The Nation editorial urging Congress to support President Obama's health-care reform legislation recognized that the measure was flawed. But it argued that there were practical and political reasons for supporting it.

The core point was that passing the bill needed to be seen as part of a process, not as a finished product.

As such, the editorial closed with the lines:

For all these reasons, we support passage of the bill, even as we urge the progressive community to begin the struggle immediately to correct its many flaws and improve its protections. Some of this can be done quickly, via the reconciliation process. Some of it can and should be done with new legislation, such as robust public option bills by Senator Sherrod Brown and Representative Alan Grayson and proposals to expand Medicare and eliminate the health insurance industry's anti-trust exemption.

If this crucial second step is taken quickly and boldly, progressives will have an agenda and an argument for maintaining the pressure through this year's election cycle and in the years to come--when the crucial details of the reform will be implemented. Are we prepared to carry on a knock-down, drag-out fight with the insurance and pharmaceutical industries? The opposition is formidable, but there is a base for mobilization in both houses of Congress. Ultimately, our message must be that genuine reform begins, and only begins, with passage of the current legislation. It ends with achievement of the goal that should be our new battle cry: Medicare for All.

On Sunday, that the House passed the legislation.

On Tuesday, it was signed by the president Tuesday at a celebratory White House ceremony, where Obama declared that: "We have now just enshrined the core principle that everybody should have some basic security when it comes to their health."

Now it is time to begin building a "Medicare for All" framework around that core principle

And, as we suggested in the editorial, there are immediate steps that can be taken.

First, however, let's be clear: This reform, while meaningful, is insufficient and must itself be reformed -- or, at the very least, dramatically expanded and improved.

Here's what the leaders of Physicians for a National Health Care Program say about it:

As much as we would like to join the celebration of the House's passage of the health bill last night, in good conscience we cannot. We take no comfort in seeing aspirin dispensed for the treatment of cancer.

Instead of eliminating the root of the problem - the profit-driven, private health insurance industry - this costly new legislation will enrich and further entrench these firms. The bill would require millions of Americans to buy private insurers' defective products, and turn over to them vast amounts of public money.

The hype surrounding the new health bill is belied by the facts:

* About 23 million people will remain uninsured nine years out. That figure translates into an estimated 23,000 unnecessary deaths annually and an incalculable toll of suffering.

* Millions of middle-income people will be pressured to buy commercial health insurance policies costing up to 9.5 percent of their income but covering an average of only 70 percent of their medical expenses, potentially leaving them vulnerable to financial ruin if they become seriously ill. Many will find such policies too expensive to afford or, if they do buy them, too expensive to use because of the high co-pays and deductibles.

* Insurance firms will be handed at least $447 billion in taxpayer money to subsidize the purchase of their shoddy products. This money will enhance their financial and political power, and with it their ability to block future reform.

* The bill will drain about $40 billion from Medicare payments to safety-net hospitals, threatening the care of the tens of millions who will remain uninsured.

* People with employer-based coverage will be locked into their plan's limited network of providers, face ever-rising costs and erosion of their health benefits. Many, even most, will eventually face steep taxes on their benefits as the cost of insurance grows.

* Health care costs will continue to skyrocket, as the experience with the Massachusetts plan (after which this bill is patterned) amply demonstrates.

* The much-vaunted insurance regulations - e.g. ending denials on the basis of pre-existing conditions - are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation. Older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female workforce can be charged higher gender-based rates at least until 2017.

* Women's reproductive rights will be further eroded, thanks to the burdensome segregation of insurance funds for abortion and for all other medical services.

It didn't have to be like this. Whatever salutary measures are contained in this bill, e.g. additional funding for community health centers, could have been enacted on a stand-alone basis.

Similarly, the expansion of Medicaid - a woefully underfunded program that provides substandard care for the poor - could have been done separately, along with an increase in federal appropriations to upgrade its quality.

