Before President Obama’s scheduled visit to Broughton High School July 29, two very different conversations about health care were taking place in Raleigh. One, heard last Thursday at the Democratic Party’s state headquarters, focused on how unfair, inefficient and fundamentally screwed-up American health care isand how desperately reform is needed.

The other, aired Friday at a forum sponsored by the Greater Raleigh Chamber of Commerce, centered on how much worse the system could get if the federal government jumps in and “fixes” it.

The warring narratives dictate the thin line Obama’s attempting to walk as he pushes Congress for action on health care this year. On one side, he must respond to the demand for fundamental change from within his own party. On the other, he keeps telling Americans that if they like the health care they have now, nothing he’s proposing will fundamentally change it.

Two questions in particular are dogging the president:

  • Why is he asking the taxpayers to spend more on health care if one major objective of health care reform is to bring costs down?
  • If costs do decrease, won’t adding more people to the system (the uninsured) and guaranteeing that their care will be equal to what others receive, lead inevitably to “rationing”and lower-quality care for those who already have insurance?

When Democrats hear Obama’s proposal for a public insurance option, moreover, most cheer it as an alternative to a private insurance system that they think is gouging them. But for many employers, the idea that the federal government will spend less on something than they do is a laugh line.

At Democratic headquarters, State Chairman David Young was joined by three dozen party activists at a made-for-TV event, with Young asserting that “reform’s time is now.” When the cameras left, some spontaneously opened up about their own health care messes.

Freelance writer Susan LaBarre said angrily that she can’t afford health insurance “because my pre-existing condition”she pointed to a tiny spot on her eyelid where a basal cell carcinoma was removedmeans no insurance is available to her except at exorbitant rates. She used to have insurance through a job. But when the job ended, so did the insurance.

Christina Stableford said that when she lost her job, she shopped around for insurance. Despite being in excellent health (but over 50, an apparent disqualifier), she was rejected by two insurance companies and finally bought a “catastrophic” plan that will pay nothing until she’s spent $5,000 herself. “And then,” she worried, “who knows what they will discover or whether they will drop me.”

“The real clincher in this absurb scenario,” Stableford added, is that while the employer-paid insurance she used to have was tax-free, now that she’s on her own doing contract work, she won’t even be able to deduct the premiums she pays with after-tax earnings. “So the people least able to maintain coverage don’t even get the privilege of writing off the [cost].”

Mike Schaul was irate about what happened to his father in the last year of his father’s life. He died at 93 from a lingering infection after undergoing a heart bypass operation that Schaul thought was unnecessary. (His father had gone to the hospital to have a heart valve repaired, an operation that revealed the arterial blockage.)

“After that, nobody was in charge of really seeing that he was OK,” Schaul said. Many tests were ordered, but there was little information sharing or coordinationhis father’s primary care physician played no role at alland the wrong medicine, in Schaul’s view, was prescribed. “Everyone seemed to acting based on incentives to do things that didn’t help,” he said.

In a few strokes, the three stories laid bare what’s wrong with American health care: The fee-for-service mentality; the lack of coordination and focus on outcomes; the lack of coverage for those who need it most; and despite it all, the enormous cost.

There was no disagreement at the Chamber forum about the problems. Bob Greczyn, CEO of Blue Cross Blue Shield of N.C., decried the “piecework, fee-for-service model.” Hugh Tilson, senior vice president of the N.C. Hospital Association, said the health care system is inefficient all around”providers,” too.

They and others representing the health care industry agreed that reform is needed, and that it should force insurers to price their coverage without regard to pre-existing conditions (known as a “community rating”) and to insure every applicant (referred to as “guaranteed issue”).

Those who can’t afford insurance should be subsidized, they said, and the industry should then focus on patients, wellness and illness prevention, not, in Tilson’s words, “chasing dollars around.”

But on cost controls, there was a deafening silence. Dana Simpson, a Raleigh attorney and lobbyist for health-care interests, pointed to the escalation of health-care spending in the United States, which is roughly twice as much as other industrialized nationsand an enormous drag, as Simpson reminded his business listeners, on the American economy.

The response, from representatives of the medical society, the pharmaceutical industry, the hospitals and the insurers was to recite all the programs they’ve started to control themselves. “Our hope” for the federal reforms, Greczyn said, “is that we will be able to continue a lot of the things we already do.”

Subsequently, Greczyn said that the panelistshimself includedhad engaged in too much “happy talk,” adding, “We all need to do a better job.”

But Greczyn encouraged questioners who thought Obama’s idea of creating a public insurance option to compete with the likes of Blue Cross would result in unwanted rationing for them and their employees. If the public option happens, he said, “the notion that the President has put forward that if you like what you have you can keep it will not be true.”

Thus the task for Obama as he travels the country in August is clear: Persuade Americans that a reformed, less expensive health care system will be good for everyone, not just for those who have no insurance now.