In the end, this vote is not about the corruption of the legislative process — although this has been tawdry and sleazy almost every step of the way.
The Democrats have bought votes with pork and special deals. They've twisted and ignored congressional rules. They've threatened and intimidated critics. And they've ended up with a new procedure that will allow them to pass the bill without actually having to vote on it.
Nor is this vote about the massive new spending and debt.
True, even by the president's circumscribed accounting, this bill will increase government spending by roughly $1 trillion over the next 10 years. But that estimate obscures the real cost behind a smokescreen of accounting gimmicks.
Some costs, like the so-called "doc fix" (avoiding a scheduled 23% reduction in Medicare reimbursements) are pushed into other legislation. And since the bill doesn't really take effect until 2014, much of the cost is pushed outside the 10-year budget window. Estimates of the bill's real cost over 10 years of actual operation run as high as $3.5 trillion.
Moreover, because this massive cost is paid for in part through budgetary tricks and promised future Medicare cuts that are unlikely to happen, health-care reform will actually add to our already crushing national debt.
It's not about the higher taxes and higher premiums that will sock millions of American workers and businesses, either.
Yes, the bill contains more than $600 billion in new taxes. And contrary to President Obama's promise, many of those taxes will fall on the middle-class. Other taxes, such as a new tax on investment income, will be job killers — this at a time when nearly 15 million Americans are unemployed.
On top of that, insurance premiums would continue to rise, nearly doubling in the next few years, according to the Congressional Budget Office. The bill would do nothing to diminish that increase. In fact, for millions of Americans who get their insurance through the individual market, rather than from an employer, this bill will raise premiums by 10% to 13% more than if we do nothing. Young and healthy people can expect their premiums to go up even higher.
And this vote is not even about how this bill will diminish the quality of health care in this country.
Of course, it will result in greater government interference with how doctors practice medicine. It will undercut our research and development efforts. And it threatens to squeeze reimbursements in a way that could put hospitals out of business and cause physicians to leave the profession. In the long run, we could see the type of rationing or long waits that are prevalent in other government-run health care systems.
All these things are bad. But they are not the worst things about this bill.
At its core, this vote is about freedom and the type of country we want to live in.
Health care is one-sixth of the US economy. It involves some of the most important, personal and private decisions in our lives. This bill would give the government unprecedented control over both the economy and those decisions.
Insurance coverage would be mandated for both employers and individuals. Government would determine what benefits insurance would have to include and force Americans to purchase health insurance that satisfies government mandates. This might require Americans who are satisfied with their insurance to switch to a plan that includes the benefits the government requires, even if that is more expensive or includes benefits they don't want or are morally opposed to.
Insurance companies themselves would become little more than public utilities, protected from real competition, but with every aspect of their operation regulated and controlled by the government.
And once in the doctor's office, government would micromanage medical decisions, deciding what treatments are most effective, or, frighteningly, most cost-effective.
All this, while accomplishing one of the most massive redistributions of wealth in US history. Millions more Americans will be added to the "dole," making them more dependent on government. America will have taken a huge step down the road to becoming a European-style social-welfare state.
That is what is at stake here. If this bill passes, America may be less healthy, and it will likely be less prosperous. And, almost certainly, it will be less free.