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The run up to the midterm elections says a lot about American ambivalence about reforming the health care system. The rhetoric about health reform – and the public’s reaction to that rhetoric – underlines why it has been so difficult to reform the health care system for the past 100 years– and, why it still might fail.

In general, whenever opinion polls are done about the health care system, people say two things: they think we should have universal coverage in this country and health care spending is too high. But, those are all positions taken in the abstract and reflect a theoretical view with no depth of understanding of the specifics that need to go along with implementing those goals. Those responses are kind of like a poll when a particular candidate is compared to “any Democrat” or “any Republican.” This kind of polling is not very enlightening about how people react when confronted with the reality of what those kinds of choices mean.

So, let’s take a look at the two things people say they want in a “reformed” health care system: universal coverage and cost control.

There are really only two fundamental ways to get to universal insurance coverage: covering everyone through the tax system or requiring everyone to have coverage either through an individual or employer mandate. The Affordable Care Act chose a mix of the two approaches– expanding government programs that are tax funded and expanding private sector coverage through the mandates (with subsidies). It is the mandate that is being challenged in the courts and seems to generate the most heated debate about why health reform represents “the federal government” telling people what to do. A fully tax funded system would have been equally disliked. So, Americans may say they want universal coverage but they also seem to say they don’t like any of the means to get there.

Controlling health care spending presents another dilemma because whatever is done to reduce spending in any meaningful way generally means not providing something that someone wants (or that someone wants to provide). That’s why politicians love to talk about prevention and wellness programs and getting rid of waste, fraud and abuse. Those strategies are all approaches that are uniformly popular because they either cut spending that goes to “crooks” or they add services that people like. And, while these are all good things to do, the problem is that they don’t make any substantive impact on health care spending trends because the cost of health care is being driven far more by expanding technology than by these things. And, even though there is evidence that much care that is provided doesn’t actually improve outcomes, and may, in fact worsen them, Americans seem to have an insatiable desire for more medical care and a belief that if someone recommends less interventionist approaches, we are not getting “the best”. Such beliefs made it easy to characterize an end of life support structure as “death panels” and resulted in a comparative effectiveness process that explicitly says it cannot be used for “rationing”. So, just as with the means to universal coverage, the approaches to actually doing something significant about health care spending are not popular.

And, today’s debate about health care reform in advance of the midterms has done nothing to reconcile these issues or even shed any light on them. Indeed, the debate has been singularly uninformative – on both sides of the question. Proponents of reform have done a terrible job in explaining it to the public. Opponents, on the other hand, have done nothing to encourage a substantive discussion about the law. Rather, they have simply talked about “repeal and replace” without giving any alternatives as to what that would look like. This approach does nothing more than pander to a fantasy view of health care reform that results in no tradeoffs. As David Leonhardt put it beautifully in the Oct 20 New York Times:

“Unfortunately, today’s political debate doesn’t seem to have room for downsides. It conjures a world of free lunches — unlimited Medicare, vague spending cuts, low taxes and balanced budgets.

It’s a nice world, until it isn’t.” And therein is the rub.