THE HEALTH-INSURANCE-reform debate has become as confusing as it is loud. Insurance mandates, public plans, insurance exchanges, millionaires’ tax — none of this sounds much like health care. Almost everyone in the country now knows we spend twice as much on average as the other industrialized countries, and that the measured health of Americans is not as good as most of the countries that spend less, sometimes just a fraction, of what we spend on health-care services, and that our spending on health services has seriously impaired our ability to make needed investments in education, housing, infrastructure and the environment.

To make matters worse, we waste much of what we spend. We spend about $5,000 per person, per year on commercial health insurance. Medicare, which is really insurance coverage for people over 65 and the disabled, costs about $9,000 per person a year.

Of what we spend on insurance, 10 to 20 percent — or $500 to $1,000 — stays with the health-insurance company for its own use. (For Medicare the number is $270 to $450 — 3 to 5 percent.) Five to eight percent of the average health-insurance premium — $250 to $400 — stays with the commercial insurance broker. Most experts agree that there is tremendous waste from unneeded services promoted by people with something to sell (and ordered by doctors who are motivated by fear of malpractice suits, and stimulated by pharmaceutical companies and medical-device makers, who manipulate the process by which recommendations are made and the process through which value of drugs and devices is tested and reported) so that a huge amount of money, something like 30 percent of all spending, provides no benefit to anyone other than the people providing the service, or selling the drug or device.

In addition, the administrative cost of billing for services, and of reporting various — and dubious — measures of “quality” to insurers and 3 zillion government oversight agencies, increases the cost of providing service by 10-30 percent. As long as everyone has their hand in the pot, it’s little wonder that we don’t have enough to pay for the care of almost 50 million people, and not surprising that most people with insurance still each spend a few thousand more dollars a year on insurance premiums and co-pays, and that the measured health of our population lags behind that of other industrialized countries.

The danger, of course, is the way all this money distorts the public process of reform. People who are profiting from the chaos — insurers, doctors, hospital administrators, pharmaceutical companies, device manufacturers, insurance agents and others — don’t want to get off the gravy train. Everyone has a reason why their deal should stay intact. And everyone with money has a lobbyist and has made large contributions to political campaigns, so the senators and representatives they’ve supported are unlikely to oppose them.

Now we get to the dangerous part.

One pillar of reform has always been finding a way to provide health care to the 50 million uninsured Americans. As the reform debate was joined, the first principle that all the stakeholders agreed on was an insurance mandate — on requiring all Americans to have health insurance. That’s the quickest, though not necessarily the best way, of bringing the hope of health care to all, and the easier principle for the stakeholders to agree on, because once everyone has health insurance, then all stakeholders, who each have something to sell, get 50 million new customers. (A more effective and less expensive way, often thought politically impossible, is to just provide health care, and not health insurance for all Americans, by building a health-care system for the U.S.)

But here’s the problem. The cost of health care, and its negative impact on the economy, and on the society itself, is a good part of what is driving reform. If all we do is create an insurance mandate, we’ll add $250 billion or more of new cost, and worsen the impact on the economy. We’ll worsen one of the problems reform was supposed to fix.

But more dangerous yet, by transferring $250 billion of new income to the sellers of health services, we enrich them further, and give them more money they can use to contribute to political campaigns, to feed misinformation to talk-show hosts, and to muddy the waters of public debate and discussion, so they can steer it where they want reform to go. They want reform to stay away from taking money away from each of them — and if the economy tanks, so be it.

A few years ago, many doctors who thought they were self-employed realized they were working for health-insurance companies. If we are not careful, before long we’ll all be working for health-insurance companies, and the U.S., as a nation, will be in a worsening economic mess.

That’s why we need the “public plan.” It ain’t perfect, but it provides a way to control the power of the health-insurance companies and the other health-care profiteers while we provide health insurance for all Americans. We’d really be better off if we just focused on what works, and built a health-care system for these United States, but as Winston Churchill so wisely observed, the U.S. usually gets the right answer, after it has tried all the other ones.

Michael Fine, M.D., of Scituate, is a family physician, managing director of HealthAccessRI, and co-author of The Nature of Health.