It's time to evaluate where health care reform stands at this point.
Guaranteed Issue: The best thing about the bill is unquestionably the fact that insurers have to issue policies to anyone who can pay. No one can be denied coverage, no matter what pre-existing conditions they have. This is a big deal. While it can help people of any age, it is most important to older people, who are more likely to have pre-existing conditions. This also helps people who are stuck with very expensive insurance because they have pre-existing conditions and if they cancel their insurance wouldn't be able to get new insurance.
Individual Mandates and cost sharing: An individual mandate forces people to buy insurance whether they want to or not. Insurance works better when everyone is covered and in the same risk pool. It also shares costs throughout the population. Individual mandates seem unfair, but they are generally instituted as part of changes to the system which reduce overall costs significantly. For example, relatively speaking, Canadian GDP/capita costs were reduced by one third compared to what they would have risen to otherwise during the ten years after changing from a US style system to single payer.
If there is no cost reduction due to systematic changes in the system, however, all that an individual mandate does is share costs through the entire population and direct profits to private insurers and medical providers of various kinds by giving them a captive consumer based, forced by government mandate to buy their services.
People who don't have insurance right now are primarily younger people or those who feel they can't afford it. What individual mandates will do, then, is subsidize older people's insurance costs and the price of guaranteed issue, which is very costly since it forces insurers to cover people who are very likely to get sick. The people who subsidize this are, generally speaking younger and poorer.
If subsidies were adequate, then in fact, it would be the government subsidizing the costs, through progressive income tax and corporate taxes. However, since the subsidies in the various bills do not cover the full cost, poorer and younger people will subsidize older people. Since many of those people didn't buy insurance because they are right on the edge financially already it means that some of them will go without food, not be able to pay tuition, or lose their homes as a result. Many people are already on the edge already, this is one more burden for them.
No Robust Public Option: A robust public option is one that is large enough and with enough pricing power to force down costs, and one which is available to everyone. At this point, the public option will likely have between 5 to 9 million enrollees (the CBO says 6 million, but we'll be generous). As such it will be smaller than most private insurers and will not have pricing power. If it were linked to Medicare and could use Medicare's clout, it could reduce costs, but the Medicare +5 amendment, which would have had it paying providers at Medicare rates +5% was defeated.
The Congressional Budget Office has stated that the public option insurance plan premiums will be higher than equicalent private plans. This is likely because of denial of care issues, insurer cherry-picking and lack of clout mean it won't be able keep reimbursement rates low relative to private insurers who have more customers and thus more pricing clout with doctors, hospitals and other providers. If the public option costs more than equivalent private plans, it goes without saying that it will not reduce costs.
Reduces Practical Access to Abortion: The Stupak amendment, passed Saturday evening, makes it illegal for any plan offered on the exchanges to finance abortions. Any woman who wants abortion access, after being forced to buy insurance that doesn't include it, will have to buy it elsewhere. The practical result of this is a reduction in access to abortions. This, of course, primarily affects young, childbearing age women though their family members, boyfriends and so on will likewise be effected.
The Bottom Line: Who's Getting What, and Who's Paying