From sea to shining sea, many Americans agree: Our health care system is broken. The uninsured now exceed 46 million and health costs keep growing faster than incomes, facts that strain household, employer, and government budgets alike. Awareness of mediocre quality and poor safety performance is spreading beyond academic whispers to mainstream headlines. Still, Washington fiddles and tries to change the subject. Why the chasm between awareness and action?

Consider this: Political extremists, with an iron grip on each party, don’t really want to solve the problem, for that would require acknowledging holes in their world views. This is why power must be wrested from them for progress to be made.

The far right, having dictated Republican priorities since 1994, finds health debates vexing; their top priority is ever-lower taxes and serious health reform threatens that. Their counter-attack, designed to keep universal coverage off the table and government small, is two-fold.

First, they claim the problems of the uninsured are grossly overstated since they can access "free" emergency care in many hospitals. This willfully ignores three facts. The uninsured must merely be stabilized in ERs (e.g., external bleeding stopped), not treated and cured (e.g., an operation to remove a tumor). Hospitals can charge people as a condition of treatment, and many now do, and hospitals can close emergency departments altogether. Finally, because of cost, shame and human nature, most uninsured get care later in disease progression than the insured, so they suffer needlessly; 20,000 uninsured Americans actually die prematurely from treatable conditions each year, according to the Institute of Medicine.

Second, the right blames high health costs on overly generous insurance, so the solution is -- surprise, surprise -- less generous health insurance. Only the far right can look out and see 46 million uninsured and declare our main problem to be too much health insurance. The right and the President would cut public benefits while limiting tax breaks to those who leave group insurance and purchase pared down policies on their own in the non-group market.

Senator Grassley (R-Iowa), the moderate chair of the Senate Finance Committee, thinks so little of this approach that he refused to even hold markup hearings on Bush’s health insurance tax cut proposals this year.

But at least the right is clear about what it really wants. The Democrats do not distinguish themselves with a coherent vision. As a result, the old labor-left view has more adherents than supporters, for lack of a better alternative. The far left vision sees 46 million uninsured and blames profit-mongering insurers and drug companies for the high costs that force inequitable access to care. The left then argues that stripping profit out of the system will lower costs so much that we can cover all the uninsured with the savings. They propose replacing private insurance with a payroll tax-financed single-payer system like traditional Medicare.

The fact that payroll taxes -- i.e., taxes on labor -- reduce both wages and jobs does not deter them, nor does the experience of the Medicare program being converted -- by stakeholder politics -- from an insurance program for the vulnerable elderly into an income support program for mediocre providers.

But of course the left doesn’t really think they can get a single payer program through the Senate with the filibuster rules they’ve recently defended for dear life. They merely plan to use the issue to seize the moral high ground -- "we’re for affordable coverage, they’re for profits" -- and re-claim control of Congress, before they move on to priorities that don’t require 60 votes.

Better health care policy will require far more intellectual honesty and an embrace of a principled yet practical vision of shared responsibility for sustainable health care for all. It will require the more numerous centrists to stare down the extremists in both parties to produce a bipartisan compromise that a majority of Americans can support.

Massachusetts offers one such vision, in which the purchase requirement is centered on the individual. In turn the government creates a market haven wherein insurance can be fairly and efficiently purchased. This subsidizes the low income population, but also appropriates only a fixed amount of premium subsidy dollars, so hard choices are still necessary.

Governor Romney, a candidate for the 2008 Republican presidential nomination, is proud enough of the bipartisan deal he helped craft that the upcoming debate within Republican circles may be robust. The far right would like to make sure the Romney candidacy, or at least its flirtation with universal health insurance, meets a Hobbesian fate: solitary, nasty, brutish and short. Their attack on freshman Congressman Joe Schwarz, MD (R-Mich.), a lifelong Republican who had the integrity to acknowledge that more government involvement is necessary to make our health system sustainable and our society fairer, signals the tenacity of this fight. The anti-tax Club for Growth contributed 86% of the money raised by Schwarz’s successful primary challenger, a minister who limited his policy statements to condemnation of gay marriage, abortion, and stem cell research.

Thankfully, there are some bright lights emerging from the partisan Washington fog. Senator Gordon Smith (R-Ore.), at a September 21 event jointly sponsored by the New America Foundation and Brookings Institution, courageously acknowledged what many politicians avoid: that we ration care today by income, coverage limits and queue. Thus he called for honesty in future dialogues about the hard choices before us. He also made clear that the only reforms that will pass are those that can command 60 votes in the US Senate, i.e., those that are truly bipartisan. Senator Blanche Lincoln (D-Ark.) joined him in support of the types of bipartisan reform that enable working families to pool their resources and efficiently buy quality health insurance. Both spoke respectfully of the Massachusetts model, and most importantly, of working together in the months and years ahead.

Senators Ron Wyden (D-Ore.) and Orrin Hatch (R-Utah), co-sponsors of the legislation that created the Citizens Health Care Working Group, have also formed an ongoing bipartisan working relationship. The Citizens’ effort has reported back that the American people actually want every American to have access to a basic but adequate health care package of services, and they want the financing to be shared enough to accomplish that.

Senators Bingaman (D-N.M.) Voinovich (R-Ohio), and Feingold (D-Wis.) and Representatives Baldwin (D-Wis.), Price (R-Ga.), Tierney (D-Mass.) and Beauprez (R-Colo.) have all worked together this summer and fall to produce legislation or near agreement on bipartisan approaches to encourage more states to experiment with coverage expansion and cost-containment. These bills match the bipartisan spirit of reforms achieved in Massachusetts and Vermont, and of ongoing reform discussions in states such as Illinois, Colorado, Washington, New Mexico, and Oregon.

For true reform to succeed, each side must see its own vision realized inside the ultimate compromise. Negating the far right’s phobia of tax increases and the far left’s compulsion to punish successful capitalists are thus prerequisites. But once we jettison these artificial barriers and the ideologues who maintain them, moderate Democrats can get all people covered with a decent benefits package made affordable for all, and moderate Republicans will see individual choice and responsibility coupled with private sector creativity. It is our national community’s obligation to make it possible for each person to help themselves. Serving as responsible stewards of aggregate resources and enhancing value per dollar spent in the long run will make the new system technically sustainable.

This kind of reform will be sustainable politically because of the bipartisan groundwork currently being laid. The only thing reformers really have to fear is fear of our own extremists. Stare down the ideologues among us, and we can all win a better health care system.