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How Washington is Screwing Up Health Care Reform – and Why It May Take a Revolt to Fix It

Let's start with the obvious: America has not only the worst but the dumbest health care system in the developed world. It's become a black leprosy eating away at the American experiment - a bureaucracy so insipid and mean and illogical that even our darkest criminal minds wouldn't be equal to dreaming it up on purpose.

The system doesn't work for anyone. It cheats patients and leaves them to die, denies insurance to 47 million Americans, forces hospitals to spend billions haggling over claims, and systematically bleeds and harasses doctors with the specter of catastrophic litigation. Even as a mechanism for delivering bonuses to insurance-company fat cats, it's a miserable failure: Greedy insurance bosses who spent a generation denying preventive care to patients now see their profits sapped by millions of customers who enter the system only when they're sick with incurably expensive illnesses.

The cost of all of this to society, in illness and death and lost productivity and a soaring federal deficit and plain old anxiety and anger, is incalculable - and that's the good news. The bad news is our failed health care system won't get fixed, because it exists entirely within the confines of yet another failed system: the political entity known as the United States of America.

Just as we have a medical system that is not really designed to care for the sick, we have a government that is not equipped to fix actual crises. What our government is good at is something else entirely: effecting the appearance of action, while leaving the actual reform behind in a diabolical labyrinth of ingenious legislative maneuvers.

Over the course of this summer, those two failed systems have collided in a spectacular crossroads moment in American history. We have an urgent national emergency on the one hand, and on the other, a comfortable majority of ostensibly simpatico Democrats who were elected by an angry population, in large part, specifically to reform health care. When they all sat down in Washington to tackle the problem, it amounted to a referendum on whether or not we actually have a functioning government.

It's a situation that one would have thought would be sobering enough to snap Congress into real action for once. Instead, they did the exact opposite, doubling down on the same-old, same-old and laboring day and night in the halls of the Capitol to deliver us a tour de force of old thinking and legislative trickery, as if that's what we really wanted. Almost every single one of the main players - from House Speaker Nancy Pelosi to Blue Dog turncoat Max Baucus - found some unforeseeable, unique-to-them way to fuck this thing up. Even Ted Kennedy, for whom successful health care reform was to be the great vindicating achievement of his career, and Barack Obama, whose entire presidency will likely be judged by this bill, managed to come up small when the lights came on.

We might look back on this summer someday and think of it as the moment when our government lost us for good. It was that bad.

Here's where we are right now: Before Congress recessed in August, four of the five committees working to reform health care had produced draft bills. On the House side, bills were developed by the commerce, ways and means, and labor committees. On the Senate side, a bill was completed by the HELP committee (Health, Education, Labor and Pensions, chaired by Ted Kennedy). The only committee that didn't finish a bill is the one that's likely to matter most: the Senate Finance Committee, chaired by the infamous obfuscating dick Max Baucus, a right-leaning Democrat from Montana who has received $2,880,631 in campaign contributions from the health care industry.

The game in health care reform has mostly come down to whether or not the final bill that is hammered out from the work of these five committees will contain a public option - i.e., an option for citizens to buy in to a government-run health care plan. Because the plan wouldn't have any profit motive - and wouldn't have to waste money on executive bonuses and corporate marketing - it would automatically cost less than private insurance. Once such a public plan is on the market, it would also drive down prices offered by for-profit insurers - a move essential to offset the added cost of covering millions of uninsured Americans. Without a public option, any effort at health care reform will be as meaningful as a manicure for a gunshot victim. "The public option is the main thing on the table," says Michael Behan, an aide to Sen. Bernie Sanders of Vermont. "It's really coming down to that."

The House versions all contain a public option, as does the HELP committee's version in the Senate. So whether or not there will be a public option in the end will likely come down to Baucus, one of the biggest whores for insurance-company money in the history of the United States. The early indications are that there is no public option in the Baucus version; the chairman hinted he favors the creation of nonprofit insurance cooperatives, a lame-ass alternative that even a total hack like Sen. Chuck Schumer has called a "fig leaf."

