providers of services who are major supporters of particular elected officials.

The other issue specifically relevant to the cooperatives is whether they can attract a broad risk pool, including not only the older, uninsured Americans or low-income uninsured, but also the healthy, young insured. Unless healthy people are part of the insurance pool to subsidize the unhealthy, it will not work. To attract the healthy, young insured, there must be an individual mandate, that is, a requirement that every adult American purchase health insurance. Without a broad individual mandate, the cooperative is unlikely to have an economically-viable broad insurance pool.
I would hope that this cooperative gives well incentives to its members and rewards high-quality care through its payment systems. If it does, it could make a major contribution not only to broadening insurance coverage, but improving the quality of care.

The Clinton health-care reform effort taught policymakers a valuable lesson: most Americans like the health care they have. Today, 84 percent of Americans, including 94 percent of voters, have health insurance and they desperately fear losing what they already possess. Having seemingly learned this lesson, President Obama assured Americans that if you like your health plan, you can keep it. However, the current health care debate raging in town hall meetings across America has made one point evidently clear: the creation of a public plan has stoked the fears of Americans once again.

A public plan that capitalized on Medicare's "take it or leave it" approach to setting reimbursement rates for hospitals and providers could offer lower premiums -- 30 percent lower according to a Lewin Group study. With this advantage, a public option available to all would result in 119 million people shifting from their current employer-based coverage to the new public plan. So while a public option may yield the positives that proponents argue for, it also reinforces the fears of 170 million Americans who currently enjoy private coverage -- the fear that they may lose what they currently have.

Health-care reform has many essential components: coverage expansion, insurance regulation, renewed public health efforts, health information technology seeding, finance and delivery system transformation, among others. Yet, the national discourse has been dominated by the public option and suspicions of a government takeover of health care. These qualms now threaten to derail wider reform.

While policymakers continue to argue the merits and necessity of public plan, the more pertinent question may be will Americans accept health care reform with a public option that heightens their fears? The U.S. health-care system is in desperate need of reform - a reform too important to be derailed by a fight over any single component, even the public option.

Economists, by training, will more eloquently articulate the dollars and sense of a public option than I, as a physician. It would seem, though, that the more options available in a free market, the more affordable and better quality those options would be (competition). In all the discussions surrounding health care reform, what remains most fascinating are people's perceptions of a public option.

Have you ever noticed that when "public" is used descriptively in conversation -- public school, public transportation, public (or county) hospital -- the quality of the item is called into question? Change the word "public" to "private" and the perception is that the product is superior. It begs the question whether the public option is concerning not because it is a public option, but because the concept of a "public" anything brings to mind images of inferior or bureaucracy-laden goods. But a public option in health care may be a good thing.

Consider public transportation. Living in Los Angeles, you soon learn that the traffic can be dreadful. If you don't want to spend three hours on the 405 freeway to travel two miles, you could take public transportation (although many still don't).

Travel to the other side of the country to downtown Manhattan and you find that public transportation is the modus operandi of city dwellers. Now, imagine stripping New York City of its public transportation system. Some will be unfettered by the change. But for others, especially those who cannot afford alternative means of transportation, their only option is gone. Imagine the consequences for businesses, communities and families.

So it is with health care coverage. Creating options gives everyone the opportunity to access health care, regardless of status. Certain demographics may use the public option more than others, but all can benefit from having such an option, especially in tough times.

This isn't to suggest that the public option will not encounter some glitches. There are lessons to be learned from the Massachusetts model. Nevertheless, the public option, as it has been discussed, will offer choice where many do not have it. And maybe, as a result, insurance companies will redress their current health care coverage offerings. Given that our goal is to have a healthier society where people can choose what works best for them, having options on the table seems like a favorable idea.