“Harry did everything he could to deliver a good healthcare bill,” Dean said. “I do not blame Harry at all for the weakness of the healthcare bill.”

Interestingly, Chuck Schumer, who shared Dean’s passion for the public option, is eager to replace Reid if he loses his reelection campaign. But Dean predicted that Reid will win in November “with 46 percent” of the vote, boosted by the presence of an official Tea Party candidate and a “none of the above” option on the general election ballot.

“There are two good signs for the Democrats: One is all this blowup happened 10 months before the election, not 10 weeks before the election. Two, the average American believes that better times are ahead. Those are two important indicators. Now, there are plenty of indicators that aren’t so good, but I think a month is a huge lifetime in politics, so I think we’re actually going to do a bit better than people are predicting.”

One of the reasons Dean sees for hope has to do with the issue he’s been most associated with over the past year, healthcare reform. The former DNC chair hasn’t been wild about the way Democrats have gone about passing a bill so far, or about the legislation itself, but he’s encouraged by what’s been happening in recent days.

“Obviously I wish this had been done a while ago, but I really think it’s terrific that the president brought the bill back. It’s a high-risk strategy and it shows that he can exhibit some strength and leadership, so that’s very, very important. And now we’ll see what comes out of it.”

Salon asked Dean how he’d handle the politics of using reconciliation to pass a bill, and the inevitable backlash from Republicans, if he were still heading up the DNC. He responded:

I think it should have been done last July, that would have made life a lot easier, but I’m glad it’s being done and I think the president is right to call it a simple majority. “Reconciliation” is an arcane Washington term, and I think we want to talk about a simple majority. One of the things that’s upsetting to the American electorate right now is nothing’s getting done in Washington, and the primary reason nothing’s getting done in Washington is because Republicans won’t pass anything in the Senate … I think the American people are really ready for somebody who’s going to step up and say, “We’re going to have majority rule here, we’re not going to let these senators hold up things that are good for the country.”

Dean also had some words of praise for his successors at the DNC and how they’ve handled the block that Sen. Jim Bunning, R-Ky., had been putting on a bill to extend unemployment benefits. The DNC and other Democrats had been working hard to make political hay out of Bunning’s obstructionism, and Dean says he thinks they did well.

“I think the DNC’s doing a very good job and I think that this is a bad thing for the Republicans. You’ve got a senator [Bunning] who voted against the so-called Pay-go bill and then pretended it was a matter of deep principle and stuck it to hundreds of thousands of Americans who are unemployed or work for the federal government. I think that’s a great opportunity and the DNC lost no time connecting that with the Republican attitude towards people in general, which is, we’ll do whatever it takes and hypocrisy is not a problem for us,” the former governor said.

Dean’s reservations have been widely echoed on the left. The healthcare bill’s big winners, they complain, are the insurance industry, pharmaceutical companies, hospitals and doctors. Because it lacks both the “public option” (a government-run insurance company competing with private ones to drive down costs) and the Medicare buy-in that was initially highly touted, then quickly shot down by Holy Joe Lieberman, some Democrats fear that the party is both providing inadequate coverage and setting itself up for a voter backlash.

Once the public realizes that the bill mandates everybody to buy private health insurance — pretty much the way everybody has to carry auto insurance — there’s sure to be unhappiness not only on the tea-party right, but also among working people who ordinarily lean Democratic. Politics Daily’s David Corn saw it coming. “I feel as if I’m watching a cheesy horror flick and some poor unsuspecting person is about to open the wrong door,” he wrote last September, “and you want to scream, ‘Hey, don’t open that door!’”

To be sure, the bill provides generous subsidies for individuals and small businesses currently unable to afford coverage. And it doesn’t kick in for a couple of years, when one hopes the current recession will be a bad memory.

© 2009 by Gene Lyons. Distributed by Newspaper Enterprise Association

Even so, Salon’s estimable Glenn Greenwald sees it as a sellout: “The healthcare bill,” he writes, “is one of the most flagrant advancements of … corporatism yet, as it bizarrely forces millions of people to buy extremely inadequate products from the private health insurance industry — regardless of whether they want it or, worse, whether they can afford it,” even with some subsidies.