Even worse, Baucus has set things up so that the final Senate bill will be drawn up by six senators from his committee: a gang of three Republicans (Chuck Grassley of Iowa, Olympia Snowe of Maine, Mike Enzi of Wyoming) and three Democrats (Baucus, Kent Conrad of North Dakota, Jeff Bingaman of New Mexico) known by the weirdly Maoist sobriquet "Group of Six." The setup senselessly submarines the committee's Democratic majority, effectively preventing members who advocate a public option, like Jay Rockefeller of West Virginia and Robert Menendez of New Jersey, from seriously influencing the bill. Getting movement on a public option - or any other meaningful reform - will now require the support of one of the three Republicans in the group: Grassley (who has received $2,034,000 from the health sector), Snowe ($756,000) or Enzi ($627,000).

This is what the prospects for real health care reform come down to - whether one of three Republicans from tiny states with no major urban populations decides, out of the goodness of his or her cash-fattened heart, to forsake forever any contributions from the health-insurance industry (and, probably, aid for their re-election efforts from the Republican National Committee).

This, of course, is the hugest of long shots. But just to hedge its bets even further and ensure that no real reforms pass, Congress has made sure to cover itself, sabotaging the bill long before it even got to Baucus' committee. To do this, they used a five-step system of subtle feints and legislative tricks to gut the measure until there was nothing left.

STEP ONE: AIM LOW

Heading into the health care debate, there was only ever one genuinely dangerous idea out there, and that was a single-payer system. Used by every single developed country outside the United States (with the partial exceptions of Holland and Switzerland, which offer limited and highly regulated private-insurance options), single-payer allows doctors and hospitals to bill and be reimbursed by a single government entity. In America, the system would eliminate private insurance, while allowing doctors to continue operating privately.

In the real world, nothing except a single-payer system makes any sense. There are currently more than 1,300 private insurers in this country, forcing doctors to fill out different forms and follow different reimbursement procedures for each and every one. This drowns medical facilities in idiotic paperwork and jacks up prices: Nearly a third of all health care costs in America are associated with wasteful administration. Fully $350 billion a year could be saved on paperwork alone if the U.S. went to a single-payer system - more than enough to pay for the whole goddamned thing, if anyone had the balls to stand up and say so.

Everyone knows this, including the president. Last spring, when he met with Rep. Lynn Woolsey, the co-chair of the Congressional Progressive Caucus, Obama openly said so. "He said if he were starting from scratch, he would have a single-payer system," says Woolsey. "But he thought it wasn't possible, because it would disrupt the health care industry."

Huh? This isn't a small point: The president and the Democrats decided not to press for the only plan that makes sense for everyone, in order to preserve an industry that is not only cruel and stupid and dysfunctional, but through its rank inefficiency has necessitated the very reforms now being debated. Even though the Democrats enjoy a political monopoly and could have started from a very strong bargaining position, they chose instead to concede at least half the battle before it even began.

Obama wasn't the only big Democrat to mysteriously abandon his position on single-payer. House Speaker Nancy Pelosi and Rep. Henry Waxman, the influential chair of the House commerce committee, have both backed away from their longtime support of single-payer. Hell, even Max-freaking-Baucus once conceded the logic of single-payer, saying only that it isn't feasible politically. "There may come a time when we can push for single-payer," he said in February. "At this time, it's not going to get to first base in Congress."

And helping it not get to first base was ... Max Baucus. It was Baucus' own committee that held the first round-table discussions on reform. In three days of hearings last May, he invited no fewer than 41 people to speak. The list featured all the usual industry hacks, including big insurers like America's Health Insurance Plans (AHIP), Blue Cross and Aetna. It's worth noting that several of the organizations invited - including AHIP and Amgen - employ several former Baucus staffers as lobbyists, including two of his ex-chiefs of staff.

Not one of the 41 witnesses, however, was in favor of single-payer - even though eliminating the insurance companies enjoys broad public support. Leading advocates of single-payer, including doctors from the Physicians for a National Health Program, implored Baucus to allow them to testify. When he refused, a group of eight single-payer activists, including three doctors, stood up during the hearings and asked to be included in the discussion. One of the all-time classic moments in the health care reform movement came when the second protester to stand up, Katie Robbins of Health Care Now, declared, "We need single-payer health care!"

