HCR

I hope everyone had a great Thanksgiving. I thought I'd offer an overview of where things stand regarding health care reform, as best I can tell.

This post by Jonathan Cohn does a great job of setting the scene, so I'll start by quoting it at length:

The ritual is becoming familiar. Health care reform passes a major political hurdle. And progressives don’t know whether to laugh or cry.

Last time, the occasion was a vote in the House of Representatives. Health care reform passed by the slimmest of margins, but not before conservative Democrats had extracted a major concession on abortion rights.

This time, it was a vote in the Senate--not on whether to pass a bill, but whether to begin debating one. This measure, too, passed by the slimmest of margins, but not before conservative Democrats and one notorious independent made clear they were prepared to shut things down later if legislation includes a public insurance option.

It’s no fun to watch this unfold. And yet this is the exactly the sort of drama you should expect for the next few weeks, as the Senate deliberations play out.

The bill Majority Leader Harry Reid introduced last week is not everything it could be--not by a long shot. And progressives will try their best to improve it. But the real battle will be an ongoing rearguard action, to fend off changes from the right--amendments that, in many cases, Republicans will support even though they have no intention of voting for the final bill. Abortion. Immigration. The mandates, for individuals and employers. You name it.

For progressives, victories are more likely to come in the form of ground not conceded than ground gained. Every day that legislation doesn’t get worse is a day to cherish.

That may not sound like much to celebrate. But to get a bit of perspective, glance over to the other ideological corner--where the right, and many of its kindred special interests, are going absolutely crazy. To some extent, they are reacting merely to the possibility that President Obama and his allies will get a political victory. But they are also reacting to the fact that health care reform, even in this highly compromised form, will have an impact.

Reform will mean government meddling with health care in a way it never has before, to discipline the insurance industry and reorient the incentives that make our care so expensive in the first place. It will mean offering financial support to millions--no, tens of millions--of poor and middle-class Americans struggling to keep up with their medical costs. And on and on and on.

That doesn’t mean the blows don’t hurt. Blanche Lincoln’s speech on the Senate floor Saturday was like a gut punch. Her condemnation of the public insurance option was not particularly persuasive, at least not if you believe--as I do--that reform with a public option would mean better, more affordable insurance than reform without one. But her stance seemed unambiguous--and unyielding. Joe Lieberman and Ben Nelson seemed equally obstinate.

Maybe somebody (Charles Schumer?) will find yet another twist on the idea, one that all three would find acceptable. It might even involve a trigger--which, truth be told, may not be as awful as its reputation. The left treats the idea like poison, perhaps because it’s so closely associated with Olympia Snowe and the frustratingly futile hunt for bipartisanship that soaked up so much of the summer. But, at least on paper, you could make the case that a well-designed trigger--emphasis on “well-designed”--could be as, if not more, effective than a poorly designed public plan, which seems to be the only kind of public plan that might possibly get by with conservative Democrats in support.

To be sure, Liberals can flex their muscle, too. Bernie Sanders made very clear, in his own statements over the weekend, that he wasn’t guaranteeing to give his vote--particularly if conservative Democrats (and former Democrats) extract even more concessions.

Sanders is right to play hardball like this, but, at the end of the day, it’s hard to imagine he’d cast the vote to kill health care reform. He simply cares too much about the people even a weakened bill would help. The same goes for Sherrod Brown, who’s emerging as a leading voice for progressives. Their interest in helping their fellow man is, in strategic terms, a great weakness.

But the public option fight--however it turns out--could also help progressives in other ways. Whether out of pique, politics, or principle, Lieberman, Lincoln, and Nelson (and maybe one or two others) want to scream about something--and to have a concession they can claim as their own. If they end up demanding the public option as the price of their support--and I’m not saying I want that to happen--perhaps the rest of the bill can go through relatively unscathed. Or, to put it more starkly, if they didn’t have the public option to attack then it’d be the subsidies, or the price tag, or the insurance regulations. Merely by including the public option in his bill, Reid has increased the chances that the final bill is a good one--even if the public option is gone by the time deliberations are done.

