Rarely, if ever, does history hand us a "right" time or opportunity to get things done, especially on an issue as complex and as personal as health care reform. But if, as the President observes, “after nearly a century of trying” we are closer than ever to achieving health care reform, Congress and the Administration would be remiss to “walk away” now. While improving the nation’s health through comprehensive reform remains our goal, taking that first legislative step, no matter how small, may be the only way to ultimately get there. As a nation, we then will have overcome the decades-long hurdle of not being able to do something on health care, and be better prepared to take on bigger issues down the road. The President and Congress should do everything in their power to move forward. The future health and prosperity of America require decisive action now!

The State of the Union Address contained no health reform surprises. But it did display resolve. The message was straightforward: “We will press ahead. We will try to pass reform along the lines of the House and Senate bills. We will support constructive additional ideas. But we will not quit.”

In the aftermath of the Massachusetts political trembler, the White House and many Congressional Democrats seemed almost as shattered psychologically as the Haitians were physically after their catastrophic earthquake. In the State of the Union address, the president needed to communicate resolve and a realistic appraisal of political resources available to effect health reform. And he did. The speech followed statements from Speaker Pelosi and other elected officials indicating that Congressional Democrats are regaining their wits and determination.

The way forward is clear. The Senate should agree to modifications in the plan it passed late last year that would convert that bill into one that would pass the House of Representatives. The House should pass the Senate bill. The Senate and House should both approve the agreed modifications under reconciliation procedures that require a simple majority vote.

This strategy will not be wholly to the liking of members of either house of Congress. Not all provisions of the Senate bill that are objectionable to the health reform supporters in the House can be fixed through reconciliation. Not all of the changes on which House members will insist are to the liking of some Senators who supported initial passage. But no other option for moving ahead offers any plausible chance for success.

This course is risky. Republicans will doubtless complain about use of these procedures and argue that the public is opposed to health reform along lines of the House and Senate bills. The procedural objection is substantively without merit. Coming from Republicans, it is disingenuous. Reconciliation exists to deal with Congressional failure to implement elements of the budget resolution. The 2009 budget resolution called for action on health reform. Effecting those instructions is no abuse. It is just what reconciliation is intended to do. Furthermore, these objections are ridiculous coming from members of the very party that in 2001 abused reconciliation by misrepresenting as temporary tax cuts that were intended to be permanent so that those cuts could be enacted with fewer than 60 votes.

The more serious risk comes from the prevailing public mood of distrust and skepticism about health reform. Public querulousness is real. But the right response is to confront it. For the past year Democrats have argued with each other about provisions of reform legislation. Meanwhile, Republicans have been talking to the public, framing the proposed health reforms through a distorting lens. They have told people that a plan based on providing tens of millions of people with private insurance coverage was a ‘government takeover.’ They have told people that a plan scored as reducing deficits was a budget-buster. They listened passively or actively abetted the mendacious mischaracterization of end-of-life counseling as ‘death panels’ (labeled ‘the lie of the year’ by Politifact). They have told the majority of Americans whose insurance arrangements would not be touched by the proposed legislation that reform threatened their coverage.

Meanwhile Democrats spent the past year arguing with each. They spent endless hours and passion on whether to include a public option. They fought over whether to have a national or state exchanges. They hashed out various other technical provisions, some of which were important, but all of which were dull and utterly bewildering to all but a few specialists.

Now is the time for Democrats to resume talking to the American voter. They should explain the many genuinely appealing features of health reform legislation. They should make sure that every American understand that reform will prevent insurance companies from cancelling coverage or jacking up premiums for the sick. They should make vivid the millions who will be newly insured. They should make understandable to all the legitimate promise of cost control and the tangible steps to improve quality of care that will result from health reform.

They have taken the hard votes, but failed to explain why those votes are in the interest of their constituents. Democrats have ten months before the mid-term elections to do the job. An effective campaign to sell health reform will take patience, money, and energy. The reasons why health reform is in the national interest will not explain themselves. Republicans will certainly not do the job for them. If Democrats cower before current public opinion polls, they will surely lose heavily come November—and, arguably, they will deserve to lose. If they stand up for the genuinely constructive legislation they have crafted, they will deserve to win and they can prevail.

President Obama failed to offer any path to break the congressional stalemate over health reform in his address last night, simply offering another rallying cry for his signature domestic policy initiative and repeating talking points he's made in countless speeches all year.

The president insists people would like his plan if only they understood it. But the American people do understand it, and they don't like it. The latest CNN/Opinion Research Corporation poll taken last week found 69 percent of Americans want Congress to either draft a new bill or drop the issue altogether.

Congress is at war with itself over the best way to proceed after Massachusetts transformed the political landscape, and Mr. Obama needed to do a lot more than restate the problems in our health sector which virtually everyone agrees must be fixed in order to move Congress off dead center.

