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If health-care reform is to succeed, we must rein in fees, costs
The goal of extending coverage to all will require considerable effort by the president and lawmakers.

One of my favorite books is "One Day in the Life of Ivan Denisovich," by Alexander Solzhenitsyn. It is a slim book that chronicles just one day at a Soviet labor camp in the 1930s. What Solzhenitsyn sacrifices in length he makes up for in impact – the cold, sobering, sorrowful impact of a life of seemingly unendurable hardship. And yet, the book is really about the resilience of the human spirit. Out of the misery is a "triumph of the soul."

I re-read it every few years to remind myself how resilient we humans are, and also how fortunate we are here in the United States to be living in this country at this time. We may be in the middle of the worst economic crisis since the Great Depression, but we are blessed with many freedoms and much opportunity.

We are free to express our views on any subject. We have honest elections in which our votes count. We are living in a country where, even now, opportunity abounds. Just last week I saw a news report suggesting that if you had lost your job, you might think of moving to North Dakota. North Dakota has the lowest unemployment rate in the country at 4.5 percent. I recognize that few who have lost jobs in Maine or New England are likely to move to North Dakota. Nonetheless, it is an indicator of the diversity of our national economy.

I find myself musing on the strengths of our democracy in part because I continue to be frustrated by Congress's approach to health-care reform. Looking at what is going on in Washington, it is a wonder that any constructive legislation emerges.

We have perfected a form of democracy that allows interest groups to thwart any attempts at reform. We can water down or vote down almost anything, but we cannot pass a sensible plan that will, of necessity, put additional burdens on most of us.

For health care, almost all experts agree that we have an unsustainably expensive system, the costliest in the world, that doesn't even cover 50 million of our people. President Obama rightly called for legislation that would cover the uninsured, contain spiraling costs and not add to the deficit.

Congress responded with plans emerging from the House and Senate that extend coverage to the uninsured at great additional cost without doing much to address cost containment.

The Congressional Budget Office and the Mayo Clinic, among others, pointed this out – incurring considerable wrath from venerable congressional committee chairmen.

Most recently, some modest proposals to control costs have emerged. Many of these involve pilot projects, which is to say they offer little but future hope. The most promising and potentially impactful proposal would create an independent commission of experts that would have (limited) power to negotiate doctor and hospital fees, pursuing both cost reduction and quality of care improvement.

It is not clear that this commission would have sufficient power to be effective. Nonetheless the American Medical Association called a news conference to denounce the proposal.

Should this be a surprise to anyone? Quite naturally, the organization representing doctors doesn't want a powerful group being able to lower doctor fees. The surprise is that even this modest proposal is likely to be emasculated as a result.

Doctor fees do need to be controlled. Ditto for hospital fees, insurance fees and drug costs. Let's do this in a reasonable way, but we must do it if health-care reform is to be successful.

This is a test for American democracy. Will Obama and congressional leaders simply fudge the issue of cost containment and give us a universal health-care plan that becomes the road to ruin (although Obama may be out of office before this is clear) or does Obama stand up for a tougher approach that makes many of the key interest groups in this equation distinctly uncomfortable? The pressure will be enormous to declare victory by just getting universal coverage and moving on.

For all his remarkable qualities, the president has yet to show us toughness. Does he have it in him? I hope so, because the stakes are high, and the penalties of a bad bill likely will be with us for a long, long time.