In reality, the research is not as far along as he made it sound; the economic stimulus package (PL 111-5) enacted in February provided $1.1 billion for comparative effectiveness research. But the idea — emphasizing “smart medicine” over “more medicine” — is central to his vision of slowing the growth of health care spending in the United States. The real dilemma, though, is what happens if the patient wants the red pill instead of the blue pill.

Obama’s challenge will be to keep control of the public discussion so it doesn’t deteriorate into charges that “bureaucrats” will make those decisions. Already, prominent Republicans such as former House Speaker Newt Gingrich, R-Ga., are trying to raise those fears by suggesting that the “smart medicine” decisions will be made by faceless bureaucrats in the government-run health plan Obama wants to compete with private insurers. “His only concern, if he’s doing his job right, will be for the government’s bottom line,” Gingrich wrote in his e-mail newsletter last week. “It’s his choice, not yours. Surgery costs too much. Make do with the painkiller.”

Sweating the Details

Until recently, Obama has been able to address the self-interest argument by emphasizing how rising health care costs affect people with insurance, not just the uninsured. Without an overhaul, he has explained over and over, health insurance premiums will eat up bigger chunks of middle-income paychecks and threaten even comfortable Americans with bankruptcy because of the uncovered costs of one major illness.

Indeed, administration officials argue that the biggest cause of public anxiety right now is not the potential costs of an overhaul, but the escalating personal costs they face with the current health care system: the rising premiums, co-payments and deductibles; the lost wages; the businesses that can’t afford to hire enough workers. “The goal of health care reform, above all, is to make sure that your health care costs go down,” said Linda Douglass, communications director for the White House Office of Health Reform.

But in the coming weeks, with actual legislative details to look at and financing decisions to be made to pay for the emerging cost estimates, the public will begin to hear more about what kind of personal costs they might face. They’ll hear about possible taxes on their benefits and other ways they might have to pay more, at least in the short term, until the changes begin to save money. And they’ll hear from Republicans about the prospect of rationed health care.

“Any government program ultimately involves rationing, which means someone is standing there telling you whether you can get the medical care you need,” said Lamar Alexander of Tennessee, chairman of the Senate Republican Conference and normally one of the most moderate and least confrontational GOP leaders in Congress.

White House officials are aware of the nervousness lying beneath the solid majority of public support for Obama’s efforts, but they think they can keep it in check by arguing that the only real alternative is to continue with a broken system. “They at one level very fundamentally want change, but the closer that change gets to them, they definitely get nervous,” White House Chief of Staff Rahm Emanuel told reporters at a recent briefing. “The flip side is that those who don’t want change are defenders of the status quo the very same public does not want. The choice is change that deals with cost in a fundamental way vs. the status quo that accepts what happens today as a good thing.”

Ultimately, though, if Obama and Congress are going to put so much faith in the emerging wisdom about effective medical care to reduce health costs, voters will need to be reassured that their own care won’t suffer. That’s where Obama may have to lead a discussion with the public about what’s really important in medical care — and why, for the greater good of a stable health system, individual patients may have to give up treatments and tests of marginal benefits so the truly important medicines and procedures can be covered.

For a recent study of what kind of medical care people consider most important, Marjorie Ginsburg, executive director of the Center for Healthcare Decisions outside Sacramento, surveyed more than 1,000 people in California and conducted follow-up conversations with 15 discussion groups. Her conclusion, she said, was that “if you explain to them that they can’t have everything on the menu, they choose, and they do so in a thoughtful way.”

“We as a society are very new to the concept of shared resources,” said Ginsburg. However, when people understand that truly necessary care will be covered but that a procedure that costs $100,000 might bring a patient only four more weeks of life, she said, “people look at that and say, ‘That’s nuts.’ ”

Support in Principle

At the moment, public support for the health care effort is solid. In an ABC News-Washington Post poll last month, 58 percent said they believe an overhaul is necessary to control costs and cover more people. A New York Times-CBS News poll found that 57 percent of Americans would be willing to pay higher taxes so everyone could have health insurance.

But the surveys also found that people are nervous about what an overhaul could mean to them personally — the same dynamic that contributed to the failure of Bill Clinton’s drive to change the health care system at the start of his presidency. In the ABC-Post poll, 81 percent said they were concerned that an overhaul would reduce the quality of their care, 84 percent worried that it would increase their medical costs and 79 percent feared that it would limit their choices of doctors or treatments. In all cases, more than half of those surveyed said they were “very concerned” about those outcomes.

