Mandates, whether for individuals or employers, are one of the most critical issues in the reform debate. Republicans fear employer mandates will impose significant financial burdens on companies and put them out of business. Democrats argue that employers have to take responsibility for the health of their workers. Both have a point.

Is it realistic to believe that if employers were not required to contribute funds to employees' health plans, they would reinvest that money into salaries? These days, sadly not. It follows that many businesses, fighting to stay alive in a global downturn, may choose the path of self-preservation and least expense. And if that path leads to a fine, management may very well choose it.

That's probably true in many, if not most, cases. Fortunately, there are a few notable and laudable exceptions in the business community. Starbucks, for example, is a successful American company that provides health benefits to all of its full and part-time employees. They serve as the example that comprehensive employee coverage and success in business aren't mutually exclusive.

On the other hand, if we legislatively compel employers to contribute to workers' health plans and the costs put them out of business, unemployment rises and with it, the ranks of the uninsured. And then we're back at square one because we'll be worse off than we currently are.

Rather than becoming mired in a debate about the means, let's focus on the desired end: How do we ensure that workers have good, reliable and continuous coverage without breaking the backs of America's small businesses?

As a nation, we face a binary choice when it comes to covering uninsured Americans: we either want universal health insurance, or we do not.

If we choose to build upon the 50-year-old employer-based health insurance system - which both President Obama and most employers seem keen to do - then employers must play a central role in funding that system.

Employers and the insured already pay a hidden health tax to pay for health care for the uninsured. According to "Hidden Health Tax: Americans Pay a Premium", a study conducted by Families USA with actuarial calculations by Milliman, the average U.S. family and their employers paid an extra $1,017 in health care premiums in 2008 to compensate for the uninsured.

Milliman found that $42.7 billion, representing 37 percent of health care costs for uninsured Americans, were unpaid in 2008. Who was then hit by the "hidden tax" in the form of higher health premiums? That would be employers, who passed a growing portion of these costs onto insured employees.

By directly taxing employers to cover the uninsured, there's more transparency and light brought to a process that's currently hidden, arcane and inequitable.

If private sector employers don't want to pay to achieve universal health care, then a public option is a must-included provision for health reform.

If, at the end of the health reform day, Americans do not believe that there is a moral imperative to achieve universal health insurance coverage, then the uninsured will continue to access the health system the way they do today: in expensive emergency rooms, retail pharmacies at full cost for prescriptions, and doctors' offices when they are treating conditions that could have been prevented more simply and cheaply.

And insured people and employers who pay premiums will continue to pay more and more hidden taxes.

The President was exceptionally eloquent in his grounding of health-care reform on moral arguments. He did many things very well:

• He made a persuasive case that, while the percentage of Americans completely without insurance coverage is relatively small, the percentage of Americans persistent insecure about health insurance is very high.
• He also made a cogent argument that when health care costs grow fast and crowd out other spending, we lose economic competitiveness.
• He stated his goals with great clarity. While I am disappointed that he did not focus on health improvement and health-care quality, his prioritization was a welcome contrast to his muddled messages over the last several months.
• His outreach to opponents on issues such as medical malpractice and low-cost coverage for the seriously ill were also welcome.

The proposed prohibitions on lifetime and annual coverage limitations, on denials of coverage for pre-existing conditions, and on terminations of coverage after someone becomes ill and the requirements for individuals to buy health insurance made sense, although an unintended consequence of a badly-designed employer mandate could be the destruction of even great employer-based health plans.

His case for the public option was flawed. State government regulation is the cause of lack of insurance competition. A public option does not create fair competition; it either creates unfair competition or it is ineffective. Nevertheless, I appreciated his message that achieving affordable coverage and care were more important than the litmus test of a public option.

He tread on dangerous ground when he spoke about financing. It's easy to talk about spending cuts, but brutally difficult to make them happen. When he speaks about "waste and abuse," he does not mention that one person's waste is another person's livelihood. There is a way to achieve these cuts, but the political challenges are enormous. The lack of specificity on how to pay for his proposals is the most serious issue in the speech.

Only time will tell whether his speech succeeded, but it was well-crafted and well-delivered.

If you go strictly by the calendar it wouldn't compute, but summer appears to be over in my corner of America. Wisconsin has been enjoying frankly autumnal weather for the past three weeks. The change in the weather combined with the general sense of let-down regarding the health-care reform legislative process have kept me from blogging for awhile. I truly wish I could get behind the House of Representatives on HR 3200, but they missed the mark, and by a wide margin. So now summer vacation is over and it's time to get back to work -- for me as well as congress.