So, to recap, we've gotten through the House, although with concessions to the pro-life crowd that would likely result in all women losing coverage for abortion procedures (Obama stepped in and said it would need to be fixed in conference. "This is a health care bill, not an abortion bill.")

And now the Senate version has made it onto the floor, although to get here a few Senators had to have their vote bought off: Nelson insisted on nixing a provision that would have removed the anti-trust exemption for the health care industry. Landrieu and Lincoln got the more traditional millions of dollars of pork projects to their states. And of course all three along with Lieberman and every single Republican are promising to oppose the bill as it currently stands going forward. (TPM peers into the minds of the fab four of health care obstruction here)

And going forward negotiations will not be taking place on a level playing field. Steve Benen:

We're dealing with a series of upcoming negotiations in which conservative Dems' indifference gives them leverage. In other words, Lieberman, Nelson, & Co. don't much care if this once-in-a-generation opportunity implodes, while reform advocates care very much. These rather obvious bargaining positions create a playing field that is anything but level.

Put it this way: imagine there's a big meeting with every member of the Democratic caucus in both chambers. You stand at the front of the room and make a presentation: "If health care reform falls apart after having come this far, tens of millions of Americans will suffer; costs will continue to soar; the public will perceive Democrats as too weak and incompetent to act on their own agenda; the party will lose a lot of seats in the midterms and possible forfeit its majority; and President Obama will have suffered a devastating defeat that will severely limit his presidency going forward. No one will even try to fix the dysfunctional system again for decades, and the existing problems will only get worse."

For progressive Democrats, the response would be, "That's an unacceptable outcome, which we have to avoid."

For conservative Democrats, the response would be, "We can live with failure."

This necessarily affects negotiations. One contingent wants to avoid failure; the other contingent considers failure a satisfactory outcome. Both sides know what the other side is thinking.

Ezra Klein follows up on this point:

I think a lot of folks imagine this as a negotiation, in which both sides want to get to yes, and so everyone is involved in a complex game to signal their comfort with failure in order to strengthen their ultimate bargaining position. But that's not an accurate depiction of the process.

If this is comparable to any form of negotiation, it's a hostage negotiation. The hostage-takers might not prefer to kill the kid, but there's definitely some upside to killing the kid, as it strengthens them in future negotiations. Conversely, the people on the other side of the phone don't want the kid to die, but also don't want a situation in which hostage-taking is encouraged. Generally, you try and resolve that by killing or capturing the hostage-takers, but that's not really an option here, with the closest analogue being a kamikaze primary challenge against Blanche Lincoln, which would come too late to affect health-care reform anyway.

And indulge me for a brief moment to consider the especially loathesome case of Joe Lieberman. Peter Beinart:

For close to a decade, he got nearly perfect scores from the American Public Health Association, which backs a single-payer health-care system, and in lieu of that, the “public option.” Now, all of a sudden, he’s so outraged by a public option that he’s threatening to filibuster any bill that contains it. The arguments he makes on behalf of his new position are remarkably weak: He says the public option will raise costs, even though the Congressional Budget Office has said no such thing, and even though logic suggests that by competing with private insurers, a government plan will actually drive costs down. Some have accused Lieberman of shifting right in order to win backing from the insurance industry in preparation for a 2012 reelection run. But, in fact, he gets relatively little insurance money, and Connecticut politicos mostly think he won’t run.

So why is he doing this? Because he’s bitter. According to former staffers and associates, he was upset by his dismal showing in the 2004 Democratic presidential primary. And he was enraged by the tepid support he got from many party leaders in 2006, when he lost the Democratic primary to an anti-war activist and won reelection as an independent. Gradually, this personal alienation has eaten away at his liberal domestic views. His staff has grown markedly more conservative in recent years, and his closest friends in Congress are now Republicans John McCain and Lindsey Graham. For Lieberman, the personal has become political, and it has pushed him further to the right.

