by Andrew Sprung

listen to its godfather. Jacob Hacker throws his support behind the surviving health care reform legislation and tells progressives where to concentrate fire in the House-Senate reconciliation process:

The lack of a public option also makes even more imperative tough requirements on insurers to make them live up to their stated commitment to change their business model and slow the spiraling cost of coverage. The most important way to do this is to move away from the Senate bill’s state exchanges and toward a national exchange such as that contained in the House bill. The federal government needs to be directly involved in implementing and enforcing strong national regulations of insurers and creating the new exchange. Otherwise, the effort for reform might fail at the hands of hostile governors.

The federal government is the only entity big enough and powerful enough to ensure a highly consolidated private insurance industry follows the law.  It can and must demand transparency and obedience to the new rules. Insurers must open their books, and subject their rates, administrative costs, and profits to federal review. These new rules must apply to all plans, not just those within the exchange. And states should have authority not only to enforce these rules, but to innovate beyond them as well.

These are not politically unrealistic goals. Most are already embodied in the House bill. In bridging the differences between the two bills, Democratic leaders and the President must insist on a final bill that delivers on these fundamentals.

Health care experts and commentators including Alan Garber, Jonathan Gruber, Ron Brownstein, and Atul Gawande have advocated or praised the cost control measures packed into the Senate bill. But most of these measure, including the strengthened MedPAC and an array of  pilot programs and efficiency incentives, pertain mainly to Medicare and Medicaid, over which Congress maintains power of the purse (an exception is the excise tax on expensive employer-provided plans).  The House bill, Hacker reminds us, provides the means for stronger control of private insurers. Viewed another way, the Senate bill's best cost control measures mainly focus on changing the behavior of health care providers; the House's, on reshaping private insurance.

It's easy to imagine a bill that combines the best -- or worst -- elements of the House and Senate bills. What we'll probably get is a messy mixture.

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