Health-care reform passed the House, quite literally, at the eleventh hour. It passed with a slim, two-vote margin. But it passed. That is more than has ever happened before. More than Truman or Nixon or Carter or Clinton managed. More than Rayburn or O'Neill or Gingrich managed. It is success, at least for this stage in the process. It is history, even, though it's hard to sense the importance of the moment when you watch members of Congress spend the day squabbling over the true meaning of the word freedom.

But it was also sobering. Harry Reid's job will be harder. Health-care reform passed the House with 50.5 percent of the vote. It will need 60 percent in the Senate. Pelosi had the luxury of losing 40 Democrats. When it comes to beating the filibuster, Reid probably won't be able to lose even one.

Photo credit: AP Photo/Alex Brandon.

The reality is that the debate that led to this bill did not really take place across congressional committees and floor speeches. It took place in think tanks and campaigns. In policy forums and among experts. The basic shape of the House's bill is virtually identical to the bills we saw during the campaign, and they were all expressions of the ideas being developed and refined in think tanks and policy shops and advocacy groups ever since Clinton's effort failed.

And good thing, too. Most members of Congress know virtually nothing about health care. Even the relevant committees only have a handful of knowledgeable legislators. Congress doesn't debate the legislation so much as debate its politics. Watching Congress consider this bill is like watching campaign ads being recorded. It's not like watching people talk about hard issues in a serious way. It's sad, actually.

But it's why, if you take a few steps back, so little has really changed in the basic bill. There's a trope in Washington that Congress should be more deliberative, that it should take more time to "debate" these big issues. But more time spent arguing over the precise contours of the public plan, or the exact language governing abortion coverage, or whether a bureaucrat will pull the plug on grandma, serves neither to enlighten the citizenry nor improve the legislation. Congress hasn't debated health-care reform. It's debated a narrow subject called "the politics of health-care reform."

The bill, however, has been debated, and at length. It has been debated in thousands of op-eds and blog posts. It has been talked through on countless news programs and radio shows. It has been the subject of endless expert panels and summary briefs. It has been estimated, analyzed, and modeled. Graphed and tabled and plugged into spreadsheets. And it has survived intact. It has the support of the Center for Budget and Policy Priorities, and AARP, AFL-CIO and Families USA, SEIU and the American Medical Association. Yesterday, eleven eminent economists released a letter (pdf) calling for passage of the bill.

Few of the debaters think the bill perfect, but most think it a step forward. That, however, is where their influence stops. They are the debaters, not the doers. And they have done their job. Now it is time for Congress to do its job.

The final compromises before a bill comes to the floor are never very pretty. This one, however, is worse than I anticipated. Opposition from anti-abortion Democrats, driven in large part by aggressive activism from the Catholic Church, forced Democratic leadership to allow a vote on Bart Stupak's amendment limiting elective abortion coverage from both private and public insurers on the exchange. It reads:

The amendment will prohibit federal funds for abortion services in the public option. It also prohibits individuals who receive affordability credits from purchasing a plan that provides elective abortions. However, it allows individuals, both who receive affordability credits and who do not, to separately purchase with their own funds plans that cover elective abortions. It also clarifies that private plans may still offer elective abortions.

Because of the limits placed on the exchanges, most of the participants will have some form of premium credit or affordable subsidy. That means most will be ineligible for abortion coverage. The idea that people are going to go out and purchase separate "abortion plans" is both cruel and laughable. If this amendment passes, it will mean that virtually all women with insurance through the exchange who find themselves in the unwanted and unexpected position of needing to terminate a pregnancy will not have coverage for the procedure. Abortion coverage will not be outlawed in this country. It will simply be tiered, reserved for those rich enough to afford insurance themselves or lucky enough to receive from their employers.

The amendment is expected to pass with relative ease. Republicans will join with anti-choice Democrats to push it over the finish line. Once the amendment passes, the bill is cleared for a vote, and all parties expect that vote to succeed. Today looks likely to end with a historic, and important, vote. A vote that is a first step towards helping more than 30 million people secure health-care coverage, and making sure hundreds of millions are better protected from the vagaries of the insurance industry. But Stupak's amendment is a bitter start. It is, however, not the end. Even if it muscles into the House bill, it will also have to pass in the Senate, and then survive conference, before it becomes law.

Photo credit: AP Photo/Alex Brandon.

I will vote yes on H.R. 3962. My vote is not an endorsement of all the provisions of the bill because I find much of the bill to be deeply flawed. There is little chance that H.R. 3962 will become law due to the long legislative process.

My reason for voting yes is to advance the cause of health care reform by forcing the Senate to act. Without passage of this House bill, the Senate could delay reform indefinitely. That would be the worst possible outcome because our current health-care system is not sustainable. Congress needs to pass good health legislation in the next few months for the good of the country.

