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It's the Building, Not the Blueprint, That Matters

One of the most revealing moments in Saturday's debate over health care reform was when Rep. Anthony Weiner of New York took the floor. Weiner is a rising star in the Democratic Party, having quickly established himself as an unusually engaging speaker. But, in this case, it was Weiner's effective use of a prop that stood apart.

The prop was the handbook for the Federal Employees Health Benefits Plan, or FEHBP--which is, very roughly speaking, a model for how a reformed health care system might work. Once a year, millions of federal workers, including members of Congress, pick one of the many private insurance options available through FEHBP. They can pick plans without worrying that an insurer will deny coverage or charge them more for a pre-existing condition. And, for the most part, they can carry coverage with the peace of mind that it will be there when they need it.

Weiner had brought the handbook in order to make a point. Opponents of health care reform have spent a lot of time complaining about the complexity of health care legislation, in many cases waving around the huge piles of paper it takes to print the full bills. It's a misleading argument: The bills are long in part because the government uses large type and wide margins to print them. And after the experience of the Bush administration, when the president and his allies frequently made policy without thinking through all of the implications, one could plausibly argue that legislative complexity is actually the product of due diligence. This is one-sixth of the economy we're talking about, after all.

But Weiner's broader argument was that legislation matters less than the reality it creates. "There's been a lot of talk about how big the bill is," he said. "Here's what it's all about. This is what members of Congress get."

He's absolutely right.

Ideological arguments about socialized medicine and government takeovers don't have much appeal beyond the conservative base. The rest of the population just wants relief (from rising health care costs) and security (from medical or financial hardship). If reform accomplishes that, they will be happy, no matter how long or complex the actual bill was.

But does Saturday's vote make that more likely? In many crucial ways, yes.

If passed into law, the House bill would, upon implementation, transform the insurance market for people buying on their own and through small businesses--the two groups who struggle most because, unlike large employers, they face stiff medical underwriting (insurers basing prices and availability on medical risk) and must shoulder a higher portion of administrative expenses. It would bolster coverage even at large employers, putting an end to practices like lifetime benefit caps. It would expand Medicaid, offer some people the option of enrolling in a government-run plan, and provide hefty subsidies--putting coverage within reach of people too poor to buy it now. And it would nudge the medical system in the direction of efficiency.

But the transformation would be slow. In order to keep the total federal outlays for coverage at around $1 trillion over 10 years, the House bill wouldn't create the new insurance exchanges--that is, the FEHBP writ large--or start offering subsidies for several years. While it would offer more financial assistance and stronger insurance protection than its Senate counterpart is likely to promise, it wouldn't do as much to reduce the cost of medical care in the long run.

To be clear, the House bill is a great start. It should just be faster, stronger, and--really--bigger.

Of course, critics would object even more if that happened. But, as Weiner says, what they think now is a lot less important than what the rest of the public thinks later on.

This item is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.