MSNBC’s self-dramatizing Keith Olbermann goes further, vowing to become what the Russians used to call a “refusenik.” “I hereby pledge,” he announced, “that I will not buy this perversion of healthcare reform. Pass this at your peril, senators. And sign it at yours, Mr. President. I will not buy this insurance. Brand me a lawbreaker if you choose. Fine me if you will. Jail me if you must.”

As diverting a spectacle as that might be, for Democrats to heed such overheated rhetoric would be catastrophically foolish. Olbermann and others spent the 2008 primaries charging that Democrats skeptical of Barack Obama had racist motives. Now that he’s poised to sign the most far-reaching enhancement of the American social contract since Lyndon Johnson, President Obama has now been rendered impure in their eyes.

Here are a few truths: First, we’ve been living in a one-dollar, one-vote corporatized democracy for a long time. If this is news to you, then you’re probably also shocked to learn that the U.S. Constitution, by awarding two senators to each of what H.L. Mencken called “the cow states” — no insult to the cows in my own barn — was deliberately crafted to make fundamental change difficult. Who made “moderates” like Blanche Lincoln of Arkansas, Ben Nelson of Nebraska and Joe Lieberman of Aetna mini-presidents? Alas, the founding fathers did.

Living in such a polity, anybody who thought entrenched interests like the insurance, pharmaceutical and hospital industries weren’t going to find ways to make money off healthcare reform probably wasn’t paying attention back at the beginning, when Obama said that despite the abstract appeal of a Canadian-style single-payer system, it was a political non-starter. As Greenwald points out, that told you right there that the White House was going to settle for the best corporate compromise it could get.

Sure, there’s a risk of backlash. The problem is no universal or near-universal health-insurance plan — public or private — can be voluntary. Mandates are, well, mandatory to prevent opportunists from gaming the system: Buying insurance only after they get sick. Nobody can insure “previously existing conditions” if clients come and go at will.

Insurers forbidden by law from canceling policies also need a base of healthy rate payers. Public or private, it’s a two-way street; costs can’t be cut without a bigger risk pool.

Indeed, a gradual counter-backlash seems likelier, as all but the most perfervid tea partiers gradually recognize that their families are more secure, and that none of the GOP scare stories — “death panels,” rationing, etc. — have any basis in reality. Retreat now is unthinkable. Imperfections notwithstanding, once universal coverage is established in principle, there’ll be no going back.

What irks him the most in the current bill, he said, is that it permits insurance companies to charge as much as 300 percent more to some customers than others. So even though they must provide coverage to anyone who applies — known as “guaranteed issue” — the price differential that can be charged to older or sicker customers virtually erases that promise. “If you have to pay $20,000 a year for insurance, what good does it do if you have guaranteed issue?” he asked rhetorically. “Which is in fact what you’d have to pay if they can charge you three times as much as they do ordinary people. They have 300 percent rate differences in that bill. In Vermont, we have 20 percent rate differences, and that works.”

The bill lacks sufficiently stringent controls on insurance company pay for executives and other wasteful expenditures as well, Dean argues, which is why he also opposes its mandate requiring all Americans (with few exceptions) to buy health insurance. “Why should you force Americans into a system that takes between 20 and 30 percent off the top for CEO salaries and return on equity?” he asked. “You’re forcing them into that system and it’s unfair.” There should be no mandate without a public option, he said.

The best way to remedy this fundamental flaw, according to Dean, is to expand Medicare, because that avoids all of the political and market problems of a system based on private insurance. In the current legislation, he supports the insurance “exchange mechanism, because I assume we would need that no matter what else we do in the bill — it is the most sensible way to buy insurance, and it was pioneered in Massachusetts,” where insurance costs have declined. “I would certainly leave in the expansion of Medicaid,” he added, “and make it bigger and have the feds put more money in it so the states don’t get left on the hook. That’s how we did universal insurance for kids [in Vermont] and I’m a huge fan of that.” He also supports the expansion of community health centers and for wellness and preventive care in poor communities.