Rep. Anthony Weiner (D-NY) crystallized the dilemma, telling reporters yesterday: "The Republicans are our opposition. The Senate is our enemy."

The president and Hill leaders spent the weekend desperately trying to convince House Democrats to pass the Senate health overhaul bill, promising the Senate would use the 51-vote reconciliation process to fix their concerns.

But that means asking House Democrats to vote for the Cornhusker Kickback, a tax on high-cost health plans without labor union exemptions, and dozens of other provisions they hate.

Yesterday, the House came up with a package of the fixes it wants the Senate to make. But the price tag was a whopping $300 billion, pushing the full cost toward $1.2 trillion even in the most conservative estimates. Senators were aghast and felt the House was preparing to target them as the reason health reform fails.

In his speech last night, the president challenged anyone to come up with a better plan, basically dissing Democratic committee chairmen who have spent countless hours trying to advance his agenda.

Virginia Gov. Bob McDonnell answered the president's request during his response last night, calling for cross-state purchasing of health insurance, a reform that University of Minnesota economists Stephen Parente and Roger Feldman found would not cost the federal government a penny but would mean 12 million more people would be insured. And he encouraged Congress to tackle lawsuit abuse as a first order of business.

Finally, if the president were a practiced politician and genuinely wanted bipartisan action, he would have done two things. He would have thanked the five Democratic committee chairmen who have worked incredibly hard over the last year to deliver on health reform. A thank you from the president in front of a national audience would have motivated them to keep working.

And if he really wanted to bring Republicans to the table, he might have thrown an olive branch to Sen. Olympia Snowe (R-ME) and a few others to try to get them to the negotiating table. None of that was to be found, only more partisan blame games.

Clearly the president is looking for another miracle that will get the Senate back to 60 Democrats to pull health reform out of the fire. Anything can happen, but that's a pretty risky strategy.

Leadership, anyone?

An abbreviated version of this post appears today on The New York Times' Room for Debate blog.

With regard to health reform, the President highlighted the need for the House and Senate to work together to get it enacted into law. I would add to those remarks that we also need his leadership to achieve that goal. The Senate bill couldn’t pass the Senate again at this point, much less the House. It has real shortcomings with regard to the affordability of premiums for working families, the taxation of health benefits, the disparity among states for new Medicaid funding, and the creation of a new Board that threatens Medicare’s future. If we are going to succeed, we will need to unite -- using majority rule procedures -- to make quality, affordable health care for all Americans a reality.

Tonight, President Obama laid out a bold plan for a 21st century economy that will rebuild, revive and restore the Middle Class and with it, the American Dream.

Our path forward must solve the healthcare crisis that has plagued this nation, dragged down our economy and cost too many lives.

Fixing healthcare will reduce the deficit. It will create up to 4 million new jobs in cities and towns all around this country. Healthcare reform is undeniably linked to our economic recovery. And let’s not ever forget, it’s the right thing to do.

And as President Obama made clear tonight, we cannot walk away from healthcare reform, we cannot walk away from the millions of families desperate for that security. This nation can – this nation must – meet this challenge now.

We must have health care reform and it must be bold. I must remind folks that the future success of our economy and reforming our health care system are directly related. The Massachusetts election might have knocked us a bit off balance; however, our resolve should be stronger than ever to achieve comprehensive reform. Our bill will save 1,800 families in Michigan's 15th district from bankruptcy. I think President Obama put us back on the right track this evening, but now I call on the President to make this a sustained effort. Another great speech is not enough. Only the President can provide the leadership now needed to get this done. This is not a time to give into fear. I urge our leadership to muster up the courage to face one of the very real threats to economic viability of our nation - our nation's broken health care system. Reform is neither easy nor cheap, but the cost of inaction is far greater - in terms of lives lost, quality of life, and dollars. Make no mistake, if we don't reduce costs we face certain economic disaster. The president said it best, 'premiums will continue to rise; businesses will continue to drop coverage and more families will deal with insurance company abuses if we don't act.' The time for action is now.

In tonight’s State of the Union Address, President Obama restated his firm commitment to comprehensive reform of our nation’s health care system. He reminded us of the historic opportunity we have to enact reform: “After nearly a century of trying, we are closer than ever to bringing more security to the lives of so many Americans.”

Nearly every American, insured or uninsured, stands to gain if health reform succeeds, because health reform isn’t only about health care—passing health reform is critical to economic recovery, deficit reduction, and financial security for American families.

Lately, many positive aspects of the health reform legislation have been obscured – changes to our current system that would help make affordable and comprehensive health care a reality for all Americans. Both the House and Senate bills:

Cover over 30 million uninsured—who now fail to get the care they need; prohibit turning away anyone from insurance; eliminate artificial limits on covered expenses; establish a standard for essential comprehensive benefits applicable to all plans; improve 24/7 access to doctors and nurses; and provide the information necessary to ensure the best care for patients.

