(Money Magazine) -- The employer-based system is crumbling, but many Americans are wary of a Canada-like system. And 1,300 health insurance companies certainly won't like being told to find something else to do. "If you say you are going to eliminate them, you've declared war on them," says Ezekiel Emanuel, a bioethicist at the National Institutes of Health.
Many reformists instead propose a mixed system. The government would guarantee you access to coverage regardless of where you work, but insurers would stay in business. The Massachusetts and California plans attempt something like this.
At a national level, hybrid reform comes in two basic flavors. The first would sever the link between your employer and your coverage, and have you choose a (highly regulated) private insurer. Emanuel and Stanford economist Victor Fuchs propose doing this with a voucher funded by a new tax. Wyden would tell employers to drop insurance - and to give you a raise - and then create an individual mandate with subsidies.
The second approach is "pay-or-play." Employers could offer insurance, but there would also be a public health system, financed by contributions from employers who didn't offer plans. That's the John Edwards plan, which is similar to one designed by Yale's Jacob Hacker under which about half of working-age Americans would join an expanded Medicare program.
The different tacks come down largely to a question of how best to rein in costs. Emanuel thinks private insurers will have the financial incentive to better organize how doctors and hospitals deliver care, which will be especially important as the population ages and more of us face chronic disease.
On the other hand, a public system would have the brute power to push down costs and wouldn't waste a lot of money on frippery. About 14 percent of the money private insurers collect doesn't go to health care at all but to administration and profits.
The messy details
We've been here before - the Clintons tried to mix private insurers with public money too. On the next try, a hybrid reform has to get a lot of details right. And not just on paper.
In a real-life legislative process, insurers will fight to limit their liability, hospitals and doctors will try to protect their incomes, employers will want to keep from paying, and the elderly and others will battle for more generous benefits. And reformers must produce a bill simple and beneficial enough for people to rally behind.
That could prove tough - at least as tough as, say, Iowa in the wintertime.
To talk about health-care reform, check out Pat Regnier's blog, Generation Risk, at generationrisk.blogs.money.com. 
