The month of reform is here

This looks like the month that will likely decide the fate of health care reform. (Picture from FloorTwo.)

Momentum is suddenly on the side of reform, with WalMart coming out for an employer mandate and Democratic plans getting a thumbs-up from the nonpartisan Congressional Budget Office. Recent polls also show support for the most controversial aspects of the plan.

Two issues are likely to dominate the coming debate:

• A mandate, that is a requirement that everyone have health insurance, and that most employers be involved in paying for it.
• A public option, in which consumers can buy health insurance through some entity created by the government.

The action will take place in the Senate, where 60 votes are necessary to cut off most debates. It is thus considered the tougher nut to crack. The arrival of Sen. Al Franken to the caucus is a hopeful sign, but skeptics warn this just moves the obstruction baton from Republican Susan Collins to Democrat Ben Nelson.

One big turning point in the debate may have been a New Yorker article last month about McAllen, Texas, showing how incentives to deliver more care turned one of the nation's poorest areas into one of the most expensive to serve.

Care, results and demographics are little different from El Paso, but costs are much higher. People get more tests, but they don't get better, wrote Atul Gawande.

Since that article came out arguments about rationing are being countered, with people noting that private insurers already ration care. Claims of "socialism" are being turned aside, with reformers noting that British citizens still have access to private care despite their National Health Service.

At some point, however, the rubber is going to have to hit the road here. We already know from the Massachusetts experience that we have too few primary care doctors and too many specialists. Resources, and careers, must be redirected for real reform to take hold.

That is going to be the real battle, and it's an open question whether reformers are prepared to follow through with market incentives that deliver more primary care and more effective treatments.

It's one thing to give the order, one thing to have the data. It's another thing entirely to rebuild an industry.

This post was originally published on Smartplanet.com