But instead the Congress and the Obama administration have saddled Americans with an expensive package of onerous individual mandates, new taxes on workers' health plans, countless sweetheart deals with the insurers and Big Pharma, and a perpetuation of the fragmented, dysfunctional, and unsustainable system that is taking such a heavy toll on our health and economy today.

This bill's passage reflects political considerations, not sound health policy. As physicians, we cannot accept this inversion of priorities. We seek evidence-based remedies that will truly help our patients, not placebos.

A genuine remedy is in plain sight. Sooner rather than later, our nation will have to adopt a single-payer national health insurance program, an improved Medicare for all. Only a single-payer plan can assure truly universal, comprehensive and affordable care to all.

By replacing the private insurers with a streamlined system of public financing, our nation could save $400 billion annually in unnecessary, wasteful administrative costs. That's enough to cover all the uninsured and to upgrade everyone else's coverage without having to increase overall U.S. health spending by one penny.

Moreover, only a single-payer system offers effective tools for cost control like bulk purchasing, negotiated fees, global hospital budgeting and capital planning.

Polls show nearly two-thirds of the public supports such an approach, and a recent survey shows 59 percent of U.S. physicians support government action to establish national health insurance. All that is required to achieve it is the political will.

The major provisions of the present bill do not go into effect until 2014. Although we will be counseled to "wait and see" how this reform plays out, we cannot wait, nor can our patients. The stakes are too high.

We pledge to continue our work for the only equitable, financially responsible and humane remedy for our health care mess: single-payer national health insurance, an expanded and improved Medicare for All.

Here's what National Organization for Women president Terry O'Neill, a particularly savvy commentator on this particular fight, has to say:

As a longtime proponent of health care reform, I truly wish that the National Organization for Women could join in celebrating the historic passage of the Patient Protection and Affordable Care Act. It pains me to have to stand against what many see as a major achievement. But feminist, progressive principles are in direct conflict with many of the compromises built into and tacked onto this legislation.

The health care reform bill passed by Congress today offers a number of good solutions to our nation's critical health care problems, but it also fails in many important respects. After a full year of controversy and compromise, the result is a highly flawed, diminished piece of legislation that continues reliance on a failing, profit-driven private insurance system and rewards those who have been abusive of their customers. With more than 45,000 unnecessary deaths annually and hundreds of thousands of bankruptcies each year due to medical bills, this bill is only a timid first step toward meaningful reform.

Fact: The bill contains a sweeping anti-abortion provision. Contrary to the talking points circulated by congressional leaders, the bill passed today ultimately achieves the same outcome as the infamous Stupak-Pitts Amendment, namely the likely elimination of all private as well as public insurance coverage for abortion. It imposes a bizarre requirement on insurance plan enrollees who buy coverage through the health insurance exchanges to write two monthly checks (one for an abortion care rider and one for all other health care). Even employers will have to write two separate checks for each of their employees requesting the abortion rider.

This burdensome, elaborate system must be eliminated. It is there because the Catholic bishops and extremist abortion rights opponents know that it will result in greatly restricting access to abortion care, currently one of the most common medical procedures for women.

Fact: President Obama made an eleventh-hour agreement to issue an executive order lending the weight of his office to the anti-abortion measures included in the bill. This move was designed to appease a handful of anti-choice Democrats who have held up health care reform in an effort to restrict women's access to abortion. This executive order helps to cement the misconception that the Hyde Amendment is settled law rather than what it really is -- an illegitimate tack-on to an annual must-pass appropriations bill. It also sends the outrageous message that it is acceptable to negotiate health care reform on the backs of women.

Fact: The bill permits age-rating, the practice of imposing higher premiums on older people. This practice has a disproportionate impact on women, whose incomes and savings are lower due to a lifetime of systematic wage discrimination.

Fact: The bill also permits gender-rating, the practice of charging women higher premiums simply because they are women. Some are under the mistaken impression that gender-rating has been prohibited, but that is only true in the individual and small-group markets. Larger group plans (more than 100 employees) sold through the exchanges will be permitted to discriminate against women -- having an especially harmful impact in workplaces where women predominate.

