This is not the health care reform battle. This only one important battle for health care reform. A well-designed, quality, universal health care system will not be passed with a single massive piece of legislation. If that is your goal in this fight, you will never win. Knowing that, it is important to focus on winning this battle as a strong foundation for the next battle.

This first battle is not about creating a workable health care system. It is also clearly not about really bringing down costs. It is about expanding coverage and making a commitment as a society that we will try to provide health insurance to all our citizens. Committing to at least not completely bankrupt people with health care costs. Getting that commitment embedded in our unspoken social contract will be a big deal. This fight is also about how we will get to insure universal coverage. Public programs, public/private partnerships, non-profit networks, highly regulated markets, massive subsidies to loosely controled private industries, etc. It is about what will be the foundation that the future of our system will be built on.

If a health care reform bill passes this year, there will be at least two more legislative battles before progressives could turn it into a quality universal health care system. The next battle will happen just before or soon after reform starts in 2013. It will be a fight to fix many of the unintended or overlooked problems with this bill. This battle will look very different than the one playing out in Congress now. Instead it is likely to be a series of skirmishes at the state and federal level about implementation, risk adjustment, and tweaks to regulation. In many ways this battle could be more important but because of the low level intensity of the action, it will make it hard to rally the grassroots supports around.

Once the current reform plan is finally “worked out,” the next battle will be several years later as a result of the impending crash. Our current health care system is on a completely unsustainable course. Some of the reform will help, but will not be nearly enough. I know the system is heading for a breakdown, I just don’t know how. It could be a mass dropping of coverage by employers. It could be a popular clamoring for access to the public option. It could be a major outcry by employers that something needs to be done about the cost of health insurance. It could be another economic downturn. It could be a looming problem related to government debt. How ever the third battle is started, it will not be pretty. Importantly, we will not get to this third battle unless the country first makes a commitment to try to cover everyone. Otherwise, the financial safety valve will always be just to put more Americans in the uninsured column.

It will be a battle (or series of battles) about really cutting cost and trying to rein in the big health industry players. Progressives need to have a proven public option and public health insurance programs in place to use as tools to push this third battle in the direction they want. This fight about reducing costs will probably be over whether to provide less care to many people versus using more government and regulation to really squeeze waste out of the system. The public option should ideally be the proof progressives will need to show that when it comes to reducing costs in health care, the government really is the solution.

Looking around the world at different health care systems, we know this is true. The goal is to lay the groundwork to be able to prove it to the American people at the moment progressives will need to. This is what PhRMA fears, what terrifies the private insurance companies, scares the Republicans, and worries the Democrats who rely on health industry donations.