To which Baucus, who looked genuinely frightened, replied, "We need more police!"

The eight protesters were led away in handcuffs and spent about seven hours in jail. "It's funny, the policemen were all telling us their horror stories about health care," recalls Dr. Margaret Flowers, one of the physicians who was jailed. "One was telling us about his mother who was 62 and lost her job and was uninsured, waiting to get Medicare when she was 65." The protesters were sentenced to six months' probation. Baucus later met with them and conceded that not including single-payer advocates in the discussion had been a mistake, although it was "too late" to change that.

Single-payer advocates have had an equally tough time getting a hearing with the president. In March, the White House refused to allow Rep. John Conyers to invite two physicians who support single-payer to the health care summit that Obama was holding to kick off the reform effort. Three months later, a single-payer advocate named David Scheiner, who served as Obama's physician for 22 years, was mysteriously bumped from a prime-time forum on health care, where he had been invited to ask the president a question.

Many of the health care advisers in Obama's inner circle, meanwhile, are industry hacks - people like Nancy-Ann DeParle, the president's health care czar, who has served on the boards of for-profit companies like Medco Health Solutions and Triad Hospitals. DeParle is so unthreatening to the status quo that Karen Ignagni, the insurance industry's leading lobbyist-gorgon, praised her "extensive experience" and "strong track record."

Behind closed doors, Obama also moved to cut a deal with the drug industry. "It's a dirty deal," says Russell Mokhiber, one of the protesters whom Baucus had arrested. "The administration told them, 'Single-payer is off the table. In exchange, we want you on board.'" In August, the Pharmaceutical Research and Manufacturers of America announced that the industry would contribute an estimated $150 million to campaign for Obamacare.

Even the Congressional Progressive Caucus, whose 80-plus members have overwhelmingly supported single-payer legislation in the past, decided not to draw a line in the sand. They agreed to back down on single-payer, seemingly with the understanding that Pelosi would push for a strong public option - a sort of miniversion of single-payer, a modest, government-run insurance plan that would serve as a test model for the real thing. But one of the immutable laws of politics in the U.S. Congress is that progressives will always be screwed by their own leaders, as soon as the opportunity presents itself. And with a bill the size and scope of health care, there was plenty of opportunity.

STEP TWO: GUT THE PUBLIC OPTION

Once single-payer was off the table, the Democrats lost their best bargaining chip. Rather than being in a position to use the fear of radical legislation to extract concessions from the right - a position Obama seemingly gave away at the outset, by punting on single-payer - Republicans and conservative Blue Dog Democrats suddenly realized that they had the upper hand. Pelosi and Senate Majority Leader Harry Reid would now give away just about anything to avoid having to walk away without a real health care bill.

The situation was made worse as the flagging economy ate away at Obama's political capital. Polls showed the percentage of "highly engaged" Democrats plummeting, while the percentage of "highly engaged" Republicans - inspired by idiotic scare stories from Rush Limbaugh and Sarah Palin about socialized medicine and euthanasia - rose rapidly. By late summer, "the depth of Republican support was starting to rival the breadth of Democratic support," said noted statistician Nate Silver. The more the Republicans and Blue Dogs fidgeted and fucked around, the easier it would be for them to kill the public option. Democrats, who on the morning after Election Day could have passed a single-payer system without opposition, were now in a desperate hurry to make a deal.

The public option is hardly a cure-all: Among other things, it does nothing to reduce the $350 billion a year in unnecessary paperwork and administrative overhead that makes the current system so expensive and maddening. "That's one of the big issues," says an aide to a member of the progressive caucus. "None of this addresses the paperwork issue. It might even make it worse." But the basic idea of the public option is sound enough: create a government health plan that citizens could buy through regulated marketplaces called insurance "exchanges" run at the state level. Simply by removing the profit motive, the government plan would be cheaper than private insurance. "The goal here was to offer the rock-bottom price, the Walmart price, so that people could buy insurance practically at cost," says one Senate aide.

