Could it be the heat that’s making people so angry and unreasonable at those town hall meetings on health care? Might it just be the effect that Raymond Chandler described so brilliantly in the opening lines of his 1938 short story “Red Wind”:

“There was a desert wind blowing that night. It was one of those hot dry Santa Anas that come down through the mountain passes and curl your hair and make your nerves jump and your skin itch. On nights like that every booze party ends in a fight. Meek little wives feel the edge of the carving knife and study their husbands’ necks. Anything can happen.”

Unfortunately, it’s not that simple. Red-faced retirees are railing against “government-run” health care and “socialized medicine” — with Medicare cards tucked inside their wallets. They could have just stayed home and harangued themselves. The August heat is punishing, but not enough to induce mass delirium.

We know that there are crazies in the town hall mobs — paranoid fantasists who imagine they hear the whop-whop-whop of the World Government black helicopters coming closer by the minute. We know that much of the action is being directed from the wings by cynical political operatives, following a script written by Washington lobbyists. But the nut jobs and carpetbaggers are outnumbered by confused and concerned Americans who seem genuinely convinced they’re not being told the whole truth about health care reform.

And they have a point.

Just so there’s no misunderstanding, I’m a true believer. It’s scandalous and immoral that the richest, most powerful nation on earth callously ignores the fact that 47 million citizens lack health insurance. I feel strongly that there should be a public option to keep private insurers honest; and I want the government to be able to negotiate drug prices with the pharmaceutical companies.

Whatever reform package finally emerges — after it’s been mauled by those snarling Blue Dogs — probably won’t go nearly far enough. But I’ll almost certainly support it, on the theory that something is better than nothing. I’ll worry about the cost, but I’ll reason that it’s worth it to save children’s lives and keep working-class families out of bankruptcy.

But reform is being sold not just as a moral obligation but also as a way to control rising health care costs. That should have been a separate discussion. It is not illogical for skeptics to suspect that if millions of people are going to be newly covered by health insurance, either costs are going to skyrocket or services are going to be curtailed.

The unvarnished truth is that services are ultimately going to have to be curtailed regardless of what happens with reform. We perform more expensive tests, questionable surgeries and high-tech diagnostic scans than we can afford. We spend unsustainable amounts of money on patients during the final year of life.

Yes, it’s true that doctors order some questionable procedures defensively, to keep from getting sued. But it’s a cop-out to blame the doctors or the tort lawyers. We’re the ones who demand these tests, scans and surgeries. And why not? If a technology exists that can prolong life or improve its quality, even for a few weeks or months, why shouldn’t we want it?

That’s the reason people are so frightened and enraged about the proposed measure that would allow Medicare to pay for end-of-life counseling. If the government says it has to control health care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending. It’s irresponsible for politicians, such as Sarah Palin, to claim — outlandishly and falsely — that there’s going to be some kind of “death panel” to decide when to pull the plug on Aunt Sylvia. But it’s understandable why people might associate the phrase “health care reform” with limiting their choices during Aunt Sylvia’s final days.

We should be having two debates. One should be about the obligation to ensure universal access to health care, which will directly benefit millions of struggling families and make this a better society. The other — a more complicated, difficult and painful discussion — should be about the long-term problem of out-of-control health care costs, which would be a looming crisis even if President Obama had never uttered the word “reform.”

Conflating the two has made the nation’s nerves jump and its skin itch. And now, anything can happen.

Eugene Robinson’s e-mail address is eugenerobinson(at)

© 2009, Washington Post Writers Group

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