A problem that seems to be getting lost in the current confusion over the fate of health reform legislation is something that has little to do with party or ideology, much less with the details of health policy. It’s cameralism.

To put it simply, members of the U.S. House and the U.S. Senate have very different perspectives, mistrust each other’s motives, and rarely communicate. In general, they don’t much like each other. They live and work in two very different institutional cultures, and with the exception of House veterans serving in the Senate, they don’t go to much trouble to find out how the other chamber functions.

Much of the time this “cameralism” is background noise in the legislative process. But when it comes to the kind of highly complex, trust-based maneuvers that health care reformers are talking about this week–you know, House passes Senate bill with assurance that Senate passes bill “fixing” their own bill via budget reconciliation, somewhere down the road–it’s a real problem that can’t just be wished away. And that’s particularly true in an environment requiring almost total agreement among Democrats in both Houses. Maybe that’s one reason the White House is talking about a “cooling off” period on health care reform.

This item is cross-posted at The Democratic Strategist.

In the wake of Tuesday’s Republican victory in Massachusetts, Scott Winship wrote a post here that expressed hope that “liberal pundits” would finally get out of “denial” about the unpopularity of health care reform.

Now as Scott knows, there’s always peril involved in making generalizations about the views of large classes of people. I don’t know which “liberal pundits” he’s thinking about in making the suggestion that there’s a general unwillingness to accept public opinion data on health reform; the links he offers don’t really support the claim. But most of the “liberal pundits” I’ve read in recent months don’t dispute the fact that public support for the particular legislation being discussed in Congress at any given moment has been flagging (though given the very fluid nature of the legislative process, it’s difficult to identify which version the public is reacting to, which is why the variations in the wording of polling questions on health reform so often produce different results).

Scott goes on to mock particular arguments that he views as rationalizations for this alleged unwillingness to accept reality: voters are uninformed, Republicans have misled them, and in any event, a significant part of the opposition to health reform bills is “from the left.”

Are these really just rationalizations? I don’t think so. Poor public information on health reform and Republican lies about “ObamaCare” are germane for the simple reason that public opinion may well change if health reform is enacted, and lo and behold “death panels” aren’t convened, Medicare benefit cuts don’t happen, and “government” does not in fact “take over” health care. And the “opposition from the left” data point is relevant to nervous Democrats in Congress because voters unhappy with the absence of a public option, for example, are not terribly likely to vote for Republican candidates who favor voucherization of Medicare or oppose regulation of health insurers.

Scott also seems to assume that “liberals” who talk about the “will of the majority” being frustrated by the de facto 60-vote requirement in the Senate are talking about public opinion. But all the examples he cites are in fact discussing the “will of the majority” of senators, and the majority of the population they represent. The rules of the Senate, after all, cannot be adjusted daily based on tracking polls of the relative popularity of this or that piece of legislation.

Finally, there’s the apparent motivator of Scott’s post: the Massachusetts results. Should the strong opposition of Scott Brown voters to health care reform (at the federal level, at least) represent an “aha” moment for those with any doubts about public opinion on this issue? Again, I see no atmosphere of denial on the subject; yes, many observers, myself included, have noted that a lot of different things were going on in Massachusetts, and have argued that it was not all just one vast referendum on health reform in Congress. But more to the immediate point, the relevance of the Massachusetts results to public opinion nationally is significantly damaged by its unique status as a state that has already enacted reforms almost identical to those attempted by the pending legislation in Congress. And this, in fact, was Scott Brown’s number one talking point on health care reform: why should Bay State citizens pay taxes to give Nebraska the benefits Massachusetts already enjoys? That’s a pretty compelling argument, on the surface at least, but it’s not one that can be made elsewhere.

Ironically, Scott closes his piece by suggesting that perhaps congressional Democrats should put aside fears about public opinion and enact health reform legislation anyway. In doing so, he reflects the real debate I’ve been hearing among “liberal pundits” for many months now: when given a historic opportunity to achieve a long-held progressive goal which happens to represent an immediate national challenge, should Democrats defer action until public opinion is completely on their side? What’s the point of running for office as a progressive if you aren’t determined to achieve progressive policy goals when you can? Is there any other approach to health reform that might be more popular? Is there any time like the present for action?

