So, how well will health reform work after it passes?
There's a part of me that can't believe I'm asking that question. After all, serious health reform has long seemed like an impossible dream. And it could yet go all wrong.
But the teabaggers have come and gone, as have the cries of "death panels" and the demonstrations by Medicare recipients demanding that the government stay out of health care. And reform is still on track. Right now it looks highly likely that Congress will, indeed, send a health care bill to the president's desk. Then what?
Conservatives insist (and hope) that reform will fail, and that there will be a huge popular backlash. Some progressives worry that they might be right, that the imperfections of reform - what we're about to get will be far from ideal - will be so severe as to undermine public support. And many critics complain, with some justice, that the planned reform won't do much to contain rising costs.
But the experience in Massachusetts, which passed major health reform back in 2006, should dampen conservative hopes and soothe progressive fears.
Like the bill that will probably emerge from Congress, the Massachusetts reform mainly relies on a combination of regulation and subsidies to chivy a mostly private system into providing near-universal coverage. It is, to be frank, a bit of a Rube Goldberg device - a complicated way of achieving something that could have been done much more simply with a Medicare-type program. Yet it has gone a long way toward achieving the goal of health insurance for all, although it's not quite there: According to state estimates, only 2.6 percent of residents remain uninsured.
This expansion of coverage has tremendous significance in human terms. The Kaiser Commission on Medicaid and the Uninsured recently did a focus-group study of Massachusetts residents and reported that "Health reform enabled many of these individuals to take care of their medical needs, to start seeing a doctor, and in some cases to regain their health and control over their lives." Even those who probably would have been insured without reform felt "peace of mind knowing they could obtain health coverage if they lost access to their employer-sponsored coverage."
And reform remains popular. Earlier this year, many conservatives, citing misleading poll results, claimed that public support for the Massachusetts reform had plunged. Newer, more careful polling paints a very different picture. The key finding: An overwhelming 79 percent of the public think the reform should be continued, while only 11 percent think it should be repealed.
Interestingly, another recent poll shows similar support among the state's physicians: 75 percent want to continue the policies; only 7 percent want to see them reversed.
There are, of course, major problems remaining in Massachusetts. In particular, while employers are required to provide a minimum standard of coverage, in a number of cases this standard seems to be too low, with lower-income workers still unable to afford necessary care. And the Massachusetts plan hasn't yet done anything significant to contain costs.
But just as reform advocates predicted, the move to more or less universal care seems to have helped prepare the ground for further reform, with a special state commission recommending changes in the payment system that could contain costs by reducing the incentives for excessive care. And it should be noted that Hawaii, which doesn't have universal coverage but does have a long-standing employer mandate, has been far more successful than the rest of the nation at cost control.
So what does this say about national health reform?
To be sure, Massachusetts isn't fully representative of America as a whole. Even before reform, it had relatively broad insurance coverage, in part because of a large union movement. And the state has a tradition of strong insurance regulation, which has probably made it easier to run a system that depends crucially on having regulators ride herd on insurers.
So national reform's chances will be better if it contains elements lacking in Massachusetts - in particular, a real public option to keep insurers honest (and fend off charges that the individual mandate is just an insurance-industry profit grab). We can only hope that reports that the Obama administration is trying to block a public option are overblown.
Still, if the Massachusetts experience is any guide, health care reform will have broad public support once it's in place and the scare stories are proved false. The new health care system will be criticized; people will demand changes and improvements; but only a small minority will want reform reversed.
This thing is going to work.