This probably isn't the most original observation, but this graf from yesterday's Times piece on the state of play in health care reform really clarified some tactical imperatives for me:
While Congressional leaders say they want to curb the explosive growth of health costs, it is unclear whether the final bill will make a serious effort to do so. Every proposal meets resistance from health care providers who fear a loss of income, even as they stand to gain millions of paying customers if nearly everyone has insurance [emphasis added].
When you think about this tradeoff, it becomes clear what needs to happen this year and what can probably wait. In the former category: Everything that will be unappetizing for insurers--the public option; taxing generous insurance plans; regulations to end things like rescisions, the denial of coverage on the basis of pre-existing conditions, and lifetime spending limits on policies. In the latter category, everything that doesn't inspire intense opposition from the insurers: generous subsidies to consumers of health care, opening the insurance exchange up to more and more people, etc.
The reason? This is really the only time we'll have a ton of leverage over insurers, thanks to the millions of new customers health care reform will bring them. It's the same reason you negotiate your salary before accepting a job. If we don't do the stuff that's painful for the insurers when our leverage is maximized, it's hard to imagine it every getting done. On the other hand, it's never really that hard (as these things go) to increase subsidies for middle class taxpayers.