These questions don’t automatically answer themselves, but I don’t think it’s fair to suggest that health reform advocates are in denial about the political risks involved in health care reform, particularly at a time when Republicans are absolutely refusing to cooperate, and when much of the beltway commentariat has been telling the president for months that he should abandon all goals other than agitating the air for more jobs and lower deficits.

Progressives need data-driven critics like Scott Winship who are willing to contribute to our debates with sometimes troubling information. But in this case, I suspect, to use an old southern expression, he’s just goosing a ghost.

There was a point yesterday when it sure looked like Scott Brown had managed to kill federal health care reform without setting foot in Washington. Senate Democrats were busily disclaiming any interest in further action on a potential House-Senate conference committee report before Brown could arrive to joyfully join a filibuster and impose the will of the minority. House Democrats were refusing to consider passage of the Senate bill (which could avoid the necessity of a conference committee report and another Senate vote) without iron-clad assurances of future action to change objectionable features (e.g., the “Cadillac tax” which unions hate, and language restricting abortion). Such assurances did not seem to be forthcoming from Senate Democrats. And no one knew where the White House was, though rumors abounded that the president had told a reporter it was time to go back to the drawing board and try to enact something less ambitious.

All this was happening as conservatives in effect snaked-danced through the streets hailing Brown’s victory as the largest political event since, maybe, World War II, and the effective end of the Obama presidency.

The general malaise among health-care-reform-minded progressives was probably best expressed by The New Republic‘s Jonathan Cohn, who has been an eternal optimist about prospects for eventually getting legislation done. He published a piece late yesterday bewailing the White House’s apparent drift, with the bitter title: “Where’s the Obama I voted for?”

As often happens, though, the panic subsided, and things look more hopeful today. Turns out the president’s comments were vague but resolute about pressing forward on health reform. Senate Democrats are not walking away from health reform, and House Democrats have stopped making angry comments about the impossibility of getting acceptable assurances from the Senate about future action in order to facilitate passage of the Senate bill. It still will be complicated to put together a “deal” that both progressives and moderates in both Houses can live with, but it seems to be sinking in that failure to enact anything, after so many Democrats have already cast votes for reform and made themselves targets for conservative attacks, is just not an acceptable outcome.

So the conservative exultation over “the death of ObamaCare” may be a bit premature. We’ll know soon enough.

This item is cross-posted at The Democratic Strategist.

As the entire political world looks to Massachusetts today to see what its voters (or at least those willing to vote in a special election) do about an open Senate seat, Republicans, of course, are excited by the possibility that they can kill health care reform by denying Democrats the 60th vote they need for final passage of the reform plan in the upper chamber. But it kinda makes you wonder why in all the obsessive coverage of the MA race, we aren’t seeing the last Republican to win a major statewide office in the Bay State: you know, Mitt Romney, supposedly the front-runner for the 2012 GOP presidential nomination.

Politico‘s Alex Isenstadt raises that question today, and the bottom line is that, well, Romney’s just not that popular in Massachusetts:

Romney’s White House run, said Jeffrey Berry, a Tufts University political scientist, left a sour taste in the mouths of state voters.“Mitt Romney is an unpopular former governor. He left the state to run for president and people feel he was insincere when he ran for governor in the first place,” said Berry. “He hasn’t really been a part of Massachusetts political culture since he left office. I think people thought he ran for office merely to run for president.”

Andrew Smith, director of the University of New Hampshire Survey Center, explained that voters in Massachusetts had recoiled after Romney took a sharp right turn on social issues during the presidential campaign — and the former Massachusetts governor went so far as to criticize his home state over its legalization of gay marriage.

“He sort of lost credibility among voters in the state,” said Smith.

This certainly helps explain why Republican candidate Scott Brown hasn’t been anxious to recruit Romney to run around the state with him, but there may be something else going on that is keeping Romney out of the picture: Brown’s support for the Massachusetts health system, which is by all accounts a major albatross for Mitt in his future presidential aspirations.

After all, Brown’s number one talking point in recent days has been that his state doesn’t need federal health care reform because it’s already enacted a strikingly similar set of reforms on its own. National action, he argues, will just mean Massachusetts taxpayers will have to help other states get up to speed in covering the uninsured.