What a toad. It's worth remembering that he didn't win his most recent election as a Democrat, but as an Independent, or to be precise, as a member of the "Connecticut for Lieberman" party. This was after losing a primary challenge to Ned Lamont. Normally what happens to members of either party who lose a primary but decide to run as an independent is they lose the perks of party membership: they don't get the advantages that come with seniority, such as chairmanships to important committees. Lieberman, however, managed to hold on to these perks because the Dem Senate leadership needed his vote on procedural matters. The fear was that if they yanked Liebermans chairmanships away he would caucus with the Republicans on these procedural votes. Procedural votes like the fillibuster. And yet here we are: Lieberman threatening to caucus with the Republicans.

When Lieberman first started making noises about joining a Republican fillibuster I thought, "as much as it hurt at the time, it's a good thing we didn't kick him out after 2006 because now we have leverage. We can say 'ok, our party is still granting you seniority even though you ran against the Democratic nominee in your last election, but here's where we get your procedural vote. You are welcome to vote against this bill, but if you want to keep your perks you will allow an up or down vote.'" But that didn't happen. Instead Democrats are saying Lieberman will still not face any consequences, because that would invite him to caucus with Republicans. The thing he is already doing. I mean I suppose it's true he would likely do it even more often than he is now, but I still find it extremely frustrating.

But to get back to passing health care (this is an ambitious blog post!), there are basically two ways of getting through the Senate. Some on the left are calling on Reid to use the Reconciliation process, which is immune to fillibusters. Reconciliation, as it now stands, is meant to be used to reduce the deficit. This strategy has its perils though, as this article explains. Because many of the provisions in the bill do not relate to the deficit it would have to be divided into two bills: one for reconciliation and one for the traditional route. There are all sorts of contingencies and possible ramifications to consider if Reid were to go this route, but for the time being he's stated clearly he has no intention of doing so. If things get desperate he could conceivably change his mind, but for the present let's set this aside simply because it seems very unlikely.

So that leaves us with the regular Senate procedures, which in recent years have come to include default fillibusters for any bill short of 60 votes. Twasn't always so, and there's much to be said about the fillibuster, but for now let's accept it as a reality and consider where that leaves us.

Mark Schmitt:

with a hundred senators, there are in theory, some mathematically unimaginable number of coalitions. But in reality, there are only two: Keep every single Democrat, including red-staters up for re-election and the now unabashedly malevolent Joe Lieberman, or lose one and get Olympia Snowe. There are no other options, and no legislative wheeling-and-dealing will open up any other possibilities.

As a result the Senate feels suffocating. It's easy to fantasize that maybe a tougher or more creative Harry Reid could do something, but even LBJ would be stuck if he drew this hand. The combination of the change in custom -- which involves not just using the filibuster to excess, but pushing to defeat legislation regardless of its content, for political purposes -- and the particular alignment of parties leaves shockingly little room for legislative maneuvering.

Of course, one of the thorniest issues is that of the "public option." An editorial in today's NYT addresses the issue:

It is astonishing, but the question of whether a small slice of Americans should be able to choose between a government-run health insurance plan and private health insurance plans is threatening passage of much-needed health care reform.

Senate Democrats barely mustered enough votes to start debating their reform bill, and some senators who voted to allow debate have said flatly that they will not support the final bill if it retains its public option clauses. If they mean what they say, their defection could make it extremely hard to overcome a Republican-led filibuster.

We got to this juncture because, in an already overheated political debate, no issue has drawn more demagoguery and less rational analysis than the public option. And while both political parties exaggerate what a public plan could do, Republican critics are particularly divorced from reality.

They say the public option would start a government takeover of all health care; interpose government bureaucrats between patients and their doctors; sound the death knell for private insurance; and lead many companies to dump insurance benefits. They also say it could cost taxpayers a lot.

Democrats, meanwhile, claim that competition from a public plan would help drive down insurance premiums and the overall cost of medical care.

