Like Kevin Drum, I've been pretty pessimistic for a while that a good health care bill will be signed into law in 2009-10 as so many seem to hope. And I agree with him that Ezra Klein's new American Prospect article does a reasonable amount to temper that pessimism. That said, the way the article is framed explicitly as a look back at the "lessons of '94" winds up leaving some of my concerns unaddressed.

For example, mightn't we see something analogous to the Medicare prescription drug fiasco where a reasonably sound proposal to help some people out with some health care problems turned into a feeding fest for pharmaceutical and insurance company lobbyists?

Speaking of which, one thing that's bothered me about the health care conversation as it's tended to play out among progressives over the past year has been a tendency to equate determination to achieve universal health care with determination to fight the entrenched power of the insurance companies. In reality, the main measures by which people are proposing to achieve universality -- forcing people to purchase health insurance and providing government subsidies to help people buy insurance -- aren't contrary to the interests of insurance companies at all. Similarly, the main measures on the table that are contrary to the interests of health insurance companies -- community rating, guaranteed issue, and public-private competition -- don't achieve universality (as Barack Obama's critics will hasten to tell you). Under the circumstances, the easiest way to get universal health care may be to not fight the insurance companies at all: just give them the mandates and subsidies they crave with none of the regulation.

Now go too far in that direction and the overall price tag gets so high that the whole thing collapses. But it's quite possible to imagine congress constructing a bill that throws public-private competition overboard and then is structured so as to both increase health insurance firms' profitability and to give everyone health insurance. Again, the 2003 Medicare reform bill would be the model. Depending on the details, a bill like that might even be an improvement over the status quo (though I kind of doubt it). After all, a program for "universal car ownership" isn't something you'd expect to achieve by fighting the car companies.