We know why those gender- and age-rating provisions are in the bill: because insurers insisted on them, as they will generate billions of dollars in profits for the companies. Such discriminatory rating must be completely eliminated.

Fact: The bill imposes harsh restrictions on the ability of immigrants to access health care, imposing a 5-year waiting period on permanent, legal residents before they are eligible for assistance such as Medicaid, and prohibiting undocumented workers even to use their own money to purchase health insurance through an exchange. These provisions are counterproductive in terms of controlling health care costs; they are there because of ugly anti-immigrant sentiment, and must be eliminated.

Fact: The bill covers only 32 million of the 47 million uninsured in this country, does not contain a meaningful public option and provides no pathway to a single payer system like Medicare for all. Democratic negotiators crumpled before powerful business interests and right-wing extremists, and until they get a spine there will be no true competition to help rein in costs.

The bottom line is that everyone -- citizen and non-citizen, undocumented immigrant and visitor -- has a fundamental human right to health care. This right has been denied in the U.S. for far too long, while the rest of the industrialized world moved ahead to assure universal and affordable care for their people.

We call upon President Obama and elected officials in both houses to commit to a process of steady improvement of our health care system that will result in true reform with universal coverage, realistically affordable rates and no discrimination. We still have a lot of work to do before we can genuinely celebrate.

Recognizing all of these criticisms as worthy of response, what's the first step in the direction of the real reform that is needed?

A smart start to consider is Florida Congressman Alan Grayson's proposal to allow Americans who lack insurance to buy into Medicare.

As Grayson says, his plan "will provide real competition to the private health insurance companies. Those companies make money by denying people the care they need. My 'Medicare You Can Buy Into Act' will go even further toward saving money and saving lives."

Grayson explains his proposal this way:

This simple four-page bill lets any American buy into Medicare at cost. You want it, you pay for it, you're in. It adds nothing to the deficit; you pay what it costs.

Let's face it. Health insurance companies charge as much money as possible, and they provide as little care as possible. The difference is called profit. You can't blame them for it; that's what a corporation does. Birds got to fly, fish got to swim, health insurers got to rip you off. And if you get really expensive, they've got to pull the plug on you. So for those of us who would like to stay alive, we need a public option.

In many areas of the country, one or two insurers have over 80% of the market. They can charge anything they want. And when you get sick, they can flip the bird at you. So we need a public option.

And they face no real competition because it costs billions of dollars just to set up a national health care network. In fact, the only one that's nationwide is . . . Medicare. And we limit that to one-eight of the population. It's like saying that only seniors can drive on federal highways. We really need a public option.

And to the right-wing loons who call it socialism, we say, "if you want to be a slave to the insurance companies, that's fine. If you want 30% of your premiums to go to 'administrative costs' and billion-dollar bonuses for insurance CEOs who figure out new and creative ways to deny you the care you need to stay healthy and alive, that's fine. But don't you try to dictate to me that I can't have a public option!"

As of Monday, Grayson's bill has 80 cosponsors -- up 30 from last week.

The petition backing it has close to 50,000 signatures, with new backers signing on at a rate of one every ten seconds.

That's a good start -- in Congress and at the grassroots.

Grayson's legislation is not the end of the process. It's a next step in the right direction -- the direction of "Medicare for All".

John Nichols is Washington correspondent for The Nation and associate editor of The Capital Times in Madison, Wisconsin. His most recent book is The “S” Word: A Short History of an American Tradition. A co-founder of the media reform organization Free Press, Nichols is co-author with Robert W. McChesney of The Death and Life of American Journalism: The Media Revolution that Will Begin the World Again and Tragedy & Farce: How the American Media Sell Wars, Spin Elections, and Destroy Democracy. Nichols' other books include: Dick: The Man Who is President and The Genius of Impeachment: The Founders' Cure for Royalism.

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