• Help families making less than about $90,000 a year and who don’t have employer insurance pay their premiums; offer coverage under Medicaid for families with incomes under about $30,000; and set a ceiling on family out-of-pocket medical expenses.
• Lower premiums and improve benefits, especially for those buying insurance on their own and employees of small firms; provide tax credits for small businesses.
• Launch an intensive effort to develop and implement innovations to transform health care delivery to improve quality, prevention, and control of chronic conditions, while eliminating waste, duplication, and need for costly hospitalization; and reducing insurance waste and overhead.
• Help ensure Medicare’s fiscal solvency while improving prescription drug benefits for beneficiaries and helping pay for home and long-term care for tomorrow’s disabled.
• Enable these reforms while reducing the federal budget deficit and middle-class family expenses.

These changes would represent a tremendous turnaround for American families and businesses who simply cannot keep up with health care costs that increase significantly each and every year. These affordability provisions offer security to anyone at risk of losing their job or health insurance coverage.

We cannot continue on our current path. Americans are suffering, and even dying, without the care they need; middle-class families with jobs and coverage are struggling to pay their increasingly high share of premiums and uncovered medical expenses; medical debt is the leading cause of bankruptcy in the United States; 72 million working aged adults have trouble with medical bills or have accumulated medical debts; and rising health care costs force employers to make decisions between hiring, paying higher wages, and providing adequate health insurance to employees.

We will not have the strong economy, healthy population, and vibrant labor market we need without health reform. The health reform legislation on the table is about addressing the problems we all face—and we cannot let the opportunity to improve our lives and our livelihoods slip by.

Tonight, President Obama reminded our nation what’s at stake for our country if Congress does not help Americans have health care security and stability. Dedicated physicians are the backbone of our health care system, and we need to strengthen what works and fix what’s broken to help them continue to provide high-quality care to patients.

The AMA applauds President Obama for his ongoing commitment to health system reform and we second his call to ‘Let us find a way to come together and finish the job for the American people.’ Every American will benefit from health insurance market reforms that eliminate unfair business practices like denials for pre-existing medical conditions. It is a tragedy that millions of Americans live sicker and die younger solely because they lack health coverage – every American should have affordable, high-quality health coverage. The pressures on our health care system have not abated; people are losing their health coverage along with their jobs and the rising cost of premiums is putting pressure on employers and families.

This week, the AMA sent a letter to President Obama and members of Congress to encourage them to continue efforts to enact meaningful health reform this year. The letter outlined eight critical elements of health reform, based on long-standing AMA policy, that include: providing health coverage to all Americans; enacting market reforms that eliminate denials for pre-existing conditions; assuring that health care decisions are made by patients and their physicians and allow them to privately contract without penalty. In addition, the AMA supports initiatives that: provide for quality improvement, prevention, and wellness; implement medical liability reforms to reduce the cost of defensive medicine; streamline and standardize insurance claims to eliminate unnecessary costs and administrative burdens and modify antitrust enforcement policies to empower physicians to improve quality and integration.

As we work on health reform, Congress faces a March 1 deadline to permanently repeal the broken Medicare physician payment formula that puts access to care and choice of physician at risk for seniors, military families and baby boomers. On March 1, physicians caring for seniors and military families face a 21 percent cut because of the flawed payment formula, which will force them to make tough decisions. The U.S. Senate must once and for all fix the broken formula to preserve the physician foundation of Medicare for current and future seniors who rely on the program.

We are pleased that Mrs. Obama will shine a spotlight on the problem of childhood obesity, and we look forward to working with the White House on this important public health issue for America’s families.

The President’s State of the Union address began to shift the momentum in the health care debate back towards passing reform. President Obama didn't walk away from the challenge of passing controversial policies. Instead, he made reform more important than ever to the success of his agenda. Without reform, Americans will have less money to spend on college for their children, more anxiety about losing their coverage, and greater health care costs in retirement.

Health care reform is also linked to the fiscal discipline that the President wants Congress to adopt. Reform will create a platform for restraining health care costs, which are driving entitlement spending higher.

Perhaps most importantly, the President called on members of both parties in Congress to stop pursuing their short term interests in ways that spread cynicism among throughout the country. He wants members of Congress to join him as leaders in the tough business of governing.

He may have given Congress just the impetus it needs to complete its work on health care. By proving he is a winner, he is showing members of Congress how they can be winners, too.

Together the President's speech and Speaker Nancy Pelosi's statement earlier in the day that she believes she can get the votes to pass a compromise based on the Senate bill have vastly improved the chances for a final vote on reform.

National Journal's Ronald Brownstein this evening wrote that House Speaker Nancy Pelosi is predicting that she can win enough votes to pass the Senate-passed health care reform bill, if the Senate agreed to make changes in budget reconciliation legislation.

