The most common defense of the Senate health care bill is that we should “not make the perfect the enemy of the good.” If this were a debate between the perfect and the good, the decision to accept a compromise that only result in “the good” would be easy.

The issue is that we are not discussing the perfect, the good, or even the very decent. The fight is between the acceptable level of small improvement and a terrible corporate giveaway with a few minor improvements thrown in.

To show how far the debate is from the perfect I want to quickly outline what the perfect would look like.

The Perfect

The perfect would have the access to top of the line equipment and procedures found in Germany. It would offer equal access for everyone to a fully integrated health care with no or very low cost sharing, like that found in the UK. The system would provide our nation with average life expectancies on par with Japan, at low per capita cost like those found in New Zealand.

The perfect would increase our average life expectancy by roughly five years, cut our health care spending by 65%, and provide every individual in the country with access to high quality care with no large personal medical costs and eliminate fear of medical bankruptcy.

The Very Good

The “perfect” is probably unobtainable for a variety of reasons beyond politics. The very good would look more like an expanded, improved version of Medicare for everyone. It would be Medicare for all with some of Medicare’s more serious problems resolved – like fixing the wasteful drug benefit program run by private insurance companies. This system would provide every American with good health insurance while reducing our national health expenditure by roughly 20-35%.

The Good

There are many different ways to get a “good” health care reform. One approach could be an option available to all to buy into a Medicare-like robust public option — this would be approximately 25% cheaper than private insurance — combined with automatic enrollment of everyone below 250% FPL in a high quality public health care program.

Another approach would be a Belgian-like system in which for-profit health insurance companies are eliminated; all non-profit insurance funds are required to only sell a few standardized high quality insurance plans; the same insurers are required to use a single government-set reimbursement rate, so all can truly afford health insurance. Such a plan would also need something like direct government negotiations with drug companies and drug re-importation to rein in the pharmaceutical companies. It would also need to provide true universal coverage instead of the Senate or House bills which will leave over 20 million in this country without health insurance.

The Decent

A decent health care reform bill would have some tough new regulations on insurance companies combined with a stronger social safety net and real cost control. Under such a bill, employers would be required to provide insurance, but they may offer only good health insurance, like in Hawaii.

A decent reform bill would need centralized reimbursement negotiators to reduce costs, as well drug re-importation to reduce cost for pharmaceuticals.

A major expansion of public insurance, like Medicaid, would also be needed for all the uninsured or provide generous subsidies to buy into a very cost effective Medicare-like public option.

The Acceptable

Acceptable reform is basically the House bill without the anti-choice Stupak amendment. There are some new regulations in the bill which cover all private insurers in the country. The bill employs national regulator enforcement so the new regulations have some bite to effect change. There is a limited amount of cost control, but not nearly enough to truly drive down overall health care costs. Employers are required to provide at least somewhat decent insurance coverage.

There is a very large expansion of Medicaid with increased payments to primary care doctors to make expanded Medicaid coverage usable. The subsidies are good for a limited number of insureds. People would be forced to buy insurance that might not be affordable but at least they are not forced to pay private insurance companies which have ruined our existing system.

Acceptable reform only decreases the number of uninsured but does not get us universal coverage.

The Bad

The Senate bill is just a bad corporate giveaway with a very few good things in it. It has some good new regulations but leaves enforcement up to the states. This is recipe for regulations which are not enforced and are therefore meaningless.

The new regulations only impact the small group market; they don’t apply to the majority of private insurance in this country. The weird “free rider” provision instead of a real employer mandate creates some bad hiring incentives along with incentives to drop coverage.

The quality of the insurance people will be forced to buy is incredibly low and the subsidies are insufficient. People will have no other choice but to buy coverage from very inefficient and wasteful private insurance companies.

The bill lacks real cost control and the new poorly-designed excise tax will result in millions of Americans getting lower quality health insurance. The bill is not even a good foundation for future reform because it works on a state-by-state basis while directing huge amounts of money and power to the industries which opposed real reform.

The Senate bill does not provide anything close to universal coverage; it also contains a major roll back of women’s reproductive health rights.

Far from perfect

It is important to remember that the perfect was never mentioned in this health care debate. The very good was declared impossible and did not even have a place at the table when they started planning reform last year. Even good reform was dismissed almost immediately.

The debate this entire time has been between what might be labeled “decent reform” at best, and terrible corporate giveaway labeled “reform.” This is not about making the perfect the enemy of the good. We were never even offered the “good” as a compromise.