OK, Democrats, do what you must to craft a health-care package you can pass.
I understand that the "public option" in the House bill, as promising as it would have been for cost control and competition, will have to go. Lose the "cornhusker kickback" that was added to win the support of Nebraska Democratic Sen. Ben Nelson and would exempt that state from big Medicaid payments. (Dare Nelson to vote no.)
No, illegal immigrants shouldn't get coverage from insurance exchanges, even with their own money. Figure out how to pay for the package. And if you're worried that America might be shocked watching you stuff the legislative offal into a big, greasy kielbasa skin, keep the negotiations secret. (Though you'll pay at the polls in November if you don't provide more transparency.)
But for crying out loud, if you can't have a public option to compete with private insurers, do something else to control the rising price of health care.
Everybody's saying Democrats can approve the benefits now, and Republicans can control costs once they regain power. Follow-up measures to limit costs will be necessary no matter what happens. The problem is Republicans haven't been fiscally responsible in a long time, and counting on Congress to do anything is a losing proposition. But legislators can get a head start if they insert a dollop of fiscal sanity now.
And Maryland might just have the answer. It would mean giving effective power to a Maryland-style commission to set prices for Medicare, the federal health program for seniors and the disabled.
Cost control in the legislation so far is "modest at best," says Dr. Eli Adashi, a medical professor at Brown University who wrote a piece in The Washington Post a few months ago, praising Maryland's unusual system as a national model. "It's not everything everybody hoped for. Will it be revisited? Yes."
The House bill has no provision for an independent Medicare cost commission. And the one in the Senate bill, as The New York Times' David Leonhardt has pointed out, gives hospitals and hospices an exemption until 2019.
A medical cost-control panel that exempts hospitals is like a peanut-butter-and-jelly sandwich that leaves out the peanut butter. And the bread.
Maryland's Health Services Cost Review Commission, unique in the nation, has been setting hospital prices not just for Medicare but for private insurance companies since the 1970s. It limits cost increases while maintaining quality, spreading the cost of charity care across the state, and preventing the numerous hospital closures seen elsewhere.
Limiting increases is a relative concept, of course, and costs have soared in Maryland along with those everywhere else. But Maryland's cost per hospital patient was 26 percent more than the national average in 1976 and 2 percent below in 2007, the commission says.
A national commission with the same effectiveness over the same period would have saved $1.8 trillion, Adashi says.
The commission being considered in Washington would control only Medicare, not payments by private insurers. Still, many analysts believe the panel is critical to cost control.
Whatever its scope, Maryland can offer lessons.
"The record on overall cost growth is pretty damn impressive," in Maryland, says Bruce Vladeck, a senior adviser at Nexera Inc. in New York who ran Medicare and Medicaid in their Woodlawn headquarters in the 1990s. "In a logical world, we'd look at this very seriously."
The world is not logical, and Congress even less so.
But if the Democrats want to strike a blow against their reputation as being fiscally clueless, they'll include a Medicare cost commission in the final bill and give it some sharp teeth.