If you’re at all interested in the health-care debate, especially if you’re coming from the progressive/liberal side of things, Ezra Klein’s reporting on his blog for the Washington Post is just essential. Klein just owns this beat, and every day he posts something from academia to think tanks to Congress that makes me think.

One recent post is especially outstanding. Most people know that the big debate right now is over the public option. Most liberal and progressive Democrats — and, um, more than half of all Americans — want some kind of public health care plan available. Some want a really robust plan, and want to fight for it; some just want something, anything, that could compete with private plans and maybe be built on for later. But most moderate Democrats and Republicans — and, um, the health care industry — don’t want the federal government in the health care business at all. So they are working to either strip the measure out of health care reform completely, reduce the scope and availability of the plan to make it as toothless as possible, or holding out for some other bribes concession to health care interests in their states.

But even if the public option has the highest profile of health-care reform measures (whether for or against), there’s lots of other less-sexy stuff that boosts access and reduces costs/prices. A little while ago, Klein asked an important question: if you give away the public option, what do you get? The thinking here is that a super-stripped-down state-run plan that can’t bargain like Medicare and is only available to a handful of people years from now isn’t automatically worth going to the mattresses for just to have something that bears the name “public option.” So instead of fighting for that idea (which the Republicans and many Democrats insist on fighting tooth-and-nail against), you use it as a bargaining chip, trading it away from something that can offer more bang for your political (and actual) buck.

For instance, instead of a state option for people on the exchange to buy into, which can’t negotiate like Medicare, Congress could allow everyone over the age of 55 to buy into Medicare itself. Klein: 

The older you get, the tougher it is to find affordable insurance. Private insurers avoid you like the plague or jack your rates sky-high. Some of that will change with health-care reform. Insurers won’t be able to reject older Americans outright, for instance. But they’ll still be able to charge them quite a bit more than younger Americans pay.

One way to ease the situation for older Americans would be to let them buy into Medicare. Medicare negotiates far better rates than private insurers, making it a potentially cheaper option. Moreover, folks over 55 will be in Medicare fairly soon anyway, so this allows for not only better insurance, but more continuity in insurance, which means more continuity in doctors, preventive treatment, etc. This idea was present in Max Baucus’s original white paper, and even in Howard Dean’s 2004 health-care reform plan. It’s due for a comeback.

Another idea (none of these are either/or, by the way): you could likewise expand Medicaid, to cover everyone who lives below 150 percent of the poverty line. In those two strokes, you’ve extended Actually Existing Single-Payer Health Care to the two groups of Americans (the old and the poor) who have the hardest time finding and paying for decent private insurance.

But what about small businesses, and the self-employed? They have a hard time bargaining for good insurance too. Here’s another idea, that achieves all of the goals of the public option without being called or strictly structured as a public option:

Currently, insurance plans are regulated by the states, which means they’re different in every state. That makes it hard for them to achieve certain efficiencies of scale or maximize their leverage against providers. But back in September, I noticed a promising provision in Max Baucus’s draft that would allow for national insurance plans, so long as they met a minimum level of federal regulation. That seemed like a potentially huge change, but I never heard another word about it, so I let it go.

The compromise being discussed is built atop that provision. The idea is that the Office of Personnel Management would choose nonprofit plans that met national standards and offer them on every state exchange (unless states opted out). These plans would be private, but the OPM would act as an aggressive purchaser, ensuring that they met high standards and conducted themselves properly. It’s a private option with a public filter, essentially. But more importantly, it’s a menu of national, nonprofit plans, which would be much more interesting from a competitive standpoint than state-based, public plans.

There’s a great scene in The Fog of War where Robert McNamara talks about how he and the other folks in Kennedy’s war room realized that Khruschev didn’t want to go to nuclear war; he just wanted a scenario where he could say, “the United States was going to destroy Cuba, and I prevented it!” The US didn’t need to invade Havana or drop bombs on Stalingrad to get that result. They could get greater concessions more safely if they didn’t do those things.

Likewise, I wonder — if we give those punk-ass anti-reform moderates the ability to say, “the Obama administration was going to institute socialized medicine, and I prevented it!”, would that be worth it if we could actually get more people better health care more cheaply without it? I think I might take that deal. I bet the pragmatic tactician in Obama might, too — which is why even as he’s pushed for the public option, he’s always left himself some wiggle room.

Two different blog entries about health care ended up in my RSS reader at the same time. They argue for diametrically opposite positions based on what appear to be identical principles.

One is by Conor Friedersdorf, who’s filling in for Andrew Sullivan. It’s essentially a follow-up to his earlier post about requiring Congress to read the laws they pass, which I commented on here.

The worst thing about “comprehensive reform” efforts are that they shut the average citizen out of the legislative process by making bills so complicated that it is nearly impossible for the average citizen to properly evaluate whether on balance it is a wise or unwise measure. Who can predict all the effects of a 3,000 page bill spanning all manner of issues? Often times not even the legislature itself. Certainly not the press, which often focuses on bits of the legislation that won’t actually have the most impact, sometimes because legislators themselves are deliberately obscuring what’s actually at stake.

It’s a conservative lesson: we should make “small, piecemeal improvements to public policy, rather than the kind of sweeping efforts that flatter vanities but fail citizens.”

And here Ezra Klein presents an argument from a reader named Lensch, who compares the current reform bill being considered to the old Ptolemaic epicycles in astronomy:

We want a “uniquely American solution.” So we have weak plans, strong plans, coops, exchanges, individual coverage, community ratings, etc., etc., etc. I still haven’t seen we are going to handle the problem of people with pre-existing conditions. If we cover them, people will take out minimal insurance until they get sick and then switch. We need some more epicycles.

If Copernicus were alive today, I am sure he would say, “If you simply give everyone Medicare, you wouldn’t need all this complication, and I’ll bet it would be cheaper, too.”

The practically radical answer turns out to be intellectually conservative; it’s a back-of-the-envelope solution.

I don’t think one answer trumps or refutes the other. I think there’s another meaning of “simple” here, which both arguments ignore. The health care proposal floated in the House, is intellectually complex not only because it’s designed to please different legislators and constituencies, but because it’s designed to have a minimal impact on most people, particularly those who already have some kind of health care. If by a stroke of law, we switched everyone from private insurance to Medicare tomorrow, it would be chaos. That’s why you get epicycles — because it turns out that asking the earth to move in this case might actually make it change its orbit.

And really, the same thing could be said about the plan to make Congress read their bills out loud and then take a day to deliberate about them. It would actually introduce a great number of brand-new complications into the legislative process, not just for them, but for us, particularly if we actually cared enough to pay attention. You mean, my politicians actually want me to pay attention to what they do and weigh in on complex issues and hold them accountable? Wouldn’t it be easier just to complain that they’re all crooks who don’t represent my interests?