By BILL KRAMER

A week ago, before the Massachusetts special election, health reformers felt that their house was almost finished. The edifice of health reform had been built painstakingly using blueprints designed by policy and political experts during the past 10 years. It wasn’t a perfect building — like many construction projects, there were concerns that it would cost too much and wouldn’t be aesthetically pleasing — but most agreed that it would provide shelter for those who had been excluded from health coverage: the uninsured and the medically uninsurable. The imperfections could be fixed later. As many said, this would be the foundation and framework on which an even better health system for the U.S. could be built. And the wolves who had ruthlessly blown down health reform houses in the 1990s and before had been kept at bay.

As the reformers stood on the top floor last week, deciding on the final touch-ups and planning for the housewarming, someone pulled the rug out from under them. The upset election of Scott Brown to fill the late Sen. Kennedy’s seat changed the political calculus. It would not be possible for the Senate to pass a bill including the final modifications, since a unified Republican minority of 41 would be able to block consideration of the bill. It turned out that under the rug was a hole in the floor, and suddenly the reformers were on the next floor down. The reformers might have to leave the top floor unfinished (the modifications that were needed to get House approval), but they could still have a pretty solid building if they could reach agreement.

But the Democrats haven’t been able to find a way to finish it off. The idea for the Senate to quickly pass the modified bill before Brown was seated was rejected as politically unseemly. The plan for the House to simply pass the Senate bill and send it to the President for signature has apparently been rejected by House members. The idea of a two-step process – the House would pass the Senate bill in exchange for a promise that the desired modifications would be included in a separate budget reconciliation bill – seems like a pragmatic if inelegant solution, but it is apparently stalled for lack of clear direction. Some have suggested that a “pared-down” bill – incorporating some insurance reforms, small business subsidies and Medicaid expansion – might be the only feasible option. Others are skeptical that any reform could pass the Senate and said that the Democrats should “pivot” to other issues like job growth. Suddenly the reform effort seems to be in free fall. The reformers have fallen through a hole in the top floor, and now it seems that every floor has a hole. It’s a panicky, sickening feeling – not knowing where the bottom might be. The memory the recent earthquake in Haiti is fresh in everyone’s mind, and we all know that the death and damage was immensely compounded by the poor construction standards in that impoverished country. Is the health reform house built of bricks or straw? Is it so easy to tear down a house that was so carefully constructed? And if the building were to totally collapse – surrounded by a new generation of gleeful howling wolves — how many decades would it be before a new house could be built? How many more uninsured people would die because there was no shelter from the storms of catastrophic injuries and chronic disease?

I think the health reform proposal is much stronger than most people think. The conceptual framework was built during decades of thoughtful policy analysis that incorporated the best of liberal and conservative thinking. The legislative details have been carefully crafted to fix the most serious problems in the current system without creating a political backlash from the health industry’s economic interests. The bill still has political momentum from the 2006 and 2008 elections, in which Democrats ran and were elected on a promise to reform our health system. The problems of our current situation haven’t gone away, and anyone that can build a better health system will deserve a lot of credit.

In the last few days, there have been signs of hope. Forty-seven distinguished health economists sent a strong letter of support for reform to Congress, and many political analysts pushed the Democrats to complete the bill. The President reasserted his commitment to comprehensive reform at a town hall meeting in Ohio, and the Democratic leaders in Congress are reportedly working on a two-step process that could pass the House and Senate. It may be that the health reform house will be completed with nearly all the floors intact. What happens in the next few days will determine the life and death of hundreds of thousands of uninsured, and it will shape the political landscape for decades.

Bill Kramer is an independent health care consultant, focusing on health care management, finance and public policy. Bill served as a senior executive with Kaiser Permanente for over 20 years, most recently as Chief Financial Officer for Kaiser Permanente’s Northwest Region. More information about Bill may be found at his website. You can read more of his commentaries on health care management and policy at his blog, Now’s the Time, where this post first appeared.