The logic behind the idea was so unassailable that its opponents often inadvertently found themselves arguing for it. "Assurances that the government plan would play by the rules that private insurers play by are implausible," groused right-wing douchebag George Will. "Competition from the public option must be unfair, because government does not need to make a profit and has enormous pricing and negotiating powers." In other words, if you offer a public plan that doesn't systematically fuck every single person in the country by selling health care at inflated prices and raking in monster profits, private insurers just won't be able to compete.

Will wasn't the only prominent opponent of reform openly arguing in favor of the insurance industry's right to continue doing business inefficiently. Sen. Ben Nelson, who together with Baucus are the Laverne and Shirley of turncoat Democrats, complained that the public option "would win the game." Senate Minority Leader Mitch McConnell admitted that "private insurance will not be able to compete with a government option." This is a little like complaining that Keanu Reeves was robbed of an Oscar just because he can't act.

For a while, the public option looked like it might have a real chance at passing. In the House, both the ways and means committee and the labor committee passed draft bills that contained a genuine public option. But then conservative opponents of the plan, the so-called Blue Dog Democrats, mounted their counterattack. A powerful bloc composed primarily of drawling Southerners in ill-fitting suits, the Blue Dogs - a gang of puffed-up political mulattos hired by the DNC to pass as almost-Republicans in red-state battlegrounds - present themselves as a quasi-religious order, worshipping at the sacred altar of "fiscal responsibility" and "deficit reduction." On July 9th, in a harmless-sounding letter to Pelosi, 40 Blue Dogs expressed concern that doctors in the public option "must be fairly reimbursed at negotiated rates, and their participation must be voluntary." Paying doctors "using Medicare's below-market rates," they added, "would seriously weaken the financial stability of our local hospitals."

The letter was an amazing end run around the political problem posed by the public option - i.e., its unassailable status as a more efficient and cheaper health care alternative. The Blue Dogs were demanding that the very thing that makes the public option work - curbing costs to taxpayers by reimbursing doctors at Medicare rates plus five percent - be scrapped. Instead, the Blue Dogs wanted compensation rates for doctors to be jacked up, on the government's tab. The very Democrats who make a point of boasting about their unwavering commitment to fiscal conservatism were lobbying, in essence, for a big fat piece of government pork for doctors. "Cost should be the number-one concern to the Blue Dogs," grouses Rep. Woolsey. "That's why they're Blue Dogs."

In the end, the Blue Dogs won. When the House commerce committee passed its bill, the public option no longer paid Medicare-plus-five-percent. Instead, it required the government to negotiate rates with providers, ensuring that costs would be dramatically higher. According to one Democratic aide, the concession would bump the price of the public option by $1,800 a year for the average family of four.

In one fell swoop, the public plan went from being significantly cheaper than private insurance to costing, well, "about the same as what we have now," as one Senate aide puts it. This was the worst of both worlds, the kind of take-the-fork-in-the-road nonsolution that has been the peculiar specialty of Democrats ever since Bill Clinton invented a new way to smoke weed. The party could now sell voters on the idea that it was offering a "public option" without technically lying, while at the same time reassuring health care providers that the public option it was passing would not imperil the industry's market share.

Even more revolting, when Pelosi was asked on July 31st if she worried that progressives in the House would yank their support of the bill because of the sellout to conservatives, she literally laughed out loud. "Are the progressives going to take down universal, quality, affordable health care for all Americans?" she said, chuckling heartily to reporters. "I don't think so."

The laugh said everything about what the mainstream Democratic Party is all about. It finds the notion that it has to pay anything more than lip service to its professed values funny. "It's a joke," complains one Democratic aide. "This is all a game to these people - and they're good at it."

The concession to the Blue Dogs comes at a potentially disastrous price: Without a public option that drives down prices, the cost of other health care reforms being considered by Congress will almost certainly skyrocket. The trade-off with conservatives might be understandable, if those other reforms were actually useful. But this is Congress we're talking about.

STEP THREE: PACK IT WITH LOOPHOLES

Even seasoned congressional aides, who are accustomed to sitting through long and boring committee meetings, have found the debate over health care reform uniquely torturous. Unlike other congressional matters, where there is at least a feeling that the process might at some point be completed, the endless sessions over health care have led many staffers to fear that they will be locked in hearing rooms for the rest of their lives, listening to words like "target" and "mandate" and "doughnut hole" being repeated ad nauseam by weary, gray-faced, saggy-necked legislators - who begin, after weeks of self-inflated posturing, to look like the ugliest people in the universe. "You come out of these hearings," says Behan, the aide to Sen. Sanders, "and the number of interconnected, moving pieces going in and out of these bills is insane - the case for single-payer health insurance makes itself."

