Tomorrow, Senate Majority Leader Harry Reid (D-NV) will unveil the merged Senate health care bill and the accompanying score from the Congressional Budget Office. The legislation, which should cost no more than $900 billion over 10 years and help lower the deficit, will include a new payroll tax, higher threshold levels for the controversial excise tax on Cadillac health care plans, and a national public health care plan that allows states to opt-out by 2014.

Reid has promised to give Senators at least 72 hours to review the legislation, and debate isn’t expected to begin before Friday, November 17th. Sixty senators will have to vote on a measure to begin what could be six weeks of debate, and 60 votes will stop it.

Before the Senate begins its marathon session — which could last many weeks and weekends — here is a summary timeline of some of how far reform has come, and how far it has to go:

June 2009: Health, Education, Labor, and Pensions Committee Releases ‘Affordable Health Choices Act’ and begins considering the legislation in committee.

June 2009: The Senate Finance Committee’s “nothing-burger” proposal is leaked. The legislation does not include a public health insurance option or a requirement that large employers provide coverage.

June 19, 2009: House releases the first draft of its Tri-Committee proposal. The legislation includes a robust public option, a requirement that all large employers provide health insurance coverage, and a surtax on wealthy Americans.

July 13, 2009: After 13 days and more than 60 hours of debate the HELP Committee passed health care reform. Not a single Republican votes for the bill. Instead, they lie about it.

July 31, 2009: All relevant House Committees mark-up and pass the House health care bill by this date.

August, 2009: Republicans misrepresent the consequences of reform in town halls across America.

September 9, 2009: Obama pushes for health care reform before a joint session of Congress.

September 2009: Sen. Max Baucus (D-MT) releases the Senate Finance Committee health care bill after 6 months of bipartisan negotiations. The bill is attacked from the left and the right. The Committee begins marking up the proposal.

October 13, 2009: The Senate Finance Committee passes the health care bill 14-9. Sen. Olympia Snowe (R-ME) becomes the only Republican to vote for health care reform.

October 26, 2009: Majority Leader Harry Reid (D-NV) announces that the final health care bill will include a national public health insurance option, but gives states the option to opt-out of the plan.

October 29, 2009: House Speaker Nancy Pelosi (D-CA) unveils the merged House health care bill.

November 7, 2009: In a 220-215 vote, the House passes bipartisan health care reform legislation. Rep. Joseph Cao (R-LA) becomes the second Republican to vote for health care reform.

November 17, 2009: Reid will unveil the merged health care bill and the Congressional Budget Office’s analysis. Will promise to bring the bill to the floor on Friday.

November 20, 2009: At least 60 senators vote to begin debate on the health care reform bill. Minority Leader Mitch McConnell (R-KY) predicts that the legislation “will be on the floor for quite a long time.” “I think it ought to be on the floor at least as long as it’s been in Harry Reid’s office,” he said on Sunday.

December 21-23, 2009: The Senate passes health care reform bill.

January 2010: The Conference committee merges the Senate and House bills. Will it keep the Stupak language? What will happen to the public option and the employer mandate? How will the conference finance reform? Will it keep the Senate’s excise tax or opt for the House’s surtax on wealthy Americans?

February 2010: The House and will Senate vote on the final conference report.

February/March 2010: President Obama signs health care reform into law.

Over at Open Congress, Donny Shaw wonders why the House health bill doesn’t extend its requirement that insurers maintain an 85% medical-loss ratio once the Exchange becomes operative in 2013:

Once the bill is enacted, all health insurance plans would be required to spend at least 85 cents of every dollar paid in premiums each year to providing actual health care. If, in a given year, an insurer doesn’t spend that amount on health care, they would have to give their extra profit back to their customers in the form of rebates. [...]

But there’s a twist to all of this. The version of the bill that was passed by the House last weekend includes the provision, but also includes some curious, new “sunset” language. The sunset language states that the new minimum medical loss ratio requirements “shall not apply to health insurance coverage on and after the first date that health insurance coverage is offered through the Health Insurance Exchange.” In other words, in 2013, when most of the bill takes effect, the medical loss ratio language would be null and void. There would be no more profit control, just the market competition that is provided by whatever form of the public option is included in the bill.

“This really doesn’t make a whole lot of sense. What’s the point of including it in the legislation if it’s not going to apply once the bulk of the bill takes effect?,” Shaw asks.

Shaw’s concern is well taken, but a higher medical-loss ratio would not prevent private insurers from shifting a disproportionate amount of premium dollars into profits. It would do very little to improve care quality. If anything, plans could be encouraged to pay more for certain services (to meet the benchmark) and exclude certain benefits from coverage (benefits which would attract a sicker risk pool).

As James C. Robinson points out in this Health Affairs article, “High ratios can be achieved either through a large numerator (high medical expenditures) or through a small denominator (low insurance premiums).” In 2007, for instance, 6 of the 7 largest publicly-traded health insurers reported that their profits increased by 10%, while their medical loss ratios also went up. The same could happen after 2013. Once the Exchange is established, insurers will spend less on administrative expenses (reform will limit their ability to underwrite policies and the Exchange will streamline certain administrative tasks), and their medical-loss ratio will likely increase. This does not mean that they’re spending more money on patient care or shifting less towards profits.

Health reform should strongly encourage insurers to spend more premium dollars on financing quality health care, and less on administrative costs. The House legislation accomplishes that goal by prohibiting insurers from maximizing profits and denying coverage to Americans with pre-existing conditions. It establishes guaranteed issue and renewal rules, prohibits rescission, requires information transparency and plan disclosure, mandates plans to offer minimum benefits packages and eliminates cost sharing on preventive services. Still, more can be done. Policy makers may better achieve the goal of forcing insurers to spend premium dollars on health care by increasing the minimum actuarial value of health plans and only admitting insurers with high quality standards and low administrative overheads into the Exchange.