Passing legislation is a little like writing a term paper in school. The first draft is usually not very good. The second draft is better -- H.R. 3962 is the second draft. The bill that the Senate will vote on will be the third draft, which I expect to show major improvement. The final draft will be written next month when the House and the Senate vote on the same bill. I will continue to work hard to make sure that the final legislation helps all of our families get quality, affordable health care.

This is what passage looks like. Unpleasant compromises. Reluctant congressmen. Ambivalent press releases. Whatever is needed, no matter how painful, to secure the necessary 218 votes and move forward.

2) The meaninglessness of shootings.

3) Health-care strategery.

4) Bruce Bartlett on deficit commissions.

Recipe of the day: A tomato soup that includes blue cheese and sriracha.

The House might pass health-care reform this weekend. Exciting!

One of the more sophisticated arguments against health-care reform is that for all the sharp policies and elegant initiatives contained in the bill, none of it will work because Congress will vote to roll back the cost savings. The evidence comes from Medicare's Sustainable Growth Rate formula, which Congress passed in 1997 but has refused to implement.

As Jon Cohn explains, however, SGR is the exception, not the rule. Congress has passed plenty of proposals that cut costs in Medicaid and Medicare, and stuck to most of them. SGR really is an exception: It was a formula passed when GDP growth was unusually high and health-care cost growth was unusually low. When GDP growth slumped and health-care costs shot back up, following the payment rates set out by the SGR came to look draconian. The problem is that rather than fix the bill, Congress just passed temporary delays. Repeal would have been more honest.

But more broadly, this argument is a form of political nihilism. In the coming decades, one of two things will happen: Congress will cut health-care costs, particularly in Medicare, or the country will go bankrupt. Saying Congress can't cut health-care costs is not an argument against this bill so much as it is a prediction of eventual economic collapse. That might be an accurate prediction, but it militates in favor of trying to rationalize the system before the moment of total crisis, not opposing attempts to do so.

Graph credit: Congressional Budget Office

At Thursday's tea party march protesting government-run health care, a participant suffered a heart attack about 20 minutes into the proceedings. As Dana Milbank reports, medical personnel from the Capitol physician's office rushed over, attaching electrodes to the man's chest and giving him oxygen and an IV.

The Capitol physician's office, unlike the bills being considered in Congress, is actually socialized health care. Government employs the physicians, and taxpayers help pay their salaries. But despite the presence of so many committed free market activists who so deeply fear the consequences of government-provided health care, no one stopped the bureaucrats from treating the protester nor developed a market or volunteer-based solution.

Photo credit: AP Photo/Jose Luis Magana.

In today's column, David Brooks echoes the conservative conventional wisdom that President Obama "is moving too fast," though he attributes the sentiment to independent voters as opposed to himself. As Tim Fernholz notes, however, it's not clear that Obama's moving all that fast. "Since the passage of the American Recovery and Reinvestment Act last winter, the president hasn't convinced Congress to pass a major piece of legislation." Obama signed the stimulus bill into law Feb. 17. Expectations are that he'll sign health-care reform sometime near, or maybe after, December 2009. It's hardly breakneck stuff.

But just as some people like planes and some people like trains, opinions can differ on that. It would be good, however, if people were clear about how fact the political system should be moving.

Take health-care reform. Putting aside the fact that Congress has been intermittently debating this issue since the early 20th century, Ron Wyden introduced his legislation in January 2007. Barack Obama released his campaign health-care plan, which looks a lot like the plans Congress is considering now, May 29, 2007. The Senate Finance Committee officially began examining the issue in June 2008.

Different people could start the clock at different points. If you're tracking Obama, then he's been moving on health-care reform for 29 months. If you're tracking the congressional process, then it's 17 months. If you're tracking the first new bill introduced in this round, then it's 33 months. And of course, you could simply argue that America has been doing this for decades, across the presidencies of Bill Clinton, Richard Nixon, Harry Truman and many others.

Which begs the question: What would an appropriately slow process look like? Be specific.

Photo credit: By Pablo Martinez Monsivais/Associated Press

Democrat Ben Nelson, a Senator from Nebraska, said the slumping economy and rising joblessness will be factors as Congress considers climate change and health care legislation. They are also driving concerns about the budget deficit, which widened to a record $1.42 trillion in the fiscal year that ended Sept. 30, he said.

“When the economy’s not strong there’s a lot of interest in controlling spending,” Nelson said.

