Photo by Darryl Estrine

Washington wags like to compare health care reform to a certain kind of cicada—an insect that emerges only once every 17 years, makes a lot of noise and then vanishes underground again. There’s a disquieting degree of truth in the joke: Fifteen years have passed since the last serious attempt at reform, led by Hillary Clinton, was buried. Will it be different this time?

Certainly there’s plenty of noise. President Obama and leaders in Congress have vowed to have health care reform enacted as a priority by the end of the year. Many different interest groups have pledged to overcome their usual animosities to get it done. And health policy experts have aired a multitude of ideas on how it should be done.

The debate is moving through its “happy talk” stage now. Compared with previous attempts at reform, “the one absolutely historic thing is the way in which major players with big egos and powerful constituencies have come together so far,” says Drew Altman, president and CEO of the Kaiser Family Foundation research group.

But the hard parts lie ahead, as lawmakers begin the immensely difficult task of writing bills that are acceptably bipartisan and might have a chance of becoming law. Large questions loom: Should all Americans be required to have insurance? Should all employers provide it? Should an optional government-run plan be allowed to compete with private health plans?

And that’s just for starters. “The real debate begins once there’s legislation on the table, once that legislation has a price tag and once elected officials have to make decisions about how they’re going to pay for it,” Altman adds. “That’s when the interest groups will start behaving more like interest groups again.”

The Obama administration has been careful to avoid what are now regarded as the central mistakes that doomed the Clinton plan—taking too long to develop complex proposals in secret and shutting Congress out of the process. It also hopes to avert any replay of “Harry and Louise”—the famous television ad campaign that in 1994 virtually annihilated public support for the plan by suggesting it would force people to pick from a few health care options “designed by government bureaucrats.” In stark contrast, Karen Ignagni—leader of the health industry trade group that spent an estimated $15 million on the ads—assured Obama at a White House summit in March: “You have our commitment … to help pass health care reform this year.”

Obama’s overall goals are fundamentally shared by all players, including AARP: to cover the uninsured, reduce costs in the system and change payment mechanisms so that doctors and hospitals are rewarded for the quality of care they provide rather than the quantity of patients they see.

Yet for all the momentum, signs of discord have already appeared, especially in regard to one Obama proposal known as the “public plan.” This would be a government-run health plan—maybe something like Medicare—offered as a competitive alternative to private insurance. In theory, the public plan, with fewer administrative costs and no need to make a profit, could provide an affordable option, especially for people currently without insurance.

On the face of it, the public plan option sounds like an answer to a hitherto elusive goal—the “uniquely American solution” to health care reform. In other words, a solution that would not copy the largely government-run “single-payer” health systems of other Western countries, but instead would build on the mix of public and private programs the United States already has. A public plan would provide a safety net for people without insurance, without threatening the employer-based coverage most Americans still rely on, its proponents say.

According to a recent Consumers Union poll, three-fourths of Americans regard the concept of a public plan positively.

But the idea has proved explosive, a potential deal-breaker that taps deeply into the old philosophical differences about the role of government in health care. Ignagni’s group, America’s Health Insurance Plans, says that if the public plan sets premiums and provider payments low (as Medicare does), the private market could be wiped out.

Republicans in Congress also balk. One is Sen. Chuck Grassley of Iowa, leading Republican on the Senate Finance Committee, who has been working closely on health care reform with committee chair Max Baucus, D-Mont. “The bottom line is that a government-run insurance program is the first step toward a [national] single-payer system,” Grassley says.

The issue divides distinguished health care experts, too. Stuart Butler, of the conservative Heritage Foundation think tank, calls it a “nuclear minefield” that “will break up the coalition that would otherwise achieve real change in this country.”

But Jacob Hacker, professor of political science at the University of California, Berkeley, argues that public and private plans could be required to compete on a level playing field, with each providing a crucial check to the other. “If the public plan becomes too rigid, more Americans will opt for private plans,” he says. “If private plans engage in practices that obstruct access to needed care and undermine health security, then the public plan offers a ready release valve.”

Asked how critical the public plan is to Obama’s agenda, his White House health czar, Nancy-Ann DeParle, told reporters: “He wants a mechanism to lower costs and to keep the private sector honest by having a competitive public plan in there. If there are other ways to do that, he’d be open to hearing them.”

Meanwhile, other possible components of reform are being hashed out as several House and Senate committees begin to craft legislation. Should everyone be required to have health coverage? The insurance industry supports the idea, and has offered in return to give up “medical underwriting”—the practice of insurers denying coverage or charging higher rates to people with preexisting conditions and charging women more than men. But requiring all employers to provide insurance for workers or pay into a system that would cover the uninsured (the “pay or play” option) is meeting resistance from business groups.

Some kind of insurance clearing-house that consumers could use to sift through a menu of private health plans (plus a public plan if one is included) is likely to be part of any ultimate deal. So is a system of subsidies that help lower- and middle-income people afford insurance. Placing a cap on out-of-pocket health expenses, such as a percentage of income, is one idea for achieving that. Expanding Medicare or Medicaid to cover more people is another.

A House bill (which is likely to include the public plan option) and a Senate bill (which probably won’t) are expected to be passed by the fall, when a conference committee will try to resolve the differences between them. Obama, who’s said that “the status quo is not an option,” fervently wants something to sign.

But the hardest part of health reform, experts say, has yet to be addressed. “If they fail in Congress, it will [only] in part be because they can’t agree how to do it,” says Altman of the Kaiser Family Foundation. “Much more it will be because they can’t put together the money to pay for health reform—specifically to expand and subsidize coverage for the 47 million Americans who can’t afford decent health insurance today. That’s the really big challenge.”

Patricia Barry is a senior editor at the AARP Bulletin.