We wish the proposed public plan could be powerful enough to demand low rates from health care providers, charge much lower premiums than private plans and attract large numbers of enrollees. But neither the House nor Senate versions would have that kind of power.

P.O. proponents point out that if we pass a health care bill that requires all Americans to have health insurance, as the proposed legislation does, without also providing affordable choices there will be a heavy political price to pay. But will the public option as it now stands in the proposed legislation accomplish it's goal of ensuring Americans have affordable options?

Josh Marshall (bold mine):

There's been a decent amount of discussion of "robust" versus non-robust public options, which has mainly referred to whether reimbursement rates are tied to Medicare rates or independently negotiated. Getting less attention is how many people are even eligible for the public option. I think a lot of people still imagine that what we're talking about is a government-administered health insurance option that you can buy into if you don't like your options in or simply can't access private health insurance at all.

However else that would effect the private insurance market, there's no question that would apply a lot of competitive pressure on private insurers. Such a plan would not, I think, doom private insurers, as they claim it would. But it would dramatically, radically transform the market they operate in. Yet, that's not even close to how any of the plans now on the table would work. The current plans would only be open to a few million people -- basically those who don't currently have private coverage through their employers and aren't eligible for Medicaid. (There are some exceptions at the margins, but broadly speaking that's how it would work.) And at that size, there are good reasons to think that the Public Option would become a dumping ground for what health care policy types call "creaming" -- health insurers wanting to maintain pools of the young and the healthy and dump responsibility for the aged and chronically ill on to public programs or on to nothing at all. Regardless of that, it's pretty questionable whether such a highly restricted public option would provide any significant competitive pressures on private insurers that would yield benefits on the cost containment front. And in part because of this, it's questionable whether the Public Option's premiums would even be cheaper.

Now, there are many people who look at this and say that the bill(s) under discussion are so anemic that they're maybe not worth fighting for at all. And that's certainly a legitimate opinion. But I think there's another question. Considering how down to the wire this is, is it really worth holding up everything else contained in the bill when the point of contention, the public option, is as measly as it is?

For perspective, Robert Reich summarizes the history of compromises made on the P.O. over the last year, and wonders at this point

what more can possibly be compromised? Take away the word "public?" Make it available to only twelve people?

Reich believes we should fight to strengthen the P.O., but given the passage of this whittled down P.O. isn't going to happen, I'm not sure where he sees that going.

So is the proposed public plan worth doing? The NYT believes it is:

Even with the constraints, a public plan could be a useful part of health care reform. Most important, it would compete in markets dominated by one or two private insurers that can charge more and not worry about losing customers.

The presence of a public plan could serve as a brake on unwarranted premium increases by the private companies. The C.B.O. said a public plan with negotiated rates would place “downward pressure on the premiums of private plans.” A public plan would also provide a safe harbor for people who do not trust the insurance industry and would prefer a government plan even if its premiums were higher. And it would be a place to test innovative ideas for controlling costs and improving quality.

The C.B.O., a notably cautious evaluator, could be wrong in its assessments. The plan might turn out to be better at negotiating lower rates. And with no need to turn a profit, it might be able to charge less than private plans and attract millions more people than expected. That could force private plans to lower their own rates.

We are not holding our breath. The public plan could face enormous practical problems entering markets where private insurers already have well-established networks of providers or where hospital groups already have the upper hand in negotiating with insurers.

Even a weak public plan would be better than no public plan. It would expand the choices available to millions of Americans and could help slow the relentless increases in the cost of health insurance. Congress certainly owes Americans a more rational and informed debate.

But the notion that "even a weak public plan is better than no public plan" is actually debateable. Paul Starr of the American Prospect wrote a column last summer about the dangers of a poorly constructed public plan, that seems all the more relevant now:

In the current battle over health reform, progressives may have set themselves up for trouble by pinning all their hopes on the creation of a government-run insurance plan. A public plan is not a bad idea -- indeed, it could be a critical element in successful reform -- but it could also easily turn out to serve the opposite purposes from the ones progressives intend.

