Health-care reform is in danger of dying on the congressional operating table. It's time to call in Surgeon-in-Chief Barack Obama.

The president isn't a miracle worker like the cranky protagonist on television's "House." But he can refocus the health-reform debate on what really matters, and on the hard decisions that lawmakers, left to their own devices, would just as soon avoid.

Last week, Congressional leaders scotched a Senate proposal to pay for health care by ending an unlimited federal tax subsidy for employer-paid health coverage. A philosophical rift also widened between House liberals and more moderate Blue Dog Democrats. The former served notice that they would refuse to back any bill that does not include a strong "public option," while the latter balked at supporting legislation that would compound the nation's debt crisis.

And in a letter to Congress, White House budget chief Peter Orszag warned that it's not enough for lawmakers to come up with ways to pay for health care reform: They must also tackle the structural roots of medical inflation, especially the widespread overuse of redundant or ineffective tests and procedures.

The faltering momentum of health reform highlights the limits of President Obama's early tendency to set broad policy goals and let Congress sweat the details. This approach produced a $787 billion economic-stimulus bill that has yet to do much stimulating. It also led to the frenzy of legislative horse trading and deal cutting that weakened the Waxman-Markey climate bill.

But revamping America's costly, wasteful and inequitable health-care system is simply too big and too important to leave to the vicissitudes of interest-group politics in Washington. That's why President Obama must intervene.

He could start by reminding Americans of the three main things health care reform must do:

1) Constrain the growth of medical costs;

2) Guarantee everyone access to affordable care; and

3) Pay for itself.

On the first point, Orszag is absolutely right: Reform must emphasize quality over quantity in the provision of medical services. He's called for a major federal investment in studies of the comparative effectiveness of various medical procedures, the cost of which often vary dramatically across the country

Republicans, apparently unwilling to set any limits on health-care consumption, have criticized the proposal. Its real problem, though, is that it probably would take a long time to "bend the cost curve" of health spending.

The most important structural reform now is to begin to nudge the entire health sector away from fee-for-service payments, which give providers a perverse incentive to maximize revenues by providing more services than patients actually need.

This is where liberal demands for a public option based on Medicare make no sense. With its fee-for-service structure and a long-term deficit exceeding $30 billion, Medicare is anything but a model of cost containment.

It's essential, instead, that health reform speed progress toward a better payment system modeled after successful "integrated" or "accountable" care organizations like the Mayo Clinic or Intermountain Health. Organizations like these may put doctors on salary, or they may charge patients a "package price" for a specific set of health care services. They also encourage providers to collaborate in managing their patients' overall health. In these ways, they align providers' incentives with the best interests of their patients and the system as a whole.

On the second question, access to affordable care, lawmakers seem to be making more progress. Any legislation will likely require that private insurers guarantee coverage to all without regard for pre-existing medical conditions. The insurance industry seems willing to go along, as long as all Americans are required to get health insurance - a mandate that will bring millions of young, relatively healthy people into risk pools.

Under the emerging system of so-called "health exchanges," individuals could choose among competing private and public plans. Lawmakers will also likely add a modest employer mandate, less to financial coverage expansions than to assure that companies don't drop their existing coverage.

Finally, there's the third and most vexing question - how to pay for all of this. At a time when the United States is facing double-digit budget deficits and a swelling national debt, it's critical that we don't make things worse by borrowing hundreds of billions more to pay for universal coverage.

A lot of the money - but far from enough - will come from cuts in Medicare payments to hospitals. The best way to cover the balance would be to repeal or limit the tax inclusion for employer-paid health benefits. Not only would that raise big money - $320 billion over 10 years - but it would give employers an incentive to stop overpaying for inefficient and wasteful health insurance plans.

Rather than embrace this obvious "two-fer," however, congressional leaders have gotten cold feet. They worry about opening the door to GOP demagoguery about "taxing your health-care benefits." Moreover, a cap on the tax exclusion would encourage a necessary shift away from the bloated, unaffordable health plans many unions negotiated for their workers.

So Congress is now toying with income-tax surcharges on Americans with incomes over $350,000. Unfortunately, this approach doesn't raise enough money to fill the hole in financing health reform. In addition, taxing the richest Americans is a well we can only go to once. If we use that money for health care, it won't be available to help close Washington's enormous budget deficits.

President Obama ought to affirm the principle that the first place to look for savings to pay for health reform should be within the health-care system itself. Yes, it will take all of his considerable communications skills to convince the public that trimming the federal subsidy for health care will make the overall system sounder. One difficulty, of course, is that Obama opposed the subsidy cap during the campaign, and he has promised not to raise taxes on middle class families.

The president should also remind the Senate of his original plan to use revenues from trading carbon allowances to pay for health reform. To mollify powerful interests and win just enough votes for passage, the House climate bill gave most allowances away. The White House should put pressure on the Senate to adjust that balance.

Congress, by design, is the arena where parochial interests compete to shape national legislation to their liking. The White House, of course, is hardly immune to special-interest pressures. But the president represents the country as a whole and must act in the national interest. In this case, his job is to rally the large but diffuse majority of Americans who say they want sweeping health reform, and rivet their attention on Congress. Without such outside pressure, the odds grow daily that what emerges from Congress won't be health reform worthy of the name.