It's obviously not very interesting for bloggers to keep quoting senators and then whining about how nobody has read Keynes. On the other hand, it should actually be a problem that senators -- and not just random senators, but key votes with enormous influence over the design of legislation -- appear to believe that the thing to do amidst a slump in demand is remove government spending from the economy, worsening everything from unemployment to child poverty.

What Nelson is literally saying is that "when the economy's not strong there's a lot of interest in weakening the economy," but this quote is carried in Bloomberg -- surely a paper familiar with economic fundamentals -- and there's no evidence that the reporter followed up, or thought this worth a quick comment. I try not to play "pin the blame on the media" too often, but if Nelson were facing a lot of fire for this sort of thing on Sunday shows and being put on lists of the "five worst senators" because he has the central economic principle of the moment backwards, he'd stopped saying this sort of thing, and maybe even stop believing it.

The House of Representatives is expected to vote on health-care reform Saturday. But the days before a big vote are rarely calm ones, and this week has been no exception. Democrats don't expect a single Republican to cross over to vote for health-care reform. That is to say, the Waxman-Markey cap and trade bill, which got eight Republican votes for what amounted to a tax on dirty energy paired with a bazillion (approximately) regulations on energy producers, was more bipartisan than an incrementalist health-care reform bill.

Amazing, huh?

That's left Pelosi's team mired in negotiations with three different types of Democrats who are proving restive at the eleventh hour.

First are the controversialists. This group is concerned about some of the traditionally electric issues: abortion, immigration, that sort of thing. The arguments are largely over language -- in some cases, very small differences in language, and in other cases, very large differences in language -- and most imagine that they'll eventually be finessed.

The abortion argument is centered on a pretty small, and slightly absurd, dispute: how best to cordon off federal funds. Under a compromise suggested by Rep. Brad Ellsworth, for instance, the public plan would hire a private contractor to pay abortion providers. The end result here is likely to be a complicated system in which insurers document that abortions were paid for through the funds that the individual contributed, as opposed to the subsidies. It's all a bit absurd, but it's workable.

Immigration may prove harder. The White House had a meeting with members of the Hispanic Caucus that does not look to have gone very well, with members of the caucus taking a hard line on the inclusion of illegal immigrants in the final bill.

The second group is made up of centrist skeptics. This group is rather better understood, with the final outcomes a bit more predictable. Some are from vulnerable districts and others are simply centrists, but these are the folks who think the surtax on millionaires is deeply offensive to American values, or that the public option goes too far, or that the whole thing is simply too ambitious. These are where you get most of the "hard Nos," the folks who can't be brought on with such legislative tweaks.

The final group is worried about the process. Some are concerned that the Senate isn't going to vote for three months and the House bill will simply hang out and get hammered by the right, leading to the Senate passing a substantially different, and politically safer, bill. If that's going to be the outcome, these Democrats don't want to have to defend a vote on a liberal bill that didn't even make it into law. This group isn't sure they want to vote first, and is all the more concerned given that they don't have assurances from Reid on either his timing or the language of the Senate bill.

There's overlap between these groups, of course. But even amid the last-minute chaos, fairly little is actually in play here. Twists in the language on abortion and immigration. Whether Rep. Anothony Weiner offers a single-payer amendment (he decided against it to spare some of these moderates with liberal bases more pressure and controversy than they're already facing). That sort of thing. The hope remains that the "rule" gets voted on tomorrow, and the bill gets voted on directly afterwards. Delay past this weekend isn't a death knell, but it's not a good sign, and the leadership knows that. The perception of a vulnerable process makes moderates more, rather than less, scared, which makes their demands more, rather than less, insistent.

Photo credit: By Harry Hamburg/Associated Press

Do you believe that the problem is a fee-for-service system where it’s profitable for physicians to increase the amount of care they deliver?

Yes. There’s a profit factor involved in doing more tests and procedures. But believing that to be true and believing that we don’t get care right for patients with chronic disease, I can still tell you that if you go back to the prices and put them to Canadian numbers, the result is our spending plummets.

Structurally, then, your argument is that America’s problem is that there’s not been a price-setting mechanism. Is that because, as some people believe, the players with the power are the providers, not the insurers?

Kaiser is building half a dozen hospitals right now. And we’re building them because we couldn’t buy, in the open market, hospital care for anywhere near what we can make it for.

When there’s enough consolidation, prices go up. Market forces work in health care. One of the reasons I say “health care will not reform itself” is that health care is making $2.5 trillion a year. It has no incentive to change behavior, and no mechanism to change behavior. Every doctor I know loves to have all the information about every patient. But you can’t get it here. You can’t get it in the U.S. There are ERISA violations if you try to share it. A lot of other countries have claims-based systems, but doctors have access to the data. I think we should mandate that every payer in the U.S. should be required to produce an electronic health record.