The great danger is that the public plan could end up with a high-cost population in a system that fails to compensate adequately for those risks. Private insurers make money today in large part by avoiding people with high medical costs, and in a reformed system they'd love a public plan where they could dump the sick. Although the proposals before Congress aim to limit insurers' incentives to skim off the best risks, the measures are unlikely to eliminate those incentives entirely.

How should a public plan work? According to one model, the public plan would resemble traditional Medicare and have lower costs than private insurers by dint of its lower overhead and greater purchasing leverage, which would enable it to pay doctors and hospitals less. On that basis, it could underprice private plans and attract an immense enrollment (131 million people, according to one estimate).

Some supporters favor this approach because they see it as a step toward single-payer, which is exactly what the opponents fear. Squeezed by the public plan, providers might raise prices for patients insured by private plans, sending those plans into a death spiral.

But a Congress that is not about to adopt single-payer is unlikely to adopt a Trojan horse for single-payer. Some compromise proposals -- such as Sen. Charles Schumer's -- offer a second model, calling for a "level playing field" between private insurers and the public plan, including limits on the latter's ability to flex its purchasing muscle. But tight controls on its bargaining power might doom it entirely if it faces severe adverse selection.

Here's the delicate political problem: Depending on the rules, the entire system could tip one way or the other. Unconstrained, the public plan could drive private insurers out of business, setting off a political backlash not just from the industry but from much of the public. Over-constrained, the public plan could go into a death spiral itself as it becomes a dumping ground for high-risk enrollees, its rates rise, and it loses its appeal to the public at large. Creating a fair system of public-private competition -- giving the public plan just enough power to offset its likely higher risks -- wouldn't be easy even if it were up to neutral experts, which it isn't.

There are a lot of ways to defeat reform, not just by blocking it entirely, but by setting it up for failure. Those who think a public plan is a good idea no matter how badly designed are not thinking ahead.

And since then we've essentially negotiated our way to exactly the kind of anemic public option Starr was warning about. Just this week a new report by the Urban Institute was released suggesting the weakened Public Option won't work. The authors argue it would be wiser to focus on trying to get a robust P.O. in a 'trigger' compromise, so that at least if there ever does come a day in which a P.O. goes into effect it will be strong enough to work.


Politico summarizes the report:

Its authors accept the likelihood of a trigger as proposed by Republican moderates but suggest it be tied to proven government data on national health expenditures rather than some new index to measure the affordability of coverage. And, in effect, the health industry would be given a three- to four-year test period to show its ability to slow the growth in costs.

Failure would trigger a more powerful public insurance competitor than either the House or the Senate has yet embraced — one that challenges not just the market power of insurers but also providers, especially hospitals.

“A strong version is necessary because there is little else in health reform that can be counted on to contribute significantly to cost containment in the short term,” the authors write. A trigger means delay, but “even the threat of such a plan being triggered offers the potential to affect market dynamics between insurers and providers.”

By comparison, if only a watered-down public option survives and costs continue to rise unchecked, both insurers and providers face the prospect of even greater government regulation of private-sector prices, the authors warn. “Indeed, a strong public option competing on a level playing field with private plans paradoxically might be the best 'last chance' for competition to work.”

The timing of the paper’s release, just prior to the Thanksgiving weekend, makes it difficult to assess its impact. But it goes to the heart of two questions now before Senate Democrats: how best to contain health care costs and what’s more important: getting a weak public option foot in the door or reserving the right to come back stronger if the private market fails to slow the rise in spending.

“I would rather have a hard trigger to a strong public plan than settle for a weak plan now that is doomed to fail,” Robert Berenson, one of the three authors, told POLITICO. And this staggered approach, he argued, could also allow more time to learn from the promised experimentation in new payment systems and the comparative-effectiveness research.

“If we need to trigger a public option because health care costs are continuing to rise out of control,” he said, “a good one in five years would be able to learn from the results of these pilot programs and apply the lessons learned.”

