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I was asked by a local TV station to participate in today’s talk-fest on the Obama administration’s first 100 days in office, and specifically about his progress on health care reform.

The President stumped against mandatory purchases of health insurance and for a public alternative to the private health insurance market. In fact, his opposition to requiring individuals to purchase insurance was the primary point of difference between Obama and Clinton on health care during the primary.  

The President scores high points for sticking to his pledge to make health care a top priority in his first 100 days. When many argued that the dire economic situation precluded any big initiatives, Obama turned the economy argument right back at them and said that the country’s short-term financial problems would not be solved without long-term reform, including a health care overhaul.

The President showed he was serious when he issued his health care framework, and included a $630 billion down-payment on health reform in his budget plan. But then he largely sat back and is letting Congress run the show.

The man in charge in the Senate is Finance Committee Chair Max Baucus – the largest Democratic recipient of health insurer and drug industry money in the last four years. He’s backed away from the public option, and has embraced the individual mandate.

The calculus for the administration, of course, is that one of the biggest Clinton-era health reform fumbles was failing to confer with Congress before sending them a fully formed plan. That got the Clinton administration instant blow-back and no buy-in. Obama has taken a hard look at history and is trying to avoid the mistakes of the past. Nevertheless, Congress can write the bill, but the President has to give them direction.  It’s time for Obama to impress upon Congress that some fundamental principles are non-negotiable. These two campaign promises – protecting Americans from being forced into purchasing private insurance plans, and making sure health reform includes a public alternative to the private market – are two of those principles. The whole health care debate will hinge on these questions. With the Senate promising hearings on legislation in early June, President Obama has to step out of the shadows now. Maybe yesterday’s confirmation of Health and Human Services Secretary Sebelius will provide the impetus.

I think Americans appreciated the President’s tough talk during the campaign about drug companies and HMOs who charge too much and offer too little care in return (here's an example of the kind of denials that make people not trust insurance companies). Now that he’s in office he can’t back down; the President has to signal that he’s not afraid to take on these powerful interests, just as he showed the auto industry and the UAW that he was willing to take them on. If the health insurance industry won’t play in health reform, we can always let them get out of the way.

This dilemma faces every member of Congress looking to make a fundamental change in American health care: how straight will they talk about the skyrocketing cost of private coverage? I was at a health reform hearing in the Senate HELP committee yesterday that was investigating the lessons to be learned from state reforms. (Our take on that front.) Panelists from Vermont, California and Massachusetts all acknowledged that cost is their number one roadblock to achieving, expanding, or maintaining reforms. Prevention, or reforming how doctors get paid, was a big part of their discussion on costs, but neither effort can solve the cost problem if reform doesn't also tackle waste and profiteering in the health insurance and drug industries.