Not bad. Did you really expect more?

Several weeks ago, I suggested that the debate on national health care issues had moved from policy to politics. We are now at the point where real horse-trading has begun to get the requisite number of votes in the Senate.

Here's one aspect of this, where certain Congressman are trying to protect medical device companies located in their states. And here's another summary, showing the interplay among several groups of constituents:

Doctors are expected to win a $240 billion boost in reimbursement rates that would shield them from a 21 percent pay cut next year for treating Medicare patients. Women who now pay higher insurance premiums for caesarean sections would be protected under antidiscrimination provisions. And although Congress is strongly considering a tax on high-cost “Cadillac’’ insurance plans, the charge is likely to be imposed on a smaller number of health plans, appeasing angry labor activists.

None of this should be a surprise. It is the legislative process in action, based on a republican form of government that was written into our Constitution by John Adams and his colleagues to assure that minority interests are considered.

In similar fashion, we should really ignore non-stories like this one in today's Washington Post. It contains complaints that the final negotiations are being held by a small group of people as opposed to the "big table" approach promised by the president during his campaign. This has been standard practice for decades, and it is necessary to actually get the final work done. It does not, by the way, guarantee full approval by either house of Congress, but without a small working group at some point in the legislative process, you never get close to a conclusion.

All that has really changed recently is that the sausage-making aspects of legislation are now more visible for the world to see.

What it will mean for the final bill, though, is that health care reform will not satisfy the President's three-part test of offering more access, lower costs, and consumer choice, but those in all segments of the industry have known since the start that this was not possible. In my view, the most important things that will be accomplished are eliminating nasty practices of insurance companies; establishing a national requirement for people to have health insurance; and subsidizing at least some of those who need it. The first will give security to those who have insurance but who fear losing it. The second will cause those healthy people who choose not to buy insurance to do so, helping to assure that they do not end up being a burden on all of us when they show up at the Emergency Room. The third will help some portion of the population get insurance and more access to preventative and diagnostic care.

We will find out months and years from now what our Congressional buddies horse-traded away to get this package. Some of it will not look pretty. Some of it will actually harm the underlying causes of more access, lower costs, and consumer choice. There will have been missed opportunities to rationalize the health care system, too. But all of that, I submit, is the nature of the legislative process, where the reality that "one person's costs are another person's income" gets transmogrified into a bill that gets enough votes to pass.