Wow, what big and unexpected news! Reforming the health care system is really hard, and Republicans want President Obama to fail. Imagine that.

Oh, yes, and when the public gets a close look at the sausage-making process in Washington, it doesn’t like what it sees. And one more revelation: In a bad economy, it’s tough for a president to maintain approval ratings in the 60s indefinitely.

A sense of crisis pervades the nation’s capital. Congress is behind schedule in pushing along health system reform and the president’s poll numbers have dipped slightly.

Thus Obama’s prime-time news conference Wednesday, aimed at defending his past actions on the economy and explaining, yet again, why reforming health care is a better idea than leaving things as they are.

When this city goes berserk, it’s helpful to entertain an alternative view of reality: that certain problems were going to have to be dealt with eventually, and that only the appearance of a crisis would bring them to the surface.

Let’s start at the end. Despite all the dire words being spoken now, some version of health care reform will pass simply because failure is not an option for Democrats who care about staying in power (which happens to be all of them).

Republicans such as Sen. Jim DeMint and commentator William Kristol have been immensely useful in clarifying this — DeMint by saying that defeating health care reform would “break” Obama, and Kristol by defining the GOP’s position succinctly with the words “kill it.” The stakes are now clear.

But it has been obvious for months that the issue of how to finance reform would be difficult because it drives a wedge right through the pro-reform coalition.

The first sign of trouble came early this year when Obama put a lot of money on the table — $318 billion over 10 years to be precise — by proposing to limit the value of various tax deductions for wealthy Americans. In a remarkable show of bipartisanship, Congress shot this idea down without much debate.

If not that, what? Policy wonks of various stripes argue that we should tax the value of the health insurance policies people now get, especially high-end plans. The substantive case for this is strong, since it’s a tax that would, on the whole, fall on better-off people, and taxing the most generous plans could help hold down costs.

However, the levy is very unpopular, and not just with the unions, who are among the strongest supporters of universal coverage and have negotiated good health plans for their members. The tax would also have unfair regional effects because of state-to-state variations in the cost of health insurance. And Obama savaged John McCain in 2008 for putting forward a version of this scheme. Aren’t politicians supposed to keep their campaign promises?

Democrats in the House responded by proposing that we tax the very rich, the latest version of their idea being a surtax on millionaires. There is nothing wrong with asking the wealthy to pay for covering the uninsured, and good for the House for showing how much money such a tax could raise.

The main objection is that we may need to tax the wealthy again later to balance the budget and we’re better off financing health coverage with taxes on the health care system itself. OK, but see above for the problems that entails.

As for measures to contain health care costs, they are absolutely essential. But I’m anxious to see what members of Congress now yelling for cost controls say after providers in their districts start complaining about the burdens such cuts would impose.

Indeed, some opponents of health care reform are playing both sides of the street, arguing for cost containment while simultaneously warning that reform would limit “freedom of choice.”

It was entirely predictable that we would have this cacophony once the debate was joined in earnest and once citizen-consumers began counting up the costs and benefits of reform.

But the only choice that matters is whether we want to cover all Americans and begin the multiyear task of fixing the health system, or whether we prefer, once again, to use the details as an excuse for evading what we know must be done someday.

The politics of escape uses difficulties as an excuse for inertia. The politics of tenacity accepts that some problems are excruciatingly difficult, and resolves to deal with them anyway. The crisis in Washington arises because that choice is now upon us.

E.J. Dionne’s e-mail address is ejdionne(at)

© 2009, Washington Post Writers Group

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