This may be an effective argument in Massachusetts, but it’s not terribly appealing to Republicans elsewhere, who typically view the kind of reforms enacted under Romney’s leadership in the Bay State as rampant socialism. The last thing Romney needs is to put himself in the middle of that particular debate.

And so, irony of ironies, the most famous Massachusetts Republican is out of public sight on the day when Massachusetts could give the GOP a very famous victory. That doesn’t bode well for Mitt’s 2012 prospects, and for that matter, for Republican claims that a Brown victory can be exported elswewhere–say, to the 49 states who haven’t enacted a health care reform initiative much like the one they are trying to kill in Congress.

This item is cross-posted at The Democratic Strategist.

Whatever happens today in Massachusetts, congressional Democrats must pass a health care reform bill. There is a lot more at stake here than curbing medical costs and expanding coverage, though both are crucial. The fundamental challenge is proving that progressives can govern the country.

A win on health care would show that Obama and his party are serious about fixing our broken political system. A loss would make Democrats look feckless and deepen public anger and cynicism toward government.

It’s gut check time for Democrats. If Republican Scott Brown wins the Massachusetts Senate race, some nervous centrists may be tempted to overread the result as a “populist” revolt against health reform or “big government” solutions in general. Some liberals will claim that voters are punishing Democrats because Obama and his party haven’t been radical enough. If only the Democrats had included a public option, or embraced a straight-up single payer architecture, then voters would at last see change they can believe in.

Well, Massachusetts voters seem to have other things on their minds besides health care, like the economy and one-party dominance of state politics. But there’s no doubt that public support for health reform has steadily eroded over the past year. During the 2008 campaign, voters routinely listed health care as their top concern; now only 39 percent favor the President’s reform blueprint.

Although conservative disinformation has taken a toll, the main reason is that Americans are more worried about the economy than health care. And as ordinary families struggle with depleted retirement savings, home foreclosures and double-digit unemployment, they also stew over the billions Washington has spent to bail out overcompensated bankers and inept auto executives. Such “populism,” however, doesn’t fit neatly within any ideological template. People are mad at Wall Street greedheads, but they’re also increasingly anxious about government regulation and deficits, which makes them wary of liberal demands for bolder, costlier initiatives.

Another reason for growing disenchantment with health reform is the process itself. The health care debate has shown Washington at its polarized and parochial worst. It has taken too long and involved endless haggling by an ever-changing cast of negotiators. Too many interests have been accommodated, at the expense of both taxpayers and policy coherence. Win or lose, the coming after-action reports on health reform will surely focus on the wisdom of President Obama’s decision to articulate broad principles and let Congress sweat the details.

Still, in the end, all of us need relief from escalating health care costs, and millions of our fellow citizens need access to insurance. And more than anything else, Americans need to know that our democracy still works. That’s why progressives ought to fall in behind President Obama’s dogged efforts to pass a bill.

“The worst thing to do is nothing,” former President Bill Clinton advised Democrats at their recent retreat. He’s right. Should Democrats lose the Massachusetts seat, they will basically face three choices. One is to speed up efforts to reconcile House and Senate bills and push for floor votes before Scott is seated in the Senate. The second is for the House to pass the Senate bill intact and send it to the President’s desk for signature. The third is to give up. Option 2 is the quickest, simplest and most procedurally defensible course. It’s one pragmatic progressives should support on policy grounds as well, since the Senate bill, though far from perfect, is more fiscally responsible and contains stronger cost control measures than the House version.

Republicans will cry foul in any case, but their credibility is shot. The post-mortems also will show that, by taking an obstructionist stance from the beginning, Republicans foreclosed any possibility of a bipartisan bill. Worse, as health care analysts Bryan Dowd and Roger Feldman argued last week on Progressive Fix, they violated their their own beliefs (for example, by piously denouncing cuts to Medicare providers) and utterly failed to offer a principled alternative.

For House Democrats, especially liberals, having to approve the Senate bill unchanged would be a bitter pill. The bill’s subsidies for low-income workers aren’t as generous, its regulations on the insurance industry are less severe and, of course, it doesn’t include their cherished public option. But they should recognize that their party’s reputation for governing competently is on the line and take one for the team.

