From one perspective, the health-care-reform process is turning out to be much more a knuckle-biter than last year’s presidential election was.

It’s perfectly obvious that the U.S. health-care system has some major problems. It’s helpful to divide these problems into two categories: lack of access to care and excessive costs. About 47 million Americans live without health insurance, more than 15 percent of the population; that number has been increasing steadily over the last six or seven years, and (not surprisingly in a system where health insurance for most people is supposed to be provided by their employer) it looks like the recession is swelling the ranks of the uninsured even faster. One study suggests that 20,000 Americans die each year due to lack of health insurance — preventable illness is not treated, health problems are caught too late, etc. Lack of coverage is a problem even beyond the core group of uninsured; 86.7 million Americans didn’t have coverage for all or part of 2006-2007; millions more face insecurity about their health care, not knowing whether their employer will continue offering insurance or whether they’ll keep their job. And of course even people with health insurance face losing it if they get sick through insurance-industry practices like rescission.

The other problem is excessive costs. The U.S. spends almost twice as much on health care per capita as other developed countries. (About half of what we spend is government spending, by the way, which means that the U.S. Government already spends more on health care than the government of Great Britain, which has genuine «em»socialized medicine.) We don’t get better outcomes for that money, by the way. Health care expenditures are also growing much faster than other consumer prices or GDP, which means that cost growth is turning the excess cost problem into an access to care problem as employers are priced out of the market and drop coverage for their employees and as Medicare faces the prospect of cutting benefits.

So health care reform is supposed to solve both these problems to some extent. I’d rather not spend my time trying to explain the current proposals; check out this writeup and this graphic for clear introductions to what’s going on. Basically, what’s on the table now gets you very close to everyone being covered by some kind of health insurance; it has a bunch of regulations on insurance that would curb the worst abuses like rescission and denying coverage for preexisting conditions; and, depending on whether there’s a public option, how strong it is, and possibly some other stuff I don’t quite understand, it would start to slow the growth in expenditures. The public option also give hope to liberals who think it would metastasize and create a de facto single-payer system similar to what they have in France or Canada.

This sounds good as far as it goes. For me personally, the insurance regulations in particular would take away a lot of worry, and a good public option that actually controlled costs could be quite a liberation from the dependence most of us have on our employer-based insurance. Of course, it looks like the public option is being thrown under the bus in slow motion by the Obama administration, so it’s probably best not to get one’s hopes up.

From another perspective, though, even the best plausible result, the current House bill, is a piss-poor attempt at reform. Perhaps the key provision to solving both the major problems, access and cost, is the “individual mandate,” the requirement that everyone buy health insurance themselves if they don’t get it through the government or their employer. It’s easy to see how you get much closer to universal coverage this way. The provision is also supposed to lower premiums by forcing the people who are cheap to insure — the young and healthy — to buy insurance along with the middle-aged and sickly, thus lowering the aggregate payouts that the insurance companies will have to make.

A major problem here is that the mandate amounts to a regressive tax on working Americans. There will be some kind of subsidies for people with low incomes (though you can look for the Blue Dogs to gut these subsidies considerably), but you’ll still have the people who can least afford it — people who don’t have cushy white-collar jobs, people who work for small businesses or are self-employed — force to pay potentially thousands of dollars a month for health insurance. And if the whole scheme doesn’t succeed in cutting costs, or slows the rate of increase less than predicted, you’ll see this mandated payment grow much faster than inflation or wages, becoming more regressive as time goes by.

Compare this outcome to the sort of systems that plausibly civilized countries have. In a single-payer system, there’s a revenue (a.k.a. tax) stream dedicated to funding universal health insurance. In exchange for being subject to this tax, you get health insurance for life, regardless of income, employment status, medical history, genetic testing, or anything else. You’re covered. I have Canadian friends who think nothing of working part-time or saving up some money and taking months off to work on a creative project; as an American who depends on employer-provided insurance, the thought gives me the heebie-geebies. “Obamacare” does not free us from our worries; it transforms them into questions like “Can I make my rent this month and still make my government-mandated insurance premium?” and “Can I get away with a few months without insurance while I move/take a new job/freelance/try and internship?”.

Put another way: You’ll notice that the health-insurance lobby and Big Pharma are promoting the current round of reforms (sans public option). And you might ask yourself why. Well, it’s because they stand to make a lot more money as uninsured Americans are legally required to pay private insurance premiums, some with a subsidy from the government.

The problem is, to really fix the cost problem (remember we pay nearly twice as much per capita as the average of other industrialized countries), you’ve got to pay someone less. The slack in the system is in payments to private insurers and private providers, doctors and hospitals, the parties who now get rich at the expense of ordinary Americans. The reforms that are on the table right now don’t ruffle the feathers of insurers or providers at all. (Some liberals hope that the current reforms will set up conditions for more reform that will finally reduce payments to insurers and providers; I’m skeptical.) This is a sign that something is wrong.

What’s wrong, fundamentally, is that the interests of the powerful are untouchable in our current system of government. Think about it: “We” elected Obama, a huge Democratic majority in the House, and a 60-seat majority in the Senate (which, you might recall, was regarded as a shoot-the-moon outcome in the days leading up to the election). And yet the best health-care reform option on the table is objectively pitiful, and we’re likely to get much worse than that. At what point do you admit things are completely broken?