The following is his report.

Speaking to columnists just hours before President Obama's first State of the Union Address, Pelosi said that if the Senate used the reconciliation process to revise elements of the legislation unacceptable to her members, the House could approve such a two-track approach. "What I'm saying to you is the Senate bill, stand-alone, I don't see any chance of it [passing the House]," she said. "Reconciliation resolving some of the issues: then we can pass this thing."

Pelosi said it would not matter whether the House or Senate begins the reconciliation process, but maintained that both chambers would need to approve the package of adjustments before the House would consider the underlying Senate bill. "Whatever the order is, the whole thing has to be finished, reconciliation, House and Senate, before we take up the Senate bill," she said.

The idea of a two-track approach revolving around reconciliation has drawn increasing attention in Democratic circles since Republican Scott Brown's upset victory in the Massachusetts Senate race reduced the party's majority to 59, one vote short of the number needed to break a Republican filibuster.

Under Pelosi's scenario, the House would pass the Senate-approved version of the bill and both chambers would adjust elements of the legislation through the reconciliation process, which cannot be filibustered. A coalition of liberal groups endorsed that approach at a press conference a few hours before Pelosi's comments.

Earlier this week, several moderate Senate Democrats expressed concerns about using the reconciliation process to advance the health care bill. And in the wake of her remarks this afternoon, one senior Senate Democratic aide cautioned that significant policy differences remained between the two chambers even if they can agree on a strategy for the process of completing the bill. "Did she tell you that the fixes that she wants in the reconciliation bill could cost 300 billion?" the aide said.

But Pelosi argued that moving the overhaul would be an appropriate use of the tool. "Reconciliation rules," she said, were "established for this purpose. It's the regular order for when you are doing a budget bill that has these ramifications.... Sixty votes for a Mother's Day resolution and everything else in between is not the regular order -- that's an obstruction. This is the kind of legislative event that reconciliation was established for."

Pelosi identified several key changes that she said must be made in the Senate bill through the reconciliation process to win support for the overall package in the House. These included eliminating the favored treatment in the expansion of Medicaid that Sen. Ben Nelson, D-Neb., won for his home state during the final stages of the Senate negotiation; providing greater affordability for people who would be required to purchase insurance under the bills' individual mandate; and structuring the new insurance exchanges, or marketplaces, that would be created under the bill. (The House created a national insurance exchange, while the Senate left the exchanges to the states.)

Pelosi seemed most insistent on adjusting the so-called "Cadillac tax" on high-value insurance plans included in the Senate bill. That measure has been a priority of the White House, which views it as a cornerstone of its efforts to control the long-term growth in health care spending. Just before Brown's victory in Massachusetts, the White House reached an agreement with organized labor to narrow the tax's application, which labor leaders argue would hit too many of their members. Pelosi described that agreement as "a good start" in revisiting the tax, but added "there are those who would like to go further than that." Indeed, at another point in the interview, she declared, "The easiest thing is to just get rid of the whole excise tax."

Asked about the role of abortion in a final resolution of the two chambers' differences, Pelosi said, "Let's just say that's not the subject of our conversations at his time. Right now, we're talking about affordability for the middle class, fairness for the states and how they help people have access to health care, those kinds of issues, how this is paid for. If we hear back from the Senate that they can't get 51 votes, there's no use having all these discussions. The sequencing is, 'what can they do, and is that something that works for us?' They know what we need."

Without offering specifics, Pelosi said that even after the reconciliation process, House members might attempt to pass further legislation to revise the Senate bill. "On a separate track, we'd want to do some of the things that you can't do under reconciliation but that you can do free-standing," she said. But, with Brown's victory, any free-standing health legislation could be blocked by a Senate Republican filibuster.

One of the key words in the question above is “easiest.” Obviously, one of the most effective ways to bring uninsured Americans into the healthcare systems would be to pair insurance reforms – including an end to pre-existing health conditions as a barrier to coverage – with an individual mandate. Interestingly, far from opposing such reforms, leaders from the health insurance industry were proposing these policy changes even before President Obama was elected.

Enacting these reforms, while being just as necessary, is no longer easy. Opposition to the individual mandate has grown on both the political right and left. Ideally, during the months spent on the health reform process, policymakers would have been communicating to the American people on the importance of all citizens having health insurance in order to keep rates affordable for everyone and the system sustainable. Instead, much of this time was squandered squabbling over a public option proposal that brought a great deal of divisive heat to the debate without shedding illumination on the best course for our future.

Even if the atmosphere in Congress right now doesn’t allow the aforementioned insurance reform-individual mandate solution, there are still smart, cost-effective steps that lawmakers should take to reduce the uninsured rolls.

