The putative reason we're going through the health care reform debate of 2009 is that

15 percent of our citizens have no health care insurance.

That's true, and the fact that 15 percent of our citizenry - and, maybe just as important, countless underinsured citizens, the number of which we have no good handle on - remain a single major health care crisis away from bankruptcy is sufficient reason to address the issue.

But that's not the only reason to address this issue.

An equally and perhaps more pressing issue is the fact that the current system can't be sustained in the long term.

Why?

Medicare.

We're getting older (thank you, Baby Boomers), and our socialized medicine for older Americans, Medicare, doesn't truly cover the cost of recipients' care. Health care providers need to make up the difference somewhere.

So the rest of us - the insured and the self-paying - are picking up the difference.

Eventually, that fact alone will kill private health insurance as we know it if we don't change the system: Private insurance will become too expensive for more and more individuals and businesses in coming years as more and more people rely on Medicare.

That's the problem in a nutshell.

Now any intellectually honest anti-socialist critic of current iterations of health care reform would also advocate the killing of Medicare, Medicaid and Social Security, as all are "socialist," not to mention the fact that they're fiscally untenable in the long term.

You don't hear them doing that: It's politically untenable.

And any intellectually honest health care administrator will tell you that, in our current system, the itemized bill you receive for your care has little to do with the actual costs of that care - and everything to do with making sure the provider gets at least some payment for the services it has provided.

It's a shell game designed to keep our current Rube Goldberg system afloat.

America's health care system is a by-product of a centrally-planned World War II-era economy: Wage freezes prompted employers to offer a new benefit - recently invented and then-cheap health insurance - to attract and retain workers. But health insurance is now neither new nor cheap, so the system, burdened by the unaccounted-for and under-reimbursed expenses of Medicare and Medicaid patients, is collapsing.

This weekend's scrambling in the U.S. House of Representatives is emblematic: The system is a mess and we have to do something.

And Senate Majority Leader Harry Reid's hinting last week that the health care reform debate could extend into 2010 is also instructive: The issue is complex and isn't conducive to a quick and easy fix.

The signal issues are these: Does health care reform fix the problems with our current socialized medicine for seniors? Does it pay for health care outcomes rather than number of procedures, an issue especially important to our area health care providers, who have pioneered the integrated, outcome-based health care delivery systems touted by the president and other reform advocates? And does reform fix the gross regional disparities in compensation for care under Medicare?

Since all the legislation so far delays Medicare reform till after the legislation is passed - despite counting on Medicare savings to help pay for the bills - it's likely that this iteration of the health care reform debate is only a prelude to what's to come.

That the loud health care argument about socialism vs. the free market so misses the real debate is unfortunate: The current system is brutally unfair because of the geographic disparities of Medicare and its unwise incentives to those providers who provide quantity of care rather than quality care. The Upper Midwest is being punished for its efficiency, and the result is that we pay the difference. That's the issue that reform naysayers seem to miss: We're already paying far more because the formula favors the wrong types of care and the result is that our bill is higher.

Critics of bills before Congress aren't short on ammunition. But unless they can come up with an intellectually honest alternative that accounts for the fact that Medicare, as it stands, is unsustainable, we'd better get used to the idea that how we pay for health care will remain a difficult question for years to come.