This is part of why so much of the data we have on, say, treatment effectiveness comes from Medicare, right?

Dartmouth did that, but the Rand study did not look at Medicare. The Commonwealth study looked at 5 million claims across a broad population and asked how much care shouldn’t have happened. They concluded that of $2 trillion spent, $500 billion was for the wrong care. Milliman did the same study but asked what would happen if we took the practices of the best medical plans, how much will we save? They got $500 billion. Then you’ve got the Dartmouth study which said that if we got to the best practices in the best parts of the country, we’ll save $500 billion, and that’s on Medicare data. But all the study shows is that if we get care right and deliver it more efficiently, we’ll save a lot of money. But only Dartmouth is Medicare data.

But most doctors can’t access that data?

No. But they can’t get Medicare data, either. Medicare as an infrastructure doesn’t exist. The infrastructure of Medicare is private insurance companies that pay its claims. But we should have a Medicare database that we’re plumbing all the time for care. Kaiser Permanente has a database now. We just did a study showing that if you had high cholesterol 30 years ago, you’re 60 percent likelier to have Alzheimer’s today. We just had this data, and noticed this disproportionate relationship. But that was just because we had the data. In most cases, however, the data is truncated, time-limited, and on paper. That's a bad way to run a railroad.

Why would anybody do it? They all have their own data. If you, as a solo practice doctor, say an allergist, create an electronic medical record, and the only data you have is allergy data, and you already have that on your paper record. It won’t happen from the inside. It can’t happen from the inside. President Obama, I think, did a brilliant thing when he put some of the recovery money into the electronic records. The challenge is that it then should have gotten into system design and decided what the records will do. Now they’re trying to do that.

I think like a minister of health. We have a population of more than 8 million people in Kaiser, which is more than 42 states and a 100 countries, and we’re an integrated care system, and so I’m always thinking in terms of population health. Within KP, when we started electronic medical records, some people wanted an oncology system and some wanted a surgery system, but putting it into separate pieces would have been really wrong.

We put it into a linked system based on two principles: all the data for all the patients all of the time, and two, make the right thing easy to do. Some of the systems that have been developed didn’t make it easy for doctors to get the information they needed quickly, and those systems have been, in some cases, rolled back. But if you have all the data and the system is designed to make the right thing easy to do, then you’ll order the right lab test, because someone else has done all the coding for what lab tests you want for what condition, and you can give the patient all their information at the end of the visit.

I want to back you up here for a second. Kaiser Permanente is an integrated-care system. You have your own hospitals and doctors. It’s not an insurer like Aetna is an insurer.

We are a single-payer system unto ourselves. For us, a hospital or an imaging center is a cost center, not a profit center. We’ll have one clinic shared by a hospital and a couple of specialties, while in the fee-for-service world, each of the specialties might have their own CT scanners so they can bill off of them. We have a lot of CT scanners, too. We probably do more of them than any other private organization in the world. But, we do them for the patients, so the CT information is shared and they don’t need to be repeated. That makes us different than folks who want to deliver great care but are organized around billing systems.

There’s a clinic in Seattle. They’re a fee-for-service clinic that did a great job developing best practices for imaging. You do a CT scan and it’s the equivalent of a 1,000 x-rays. You don’t want them to do that too often. But they did a great job on these protocols. Reduced the number of CT scans by 30 percent. But that meant they lost 30 percent of their revenue. It was a huge financial hit. The people who did that study were not very popular in the organization.

In the traditional setup, the insurer has an incentive to get hospitals to do fewer CT scans and the hospital has an incentive to do more CT scans, and people don’t really know who to trust. But they know they don’t trust the insurers.

That’s why you need protocols. So it’s not just one opinion versus another opinion. If all the parties agree on a medical best-practice protocol, you end up in a position where you can have multiple payers and providers. The European model works just fine with multiple competing plans. In some countries, they’re actually trying to figure out how to become more coordinated. Many of them come to Kaiser to look at our stuff, kick our tires.

A number of the organizations that are considered the best and most cost-efficient in the United States – Kaiser, Mayo, the Veteran’s Health Administration – are integrated at a level that’s really quite rare. Normally, you’d expect that to give them a competitive advantage, and they’d eventually take over the market. But that doesn’t seem to happen. Why?

Well, the VA has its own population. When you look at the Mayos of the world, they’re doing well. They have a good business model that’s working for them. But everyone else has a good business model that’s working for them, too. There are $2.5 trillion in this market. There’s no reason, if you have a comfortable cash flow, why would you do hard things and heavy lifting to get to a different model? That’s one reason I’ve been such a strong proponent of exchanges. I believe we need a truly competitive market for insurance.