• Eight of every 10 uninsured Americans live in a household in which at least one member draws a paycheck. In half of these instances, the working individual is offered health insurance by an employer but turns it down because they can’t afford their share of the premium. Federal subsidies could bridge the gap between what working Americans can afford and the money their employers are willing to put on the table. We need to do a better job of leveraging the health coverage contributions that many business owners are willing to make.
• Congress should support a sensible increase in Medicaid eligibility, up to 100 percent of the federal poverty level. The much larger thresholds called for in both the Senate and House health reform bills would bring millions of Americans into the Medicaid program at a time in which many physicians can’t accept Medicaid patients due to the low payment rates. Also, in the current economic environment, states can’t afford the future financial obligations (presuming that the so-called Cornhusker Kickback isn’t spread to the rest of the union).
• One commodity that has been seriously overlooked in the health reform discussion is outreach. We have millions of adults and children eligible for Medicaid and CHIP that are not enrolled. Two years ago, we conducted an initiative at the Healthcare Leadership Council called Health Access America. In 10 U.S. cities, we established networks with community organizations and used those alliances to attract uninsured individuals and small business owners to forums where we provided information about health coverage options and had experts on hand to assist with enrollment in public programs or application for private insurance policies. In just a few months, our relatively small project reached over 34,000 people, and nearly one of every two people we touched ended up with either private or public health coverage. Imagine the strides we could make if meaningful federal resources were devoted to this kind of effort.

The members of the Healthcare Leadership Council continue to support comprehensive health reform that elevates both the quality and the accessibility of healthcare. But, even if the current political dynamic delays that progress, there are steps that need to be taken to open the doors to high-quality healthcare for Americans currently without coverage.

If Washington is in fact going back to the drawing board, politicians need to get themselves clear on what the actual objectives are. Is it the uninsured, the fact that the United States is the only country without universal, third party coverage? Is it the out of pocket cost of insurance and health care to American households? Is it the amount of total private and/or public sector spending on health care, most of it “off-budget” from the American household and therefore obscured from the day to day finances of Americans? Is it the alleged inefficiencies of the small employer and individual insurance market? Is it the struggle that individuals without insurance and with preexisting conditions have in securing coverage?

The 46.3million uninsured of which 8 million are chronically ill without insurance for two years or more, get much focus, yet the fact remains that 8 in ten Americans—and 9 in ten voters—have third-party coverage. For them, the loss of something they like—or significantly increased price for it—will outweigh the promised benefits of expanding the insurance pool. On a hierarchy of needs, a job with good pay is far more important than a job with decent pay and health insurance. I believe that for most Americans, the kitchen table focus is on dollar cost to their family budget and the insecurity of losing coverage when they need it.

One productive place to focus efforts is on state high risk pools and HIPPA coverage. Once someone is covered for insurance in the United States, they should be able to maintain coverage, provided they pay into the system. Congress addressed this with HIPPA and COBRA, yet it’s not well understood or, in fact, widely used in the marketplace. If this safety net was working properly, even a person uninsurable from birth could maintain private insurance throughout their lifetime by moving from parent’s coverage to their own work or individual coverage. The key is that they’d have to stay insured—even when it appeared they didn’t need it or funds were tight—or they’d lose the right to re-enter on favorable terms.

This area is not sexy, the details are complicated, and it involves three and perhaps four layers of bureaucratic players. Yet for politicians serious about extending coverage that protects real people without moving to a government dominated system, the payoffs could be big.

I do not believe we should be entertaining calls for incremental reform because neither policy nor politics support a piecemeal approach. The policy argument is simple – you cannot reform the insurance market without a requirement to purchase coverage; you cannot require people to purchase coverage without subsidies; and, you cannot (and should not) finance coverage expansion without reforming the delivery system.

The politics are flawed as well. The idea that somehow incremental reform will give way to bipartisan compromise is naïve at best. Most of you know that I am and will always be for bipartisan reform. It is very difficult for America to take major steps toward solving its largest problems without bipartisan consensus. I must say, however, even I do not know what bipartisan health reform means in 2010.

Senator Max Baucus and the Finance Committee tried about as hard as you can try to meld what should be our common goals – how to get all Americans covered at a cost that families, employers, and governments can afford – into legislation capable of achieving bipartisan support. The “Group of Six” – Baucus, Conrad and Bingaman for the Democrats, Grassley, Enzi and Snowe for the Republicans – met over 30 times for more than 60 hours by one official count. Staff and eggheads spent countless additional hours in the name of bipartisan reform. Yet in the end, only Senator Snowe supported the Finance Committee bill and even she voted against the version considered by the full Senate. Even still, at least Snowe and her Maine-colleague Senator Collins remained engaged throughout the Senate process. I do hope they still might be willing to devise a way forward.

