The givens: our country over decades has jerry-built a health care "system" that is unfair and inefficient. We pay far more for far less care than any other industrialized nation. And we have forty million people uninsured for whom a major illness can mean mortgaging a home, not sending a kid to college, or worse.

Now the country is finally beginning to address health care reform in a meaningful way, in what could well be the most important domestic policy debate since the New Deal.

Key elements in this debate are competition, costs -- and courage.

Competition. A huge point of contention is defining what additional role, if any, government should play in health care. As we see, this argument quickly descends from policy to ideology, which is why it is so difficult.

Many Americans favor a "single-payer" national health care system run by the Federal government -- a huge shift from the current system managed by private insurance companies whose primary goal is to turn a profit. Statistics show that the single-payer systems used by most other industrialized countries are more equitable and efficient than the hodge-podge we now have here.

But single-payer is not on the table in 2009, shelved by strategists in the White House and in Congress who fear the power of the health insurance lobbies to scuttle any reforms that contain it. Single-payer could put health insurance companies out of business and they will fight to keep that from happening.

There's a compromise afloat -- the so-called "government option" in which a government-run health care plan would be just one option for consumers, competing with private plans to enroll members. The plan or plans that worked best for lowest costs would gain customers, forcing others to either improve or leave the market. Sounds like classic capitalism, right?

But even this thoroughly sensible idea is in under attack because the insurance companies are afraid that they would lose such a competition, forcing them to either better meet peoples' needs -- or lose business. They are already arguing that the playing field would be tilted against them. Unlike the government, for example, health insurance companies find it difficult to pressure themselves to use their leverage to contain costs -- because those costs add to their own profits. They also argue that they have expenses that the government doesn't -- like the billions they spend on advertising and inflated CEO salaries.

The arguments against a government option would collapse of their own weight were it not for the support of lawmakers eating at the trough filled by the health insurance lobby. As President Obama put it last week to Republican lawmakers:

"Why is it that the government, which private insurers say can't run anything, suddenly is going to drive them out of business? That's not logical...they should be able to compete."

Cost-containment. Three of the best new ideas:

• Focus more attention and dollars on prevention, which costs far less than treatment, especially treatment in ERs.
• Put more attention and dollars on expanding primary care, which is a low-cost way to keep people healthy and reduce the number of higher-cost interventions.
• Create a national electronic database of medical records, which would drastically cut administrative costs while reducing medical accidents.

But that's the "easy" stuff. There can be no serious effort to cut health care costs in this country until we as a people accept that we can't have it all. We can't have an MRI machine in every clinic and we can't provide unlimited options for treatment and at the same time complain that our health care costs are too high.

Medicare paid for expensive exploratory surgery for my dying 94-year old mother that, even had it succeeded, would have given her only a few more months. Her case is hardly unique. Studies show that, overall, adding expensive high-tech options does little or nothing to improve health care outcomes.

But do I want a government bureaucrat telling me whether or not I can have a certain medical procedure? No, I do not, but even more I don't want an accountant in an insurance company making that decision. I want a doctor helping me and my family choose options. And if those options are limited, at least I want them limited by some sensible parameters created by experts who have no economic stake in the outcome.

Means testing is another difficult cost-containment option. My mother left an estate of $250,000. Her final illness cost $35,000, yet her estate paid not a dime of it. In my view, Medicare should have taken all or part of that $35,000 from her estate.

Courage. No health care reform will succeed until the White House and the Congress are finally willing to stand up to the health care lobby. The shameful hold on Congress by that industry must end; the names of legislators beholden to it must be widely publicized, so voters can assess who's listening to the money, not the needs of the people.

Government must use its enormous bargaining power to lower the costs of the health care it pays for, such as Medicare and Medicaid. It was outrageous for Congress in 2003 to forbid Medicare from negotiating lower drug costs with pharmaceutical companies.

But our leaders need our support if we expect them to make tough decisions like these. There won't be meaningful health care reform if citizens remain frightened, insular and uninformed. All of us need to:

• Accept that health care reform must happen, even though it may mean changes we think might be risky or that reduce treatment options the nation can no longer afford.
• Accept that covering all Americans is going to cost a lot of money upfront; many of the best cost-containment measures may take years to implement.
• Wake up. Giving for-profit companies the primary power to manage our national health care pleases libertarian and rightwing ideologues, but it's not a policy that can ever lead to efficient and equitable outcomes. If for-profit companies are to continue to play a role, it must be tightly regulated, as it is now in the popular plan enjoyed by Federal employees.
• Be prepared to stand up to Harry and Louise. The more capable we are of making informed decisions, the less vulnerable we are to the simplistic scare tactics sure to be thrown at us by the protectors of this woeful status quo.

We deserve better than what we have.

We deserve better than what the health care industry is willing to give us.

We deserve better than a weak compromise from Congress described as victory.

We will have to fight for it.