Drew Altman, president of the Henry J. Kaiser Family Foundation, said the main lesson from the polls is not that Americans are “afraid of health care reform,” but that “public opinion is movable.”

Still, lawmakers are keenly aware of the public’s views, which is why they’re watching Obama’s efforts — through frequent speeches and town hall forums — to assure the majority of Americans with health insurance that they won’t lose out because of an overhaul. “The outcome is going to be determined by the people who already have coverage,” said Democratic Sen. Evan Bayh of Indiana.

Robert Blendon, a Harvard University professor who studies public opinion on health care, said the findings highlight the challenges Obama faces when people focus on “snippets” they hear about bills being drafted at the Capitol — even though all the bills are far from complete. They also show that the health care effort isn’t just about whether lawmakers are willing to make the necessary policy compromises to get an agreement.

“As someone who focuses on public opinion,” Blendon said, “I worry that when members go home after the bill comes out, they may find that people are not as enthusiastic about the trade-offs as they were.”

Blendon says Obama will be able to play a critical role as a salesman for the final product. So far, the reviews for his performance in the bully pulpit are mixed. Democratic strategist Steve Elmendorf views Obama as saying the right things — by focusing on how a revamped health care system will be better for average Americans — and urges the president to just keep on saying them, because “politics is about repetition.”

Kessler, however, argues that by focusing on concepts such as costs and access, Obama and his team haven’t made the emotional connection people are looking for on an issue as deeply personal as health care. “They’re using Mr. Spock language in a Dr. Spock debate,” Kessler said.

A survey two weeks ago by Democracy Corps, an organization that provides polling and strategic advice to Democrats, concluded that most Americans would support an overhaul if Obama explained clearly how it would work and how it would lower their costs, since many right now are convinced their costs will go up, not down. That means Obama will have to be aggressive in his teaching role, said pollster Stan Greenberg, one of the organization’s founders. Staying clear of too much involvement in the stimulus bill “served him well in that process, but you can’t do health care in that way,” said Greenberg. “You can’t wait until the Senate acts. It’s too big a window for this to be distorted.”

There’s only so much explaining Obama can do now, though, because the bills are still being written. Complicating matters is the fact that all of Obama’s talk about eliminating wasteful medical care may have little to do with what’s actually in the legislation. “Those are real issues about the future of the health care system, but they’re not real in the legislation that’s currently being written on Capitol Hill,” said Altman. He sees the writing of the legislation as the biggest challenge, and particularly the negotiations over the financing package, because that’s “where the hot-button ideological differences and financing challenges really come together.”

Still, the potential is there for a distorted debate to convince people that their health care costs will go up, not down, in various ways. That’s why Mark McClellan, a commissioner of the Food and Drug Administration and administrator of the Centers for Medicare and Medicaid Services under President George W. Bush , says it’s so crucial for Congress to get a bipartisan bill rather than having Democrats ram it through on their own.

“They’re understandably nervous about change, and having members from both sides telling them this is the right thing to do could go a long way toward addressing that anxiety,” said McClellan, who consulted on the development of the bipartisan health care proposal by the former Senate majority leaders.

Getting to Yes

The path to a bipartisan deal would have to involve both policy and political trade-offs. On the political side, Democrats would have to convince Republicans that there are limits to how much government can get involved in health care, since the GOP — as well as some liberal Democrats — sees the public option as a back-door way to convert the health care system into a government-run, single-payer program. Obama has said many times that’s not his goal, but the Republicans “aren’t dealing with the president now. They’re dealing with Congress,” said Len Nichols, director of the health policy program at the New America Foundation. “They want to see it in print.”

Republicans, meanwhile, can signal their seriousness by accepting strong revenue and savings measures to pay for the overhaul — and by knocking off all the talk about rationing, said Nichols. “Each side has to reduce the other’s fears,” he said.

On the policy side, Chris Jennings, a health policy adviser in the Clinton White House, says Republicans have to be careful not to drive away Democrats who would otherwise want to negotiate with them. That seemed to happen two weeks ago, when Democratic Sen. Charles E. Schumer of New York, who had been negotiating over a possible alternative to the public option, essentially threw up his hands when he found no Republican interest in making the alternative approach a strong enough competitor to private insurance. “We can only bend so much to try to win over opponents of health care reform,” Schumer said. “We cannot bend so far that we break.”

