Will serious health reform meet the fate of the scorpion and the turtle? In that fable, the scorpion pleads with the turtle to carry him across a river. The turtle resists, fearing the scorpion�s sting, but the scorpion reassures him that he�d do nothing so foolish, since both would drown if he did. Finally the turtle agrees. Halfway across, the scorpion betrays his promise with a lethal sting. As the turtle begins to drown, he asks why he took both their lives. �It�s just who I am,� the scorpion replies.

I fear we�re about to get stung again. When people look back at the failure of the Clinton-era health care initiative, they point, accurately, to an opaque process that produced a baroque Rube Goldberg mess that satisfied no one. That happened even before the insurance industry went on the attack with their Harry and Louise ads. But another missing element parallels our current challenge -- appeasement of the insurance companies as the plan�s centerpiece, and the inevitability that these same interests will betray us again.

The Clintons assumed the insurance companies were too powerful to confront, so the plan had to go along with them. But once they assumed any bill had to get the companies� approval, no plan could work, because it had to build in ways for the companies to maintain their profit margins and the immensely wasteful overhead they spend on advertising, processing claims, and turning down as many sick people as they can. Their approach also creates corollary wastes, like the third of the expenses of the average medical office that go toward dealing with insurance company paperwork.

Our health care crisis is so dire that the simple single-payer approach, as in Canada, should be at least seriously debated. Compared with us, most Canadians are satisfied with their system, in contrast with a recent US poll where 49 percent said our health system needed fundamental changes and 38 percent said it should be completely rebuilt. Canadians get a full choice of doctors (unlike in the US, where households have to switch doctors when employers change their insurance or insurance companies change their preferred provider lists). Tommy Douglas, the Canadian New Democratic Party leader who pushed through national health care in the mid-60s (replacing a system like ours), was recently voted Greatest Canadian in a recent contest, beating hockey star Wayne Gretzky and Prime Minister Pierre Trudeau.

Even if single-payer isn�t politically achievable yet, there�s no reason to take it off the table from the beginning. Doing so means most Americans never get to hear the contrast in cost savings, in allocation ease, in impact on ordinary citizens and their health outcomes. They never get to hear the story that might allow them to overcome current fears about losing the health care they have, being unable to see their preferred doctor, or being condemned to the Purgatory of endless waiting. Maybe we�ve been so conditioned that we can�t quite get the support for a full-fledged switch. A recent Kaiser Foundation poll still gives single-payer a narrow 49 to 47 percent majority, versus 67 percent for including a fully competitive public option, and maybe that isn�t enough. But at least we need to tell the story, so the probably inevitable compromise works down from full public coverage, as opposed to considering options that gut even the option of serious public coverage entirely.

Instead, because we�ve accepted the premise that the private insurance companies have to be included, we�re now starting to consider including a public option only if it includes poison pills that will doom it to fail, like requiring it be triggered by a set of exceedingly unlikely circumstances deferred to the indefinite future. Or requiring it to play by rules so onerous that it can�t achieve its straightforward cost savings. Or turning it over to the states, so Big Pharma and Big Insurance interests can simply, as Robert Reich warns, �buy off legislators and officials as they�ve been doing for years.�

But why assume that the insurance companies are our friends? Why appease them at all? It�s not as if they�ve played a helpful role in our current system. Rather, they�ve gamed it in every possible way, leaving our country with the highest health care costs in the world and worst health outcomes of any advanced industrial country. While they�ve made promises to cut costs, their promises are only that (like the scorpion�s), and they�re already lobbying with everything they have to gut any seriously competitive public option. Add in examples like former HCA/Columbia CEO Rick Scott. after his company paid a $1.7 billion fine (the largest in US history) for defrauding Medicare, Medicaid, and the program that serves our armed forces, he is now organizing attacks on any public program (hiring the PR firm that coordinated the �Swift Boat� attacks on John Kerry). We need to challenge the insurance companies, not appease them. There�s no evidence that suggests they�re constructive players, or are likely to do anything except defend their own parochial interest.

The insurance companies and other major financial interests are talking a good line of late. They have no choice if they don�t want to be cut out of the game. But ultimately, they are who they are, and their behavior reflects this. It makes no sense to embrace a partner who you know will ultimately betray you.

Maybe the public private mix is the best compromise we can get at the moment. But we must raise our voices now to demand a full debate on the other alternatives, like single-payer, and then if necessary settle for something that gives a public option a chance, under equitable rules, to see how it plays out in efficiency, service, and cost. Trusting the insurance companies and stacking the deck to guarantee that private options will prevail merely assures we continue our dysfunctional system until its human and financial costs drown us all.