For the governing party, winning ugly beats losing ugly. Passing a bill, moreover, is the beginning, not the end, of improving health care quality and delivery in the United States. The government will have to issue new regulations to put the bill’s often vague provisions into force, and like any piece of landmark legislation, it will be tweaked and revised as we go along.

So on health care reform, progressives ought to hang together or – you know the rest.

As Congress makes sausage out of health care reform, Republicans have complained bitterly that they have been excluded from the process. As health economists whose work generally reflects a market-based perspective, it might be surprising to hear us say that exclusion is just what the Republicans deserve. There are three reasons why.

Private health insurance works best for Americans who get it in groups through their employers. But virtually all such Americans know they are only one layoff away from losing their health insurance. If they have a pre-existing medical condition, they will have to pay astronomical premiums for an individual insurance policy, if they are lucky enough to get coverage at all. Those who are turned down can face financial ruin from the cost of illness. Any rational person would want to insure against the risk of losing his or her health insurance, but that is virtually impossible to do in the current health insurance marketplace.

This is a clear case of market failure and it has persisted for decades, yet Republicans simply don’t recognize this as a problem that needs to be solved. The individual insurance market is the source of most of the horror stories that plague and sully the health insurance industry, yet Republicans, who say they want to preserve private insurance, have proposed nothing that would address the problem.

The obvious solution is to impose some type of structure (i.e. “insurance exchanges”) on the individual insurance market, including a guarantee that affordable coverage would be available to anyone who shops in the individual market. State governments would be the natural entities to manage this market, but government involvement, even in the face of clear market failure, is anathema to Republicans. In addition, the Democrats’ mandate requiring individuals to purchase insurance is too much for many libertarian-oriented conservatives to bear, especially if costly subsidies are tied to the mandate. But at least they’re attempting to solve a complex problem, something Republicans can’t seem to do.

The second Republican failure is their criticism of the Democrats’ proposed cuts to Medicare. Part A of Medicare (which pays for hospital care) is scheduled to run out of money in 2017, or sooner if the recession continues to depress federal tax revenues. Young Americans have not mismanaged the Medicare program and don’t deserve to pay the bill for that policy failure. Drastic cuts in the cost of Medicare (coupled with higher premiums and a dramatic increase in price competition at all levels) will be necessary to solve this problem, and the sooner the better. The cuts proposed by congressional Democrats – mainly in payments to hospitals, other providers, and private Medicare Advantage plans – are a tepid attempt to deal with this problem. Like many Democratic proposals, they go hand in hand with a misplaced distaste for private health insurance plans. But vilifying the Democrats on that score, without offering alternatives to shore up the program, is fiscally irresponsible.

The third Republican failure is their knee-jerk criticism of “comparative effectiveness” research. This research aims to discover which medical treatments work better than others. It’s perfectly acceptable to worry that comparative effectiveness research in the wrong hands (like the government’s) could lead to rationing. But blanket condemnation of comparative effectiveness research leaves the impression that the current level of ignorance regarding the effectiveness of medical treatments is an inconsequential feature of the health care system. This is an embarrassment to the party that claims to be a prudent steward of the public’s money.

Republicans need to start listening to their constituents and propose innovative, conservative remedies to the numerous problems that plague the U.S. health care system. People who truly are market-oriented should be able to see market failure when it exists and propose corrections, even when those corrections include a role for government. Since the insurance industry has failed to fix itself, Republicans should have proposed a new set of products that protect people from losing insurance coverage. They should have proposed remedies including regulatory constraints that would lead to more stable and affordable health insurance coverage without the need for government subsidies. Finally, Republicans should have promoted their own proposals to fix Medicare, instead of demagoguing the issue. The Republicans’ silence on these fronts has been deafening – and explains why they deserve to lose the health care debate.

Bryan Dowd and Roger Feldman are professors at the University of Minnesota. They split their votes between Barack Obama and John McCain in the 2008 presidential election.

From The New Republic‘s Jonathan Cohn comes word that congressional Democrats are looking to ditch a formal conference committee to reconcile the House and Senate health care reform bills in favor of informal negotiations — or “ping pong,” as it’s called.

According to one of Cohn’s sources, a House staffer, “There will almost certainly be full negotiations but no formal conference,” noting that there are too many procedural obstacles in the Senate to convene a formal conference. A conference to reconcile the bills would require a series of motions in the Senate that call for votes with full debate, offering Republicans a fresh spate of opportunities to stall final passage of the bill (which you know they will not pass up).