For those looking to fuck up health care reform - or to load it up with goodies for their rich pals - the tedium actually serves a broader purpose. Given that five different committees are weighing five different and often competing paths to reform, it's not surprising that all sorts of bizarre crap winds up buried in their bills, stuff no one could possibly have expected to be in there. The most glaring example, passed by Ted Kennedy's HELP committee, would allow the makers of complex drugs known as "biologics" to keep their formulas from being copied by rivals for 12 years - twice as long as the protection for ordinary pharmaceuticals. The notion that an effort ostensibly aimed at curbing health care costs would grant the pharmaceutical industry lucrative new protections against generic drugs is even weirder when you consider that earlier proposals, including one supported by Obama, would have protected brand-name drugs for only seven years.

Another favor to industry buried in the bills involves the issue of choice. From the outset, Democrats have been careful to make sure that a revamped system would not in any way force citizens to give up their existing health care plans. As Obama told the American Medical Association in June, "If you like your doctor, you will be able to keep your doctor, period. If you like your health care plan, you'll be able to keep your health care plan, period. No one will take it away, no matter what."

That sounds great, particularly in conjunction with the new set of standards for employer-provided insurance outlined in the House version of reform. Under the bill - known as HR 3200 - employers must provide "essential benefits" to workers or face a stiff penalty. "Essential benefits" includes elements often missing in the fly-by-night plans offered by big employers: drug benefits, outpatient care, hospitalization, mental health, the works. If your employer does not offer acceptable coverage, you then have the right to go into one of the state-run insurance "exchanges," where you can select from a number of insurance plans, including the public option.

There's a flip side, though: If your employer offers you acceptable care and you reject it, you are barred from buying insurance in the insurance "exchange." In other words, you must take the insurance offered to you at work. And that might have made sense if, as decreed in the House version, employers actually had to offer good care. But in the Senate version passed by the HELP committee, there is no real requirement for employers to provide any kind of minimal level of care. On the contrary, employers who currently offer sub-par coverage will have their shitty plans protected by a grandfather clause. Which means ...

"If you have coverage you like, you can keep it," says Sen. Sanders. "But if you have coverage you don't like, you gotta keep it."

This grandfather clause has potentially wide-ranging consequences. One of the biggest health care problems we have in this country is the technique used by large employers - Walmart is the most notorious example - of offering dogshit, bare-bones health insurance that forces employees to take on steep co-pays and other massive charges. Low-wage workers currently offered these plans often reject them and join Medicaid, effectively shifting the health care burden for Walmart employees on to the taxpayer. If the HELP committee's grandfather clause survives to the final bill, those workers who did the sensible thing in rejecting Walmart's crap employer plan and taking the comparatively awesome insurance offered via Medicaid will now be rebuffed by the state and forced to take the dogshit Walmart offering.

This works out well for the states, who will get to purge all those Walmart workers from their Medicaid rolls. It also works great for Walmart, since any new competitors who appear on the horizon will be forced to offer genuine and more expensive health insurance - giving Walmart a clear competitive advantage. This little "glitch" is the essence of the health care reform effort: It changes things in a way that works for everyone except actual sick people.

Veteran legislators speak of this horrific loophole as if it were an accident - something that just sort of happened, while no one was looking. Sen. Ron Wyden of Oregon was looking at an early version of the bill several months ago, when he suddenly realized that it was going to leave people stuck with their employer insurance. "I woke up one morning and was like, 'Whoa, people aren't going to have choices,'" he recalls.

As a means of correcting the problem, Wyden wrote up a thing called the Free Choice Act, which like many of the prematurely sidelined ideas in this health care mess is actually quite sensible. The bill would open up the insurance "exchanges" to all consumers, regardless of who is offered employer-based insurance and who isn't. But Wyden has little hope of having his proposal included in later versions of the bill. Like Sanders, who hopes to correct the committee's giveaway to drugmakers, Wyden won't get a real shot at having an impact until the House and Senate meet to hammer out differences between their final bills. In a legislative sense, the bad ideas are already in the barn, and the solutions are fenced off in the fields, hoping to get in.

