RW: If you don’t have cost containment, you can’t get affordability. Lack of cost containment flows from an unwillingness to make the special interests hold the costs down. If you don’t have real cost containment and just tell the special interests we’re going to guarantee markets and subsidies, you’re in a vise. The [comprehensive] benefits are not there.

TL: Will people still be underinsured when illness strikes?

RW: Nobody has guaranteed all Americans good quality, affordable health care. There’s no question that, under the bill, underinsurance will remain a very substantial problem. Bankruptcies will still continue. People will be paying nineteen percent of their income out-of-pocket on health care—even people with subsidies. This is going to take a toll when you’re falling farther and farther behind every year. I’m very, very concerned with the issue of underinsurance.

TL: Can this problem be fixed legislatively?

RW: I’d like to improve the baseline plan, but we’re in a vise. Unless we have good cost containment, it’s very hard to fluff up the benefit package without blowing up the deficit. That’s the vise that has been created.

TL: Right now, the indexing in the bill that’s based on increasing premiums will mean that people with low incomes will be hurt. Is this troubling?

RW: I don’t support the indexing in the bill. We want to protect middle class families who would spend no more than 9.8 percent of their income for health insurance. They shouldn’t have to spend more than X percent. It shouldn’t grow. But with premiums growing faster than income, the percent of income that low income people have to spend on health care can rise over time.

TL: What can we learn from Massachusetts?

RW: Massachusetts is an extremely important lesson. They have one of the most sophisticated health networks, and they haven’t been able to contain costs. If we can’t contain costs, the public will lose confidence. The issue will leave reformers discredited. The public is not going to buy it—that they’ll come back and do it [cost containment] later.

TL: How would you sum up where we are today?

RW: The cake is not baked. We have to talk about issues that represent the real concerns of how health reform affects the typical Americans. Congress has the time and opportunity to fix many of these concerns. The country won’t get this opportunity again—not in my lifetime. Reformers have to dig in and get them fixed. We’ve got to go on the offense and fix these significant problems.

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.