To clarify, ping pong doesn’t necessarily mean that the House has to approve, without any say, the Senate health bill. As Cohn notes, ping-ponging can be used as a generic term for informal talks, with the idea that the Senate and House pass the bill back and forth to each other until they’ve agreed on a final version.

Considering the unprecedented obstructionism that Republicans have shown over the course of the past year, going the ping pong route is certainly understandable. From a policy standpoint, it limits the possibility of the bill becoming derailed as the Republicans stretch the process out and strike fear in the hearts of wavering lawmakers. From a political standpoint, its appeal, even to House Dems who don’t particularly like the Senate health bill, is obvious: it allows them to get the protracted health reform debate over with and pivot to jobs.

For the White House, it seems like a no-brainer: play ping pong, pass the bill, and sign it before the end of the month. That would be in time for President Obama’s State of the Union address, when he can stand in front of the American people boasting of a major victory on health care and charting a new path — jobs, jobs, jobs — for 2010.

The Senate today passed health care reform legislation by a 60-39 vote. It’s a historic achievement, the farthest health care reform has ever come. Progressives should cheer today’s news.

Yet because the legislative sausage-making occurred under the bright lights of the 24-hour news cycle and incessant blogorrhea, the sense of achievement is tempered by disillusionment — even disgust — with a political system that seems designed to chip away at bold reform. Horse-trading and bickering are hallmarks of the legislative process, but we experienced something different with this bill: because of its momentousness, and because of the media ecosystem, more Americans than ever saw more of the process than ever. And what they saw was a politics that seems horribly ill-suited to solving the public problems that face us today.

Even President Obama, who has shown remarkable faith in messy pluralism throughout the entire ordeal, indicated his frustration with the system, telling PBS:

I mean, if you look historically back in the ’50s, the ’60s, the ’70s, the ’80s – even when there was sharp political disagreements, when the Democrats were in control for example and Ronald Reagan was president – you didn’t see even routine items subject to the 60-vote rule.

So I think that if this pattern continues, you’re going to see an inability on the part of America to deal with big problems in a very competitive world, and other countries are going to start running circles around us. We’re going to have to return to some sense that governance is more important than politics inside the Senate. We’re not there right now.

Meanwhile, that up-close view of lawmaking no doubt contributed to the backlash that has emerged in the netroots over the bill. Dissent was not unexpected, but mutiny? That’s what the president faces on the left. On Firedoglake, one the left’s leading blogs, Jon Walker called the bill’s passage “a loss for the country.” Jane Hamsher accused President Obama of throwing progressives under the bus, calling his deal-making “the move of a deeply cynical politician who believes in nothing but shameless manipulation for political convenience.”

The netroots’ disdain for the president seems at odds with the messianic powers they ascribe to him. Apparently, all the president need do is give a speech or sweet-talk a legislator or two and he can get the left whatever it wants. You make laws, however, with the system you have, not the one you wish you had. Navigate the process — the only one we have — is what the president did. The wonder is that this legislation passed at all. Facing a fractious Democratic caucus, a phalanx of industry stakeholders, and — the biggest factor of them all — a Republican Party that has placed its bet on sinking this presidency, the president is close to notching, in the words of The New Republic‘s Jonathan Chait, “the most significant American legislative triumph in at least four decades.”

It’s not over yet. Anguished negotiations in conference will follow. Continued pressure from Republicans and interest groups, the conservative base and progressive blogs, will try to erode the resolve of congressional Democrats. The Republicans in Congress are a hopeless cause — a fact that, more than any other political consideration, should dominate progressive thinking about tactics and strategy. Seek to improve the bill in conference by all means. But attacking the bill with talking points that could easily come from Republicans (A “deeply cynical politician”? Really?) does the progressive cause no good.

Last year’s campaign showed Obama to be a really good closer. An even bigger test now awaits.

So: at about one o’clock this morning, the United States Senate, or at least the 60 members of its Democratic Caucus, passed the long-awaited cloture vote to proceed to a final consideration of a health care reform bill.

As one who has had an irrational faith that the Senate would get to this point somehow or other, I have to say it was still an improbable accomplishment.