STEP FOUR: PROVIDE NO LEADERSHIP

One of the reasons for this chaos was the bizarre decision by the administration to provide absolutely no real oversight of the reform effort. From the start, Obama acted like a man still running for president, not someone already sitting in the White House, armed with 60 seats in the Senate. He spoke in generalities, offering as "guiding principles" the kind of I'm-for-puppies-and-sunshine platitudes we got used to on the campaign trail - investment in prevention and wellness, affordable health care for all, guaranteed choice of doctor. At no time has he come out and said what he wants Congress to do, in concrete terms. Even in June, when congressional leaders desperate for guidance met with chief of staff (and former legislative change-squelcher) Rahm Emanuel, they got no signal at all about what the White House wanted. On the question of a public option, Emanuel was agonizingly noncommittal, reportedly telling Senate Democrats that the president was still "open to alternatives."

On the same day Emanuel was passing the buck to senators, Obama was telling reporters that it's "still too early" to have a "strong opinion" on a public option. This was startling news indeed: Eight months after being elected president of the United States is too early to have an opinion on an issue that Obama himself made a central plank of his campaign? The president conceded only that a "public option makes sense."

This White House makes a serial vacillator like Bill Clinton look like Patton crossing the Rhine. Veterans from the Clinton White House, in fact, jumped on Obama. "The president may have overlearned the lesson of the Clinton health care plan fiasco, which was: Don't deliver a package to the Hill, let the Hill take ownership," said Robert Reich, who served as labor secretary under Clinton. There were now so many competing ideas about how to pay for the plan and what kind of mandates to include that even after the five bills are completed, Congress will not be much closer to reform than it was at the beginning. "The president has got to go in there and give it coherence," Reich concluded.

But Reich's comment assumes that Obama wants to give the bill coherence. In many ways, the lily-livered method that Obama chose to push health care into being is a crystal-clear example of how the Democratic Party likes to act - showering a real problem with a blizzard of ineffectual decisions and verbose nonsense, then stepping aside at the last minute to reveal the true plan that all along was being forged off-camera in the furnace of moneyed interests and insider inertia. While the White House publicly eschewed any concrete "guiding principles," the People Who Mattered, it appeared, had already long ago settled on theirs. Those principles seem to have been: no single-payer system, no meaningful public option, no meaningful employer mandates and a very meaningful mandate for individual consumers. In other words, the only major reform with teeth would be the one forcing everyone to buy some form of private insurance, no matter how crappy, or suffer a tax penalty. If the public option is the sine qua non for progressives, then the "individual mandate" is the counterpart must-have requirement for the insurance industry.

"That was their major policy 'ask,' and it looks like they're going to get it," says Dr. Steffie Woolhandler, a Boston physician who is a prominent single-payer advocate.

The so-called "individual mandate" is currently included in four of the five bills before Congress. The most likely version to survive into the final measure resembles the system in Massachusetts designed by Mormon glambot Mitt Romney, who imposed tax penalties on citizens who did not buy insurance. Several of Romney's former advisers are involved in the writing of Obamacare, including a key aide to Ted Kennedy who was instrumental in designing the HELP committee legislation. The federal version of the Massachusetts plan would slap the uninsured with a hefty tax penalty - making the HELP committee clause barring people from opting out of their employer-provided plan that much more outrageous.

If things go the way it looks like they will, health care reform will simply force great numbers of new people to buy or keep insurance of a type that has already been proved not to work. "The IRS and the government will force people to buy a defective product," says Woolhandler. "We know it's defective because three-quarters of all people who file for bankruptcy because of medical reasons have insurance when they get sick - and they're bankrupted anyway."