There’s another reason both sides will be needed to make the necessary policy trade-offs: The financing of the overhaul is, in fact, likely to raise some people’s costs. Chairman Max Baucus of the Senate Finance Committee seems to be heading toward a financing package that would tax at least the most generous employer-sponsored health benefits for the first time. Obama says he’s not enthusiastic about that idea, but he opened the door to it at the ABC News forum, noting that “there is going to have to be some compromise at the end of the day.”

If so, he’ll have to put his salesman skills into overdrive. In an NBC News-Wall Street Journal poll last month, 59 percent said a financing package that taxes the most generous health benefit plans would be “not acceptable.”

Citizens or Patients?

If there are going to be costs to the public to an overhaul, it will be crucial for Obama to convince the public that what they’re going to be paying for is worth it, analysts and legislators concur. He has already laid the groundwork by explaining why the system can’t continue as is, with escalating costs and wasted money. But to speak directly to people’s worries about being denied important treatments and tests, Obama’s best bet may be to convince them that the current system does that far more often than a retooled health care system would.

“You solicit questions like that, and you answer them,” said Democrat Robert E. Andrews of New Jersey, who is chairman of the House Education and Labor Subcommittee on Health. Comparative effectiveness research, he said, is about paying more to hospitals that follow proven practices and paying less to hospitals that don’t; it’s not about denying care to individuals. Besides, he said, people already are being denied coverage under the current system, and those denials often do threaten the medical care people need the most.

“The answer is, you’re not going to be denied care that you need, and you are now, and we’re going to fix it,” Andrews said. That’s an angle Obama administration officials are focusing on as well. “Do you think you’re getting every test and procedure you need now?” asked Douglass of the White House Office of Health Reform.

The best way to frame the entire discussion, said Kessler of Third Way, is to show how a revamp would offer stability to most Americans — stable costs and stable coverage. “Stability,” he says, is the term that makes the emotional connection that abstract ideas like “costs” and “access” don’t. “They need to say, ‘Over the next 10 years, what do you think is going to happen? Do you think your coverage is going to become more stable? Do you think you’re going to get the treatment you want over the next 10 years?’ ” said Kessler. “I think most people will say, ‘No.’ ”

Still, that stability won’t come if health spending continues rising at current rates — which is why Obama has put such an emphasis on reining in costs. To succeed, he may have to begin a national discussion not just about what everyone can expect to gain from an overhaul, but also about how everyone can play a role as citizens in cutting back on medical care they don’t really need.

When Ginsburg held her discussion groups in California for her study of what people expect from health care, she said her organization “asked people to put on their citizen hats, which is different from their patient hats.” They were asked to consider a series of scenarios and rank them in order of priority for coverage. As they considered what to do if there’s not an infinite amount of money for health coverage, she said, “you see them realizing, ‘Health care is a collective. It’s not just designed around my needs.’ ”

The report, “What Matters Most,” issued in May, captures how people sorted out the cases they thought truly deserved coverage (a woman has migraine headaches so severe she has to miss work) from the ones that struck them as less important (a woman has a stiff ankle from salsa dancing). In most cases, Ginsburg said, people were able to identify and give their highest priorities to medical care that’s “critical for life functioning.”

They also ranked borderline cases and showed how their coverage priorities change under slight twists in the scenarios. In one, involving an 82-year-old woman who is expected to die soon, only 61 percent thought insurance should pay for a transfer to the intensive care unit — which would help her hang on only for days or weeks — if her family wanted it. Slightly more — 74 percent — thought an ICU stay should be covered if the patient herself wanted it. But 93 percent thought insurance should cover another option: hospice care to give her medical and emotional help as she prepares to die.

In these discussions, Ginsburg said, people didn’t care much about saving costs to the entire health care system, but they did care about whether money is being spent effectively. “There’s a point where you have to ask, ‘Do I really expect my fellow citizens to pay for things that have no real value?’ ” she said. “Ultimately, it isn’t just about me and my family. This is about what we expect to do for each other. Very few people pay for this themselves.’ ”

Leading the public in a discussion of what they can live without, even if it’s necessary to save the health care system, may be more than any political leader wants to take on — even one with Obama’s communication skills. But there really isn’t anyone else who can do it on a national level. And despite the political risks, Ginsburg thinks Obama can succeed if he convinces the public that they’ll get something better than the current system, in which people effectively face rationed care when they’re bankrupted by gaps in the health coverage they thought they had.

“It’s not about the takeaways. It’s about what you’re going to get,” said Ginsburg. “We ration health care now. Everyone knows that who has given it more than two seconds of thought. And we do it unfairly. Let’s do it a little more thoughtfully.”