As recently as a few days ago, Joe Lieberman looked all but unreachable for this vote. Then Ben Nelson looked unreachable, even as Republicans Olympia Snowe and Susan Collins made it clear they had decided that nearly a year of begging from the White House and Senate Democrats wasn’t enough to overcome the right-wing heat they were experiencing. Then Democrats like Sherrod Brown and Bernie Sanders came under intense pressure to hold up the bill from progressives determined to derail the latest deal and force a recourse to a 2010 reconciliation strategy.

More fundamentally, a 60-vote Democratic Caucus was an exceptionally improbable achievement. It took (a) a near-sweep by Democrats of winnable seats in 2008; (b) a complex deal to keep arch-apostate Lieberman in the Caucus; (c) a favorable resolution of the near-tie vote in Minnesota after months of GOP legal obstruction; and (d) swift action by the Massachusetts legislature to provide for an interim Senator to replace the late Ted Kennedy.

It all came down to a one a.m. vote after a rare Washington snow storm, with Republicans openly praying that someone (i.e., the infirm Robert Byrd of West Virginia) wouldn’t be physically present.

The current conservative caterwauling about a “rushed” vote is pretty hilarious, given the endless delays undertaken by Senate Democrats all summer and early fall in an effort to engage Republicans, the open and notorious GOP strategy of running out the clock (reminiscent of the Bush strategy for securing the presidency nine years ago), and the front-page status of every detail of the legislation since last spring. Does anyone doubt for a moment that if Democrats had gone along and delayed final Senate action until after the holidays, the same people whining about their spoiled Christmas would be demanding the legislation be put off until after the 2010 elections? Indeed, that’s what we will in fact be hearing in January when a House-Senate conference committee completes its work.

That conference committee, and the House and Senate votes necessary to ratify its report, is far from a slam dunk, given House Democratic resentment of Senate deal-making, and substantive disputes on issues ranging from the public option to abortion. But the struggle to get to 60 votes in the Senate makes the endgame of health care reform look manageable by contrast.

This item is cross-posted at The Democratic Strategist.

The never-ending story of health care reform took another turn for the weird this week.

It began with liberals working themselves into a lather over Sen. Joe Lieberman’s threat to scuttle reform unless the Medicare buy-in was dropped. Now Howard Dean, liberal paladin and former Chairman of the Democratic National Committee, is campaigning openly to kill a Democratic president’s top domestic priority. Vermont’s Sen. Bernie Sanders, the Senate’s sole self-avowed social democrat, warns the White House that he is not a certain vote for health reform, though it’s unlikely that he would cast a vote with the Republicans to filibuster it either.

Liberals believe, perhaps with some justification, that Sen. Lieberman has forced changes in the bill simply to spite them. But it has to be said that Lieberman, at least, makes no pretense of being a party loyalist. He crossed the political Rubicon by appearing at the Republican National Convention in 2008 to endorse his friend John McCain. His decision to caucus with the Democrats is a marriage of convenience, so charges of infidelity seem beside the point.

No good purpose is served by the left’s fixation on Lieberman as a kind of progressive Judas. It’s creepily reminiscent of the orchestrated venom directed against the fictional turncoat “Goldstein” in George Orwell’s 1984.

What prompted Dean’s scream on health reform was the decision by Senate leaders, backed by the White House, to drop both the public option and the Medicare buy-in in pursuit of the 60 votes needed for passage. In a characteristically self-righteous outburst in today’s Washington Post, Dean helpfully accused his fellow Democrats of selling out to the health insurance industry.

The rifts among Democrats, coupled with monolithic Republican opposition to the Senate bill, have fed growing public doubts about health reform. According to a new NBC-Wall Street Journal poll, more Americans oppose the legislation than favor it (44-41 percent). Other surveys show that voters are worried that they’ll actually wind up paying more for health care after reform.

The President’s Principles

Now, liberals are understandably angry that Senate filibuster rules effectively give a handful of moderates inordinate power to block progressive measures backed by a majority of Senate Democrats. That’s triggered an important debate – featured here on P-Fix over whether it’s time for progressives to change those rules to either circumscribe or abolish the filibuster.