STEP FIVE: BLOW THE MATH

Health care is a beast - a monster. The House 3200 bill alone is 1,017 pages long and contains countless inscrutable references to other pieces of legislation, meaning that in order to fully comprehend even those thousand pages one really has to read upward of 9,000 or 10,000 pages. There are five different versions of this creature, each with its own nuances and shades, and solving a highly complex mathematical challenge like reconciling the costs of each of the five plans would be beyond even minds who were (a) expert at such things and (b) motivated to get it right. Imagine the same problem in the hands of a bunch of second-rate country lawyers and mall owners, and you about get the idea of what the congressional picture looks like.

For instance: All five of the bills envision a significant expansion of Medicaid. As it stands, the LBJ-era program, which celebrated its 44th birthday on the day before Nancy Pelosi laughed at the progressives, awards benefits according to a jumbled series of state-by-state criteria. Some states, like Vermont, offer Medicaid to citizens whose income is as high as 300 percent of the federal poverty level, while others, like Georgia, only offer Medicaid to those closer to or below the poverty level.

The House plan would expand Medicaid eligibility to automatically include every American whose income is 133 percent of the poverty level or less. For those earning somewhat more - up to 400 percent of the poverty level - federal subsidies would help pay for the cost of a public or private plan purchased via the insurance "exchanges." That worries state governments, which currently pay for almost half of Medicaid - and which are already seeing their Medicaid rolls swelled by the economic meltdown. A massive surge in new Medicaid members - as many as 11 million Americans under the current proposals, according to the Congressional Budget Office - might literally render many big states insolvent overnight.

Democrats pointed out that under the House plan, the federal government would pay the costs of any "newly eligible" members of Medicaid. But that phrasing, it turns out, was a semantic trick designed to undersell the cost to the states. When Massachusetts imposed a similar mandate under Romney, thousands of people who were already eligible for Medicaid, but had not enrolled, immediately joined the program in order to avoid the tax penalty for being uninsured. So while the House plan would pay for "newly eligible" patients, it won't cover the "oldly eligible."

Congress in this instance is behaving like corporations in the Enron age, orphaning hidden costs and complications through clever wording and accounting. Another neat trick involves the federal subsidies for low-income people who make up to 400 percent of the poverty level. The Congressional Budget Office projects that under the House bill, the subsidies will cost upward of $773 billion by 2019. But some aides think that number could end up being much higher. "Without a real public option to drive down costs, the federal support to make sure everyone gets coverage is going to get very expensive very fast," says Behan, the aide to Sen. Sanders.

Here's the other thing. By blowing off single-payer and cutting the heart out of the public option, the Obama administration robbed itself of its biggest argument - that health care reform is going to save a lot of money. That has left the Democrats vulnerable to charges that the plan is going to blow a mile-wide hole in the budget, one we'll be paying debt service on through the year 3000. It also left them scrambling to find other ways to pay for the plan, making it almost inevitable that they would step in political shit with seniors everywhere by trying surreptitiously to whittle down Medicare. As a result, the Democrats have become so oversensitive to charges of fiscal irresponsibility that they're taking their frustrations out on people who don't deserve it. Witness Nancy Pelosi's bizarre freakout over the Congressional Budget Office. When the CBO questioned Obama's projected cost savings, Pelosi blasted them for "always giving you the worst-case scenario" - which, of course, is exactly what the budget office is supposed to do. When you start asking your accountant to look on the bright side, you know you're not dealing from a position of strength.

To recap, here's what ended up happening with health care. First, they gave away single-payer before a single gavel had fallen, apparently as a bargaining chip to the very insurers mostly responsible for creating the crisis in the first place. Then they watered down the public option so as to make it almost meaningless, while simultaneously beefing up the individual mandate, which would force millions of people now uninsured to buy a product that is no longer certain to be either cheaper or more likely to prevent them from going bankrupt. The bill won't make drugs cheaper, and it might make paperwork for doctors even more unwieldy and complex than it is now. In fact, the various reform measures suck so badly that PhRMA, the notorious mouthpiece for the pharmaceutical industry which last year spent more than $20 million lobbying against health care reform, is now gratefully spending more than seven times that much on a marketing campaign to help the president get what he wants.

