On Friday, Oregon Sen. Ron Wyden got the Senate health care duo, Max Baucus and Harry Reid, to agree that some workers who cannot afford their share of the premiums for employer coverage could shop in the government’s new brokerage service, called the Exchange, so that they might find something that fits their budget. A baby step, perhaps, for addressing the affordability issues clouding reform. So far, few pols—or journalists, for that matter—have dwelled on the point that insurance is likely to remain unaffordable for millions, even with help from the feds. Campaign Desk sat down with Wyden, one of the few politicians willing to talk about this thorny issue.

Trudy Lieberman: Why has the affordability issue been so hidden?

Ron Wyden: Because of the Washington spin. The Washington press sees this in terms of what the CBO, some office, or agency says, with the razzamatazz math. There’s a big Washington D.C. establishment bias for these kinds of stories. Will the CBO come in at $940 billion? No, here’s a news alert; it will come in at $890 billion. It’s all about the horserace and a lot of the rest is about personalities.

TL: Why hasn’t affordability caught on with the press?

RW: It doesn’t fit their idea of news. Their idea is liberals for and conservatives against. It’s the clash on Capitol Hill over the public option. The public hasn’t been informed.

TL: How did the media miss the boat by covering all the hullabaloo about the public plan?

RW: I decided the fix was in for the news coverage when millions and millions were spent on advertising for the public plan. The House public option would cover six million people and the Senate three to four million—roughly one out of eight people. United Healthcare has seventy million policyholders. Why haven’t the American people been told that under ten million would be eligible? How can six million people hold United Healthcare accountable? You never see the press writing how virtually nobody would be eligible.

TL: What should the press be talking about?

RW: The typical consumer is getting clobbered right now. They want to know what’s in it for me—how does it affect me?

TL: How will they be affected?

RW: For the typical consumer, very little. On day one, the typical person is not going to have choice or a public plan. For the typical person nothing is going to change.

TL: Are people in for a big surprise if Congress passes a bill?

RW: I think people will be flabbergasted by the idea that the typical person is going to be virtually defenseless against the insurance companies.

TL: When will affordability hit home?

RW: I’ve been trying to persuade my colleagues that people will be signing up for health insurance in 2010 and 2012 with ballot in hand before the bill goes into effect. They will sign up for open enrollment, paying more and getting less absent some defenses to protect consumers.

TL: Does the potential affordability problem mean people will take the penalty rather than buy required coverage that they might not be able to afford?

RW: I think they will have no choice. We’re walking people into a no man’s land. They will have no coverage, pay a penalty, and put off health care concerns. It’s a prescription for people not getting the health care that they should get. People would rather pay $750 penalty in 2016 or $350 in 2015 than buy coverage. It’s way cheaper, and they’re going to say to themselves I’m looking at the odds of getting sick. They have rent to pay and other things. When they get sick, they can go to the Exchange and buy a policy. If they do that (and drop the policy when they don’t need it) that makes it harder to have a big risk pool to spread the costs and risks.

TL: How does real cost containment square with affordability?

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.

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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.