Sadly, however, most Republicans appear to have adopted the DeMint strategy – say the bill is socialism and just keep moving on a scorched earth rhetorical strategy to destroy the Obama agenda as imagined by the tea baggers. In particular, it makes me sad to hear people as knowledgeable as Senators Grassley and Hatch speak out against changes to the Medicare program. They know Medicare is going broke. If you are not going to drive Medicare toward value through payment policy, how are you going to make the program solvent so it will be there for all seniors in 20 years? These senators and others know better than the RNC talking points.

This rhetoric is one example of why I distrust current offers of bipartisanship. In order to achieve bipartisan reform, Republican leadership must be sincere about solving our problems. Currently, this is simply not the case. Government is required to solve our health care problems. Republican leaders seem unwilling to admit this. The truth is you cannot solve insurance market or delivery system problems without some additional government involvement. The government must play some role in setting market rules to prevent insurers from denying coverage to the sick, in financing the subsidies necessary to make insurance more affordable for many, and in changing incentives and information so that providers embrace value instead of volume to lower cost growth and improve quality.

You can do all of this without initiating a government “takeover” of health care. Indeed, the current legislation in both the House and Senate is closer to Senator John Chafee’s bill in 1993 (co-sponsored by Senators Orrin Hatch, Chuck Grassley, and Bob Bennett, among 16 other Republicans) than it is to President Bill Clinton’s Health Security Act. But you cannot fix our health care system without expanding our commitment to each other to make quality health care affordable for all. Republican leadership seems dead set on opposing this expanded commitment and I don’t know how you “start over” on health reform without it. So, if bipartisan legislation includes serious discussions about how to cover all and improve delivery system value, fine. But if it just involves watered down window dressing that compromises the health of our people and economy as well as an implicit agreement that the tea baggers are right on health care when they are in fact manifestly wrong on many levels, I’m not interested and Democrats should not be either.

Congress should pass the Senate bill and amend it in a reconciliation sidecar that enshrines a critical mass of the conference agreement worked out before the special Massachusetts election. Then, Democrats should explain the bill to the American people over the next 10 months, being sure to contrast it with the full implications of Senator Mitch McConnell’s plans for America’s health care system.

Congressman Dingell is exactly right. We need comprhensive reform and we need it now.

As I explained before, Democrats won't win politically by scaling back (have you seen even one Republican who's said they're interested in a bipartisan health care bill in the Senate?), and they won't solve the crushing moral and economic problem that is our health care system without systematic change. But I'll let others take up the argument.

The Associated Press' news analysis is almost all you need to read:

Trimming back the 2,000-page, trillion-dollar Democratic health care bills to the parts that average folks understand and like may not be as simple as it sounds.

A complete ban on insurance companies denying coverage to people with medical problems would be out of the question. Forget about guaranteed health insurance for all Americans - it costs too much. Still, Congress might be able to craft legislation that takes some rough edges off today's coverage problems and makes progress in controlling costs.

That's if Democrats and Republicans can call a truce.

Republicans, who for months have been urging "commonsense" alternatives to the Democrats' sweeping overhaul plan, may still be unwilling to help pass anything that lets President Barack Obama claim an election-year victory. They'll have 41 votes in the Senate to block it once Massachusetts' Scott Brown is seated.

Yet the nation's health care system is unlikely to heal itself. The number of uninsured will rise above 50 million unless government steps in, while ballooning costs could leave the baby boom generation with a bare-bones Medicare.

…

Obama has suggested shifting the focus to popular proposals like banning denial of coverage to those with medical problems. That particular fix is unlikely because it would encourage people to put off getting insurance until they're sick, driving up premiums for everybody else.

"In health care, everything fits together," said Sen. Jay Rockefeller, D-W.Va. "It's very hard to say we can cut this out and do that." Banning pre-existing condition denials would have to go hand-in-hand with coverage for all.

Karen Tumulty echoes the point in Time:

The basic premise of insurance is shared risk. But if a disproportionate number of the people who have it encounter a catastrophe, everyone ends up paying so much that they might as well not be covered at all.

Take the "community rating" laws that five states have passed. They sound great; everyone pays the same premium, regardless of their individual health history. But absent a requirement that everyone have insurance, what they have done is drive up the price of premiums–an additional 40%, estimates Massachusetts Institute of Technology economist Jonathan Gruber, who is also a technical consultant for the Obama Administration.

That is because these kinds of well-intentioned smaller reforms create a vicious cycle:

*Sick people buy insurance. What choice do they have?

*Healthy people, knowing they won't be discriminated against if they get sick, decide to go without coverage.

*Insurance companies, which are footing the medical bills for a lot of sick people without offseting premiums from healthy ones, raise their rates.

*Even more healthy people decide to drop their insurance.

* With an even sicker pool of people, proportionately, insurance companies raise their rates more …

The lesson has been that, unless you have pretty much everyone covered, insurance reforms won't work. "What many people don't understand is there is a very high level of interdependence among the parts. The legislation that is in front of Congress now is incremental reform," says Princeton University public affairs professor Paul Starr. "You just can't go down much further than this."