But it’s also true that liberals should not have expected that the Senate bill include a public option or the provision allowing people as young as 55 to buy health coverage from Medicare. The Senate Finance Committee bill did not include them and Obama promised neither during the campaign. In fact, the president has explicitly ruled out a single-payer approach, instead echoing PPI’s call for a distinctly American approach to universal health care, a public-private hybrid based on the principle of “shared responsibility.”

Many single-payer advocates, however, apparently view the president’s stance as purely tactical; surely, deep down, he’s with them. They see the public option and the buy-in as incremental steps toward a “Medicare for all” approach that ultimately will displace private health insurance.

Obama, however, has been admirably consistent about his top-line goals: expand coverage through public subsidies and mandates; prevent insurance companies from denying coverage or dropping people who get sick; drive medicine toward higher quality and lower costs; and do it all in a way that adds nothing to the deficit. The Senate bill, though riddled with imperfections and compromises, does an acceptable job of advancing those goals and moving the process forward to the final stage: a conference to reconcile House and Senate versions of reform.

So liberals have a choice. They can torpedo a bill backed by a Democratic president and nearly all Senate Democrats, a bill that would cover 30 million uninsured Americans, discipline health insurance companies, and begin the challenging task of containing health care cost growth, in favor of alternatives that stand no chance at all of passage. Or they can pocket the undoubted progressive gains embedded in the House and Senate bills, help their party pass landmark legislation, and keep working to build support in the country for their vision of health reform. Congress meets every year and there will be ample opportunities to refine whatever emerges from today’s legislative scrum.

Despite the public infighting and fratricidal rending of garments, congressional Democrats are only one vote away from an historic victory on health care reform. So progressives should stop obsessing over Joe Lieberman, turn off Howard Dean, and help Barack Obama bring home the prize.

As the Democrats try to pick up the pieces of the blown-up public option compromise and move forward on health reform, some on the left have thrown up their hands and claim that the bill as it stands isn’t even worth passing any more. Cue Howard Dean:

“The Senate version is not worth passing,” former Democratic National Committee Chairman Howard Dean told POLITICO, referring to plans to strip the latest compromise from the bill, a Medicare buy-in. “I think in this particular iteration, this is the end of the road for reform.”

Dean said there are some good elements in the bill, but lawmakers should pull the plug and revisit the issue in Obama’s second term, unless Democrats are willing to shortcut a GOP filibuster. “No one will think this is health care reform. This is not even insurance reform,” he said. [emphasis mine]

Does Howard Dean really think that Obama is a shoo-in for a second term — and, on top of that, will face a more favorable Congress then — if the health reform effort collapses? That the bill’s failure now would lead to better chances for passage later? As Kevin Drum wrote, “If healthcare reform dies this year, it dies for a good long time.”

The estimable Nate Silver offers some forceful policy commentary to shake some sense into his fellow progressives, comparing the different scenarios for a family of four earning $54,000 under the Senate bill, under the status quo plus inflation, and under the status quo plus inflation plus S-CHIP. The result, you won’t be surprised, is that the family by far fares best under the Senate bill. Some might rightly argue that the cost is still not so affordable if a member of the family gets sick. But the costs would be debilitating without health reform at all.

Ezra Klein, who’s been banging the drum for passage, gets it right:

“This is a good bill,” Sen. Sherrod Brown said on Countdown last night. “Not a great bill, but a good bill.” That’s about right. But the other piece to remember is that more than it’s a good bill, it’s a good start. With $900 billion in subsidies already in place, it’s easier to add another hundred billion later, if we need it, than it would be to pass $1 trillion in subsidies in 2011. With the exchanges built and private insurers unable to hold down costs, it’s easier to argue for adding a strong public option to the market than it was before we’d tried regulation and a new competitive structure. With 95 percent of the country covered, it’s easier to go the final 5 percent. And with a health-care reform bill actually passed, it’s easier to convince legislators that passing such bills is possible.

Let’s hope progressive activists maintain their perspective on the bill and listen to the wonks (a divide that Steve Benen wrote about yesterday). Medicaid, Medicare, and Social Security all had their inadequacies when originally passed. But those shortcomings were addressed over time. The same would go for health care reform. But first you have to pass a bill.

If you’ll forgive me for egregiously mixed metaphors, I want to draw attention to an implicit assumption among many health care reform advocates related to controlling healthcare spending: that if not for the politics involved, it would be fairly easy to rein in costs.

