Don't let the perfect be the enemy of the good. That's the message from Adam Searing, director of the N.C. Justice Center's Health Access Coalition, who says that despite the deep Democratic schism over health care reform, the prospective legislation constitutes a major breakthrough.

"So for people who say, 'Oh, this isn't what I want,' I would say to them that the political process is not perfect, but we are talking about bills here that would cover between 94 and 97 percent of people in the country, and I think that's something worth doing."

Click for larger image • Protesters demonstrate against Blue Cross Blue Shield's recent postcard campaign urging policyholders to call Sen. Kay Hagan to oppose health care reform. Photo by Jenny Warburg

Nearly 2 million North Carolinians who either lack health insurance or are saddled with expensive nongroup policies would be eligible for affordable coverage under both the Senate and House bills, according to U.S. Health and Human Services Secretary Kathleen Sebelius.

Last week, by a 220-215 margin, the U.S. House of Representatives passed its version of health care reform, which includes only a weak public option. On Nov. 21, the Senate voted 60-39 to start debate on a more conservative version with a weak public option and a provision that would allow each state to choose to eliminate it. If the tally sounds like a wider margin, it wasn't: 60 votes were required to break a threatened Republican filibuster.

And even as the 60 senators (58 Democrats and two independents) were voting to consider the bill, four of them announced that unless the public option is dropped or gutted, they would support a filibuster to prevent an up or down vote. (The four are Mary Landrieu of Louisiana, Joe Lieberman of Connecticut, Blanche Lincoln of Arkansas and Ben Nelson of Nebraska.) It appears that when the Senate does take up the bill, even the weak public option may be jettisoned in favor of a "trigger" amendment that would shelve it indefinitely.

As Congress enters the home stretch toward enactment of a health care law, progressives are split on whether the final product will be better than nothing at all. With no viable public option and with all the concessions made by the White House and congressional leaders to the pharmaceutical industry and other interest groups, some critics charge that the result will require everyone to buy overpriced insurance coverage.

Dr. Marcia Angell, former editor in chief of The New England Journal of Medicine and now on the Harvard Medical School faculty, is among the critics. In an essay for The Huffington Post, Angell said that far from being a "government takeover," as Republican critics charged ("I wish it were," she added), the House bill "enshrines the 'takeover' by the investor-owned insurance industry" that began in the '90s after the Clinton administration's reform efforts failed.

"Is the House bill better than nothing?" Angell asked. "I don't think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges."

Progressive Democrats of America agreed: "Just because a massive bill manages to include a few sensible measures that should have been enacted years ago," National Director Tim Carpenter said, "a mandate that we all buy a defective product to swell the profit margins of the very corporations who created this crisis does not make it reform."

Carpenter also denounced "the further degradation of women's reproductive rights" that would occur if House-passed anti-abortion language survives in the House-Senate conference bill.

However, the left-wing activist group MoveOn.org told its members, "We're closer than we've been in decades to meaningful change that will benefit millions of Americans."

In a mixed message, MoveOn said that the Senate bill, "for all its flaws," contains a public option: "The fight for real health care reform with a public option is one of the most important we've ever taken on together. We can't afford to lose."

Speaking for the Obama administration, Sebelius said health insurance reform "will improve health care for all Americans," showing as evidence a state-by-state breakdown of the benefits (at www.healthreform.gov).

Searing says there are many positive aspects of the bills, starting with the expansion of Medicaid, which he says is glossed over in most analyses. The Senate and House bills would extend eligibility under Medicaid to persons who earn up to 133 percent or 150 percent, respectively, of the federal poverty standard ($22,000 a year for a family of four). Equally important, Medicaid would cover more people, including those who've lost their jobs, Searing says, where now it covers only "the deserving poor"—mainly children and their mothers—but not the merely unemployed.

About half of the approximately 35 million uninsured Americans who would be covered under the reforms, Searing says, would come in under Medicaid. The other half would be able to buy insurance with the help of government subsidies on a sliding scale up to 300 percent (Senate) or 400 percent (House) of the poverty standard.

The bills would also initiate a regulatory regime on private health insurance, barring providers from disqualifying applicants with pre-existing conditions or dropping coverage when people get sick. The bills would also limit how much more an insurer can charge its older customers compared to younger ones: In the House bill, the limit is twice as much; in the Senate version, three times as much. Right now, insurers are free to quote any rates they like as they try to sign up healthy, younger folks and dodge older, and potentially more costly, ones.

Searing says most progressive reformers expect to support the final outcome—and expect some type of public option to be included.

But the public option was never going to cover many people, he notes. In most bills it was limited to individual buyers and the employees of very small companies that would be exempt from the requirement that businesses offer group coverage to their workers.

Searing is an outspoken critic of N.C. Blue Cross Blue Shield, and he says it's vital that a public insurance option be available in the state as an alternative to the stranglehold BCBS has on the market, especially for single buyers.

But even without it, Searing says, the reform measures contain some meaningful curbs on the skyrocketing cost of health care. They include pilot programs to test results-based payment methods, instead of the traditional "fee-for-service" (whatever the doctor ordered) model, and a Medicare payment commission charged with determining the cost-effectiveness of services.

Critics say the public option has been so weakened that it's likely to have a sicker pool of clients than the private insurers can attract. Thus, its premiums, which otherwise could've been substantially less than the private companies, may end up being higher.

That's a major problem, Searing concedes. But even a "robust" public option with a healthier pool and premiums tied to Medicare's low rates is less likely to impact health care costs than fundamental changes in how providers are paid.

Health care isn't going to turn around quickly, even with a public option," he says. But for the first time, the current reforms offer a chance to start chipping away at it.