Say, for instance, you pass a bill that makes it impossible for the insurance companies to discriminate against sicker and older people. "You're going to make it expensive for young people to get insurance, especially with the inefficient individual insurance market we have today," says Starr. "Basically, health insurance becomes just a very bad deal for young people." And without healthy people in the pool of those covered, it also becomes unaffordable for sick people, too.

Steven Pearlstein backs them up from the Washington Post opinion pages:

One reasonable-sounding idea is that the president should reduce it down to just a few of its most popular provisions, such as the one requiring that insurance companies be barred from refusing to cover people with preexisting conditions or charging them sky-high premiums.

The problem with that, of course, is that if you don't require everyone to buy insurance, then there will be lots of people who will wait to buy their policies until they get sick and then demand coverage at the "community" rate. That's a great way to drive up premiums, which in turn will drive even more healthy people to drop coverage, which will raise premiums even further.

To prevent this kind of debilitating "insurance spiral," you could add one more feature — a mandate requiring everyone to buy at least a basic insurance package. Unfortunately, there are lots of low-income households for which the newly mandated premiums could eat up as much as a half of after-tax income, which hardly seems fair. So you'd probably want to make sure that there's enough competition among insurers to keep premiums down, which is what those government-supervised exchanges are all about. And you'd want to have some subsidies to limit the financial hit to low-income families. To pay for the subsidies, you'd either have to raise taxes or cut spending in other areas.

And that, basically, is the outline of Obama's health plan, just as it was Clinton's health plan and the Nixon plan before that. In fact, if you want a health-care system that's universal and affordable and based on a competitive market of private insurers and health-care providers, that's pretty much where you have to start. There is no simple solution to this puzzle.

That's the policy argument. But there's airtight political reasons Democrats must pass real, comprehensive reform that works for everyone in America, too. We'll start with David Axelrod, the President's own political adviser:

We need to move forward aggressively, continuing on job creation, and on financial regulatory reform. But we should finish health care because the caricature of that bill is there and everyone who voted for it will have to live with that. The way to deal with that is to pass the bill and let people see… the value of it.It is not just getting the achievement under the belt. I think there are tangible benefits that people will accrue across this country as soon as this bill is signed. They will have more leverage, have more prescription drug coverage, Medicare is going to be extended by a decade… If we don't pass it and [Obama] doesn't sign it than the caricature created by the insurance industry and opponents in Congress will prevail and everyone will have to live with that. There is no political sense to that and I hope people will see that and move forward.

Jon Cohn has a letter from a "veteran Democratic strategist" saying the same thing:

Now is the time to write stories about how strategically and politically insane it would be for the House to not find a way to pass the legislation.

If they fail to do so, the Republicans will be the writers of history–because the victors, not the vanquished, get the pen and the paper to do so. They will get to define what was in it and why it died. And this will have implications not just about the past but the future. Republican will say, and more effectively (but no less inaccurately) than ever, that, given the chance, the Democrats will be right back at it again with their "evil, secret fantasy to take over the health care system." They will more successfully (and inaccurately) define "it" as being a deficit busting, government take-over that will ration care and harm seniors.

Democrats have to understand that virtually all of them have already voted for a bill that will therefore be defined by the Republicans. As such, they–and even those Democrats who did not vote for the bill–will be linked to that party that embraced to "Obamascare." And, for those who are completing embracing a fall-back, small-ball approach, think again. That seductively tempting option won't come to pass either. Why? Because the Republicans will work to ensure it does not.

Mike Lux agrees:

If the Democrats turn from this path and give up on comprehensive reform after spending the last year working on it and coming so close, it would be one of the greatest tragedies in American history, a historic failure of nerve so unforgivable that I think it might literally break the party in two. If after spending a year on this, and putting Democrats' votes on the board in both houses in favor of it, they walk away and get nothing, they would be seen as utterly incompetent by swing and base voters alike. And don't think that going back to the drawing board and trying to get a scaled back bill that "everyone is in favor of" gets anything done. Having been successful by being the party of no, what exactly is it that the Republicans- any of them- would agree to? Olympia Snowe got every single thing she asked for in the Senate bill after delaying the bill for six months, and she still voted no. What makes anyone think she or any other Republican would vote yes for anything in an election year when it's working so well for the Republicans to say no to everything? And how long would it take to work out a deal with Republicans when we tried for a year and not one of them agreed to anything? While I'm asking questions, let me ask another: exactly which voters do Democrats think we pick up by walking away from health care reform after a year of work and already recorded votes on it in both houses? Certainly not the desperately disappointed base. Do Democrats think swing voters will reward them for spending a year on something, and then giving up on it and getting nothing? Swing voters are wanting results and real change. How does delivering nothing changing nothing on the main thing they have worked on the last year help them with those voters?

