Steve Coll on the Hidden Reform

Obama may have already secured health care's biggest change for the better

Anticipation for Obama's health care speech to Congress tonight is high, with dozens of pundits weighing in on what Obama should and should not do. But Steve Coll, New Yorker writer and head of the New America Foundation, argued that one of the most important aspects of health care reform is already in the bag. With a reform bill not even yet solidified to vote on, the health insurance industry has agreed to "guaranteed issue," which means people with a preexisting condition cannot be refused coverage.

In a historical sense, this represents an enormous shift of political and economic will within the insurance industry—and it is a shift that has held firm throughout the rancor and political fear-mongering this year. It also promises real change in the lives of some American families; right now, it is estimated that more than twenty thousand people die each year in this country because they do not have health insurance. Obama will probably make pointed reference to this emerging policy consensus in his speech tonight; rather than using the wonky terms above, he will likely use the language of "security" to remind Americans what will be achieved if a bill can be passed that enacts the bargain to which the insurance industry has, essentially, already agreed.

For all of the flaws and unfinished work in the health-reform legislation now pending—and there are big problems involving cost controls and delivery-system incentives that likely will go unaddressed by whatever bill finally passes this fall (and one will pass, sayeth me)—this is nonetheless a big and important change in the American system of social insurance, one that only awaits the passage of an actual law.

Coll wins the day for avoiding speculation over what will happen, pointing out what has already happened, and making the case that the most important reforms have already been secured even before tonight's speech. While everyone had their eyes on the political speech that will be this evening's address, Coll looked for the substance.