I was very pleased this past Sunday to note that my friend, Serigraph CEO and Milwaukee JournalSentinel columnist John Torinus again did a really good job of highlighting the major deficiencies in HR 3200 in his weekly column. To paraphrase John in a nutshell: HR 3200 fails to address the $30 trillion unfunded liability for Medicare, fails to allow insurance to be purchased across state lines, fails to deliver pricing transparency, fails to deliver bundled pricing for care episodes, fails to mandate quality reporting and fails to stimulate individual responsibility for staying healthy. My biggest gripe is that the bill fails to address what I believe to be the root cause of the huge difference between what the U.S. spends as a percent of its GDP and the rest of the world, namely the incredible inefficiencies promoted by the piecework payment methodology we use. HR 3200 makes no serious provision for promoting patient-centered primary care which we, at QuadMed, have proven delivers higher quality care at lower cost. Nor does the bill provide any impetus to apply lean transformation principles to health care.

So, as I contemplate the topic of how, politically speaking, the Obama White House can get meaningful health-care reform legislation back on track, it is with John Torinus' observations freshest in my mind. I go back to a couple of principles I enumerated early on as an invited panelist for the Post: That health-care reform must be a separate issue from health-care delivery transformation. That our current non-system is un-sustainable and that merely deciding to pay more for the same-old-same-old is probably the worst option we face and shouldn't even be on the table.

So here are my recommendations: First, hit the brakes. I believe that people are as upset by the rush to jam through a more than 1000-page bill as they are about its estimated price tag. I learned a very helpful 'mental construct' when I worked in IT, called, "Good-Fast-Cheap." In essence, when rolling out any new project or system, you could have one or at most two out of the three -- but not all three at once. HR 3200 certainly came at us Fast, but it doesn't look too Good and it is certainly not Cheap.

Second, chunk out reform into multiple bills. To some extent, the Senate Finance Committee signaled last spring that it was contemplating reform as an opera in three acts when they published their three white papers. Determine which aspects of reform should be stand-alone legislation and take out the nice-to-have distractions (to be addressed in future legislation). The recent uproar over advance directives, necessary as they are, is a case in point. Here are my major chunks. Problem: 47 million uninsured. Solution: individual mandates, verified on the tax rolls and publicly supported for the impoverished; employer mandates to play-or-pay, with preferential tax treatment for those employers who deliver superior value for their employees. Problem: Inefficient, fragmented, expensive care. Solution: Patient-centered primary care, which leads to overall better outcomes at lower cost. While we're at it, nuke the toxic Current Procedural Terminology (CPT) piecework payment methodology for chronic care management and replace it with a pleasant mix of capitation, fee-for-service and just a gentle sprinkling of pay-for-performance. Address the deficiencies noted in paragraph 2 above. Insurance reform as a separate bill. Wellness incentives as a separate bill (Sen. Enzi, anyone)? Tort reform must be addressed, but again, as a separate bill.

Third, strive for bipartisan solutions. 'Nuff said.

As the August congressional recess comes to an end, it should be "back to school" time for our elected officials in Washington. Time to put the summer behind, hit the books and focus a little "remedial education" on creating a sustainable model of health-care financing that doesn't bankrupt employers and which doesn't keep shoving under-funded health-care liabilities onto our children to pay for later.

Whether member-owned cooperatives can create an affordable health insurance option to get more Americans covered depends on a variety of factors, some of which are unrelated to the characteristics of the cooperative:
• Whether the cooperatives are required to take in anyone who applies for coverage, regardless of medical history or status (this feature is called guaranteed issue);
• Whether lower-income insured participants are subsidized in some way to make insurance affordable;
• Whether the cooperatives can define a reasonable benefit package without a lot of political interference that adds expensive, marginally-beneficial coverage mandates; or
• Whether elected officials will allow the cooperative to operate as cost-efficiently as possible, or whether they will try to impose a variety of policies on them unrelated to their core mission, such as the requirement that the cooperatives pay "prevailing wages" or requirements that they get work done via preferred providers of services who are major supporters of particular elected officials.

The other issue specifically relevant to the cooperatives is whether they can attract a broad risk pool, including not only the older, uninsured Americans or low-income uninsured, but also the healthy, young insured. Unless healthy people are part of the insurance pool to subsidize the unhealthy, it will not work. To attract the healthy, young insured, there must be an individual mandate, that is, a requirement that every adult American purchase health insurance. Without a broad individual mandate, the cooperative is unlikely to have an economically-viable broad insurance pool.
I would hope that this cooperative gives well incentives to its members and rewards high-quality care through its payment systems. If it does, it could make a major contribution not only to broadening insurance coverage, but improving the quality of care.