Reform for Some

Saturday’s editorial examines how health-care reform seems poised to aid the uninsured and those who can’t get insurance for their employers, but will do little for the majority of Americans who receive insurance through their workplace.

Washington's long effort to overhaul the nation's health-care system is now closer to reality than it ever has been, with five House and Senate committees all passing similar bills. While the plans have their differences, they all indulge in the apparent paradox of completely rebuilding the system – without major change to most people's coverage.

In the end, more people will have insurance and some of the private insurance system's worst cruelties will end – dropping patients for unknown pre-existing conditions once they develop a serious and costly illness, for example. Both outcomes are desirable. If President Obama stands by his word, the bills are unlikely to add much to the federal deficit, which is also a positive. But the vast majority of Americans who get insurance through their workplace – who have little idea how unwieldy a system we have, except to note that year after year, their share of the premiums creeps up and up – are likely to see little relief at all. This opportunity, once missed, may be difficult to revisit.

THE MANDATE Recent controversies center on the bill's new mandate to buy health insurance. Many readers oppose the idea in principle, though the fact that the majority of the country is insured suggests few of us will be directly affected by a mandate. Yet, this mandate enables all the other reforms that are so needed. Reform will force insurers to accept all patients regardless of pre-existing conditions and end the horror stories such as organ donors suddenly becoming ineligible for insurance. Yet, for insurers to be able to afford to cover the sickest patients, the healthy young people now gaming the system by going without insurance must be added into the rolls.

THE EXCHANGE The “exchange” will be a major change, but it's the reform most people know the least about, and again, will be least affected by. Congress aims to build a new marketplace for health insurance plans, either state-by-state or nationwide, creating the type of interstate competition that many conservatives believe will drive down costs. Yet, only the smallest businesses or people who can't get insurance through their work will be able to shop on the exchange for new policies, leaving most Americans with no new choices.

THE PUBLIC OPTION The possible creation of a government-sponsored insurer is the most hotly debated item in the bill, yet the one we feel most ambivalent about. As constructed, the “public option” will be open to only a few Americans, most of whom are uninsured now, and thus poses no risk to private insurers. It's the fact that the government may get some of new business, instead of it all going to private insurers, that has the industry so upset, but so few people will be eligible for it anyway that it is a far cry from the “government takeover” bogeyman so loudly decried.

THE DEFICIT The biggest cost of health reform is the new subsidies to help poorer workers buy insurance. It's offset by a number of new taxes and cost cutting measures that vary by bill but are expected to cost around $1 trillion over the next 10 years. At least one bill is deemed “deficit neutral,” however, cutting enough costs and raising enough revenue to keep from adding to the nation's budget. Despite some trickery in this calculation (cuts in Medicare payments to doctors that often fail to materialize), lawmakers and the public should insist Obama fulfill his pledge not to sign a bill that adds to the budget.

THE REST OF US Has your employer told you what next year's premiums will be? How about next year's raise? Which one's higher? That sad pattern is what's least likely to change for most people even if reform passes, amid everything it accomplishes. More far-reaching approaches – the left's desire for everyone to be insured by the government, or the more conservative attempt to move from an employer-based system to one where individuals all have their own insurance – have largely been rejected for political expediency. What the country will be left with after reform passes is a health system that is better for some people, but about the same struggle for most – and even harder to change the next time around.

In the end, more people will have insurance and some of the private insurance system's worst cruelties will end – dropping patients for unknown pre-existing conditions once they develop a serious and costly illness, for example. Both outcomes are desirable. If President Obama stands by his word, the bills are unlikely to add much to the federal deficit, which is also a positive. But the vast majority of Americans who get insurance through their workplace – who have little idea how unwieldy a system we have, except to note that year after year, their share of the premiums creeps up and up – are likely to see little relief at all. This opportunity, once missed, may be difficult to revisit.

THE MANDATE Recent controversies center on the bill's new mandate to buy health insurance. Many readers oppose the idea in principle, though the fact that the majority of the country is insured suggests few of us will be directly affected by a mandate. Yet, this mandate enables all the other reforms that are so needed. Reform will force insurers to accept all patients regardless of pre-existing conditions and end the horror stories such as organ donors suddenly becoming ineligible for insurance. Yet, for insurers to be able to afford to cover the sickest patients, the healthy young people now gaming the system by going without insurance must be added into the rolls.

THE EXCHANGE The “exchange” will be a major change, but it's the reform most people know the least about, and again, will be least affected by. Congress aims to build a new marketplace for health insurance plans, either state-by-state or nationwide, creating the type of interstate competition that many conservatives believe will drive down costs. Yet, only the smallest businesses or people who can't get insurance through their work will be able to shop on the exchange for new policies, leaving most Americans with no new choices.

THE PUBLIC OPTION The possible creation of a government-sponsored insurer is the most hotly debated item in the bill, yet the one we feel most ambivalent about. As constructed, the “public option” will be open to only a few Americans, most of whom are uninsured now, and thus poses no risk to private insurers. It's the fact that the government may get some of new business, instead of it all going to private insurers, that has the industry so upset, but so few people will be eligible for it anyway that it is a far cry from the “government takeover” bogeyman so loudly decried.

THE DEFICIT The biggest cost of health reform is the new subsidies to help poorer workers buy insurance. It's offset by a number of new taxes and cost cutting measures that vary by bill but are expected to cost around $1 trillion over the next 10 years. At least one bill is deemed “deficit neutral,” however, cutting enough costs and raising enough revenue to keep from adding to the nation's budget. Despite some trickery in this calculation (cuts in Medicare payments to doctors that often fail to materialize), lawmakers and the public should insist Obama fulfill his pledge not to sign a bill that adds to the budget.

THE REST OF US Has your employer told you what next year's premiums will be? How about next year's raise? Which one's higher? That sad pattern is what's least likely to change for most people even if reform passes, amid everything it accomplishes. More far-reaching approaches – the left's desire for everyone to be insured by the government, or the more conservative attempt to move from an employer-based system to one where individuals all have their own insurance – have largely been rejected for political expediency. What the country will be left with after reform passes is a health system that is better for some people, but about the same struggle for most – and even harder to change the next time around.