There was a time, just a few months ago, when liberal backers of Senator Maria Cantwell were baffled by her stance on health-insurance reform. Why was Washington's junior sen-ator hedging, dodging, and making contradictory statements about the public option, a central pillar of real reform? Why couldn't she just do what other members of Washington's congressional delegation had already done and come out strongly and unambiguously in favor of a government-run health-insurance plan that would compete with private insurers to bring down costs for everyone?

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Cantwell, who in 2006 scored a seat on the powerful Senate Finance Committee, appeared to be trying to avoid a public fight with her committee chairman, Max Baucus (D-­Montana), who had set out to find a "bipartisan" solution on health-insurance reform by cooking up a reform bill that didn't include a public option. How far would Cantwell go with this deference?

Not very far, it turned out. When Baucus, after months of delays and a notable failure to find strong bipartisan support, finally introduced his bill on September 16, Cantwell pounced. She made it clear that she wouldn't vote for a bill that didn't include a public option, and she filed a raft of amendments intended to pull the so-called Baucus bill to the left. Here are some of her best ideas, translated out of wonky jargon into plain English:

The public-option amendment. This was Cantwell's most important amendment, one that she cosponsored with Senator Charles Schumer (D-New York). It tried to strip the Baucus bill of an unpopular half-measure known as the "co-op compromise" and insert in its place a strong public option. The amendment was defeated on September 29 by a committee vote of 13–10, but its existence helped the overall effort to keep the public option at the forefront of congressional debate. Just as important, it was the clear public rebuke of her committee chairman that Cantwell's constituents, including small-business owners in Seattle, had long been waiting for. Ice-cream entrepreneur Molly Moon, who over the summer slammed Cantwell for failing to lead and ignoring the needs of small-business owners, was among the mollified. "Senator Cantwell is showing real leadership and loyalty to her constituents," Moon said in a statement.

The fixing-the-backward-Medicare-payment-­system amendment. Currently, Medicare uses a "fee for service" system that encourages doctors who want to make more money to simply perform more services—unnecessary tests, senseless procedures—and has the overall effect of screwing responsible doctors (such as those in Washington State, who on average bill Medicare a relatively low amount per patient) while setting Medicare on a path toward insolvency. Cantwell's proposal is to jettison that for a smarter reimbursement structure that bases payments on the usefulness of the services provided. It makes so much sense that Baucus has already incorporated the idea into the most recent draft of his bill.

The community-care-for-the-elderly amendment. It currently costs Medicaid about $70,000 a year to keep an elderly American in a nursing home. What if there were a system of care for the elderly that saved money for Medicaid and kept people out of nursing homes they didn't need to be in? In fact, there is such a thing, and Washington State has been pushing it. Cantwell wants to get the federal government to follow suit and provide matching funds to states that offer services like fall-prevention classes, nutrition classes, exercise classes, and home health-care visits for elderly people who need them (for example, a nurse to occasionally come and monitor a person's diabetes medications). "It's a quality-of-life issue," said Cantwell spokesperson Ciaran Clayton. "I think more people would rather get care at home, or through their primary-care doctor, or at their community center, than in a nursing home." And, of course, it could save money.

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The "pharmacy benefit management" amendment. What's a pharmacy benefit manager? Exactly. Turns out they work in an unregulated corner of the health-care supply chain and make money in crafty, complicated ways. Basically, a PBM acts as the middleman between health-insurance plans (like Aetna) and pharmaceutical retailers (like Rite Aid). A PBM sets prices, chooses brands, figures out who gets what instead of what. No surprise, there is a lot of potential for devious deeds, and as PBMs aren't well-regulated, devious deeds have been occurring. "It's been found that sometimes prescriptions will be switched, without a patient's knowledge, to save money for the pharmacy," said Clayton. Under this Cantwell amendment, which Senator Baucus has also incorporated into his draft bill, PBMs will have to share information about their methods with oversight agencies. Why wasn't this happening before? Take a wild guess.

But thanks to Cantwell, it may be happening soon—along with a number of other important health-insurance-reform ideas. Her amendments number more than a dozen, and also include proposed action on überwonky matters such as using tax-exempt bonds to pay for fixed-wing air ambulances and broadening inheritance rights for health reimbursement accounts. Go to www.finance .senate.gov/sitepages/legislation.htm if you want to dive into those weeds. recommended

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