At the center of his argument with the Senate leadership and the White House is his insistence that their bill is a hodgepodge of “hocus pocus” and not “real insurance reform.” He still believes that Congress could pass a Medicare expansion next year using the reconciliation process, needing only 51 votes rather than 60 — and including $500 billion in cuts applied to Medicare Advantage subsidies to private insurers to pay the cost.

So does he really want to kill this bill? “Oh, I think they should vote no on it. I would like to see it redone,” he said. “You can’t vote for a bill like this … You can’t say, oh, we’ll all vote for this piece of junk now, just to get it to the conference committee [with the House], because it’s not going to get any better when it comes out of the conference committee if four Senators from the insurance industry can veto the result.” He declined to name those four Senators, because “I’m trying not to get too much into ad hominem attacks.”

Regardless of the nasty personal remarks about him that have been emanating from the White House, Dean wanted to emphasize that he still supports the president. He dismissed any talk of another run for president. “I plan to support President Obama vigorously in 2012. I think he’s done a terrific job on things like the environment and restoring America’s name in the rest of the world,” he said. “I remember what it was like to have George Bush as president and I’m not on a mission to destroy the Democratic Party, having rebuilt it. But we didn’t elect Democrats to pass crap. We elected Democrats to make a difference”

Will this bill make a difference despite its flaws? He doesn’t think so. Although much of Dean’s critique makes sense — and he is hardly alone in his disappointment — some of his arguments have been disputed by other progressive experts, notably Ezra Klein and Paul Starr.

But the real crux of the argument between Dean and the bill’s supporters is less about the details than over what this act means for the future of healthcare in America. For those who want the bill to pass despite its defects — a position that I have come to share — this is the moment when the nation decides that health insurance must be provided to every citizen, period. That tidal shift is why right-wing politicians and pundits are so ferociously opposed to this bill — and why its passage would represent an important victory on the way to restoration of the American social contract.

Then, around some suggested changes, he gets to the politics of its passage or rejection:

To be clear, I’m not giving up on health-care reform. The legislation does have some good points…

Improvements can still be made in the Senate, and I hope that Senate Democrats will work on this bill as it moves to conference….

In Washington, when major bills near final passage, an inside-the-Beltway mentality takes hold. Any bill becomes a victory. Clear thinking is thrown out the window for political calculus. In the heat of battle, decisions are being made that set an irreversible course for how future health reform is done. The result is legislation that has been crafted to get votes, not to reform health care.

I’m not convinced that Dean’s voice carries as much weight as it once did. Opponents will undoubtedly rally behind him; as a doctor and former presidential candidate who excited key elements of the Democratic base, he lends credibility to critics that those who are dismissing them as looney lefties.

Ezra Klein, who is taking a lot of guff from conservatives while at the same time disappointing liberals for supporting the Senate compromise–calls Dean one of the hostage-takers in the debate:

In his op-ed, Dean names John Kerry as the senator who has been working hardest on this question. This morning, I spoke to Kerry’s staff, who got me a statement from Kerry himself. “The prudent purchasing provisions in the Senate health bill will lower costs and increase affordable options for consumers,” Kerry says. “It’s strong language that will allow the exchange to deliver competitive prices and offer high quality care, and I’m thrilled to see national reform honor the best innovations already succeeding in Massachusetts.”

I’m sure there’s some theoretical way in which the language could be stronger. Dean doesn’t say what it is, but I don’t doubt it exists. But now we’re talking about killing the Senate health-care bill — with its $900 billion in subsidies and its delivery system reforms and its Medicare Commission and its Medicaid expansion and its exchanges and its regulations on insurers — unless we make the exchanges slightly stronger prudent purchasers, when they’re already strong enough to “thrill” the original sponsor of the prudent purchaser amendment?

I guess this is the logical outcome of a system in which the greatest gains accrue to those making the most credible and severe threats. But it’s not healthy.