So what's left? Well, the bills do keep alive the so-called employer mandate, requiring companies to provide insurance to their employees. A good idea - except that the Blue Dogs managed to exempt employers with annual payrolls below $500,000, meaning that 87 percent of all businesses will be allowed to opt out of the best and toughest reform measure left. Thanks to Harry Reid, Nancy Pelosi and Barack Obama, we can now be assured that the 19 or 20 employers in America with payrolls above $500,000 who do not already provide insurance will be required to offer good solid health coverage. Hurray!

Or will they? At the end of July, word leaked out that the Senate Finance Committee, in addition to likely spiking the public option, had also decided to ditch the employer mandate. It was hard to be certain, because even Democrats on the committee don't know what's going on in the Group of Six selected by Baucus to craft the bill. Things got so bad that some Democrats on the committee - including John Kerry, Chuck Schumer and Robert Menendez - were reduced to holding what amounts to shadow hearings on health care several times a week, while Baucus and his crew conducted their meetings in relative secrecy. The chairman did not even bother to keep his fellow Democrats informed of the bill's developments, let alone what he has promised Republicans in return for their support of the bill. "The Group of Six has hijacked the process," says an aide to one of the left-out senators.

This leaves Democrats on the committee in the strange position of seriously considering pulling their support for a bill that will emerge from a panel on which they hold a clear majority. Other Democrats are also weighing an end run around their own leadership, hoping to sneak meaningful reforms back into the process. In the House, Rep. Anthony Weiner of New York refused to support the bill passed by the commerce committee unless he was allowed to attach an amendment that will enable Congress to vote on replacing the entire reform bill with a single-payer plan (Bernie Sanders is working on a similar measure in the Senate). On the labor committee, Rep. Dennis Kucinich of Ohio took a more nuanced tack, offering an amendment that would free up states to switch to a single-payer system of their own.

It's highly unlikely, though, that the party's leaders will agree to include such measures when the five competing reform bills are eventually combined. On the House side, "Pelosi has unfettered discretion to combine the bills as she pleases," observes one Democratic aide. Which leaves us where we are today, as Congress enjoys its vacation, and the various sides have taken to the airwaves in an advertising blitz to make sure the population is saturated with idiotic misconceptions before the bill is actually voted on in the fall.

The much-ballyhooed right-wing scare campaign, with its teabagger holdovers ridiculously disrupting town-hall meetings with their belligerent protests and their stoneheaded memes (the sign raised at a town hall held by Rep. Rick Larson of Washington - keep the guvmint out of my medicare - is destined to become a classic of conservative propaganda), has proved to be almost totally irrelevant to the entire enterprise. Aside from lowering even further the general level of civility (teabaggers urged Sen. Chris Dodd to off himself with painkillers; Rep. Brad Miller had his life threatened), the Limbaugh minions have accomplished nothing at all, except to look like morons for protesting as creeping socialism a reform effort designed specifically to change as little as possible and to preserve at all costs our malfunctioning system of private health care.

All that's left of health care reform is a collection of piece-of-shit, weakling proposals that are preposterously expensive and contain almost nothing meaningful - and that set of proposals, meanwhile, is being negotiated down even further by the endlessly negating Group of Six. It is a fight to the finish now between Really Bad and Even Worse. And it's virtually guaranteed to sour the public on reform efforts for years to come.

"They'll pass some weak, mediocre plan that breaks the bank and even in the best analysis leaves 37 million people uninsured," says Mokhiber, one of the single-payer activists arrested by Baucus. "It's going to give universal health care a bad name."

It's a joke, the whole thing, a parody of Solomonic governance. By the time all the various bills are combined, health care will be a baby not split in half but in fourths and eighths and fractions of eighths. It's what happens when a government accustomed to dealing on the level of perception tries to take on a profound emergency that exists in reality. No matter how hard Congress may try, though, it simply is not possible to paper over a crisis this vast.

Then again, some of the blame has to go to all of us. It's more than a little conspicuous that the same electorate that poured its heart out last year for the Hallmark-card story line of the Obama campaign has not been seen much in this health care debate. The handful of legislators - the Weiners, Kuciniches, Wydens and Sanderses - who are fighting for something real should be doing so with armies at their back. Instead, all the noise is being made on the other side. Not so stupid after all - they, at least, understand that politics is a fight that does not end with the wearing of a T-shirt in November.

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