The Actual Debate Over Health-Care Reform

A bit later today, I'll be putting up an interview with Nancy-Ann DeParle, director of the White House's Office of Health Reform. But there's a particular argument that I want to focus on. "When you step back," she told me, "there is broad agreement about 85 percent of what we're talking about."

You hear this a lot from the White House. In fact, you hear it often enough that it's tempting to think it untrue. But it's very true. And in this moment of violent town halls and ferocious controversy, it's worth remembering.

Here are the things that, broadly speaking, legislators agree about: insurance market reforms, including community rating, guaranteed issue, an end to rescission, an end to discrimination based on preexisting conditions, and an individual mandate. Subsidies for low-income Americans. Delivery system reforms. Health insurance exchanges. An expansion of coverage to about 95 percent of legal residents. Prevention and wellness policies. Retaining and strengthening the employer-based insurance market. Creating some kind of incentive for employers to offer, and keep offering, health benefits. Expanding Medicaid to about 133 percent of poverty.

Here are the things that legislators disagree about, but are discussing, and will probably figure out: whether subsidies should reach 300 percent of poverty or 400 percent. Whether there should be an employer mandate or something milder. Whether medium-size employers should be eligible to enroll in the health insurance exchanges. Whether health reform should cost $1 trillion over 10 years or $1.4 trillion over 10 years. Whether it should be paid for through new taxes on the wealthy or a change to existing tax subsidies in the health-care system.

Here are the things legislators don't agree about: whether we should have a public option that is open only to the minority of Americans on the exchanges or a co-op option. How to handle abortion. How to handle geographic disparities in insurance costs.

Here are the things that aren't under consideration but are alive in the public debate: socialized medicine. Euthanasia. Government-driven rationing. Death panels. Illegal immigrants.

The town halls might be reminiscent of the ferocious argument over Clinton's health-care reform bill, but the underlying reality is that the actual argument is much narrower. Clinton's bill, after all, reorganized the whole health-care system. It ended employer-based insurance. It changed the arrangement of every privately insured American. It imposed managed care on Americans (which they got anyway) and managed competition on insurers (which they escaped).

The bills under consideration now do none of that. The Democrats conceded so much up-front that the actual range of debate is strikingly slim. The public option attracts most of the attention, but the reality of the policy, even in the liberal House bill, is that it's limited to the insurance exchanges and isn't expected to serve more than 12 million people by 2019.

In part, that's why the debate has had to move toward fear-mongering and lies: There just aren't that many scary elements in the bills, because the legislation is oriented toward preserving the existing system and avoiding points of controversy. You can make an argument that the policy is worse because of its modesty. A more ambitious approach could save more money and do more to fix the system. But that's the way it is.

Insofar as there are real debates remaining, they are not about the policy. They are about whether people trust the Obama administration, and the government more generally, to do anything at all. They are about whether Republicans want some sort of bill, or whether they see more political upside in handing the president his "waterloo" on health-care reform. They are about whether people will fall to fear and retrench to the relative predictability of the status quo when faced with the chaos and polarization present in our political system. But beneath all that is a health-care bill that is not necessarily finished, and that is not necessarily agreed-upon, but is a lot closer to done than most people think.

Photo credit: Bradley C. Bower -- Associated Press Photo.