Comprehensive health-care reform is necessarily complicated. It presents a huge target for special interests.

Contrast the Kennedy and Johnson administrations. It is uplifting to dream dreams and see possibilities for a brighter future. But when it comes to the rough-and-tumble of passing legislation, one must count the votes and keep the bill simple enough to obtain passage.

Three important issues have wide popular support and should garner 60 votes in the U.S. Senate.:

-- Insurance companies should not be allowed to deny coverage or impose surcharges for "pre-existing conditions."

-- Health insurance should be portable when one changes employment or moves to a different part of the country. (That's the concept behind the existing COBRA law, without the 18-month limit).

-- Most important, we must find a more rational way to care for the 46 million people without insurance coverage. Emergency rooms are required to provide care for all. An ER visit is unfathomably more expensive than a doctor's-office visit. That cost is passed on to all of us in the form of higher insurance premiums, co-payments, higher taxes and hospital billings to Medicaid. Businesses charge a little more for everything we buy to cover the cost of employee benefits.

A short, readable bill, not 1,000 pages in order to obtain buy-in from interested groups, should generate overwhelming support.

Yes, much more needs to be done, urgently. Rising costs of both private and public health care in America are unsustainable and will reach a crisis. However, comprehensive reform efforts have consistently been stillborn since Harry Truman.

After the congressional elections in 2010, we can do more. First, build public confidence by agreeing upon essentials.

How might we cover our 46 million uninsured, who lack health insurance because they cannot afford it or do not perceive the need for it?

-- A dedicated, coherent payment mechanism to fund care for the uninsured. (Shifting of the bill raises costs.)

-- An individual mandate requiring all of us to maintain at least a minimal level of coverage. (We already mandate treatment for everyone at emergency rooms.)

-- Finally, budgeting for a reasonable level of care. (Match our sense of justice and compassion with our ability to pay.)

Above a basic level of care, each of us should be allowed to determine how much additional care we desire, how much we are willing and able to pay for, and how to finance those payments.

All children should have access to immunizations. Emergency rooms should remain open to all until the patient's condition is assessed and stabilized. However, second liver transplants for alcoholics should not be provided at public expense.

A qualified medical commission could rate cost-effectiveness of each procedure. After Congress set a budget level, the commission could specify which procedures are most affordable. Our representatives in Congress should have the ultimate vote. They are accountable to us.

Our nation should self-insure for a basic level of care. The broader the risk pool, the smaller the risk premium. Administrative cost could be streamlined. Some things government can do better than private industry, many things it cannot. Spreading risk is one area where government has a natural advantage. Wherever the health insurance industry provides added value, it will remain competitive. We cannot afford unnecessary overhead.

Once Congress agrees upon a minimum benefits package, uninsured citizens could be given the option of a public insurance plan or receiving a voucher or tax credit to obtain equivalent or better private coverage. To prevent cherry-picking of low-risk individuals, insurance companies would be required to submit a composite risk profile of their policyholders.

A dedicated, readily identifiable source to pay for limited health care for the uninsured would clarify the costs to our economy and to personal households. We could more easily recognize trade-offs when we advocate greater or lesser levels of care.

An incomplete bill, accomplishing all these objectives, will advance the solution. Let's start by reforming insurance and explicitly covering all Americans.

Tom Goergen lives in Southern Pines. Contact him at tgoergen@nc.rr.com.