In that merging, the focus shifted to a one-sided political calculus, and away from critical questions like just how much it would cost Americans to carry the minimum amount of insurance coverage required under the emerging bill. Rather than address such concerns, the Democratic leadership, in the interest of political expediency, expanded the scope of the legislation, adding more regulation, spending and taxes. Soon health care reform, which had been achievable, became endangered.

At the same time, Democrats trying to lead health care legislation through Congress made a multitude of missteps. One of these was to fixate for months on the “public option,” only to wholly discard it. Yet Senator Snowe had long offered the option of a “fallback” public plan. This would have allowed insurance market reforms to work, but would have applied the threat of intervention by a public plan to ensure that private health plans actually performed. The Congressional Budget Office confirmed that such a strategy would have pressured private insurance plans to reduce costs.

No less embarrassing was the way the majority leadership killed a bipartisan amendment to establish an F.D.A.-regulated system for importing prescription drugs. Safe importation would have produced nearly $100 billion in savings, $19.4 billion of which would have been realized by the federal government. But the amendment conflicted with the deal Democrats had made with the pharmaceutical industry.