Congress has been formally debating health care reform for almost nine months. And the country, as a whole, has been debating it for years. But now that the last congressional committee with jurisdiction has approved legislation, lawmakers are confronting the essential conundrum that's bedeviled this issue all along: Their desire to expand health insurance coverage exceeds their willingness to pay for it. As deliberations move to the House and Senate floors, then on to conference-committee negotiations, something has to give.  

You can see the dilemma in the bill that the Senate Finance Committee passed last week. The Congressional Budget Office (CBO) determined that the Finance bill both pays for itself and would actually reduce federal spending (relative to what it would otherwise be) over the long term. But to produce a bill that would get the CBO's blessing, the committee decided to scale back what reform would offer. Relative to the bills that passed the Senate Health, Education, Labor, and Pensions Committee or its three counterparts in the House, the Senate Finance measure offers, overall, less financial assistance to people buying insurance, while guaranteeing less insulation from medical bills for those who buy it. A family earning $55,000 per year, for instance, could owe more than $11,000 in combined premiums and out-of-pocket expenses--or roughly one-fifth of its total income.

Nobody seems particularly thrilled about this. On the Finance Committee, liberals like Jay Rockefeller and Charles Schumer voted for the bill but pledged to address these problems as the legislative process moves forward. Olympia Snowe, who provided the bill with its critical Republican vote, made similar vows. The same consensus seems to exist in Congress as a whole and, if the will to make improvements is strong enough, there is certainly a way.

Many ways, in fact. Making health insurance less of a financial reach--and guaranteeing that it offers more protection--is simply a matter of finding a little more money. Congress could increase the Senate Finance bill's proposed excise tax, which would affect the most generous benefit plans. Most economists believe that the tax would not only generate revenue; it would also prod the health care system toward greater efficiency and lower cost. Alternatively, the House bills all contain an income surtax that would affect only the very wealthiest households. And President Obama has proposed a cap on the deductibility of charitable contributions, which would hit essentially the same people.

One final source of funds is the health care industry itself. The Finance bill calls for changes in the way doctors, hospitals, and the makers of drugs and devices get paid--changes that would, in theory, encourage them to be more efficient while freeing up government dollars. But the industries--particularly the drug industry and hospitals--got off relatively easy. Legislators could push for more aggressive changes and, in the ideal world, create a public insurance option that would use its bargaining leverage to make those changes stick.

With so many ways to raise revenue, finding some combination capable of winning majorities in both chambers would seem simple. It isn't. Liberals don't like the insurance excise tax, in no small part because unions don't want it affecting older workers who won generous benefits in past collective bargaining agreements. Centrists want no part of taxes outside the health care system, particularly those that target the wealthy. And neither group seems seriously interested in extracting more concessions from the health care industry, which may have a little something to do with the fact that it bankrolls so many political campaigns.

It's possible that everybody is posturing in order to gain maximum bargaining power for the conference-committee negotiations--which is where, quite possibly, the final deal on money will come together. If that happens, finding additional revenue will be possible. But it's just as possible that Congress will further cut funding and that the White House will say OK. On the Finance Committee, Schumer and Snowe partnered on amendments to weaken the requirement that people buy insurance. Without more money on the table and a better set of insurance options--including, ideally a public plan--there will be pressure to weaken that requirement further. 

The argument is that it's not fair to make people buy insurance when it's too expensive and doesn't cover enough. That's true. But the answer is to make insurance more affordable and more protective, not to let more people out of the requirement. Make no mistake: A bill with less funding is a bill that helps fewer people. That's bad policy and, by the way, bad politics, too.