McJoan at Daily Kos doesn't think such a plan would get anywhere:

What's baffling is that anyone could imagine that a trigger would be enough to mollify the opponents of a robust public option, particularly a trigger that was designed to actually work. The opponents of the public option want just don't want competition for the private insurance industry. Period. They don't want a public option that would work, and a trigger that might actually be pulled could allow that.

The Urban Institute might be right on the policy question here, but they are seriously misreading the politics of it. If there was the political will for a triggered robust public option, the robust public option would have survived in the House.

She may be right, although I think she overstates her case. Given Sen. Snowe's continued advocacy for a trigger (for a weak public option) I can at least imagine this plan getting somewhere. I think it's worth pursuing anyway.


Matt Yglesias, on the other hand, isn't convinced:

The stronger you make the hypothetical public option, the less likely it seems that the trigger will ever be pulled. The genius of a public option that actually exists, no matter how watered-down or opted-out or whatever, is that it actually exists and whatever good it can do it can actually do.

But I think this leaves out an important political calculation. The reason the P.O. has gotten so much attention is because the whole concept goes to the heart of the difference between liberalism and conservatism: can the government be used to improve people's lives or is government itself, as Reagan put it, the problem. So if a P.O. does go into effect its success or failure will have important political ramifications. A bad public option could be much worse than none at all if it ends up discrediting liberal philosophy more broadly. Because of this I think the Urban Institute's proposal for a trigger tied to a strong public option is probably the way to go. If that fails, I would argue for using the symbolic value of a public option as a bargaining chip for other proposals (for starters, put that removal of anti-trust exemption back in the bill).

But at the end of the day we've got to get this thing passed, public option or no. Even without a public option there's lots of great things in it that will improve the lives of Americans. And the political consequences of failure would be devastating to Democrats. Likewise, the dividends of success are also impressive. Jacob Weisberg considers the bill from Obama's point of view:

The bill he signs may be flawed in any number of ways—weak on cost control, too tied to the employer-based system, and inadequate in terms of consumer choice. But given the vastness of the enterprise and the political obstacles, passing an imperfect behemoth and improving it later is probably the only way to succeed where his predecessors failed.

We are so submerged in the details of this debate—whether the bill will include a "public option," limit coverage for abortion, or tax Botox—that it's easy to lose sight of the magnitude of the impending change. For the federal government to take responsibility for health coverage will be a transformation of the American social contract and the single biggest change in government's role since the New Deal. If Obama governs for four or eight years and accomplishes nothing else, he may be judged the most consequential domestic president since LBJ. He will also undermine the view that Ronald Reagan permanently reversed a 50-year tide of American liberalism.

I found this article by Ronald Brownstein especially helpful in understanding how much good the bill will do, irregardless of the public option. In it he gets into the weeds of whats actually in the bill, interviewing a number of experts who help explain and critique the bill...

When I reached Jonathan Gruber on Thursday, he was working his way, page by laborious page, through the mammoth health care bill Senate Majority Leader Harry Reid had unveiled just a few hours earlier. Gruber is a leading health economist at the Massachusetts Institute of Technology who is consulted by politicians in both parties. He was one of almost two dozen top economists who sent President Obama a letter earlier this month insisting that reform won't succeed unless it "bends the curve" in the long-term growth of health care costs. And, on that front, Gruber likes what he sees in the Reid proposal. Actually he likes it a lot.

"I'm sort of a known skeptic on this stuff," Gruber told me. "My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really make the best effort anyone has ever made. Everything is in here....I can't think of anything I'd do that they are not doing in the bill. You couldn't have done better than they are doing."

Gruber may be especially effusive. But the Senate blueprint, which faces its first votes tonight, also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush and Len Nichols, health policy director at the centrist New America Foundation. "The bottom line," Nichols says, "is the legislation is sending a signal that business as usual [in the medical system] is going to end."

