Now that the Senate health care bill is nearing its home stretch, some are wondering if I continue to support reform.

As a reminder, I wrote back in July that doctors should support Congress’ health care reform efforts, because, “some reform is better than none, and doctors advocating for a free market-based system shouldn’t hold out, hoping for the perfect package.”

There were deuling columns in last Friday’s New York Times, one from progressive economist Paul Krugman, and the other from moderate conservative David Brooks. Both had strong reservations about what was coming out of the Senate.

In Krugman’s piece, he tells radical progressives opposing the Senate bill, like Howard Dean and Keith Olbermann, to put aside their anger and just pass the damn thing. Sure there’s plenty wrong with it, but 30 million Americans will gain coverage, and if it doesn’t pass, health reform will be dead for another generation.

Brooks also cites the proposal’s many flaws, primarily noting the lack of cost controls and the fact that the health system won’t be fundamentally reformed. He’d vote “no” when pressed. I often agree with Brooks, and his analysis is bang on.

So, who’s right?  Both of them are.

Health care costs are rising because, as Brooks accurately writes, “Consumers are insulated from the costs of their decisions and providers are punished for efficiency.” Simply paying doctors less, which is what expanding Medicare would have done, isn’t the answer as it simply entrenches a broken payment system. That option has since been removed.

We need to completely divorce ourselves from a fee-for-service payment system, which would then provide the necessary incentives for doctors to become more efficient. There is little such language contained in the bill.

And despite Atul Gawande’s assertion that the myriad of pilot programs contained within the bill will help control costs, the required, sweeping change is lacking.

But Krugman is also right in saying the crux of the bill is giving help to those who need it the most: “The result [of passing health reform] would be a huge increase in the availability and affordability of health insurance, with more than 30 million Americans gaining coverage, and premiums for lower-income and lower-middle-income Americans falling dramatically.” That can’t be ignored.

“But what about tort reform?” is a question I often hear.

The lack of any substantive medical malpractice liability reform is why many doctors oppose the progressive approach to health reform. And I agree, much more needs to be done. But keep in mind that, according to the non-partisan CBO, medical liability reform will save only $54 billion over ten years, or 0.5% of the nation’s health spending.

It’s not a huge amount, but certainly not insignificant. Reformers are leaving money on the table here.

And, as I wrote earlier this year in the USA Today, medical malpractice needs to be reformed for the patient’s sake, not the doctors’.

(As an aside, I often wonder why progressive reformers ignore the olive branch that malpractice reform represents to doctors, and choose to antagonize the medical profession by continually harping at how much money physicians make. I firmly believe that more than a few will go as far as support a single payer system – the progressive Holy Grail – if it was explicitly paired with comprehensive medical malpractice reform.)

The question of supporting the current reform efforts, or not, comes down to whether one thinks the status quo is sustainable. I believe the answer is no. The number of uninsured is rising at an unacceptable rate, and, combined with spiraling costs, will lead to the health system’s collapse. Once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.

The Senate bill is a flawed, incremental effort, that doesn’t do enough to make primary care the required focus of our health system. Nor does it make any meaningful attempt to reform medical malpractice.

But it brings us closer to universal health insurance coverage, which is a significant achievement. And it does so without significantly expanding government involvement through an expansion of Medicare, or institution of a public plan option, which would have exacerbated the government monopsony on health care.

So, given the choice between seriously flawed reform and none, I’d have to say “yes” to reform.

By the slimmest of margins.