That’s because, the argument goes, there is easily identifiable inefficiency in the way we currently spend health care dollars. There are enormous regional disparities in, for instance, per capita Medicare spending. What is more, these differences are apparently unrelated to differences in the health of the underlying populations, and they don’t produce better outcomes. Rather, the differences reflect the ways that health care providers diagnose and treat patients in different parts of the country. So say the much-revered Dartmouth College health researchers, whose findings have been fairly uncritically embraced by many on the left.

Politics aside (the difficulty is that one person’s wasteful diagnostic test is another’s life-saving intervention), I always was suspicious of this argument. If there are excess profits to be made, then why is it that providers in only some parts of the country go after them or successfully extract them? Then a fascinating study came out that was mostly ignored but that should have raised questions about the Dartmouth research.

A potential problem with the Dartmouth research is that if there are unmeasured differences in health between patients who go to different providers, then the finding that greater spending is unrelated to outcomes could simply derive from people in worse health being very expensive to treat. The Dartmouth researchers use relatively crude measures to statistically control for these differences (because they are the only ones available).

MIT economist Joseph Doyle got around this problem by looking at patients who needed emergency care while they were visiting Florida. Because there is no reason to expect that unhealthy tourists are more likely to end up in higher-spending ERs, any differences in outcomes between those who went to high-spending hospitals and those who went to low-spending ones should reflect only the spending difference. Doyle found that higher spending did produce better outcomes.

Disparities in Data

Now MedPAC, the panel that monitors how Medicare reimburses providers and makes recommendations to Congress, has released a study that shows that disparities in Medicare spending are quite a bit smaller when other important factors — such as regional differences in wages and extra reimbursement related to medical education — are taken into account (hat tip to Mickey Kaus). If one looks only at per capita Medicare spending, high-spending areas of the country have costs that are 55 percent higher than low-spending areas of the country (I’m talking about the 90^th and 10^th percentiles, for those of you statistically inclined). After making MedPAC’s adjustments, however, that difference shrinks to 30 percent.

Thirty percent might still be considered a big number — in a perfect world adjusted spending shouldn’t differ at all — but other evidence in the MedPAC data gives reason to question the precision of any of these kinds of comparisons. I put the figures for all 404 geographic areas into a spreadsheet (which you can get from me if you’re interested — data wants to be free!) and looked at the top and bottom quarter of adjusted spending.

High-spending areas are dominated by the South, particularly the states stretching from Florida across to Texas and Oklahoma. They also include 15 of the 30 biggest metropolitan areas, including all of the biggest southern and midwestern metros, save Atlanta and Minneapolis, and none of the biggest northeastern or western metros, save Los Angeles, Las Vegas, Phoenix, Denver, and Pittsburgh.

On the other hand, low-spending areas are dominated by the West, particularly Alaska, Hawaii, Washington, Oregon, Idaho, and most of California (with the exception of Los Angeles and San Diego). Also overrepresented are small metropolitan areas in the upper Midwest and Dakotas, in New York, Maine, Virginia, and Georgia. None of the biggest ten metropolitan areas are represented in the bottom quarter, and only four of the biggest thirty are (San Francisco, Seattle, Portland, and Sacramento).

Compare these findings to those of the Dartmouth folks (Map 1). While many of the same conclusions show up in their map, there are some notable differences. Most importantly, California and the Boston-Washington corridor look like they spend a lot more in the Dartmouth map than they do in the MedPAC data (and the Mountain West states look like they spend a lot less).

Fixing Inefficiencies Not a Silver Bullet

If different sets of rankings differ as notably as these two do, then that says to me that there is a lot of noise in these rankings and that perfectly adjusted spending figures would potentially produce a distribution of areas that would look different from either set. In particular, I suspect that it would show that the vast majority of spending variation could be explained by factors that had nothing to do with inefficiencies.

The point is that even discounting the political difficulties of enacting policies that rely on comparative effectiveness research to weed out inefficiencies in healthcare spending, it’s not at all clear that regional variation in healthcare spending is proof that such inefficiencies exist. That’s not to say that there are no inefficiencies, but weeding them out won’t be as simple as making Florida providers act like Minnesota ones.

The views expressed in this piece do not necessarily reflect those of the Progressive Policy Institute.