And Ezra Klein makes the point that if Democrats can't do this, they probably can't do anything:

It's worth taking a step back from health-care reform for a second. What Democrats are doing isn't just abandoning a particular policy issue. They're proving themselves unable to govern.

Democrats spent most of 2009 with 60 votes in the Senate and about 256 in the House. They had a popular new president who was following a disastrous Republican administration and a financial crisis. The opposition party was polling somewhere between foot fungus and spoiled meat. You don't get opportunities like this very often. The Senate majority, in fact, was larger than either party had enjoyed since the 1970s.

…

If Democrats abandon health-care reform in the aftermath of Brown's victory, the lesson will be that they can't govern. No majority within the realm of reason will give them the votes to move their agenda swiftly and confidently. Even the prospect of the most significant legislative achievement in 40 years, an achievement that will save hundreds of thousands of lives, will not keep them from collapsing into chaos when they face adversity.

At that point, what's the pitch for voting for Democrats? That they agree with you? A plumber and I both agree that my toilet should work. But if he can't make it work, I'm not going to pay him any money or invite him into my home. Governance isn't just about ideology. It's also about competence and will. That's where Democrats are flagging.

In 2008, voters across this country voted for change. They voted to end the gaping moral failure of our time - the fact that 46 million Americans lack health insurance, the fact that we spend one out of five of our dollars on health care, the fact that businesses are going out of business and those with insurance going bankrupt because we can't get the insurance companies in line. There is no question that voters want Congress to deliver on sweeping health care reform that finally enshrines health care as a human right in this country.

Congress must deliver. They can't deliver small - you can't do the "popular" things without going big. And Democrats can't under-deliver (or fail to deliver) for the American people if they expect to keep their jobs.

There is no excuse. Democrats have a huge majority in both Houses of Congress, and both Houses have already passed a health care bill. We simply need to finish it right - fix the excise tax so we don't tax middle class workers, fix subsidies so health care affordable to everyone, hold insurance companies accountable with strong regulations and a public option, and make sure health care is affordable at work by asking employers to pitch in their fair share.

It doesn't much matter how reform gets fixed and passed (the reconciliation fix going through with the Senate bill seems the most likely right now), only that it's fixed and passed now.

Lots of things could be done – both big and small. Here are ten ideas, for starters.

Problem is, successful reform requires a 180˚ shift in the way Congress is thinking. To solve the problems of cost, quality and access we need to liberate people – 800,000 doctors, 300 million patients, etc – so they find it in their self interest to achieve low-cost, high-quality, accessible health care.

In health care, public policies do not solve problems. Third party bureaucracies do not solve problems. Government agencies do not solve problems.

Only people solve problems.

When we set out to address the health crisis the nation faces, we determined it was imperative to accomplish two important goals—improve the health care currently enjoyed by millions of Americans and make the dream of access to health care a reality for the millions of Americans currently without it. I have long advocated the moral need to lower the ranks of the uninsured. However, over the years, it has become more and more apparent, that there are also economic reasons to do so. The health of our people, businesses, and medical institutions depend on it. The health reform bill which passed the House last November substantially lowered the ranks of the uninsured, providing coverage for 94% of the population. The Senate bill reaches a similar percentage.

Coverage, in both the House and Senate bills, was accomplished through a variety of means—expanding Medicaid eligibility for the low-income; providing affordability credits to help individuals afford private insurance, and strengthening the Medicare program for the elderly. I am confident we effectively leveraged both public and private programs to achieve our coverage goals.

Some things may have changed in light of the Massachusetts special election Tuesday, but one thing that hasn’t changed is the health insurance crisis in America. We must address this crisis. Health care costs are unsustainable; they’re still crushing families, small businesses and large companies. When people lose their jobs they lose their health insurance. People who do have jobs and want coverage and find out they have a pre-existing conditions still can’t get coverage. Businesses large and small continue to tell us how they’re going to have to drop coverage for their employees or go out of business. All of these problems remain, and so does our need to address them.

Make no mistake, the economy and health care reform are directly related, and we can and must focus on both at the same time. Reforming health insurance is key to whether employers will hire or not. Reports show that reforming health insurance will create millions of jobs over the next decade. It will help us reduce the deficit by billions of dollars.

I have been fighting for comprehensive, affordable health care reform for 53 years, building off of the effort my father started with President Truman. If this were easy, it would have been done long ago. The path to reform has been made more difficult by Tuesday’s election, but it has been made no less urgent of a cause. I will continue to fight for key reforms that deliver quality, affordable health care for the American people and bring security to Michigan’s families and businesses.

We are closer than we have ever been to enacting meaningful health care reform, and cannot abandon ship now. The best thing we can do is take a deep breath, regroup and move forward.

Saying “no” is not a solution. We must work swiftly on reviving our economy, which also means stabilizing our health care system.