The article goes into the specific mechanisms in the bill and is well worth reading in full, but for the purposes of this post I'll skip the take-away statements:

No one can say for certain that these initiatives will improve efficiency enough to slow the growth in health care spending. Some are only pilots; others would affect only a small portion of providers' revenue from Medicare. CBO typically evaluates them skeptically: it generally scores little or no savings from most of them. Former CBO director Robert Reischauer, who signed the November 17 letter, says that's not surprising. "CBO is there to score savings for which we have a high degree of confidence that they will materialize," says Reischauer, now president of the Urban Institute. "There are many promising approaches [in these reform ideas] but you...can't deposit them in the bank." In the long run, Reischauer says, it's likely "that maybe half of them, or a third of them, will prove to be successful. But that would be very important."

The attempt in all these ideas to nudge the medical system away from fee-for-service medicine toward an approach that ties compensation more closely to results captures how much the health care debate has shifted toward cost-control. So far, the rise in health care spending has proven almost invulnerable to every previous attempt to tame it, like the managed care revolution in the 1990s. Even if Obama signs into law a final bill embodying all these reform proposals, many skeptics wonder if they can bend, much less break, the seemingly inexorable increase in health care spending. Reischauer understands that skepticism, but isn't able to entirely suppress a kernel of optimism that this latest reform agenda may prove more effective than its predecessors. "One never knows whether we're turning the corner or if this is just playing the same old game for another inning," he says. "But I sense there's something different out there. I think the medical profession and its leaders have read the handwriting on the wall and are trying to evolve." If so, the ideas the Senate will begin voting on could mark a milestone in that journey.

There's still a lot of haggling to come before we get to a final vote. And if, for example, the public option were to be nixed its removal would have to get sixty votes. So that means there would need to be something to placate liberals to go along with such a move. Meanwhile the Fab Four are (supposedly) concerned about cost control and the deficit. Lucky for them there's lots of ways to address that going forward, as David Leonhardt explains in the NYT:

All along, these centrist senators— Blanche Lincoln of Arkansas, Ben Nelson of Nebraska, Olympia Snowe of Maine and others — have claimed that containing costs was among their highest priorities. Yet it’s never been clear how serious how they were. Most have not been aggressively pushing cost containment proposals.

The bill brought to the floor last week by Harry Reid, the Senate leader, has offered them a chance to make good on their rhetoric.

On the positive side, the bill includes nearly every big idea that health economists and medical researchers have for slowing cost growth — as well as for improving the patchwork quality of American health care.

But many of the ideas, like the rule on Medicare reimbursement, have been at least partly neutered. A provision to punish hospitals for infecting their patients, for example, would cut payments for the related treatments by a mere 1 percent. A provision meant to help people who don’t like the insurance options offered by their employer would apply to only a tiny fraction of them. A provision to encourage more cooperation among doctors would not apply to the areas where it is needed the most: chronic diseases like diabetes and congestive heart failure.

“There is a lot to like in the bill,” Dr. Alan Garber of the Stanford School of Medicine says, “but it needs to go further.”

Thus the opportunity for those centrist senators: to achieve their stated goal, they don’t suddenly need to turn themselves into health care wonks and rewrite the bill. They just need to improve what’s already there.

Ezra Klein follows up on this idea:

Indeed, the bill is chock-full of cost control opportunities of every shape and size, opportunities that the administration would happily support (they have always been far more committed to cost control than the average member of Congress). The conservative Democrats -- or, for that matter, the many Republicans -- who oppose this bill because they believe it insufficiently committed to deficit reduction have the opportunity to leverage their vote to do more to reduce the deficit than any single senator has in a generation, and possibly in the history of the republic.

But that is where things get tricky: There is a difference between someone who wants to reduce the national debt and someone who wants to use the debt as an excuse for casting a particular vote. It can be hard to identify such people in advance. But it will not be hard to identify them once debate on the health-care bill opens.

Ok, that's all I've got for now. I'm really hoping our guys can pull it together and get something done in the next couple months. We've never gotten this far before, and if we fail it will be years before we get here again. Now's the time to make it happen!