President Obama is rightly concerned that our health care system leaves many Americans without insurance when they need it most and is hugely inefficient, with costs soaring toward crisis proportions unless something changes.

Few of Obama’s Republican critics have signed on to any credible plan of their own to address these inexorably growing problems. Some have reneged on earlier support for mandating that individuals buy insurance. And many hurl demagogic accusations that the president would usher in "death panels" and overheated alarums ("You lie!") about peripheral issues such as whether illegal immigrants or abortion-seekers would benefit.

As for voters, most seem satisfied with their own health care — still the world’s best in important ways — and unwilling either to pay more to help less fortunate people or make even small sacrifices to control costs. They also seem oblivious to the real problem underlying the "death panel" demagogy, which is the unavoidable need to hold down the 30 percent of Medicare spending that goes to sometimes-unwanted, often-not-very-beneficial treatments for chronically ill patients in the last two years of life.

So it would be unrealistic to expect complete candor from any president about the costs and risks of extending health insurance to 30 million more Americans. If Obama can meet the truthfulness test applied by Huckleberry Finn to his creator Mark Twain — "There was things which he stretched, but mainly he told the truth" — that would be good enough for me.

But can he? Despite Obama’s good intentions, I can’t help thinking that the deviations from truth-telling identified by various critics go to the heart of his plan, compromise his credibility, and could accelerate health-cost inflation with ruinous consequences for the economy. Examples:

• "The problem of rising costs." The centerpiece of Obama’s advocacy has been that "my plan" will "slow the growth of health care costs," now nearly 17 percent of gross domestic product and racing higher. But his plan would quite clearly increase costs dramatically, which is why he is proposing so many new taxes, "fees," and other levies.

Mandating health insurance (or Medicaid) for 30 million more people will cost hundreds of billions of dollars. Requiring insurers to accept people with costly-to-treat pre-existing conditions will cost billions more.

These particular costs are justifiable, in my view. But they are surely costs. And they are not sustainable in the long run unless they are offset by savings far more serious than Congress is likely to adopt on Medicare (see below) or anything else.

While Obama and Senate Finance Committee Chairman Max Baucus, D-Mont., have proposed significant steps to restrain the growth of health care costs, to their credit, it would probably require much more focused public advocacy to persuade Congress to make fundamental changes in the single biggest driver of the waste and inefficiency that feeds health care inflation. That is the fee-for-service system, under which doctors make more money if they do as many marginally beneficial and arguably unneeded procedures and tests as possible.

Nor has the president made more than a token effort (by proposing to tax "Cadillac" insurance policies) to give consumers a stake in holding down costs. People who would decline to pay out of pocket for many tests, treatments, and drugs almost always consent to them when insurance picks up the tab. And insurance plans often cover such wasteful costs. Because of a decades-old tax subsidy, employer-provided insurance covers not only the necessary, unexpectedly large costs that consumers cannot afford — the traditional reason for buying insurance — but also many not-so-necessary tests, procedures, and drugs.

The bill proposed by Baucus, which Obama backs except on some details, would diminish consumers’ already weak incentives to hold down costs by requiring insurers to reduce co-payments and deductibles.

• Slashing Medicare’s waste and fraud. Obama has vowed to save "hundreds of billions in waste and fraud" from Medicare — without affecting benefits. This is a fantasy discredited by the countless broken promises of other politicians over the decades to do the same and by Obama’s own failure to offer credible specifics.

While Medicare includes plenty of waste, much of it is inextricably intertwined with the benefits that Obama promises not to cut. The Congressional Budget Office has confirmed that the Baucus bill’s $130 billion in cuts (over 10 years) to Medicare’s managed-care plans would reduce benefits. Some benefits probably should be cut as insufficiently cost-effective. But that doesn’t make them "waste and fraud."

• Preventive care saves money? Obama has suggested that requiring insurance companies "to cover, with no extra charge, routine checkups and preventive care" will cut costs. The opposite is probably true. Although judicious expansion of preventive care makes sense, the savings from early detection of some medical problems will be exceeded by the overall cost of requiring insurers to cover tests and marginally beneficial (as well as necessary) preventive care.

My daily statin pill seems sort of necessary (to me, at least) because it may extend my life by keeping my cholesterol down. But it costs my insurer over $2 a day and lessens my incentive to cut cholesterol by changing my diet. Justified costs are still costs: The longer statins keep me alive, the more my other medical problems will cost my insurer and eventually Medicare.

• "Absolutely not a tax increase." That was Obama’s response when asked by ABC News about what Baucus calls the "excise tax" of as much as $3,800 a year (since lowered to $1,900) on families who defy his bill’s mandate to buy comprehensive health insurance.

T he mandate itself is a kind of tax. CBO projected that by 2016, the original Baucus bill would require an individual earning $32,400 a year to pay $4,100 in premiums before getting any subsidy, plus an average $1,500 in deductibles and co-payments. (The much cheaper catastrophic coverage that many people would prefer would not satisfy the mandate.) Baucus has been scrambling to lower these premiums by raising subsidies. But the only ways to get the money are to raise other mandated premiums or taxes, make more Medicare cuts, or incur bigger deficits.

So much for Obama’s campaign pledge that "no family making less than $250,000 will see their taxes increase." Maybe it’s a good idea to require young, healthy people to buy more-costly insurance than they want or need and then use their premiums to subsidize older, sicker people. But it’s deceptive to pretend that this is not a tax.

Maybe it’s a good idea to require young, healthy people to buy costly insurance. But it’s deceptive to pretend that this is not a tax.

Consumers would also end up paying the original Baucus bill’s 35 percent excise tax on insurance companies that offer Cadillac policies valued at $8,000 (now $8,750) for individuals or $21,000 (now $23,000) for families — an estimated $215 billion over 10 years — and more than $50 billion in fees on medical devices, lab tests, and prescription drugs. Plus $27 billion in taxes on employers who don’t provide health insurance.

• Deficits won’t increase? Obama vowed in his September 9 speech, "I will not sign a plan that adds one dime to our deficits — either now or in the future." The good news is that this should force Congress to produce a plan that at least looks deficit-neutral.

The bad news — apart from the illusory nature of the promised cuts in Medicare waste and fraud — is that Obama added an escape hatch. His plan "requires us to come forward with more spending cuts if the savings we promised don’t materialize." But when they don’t, the "required" cuts probably won’t materialize either. That’s because nothing can force Congress to deliver any future savings that it "requires" now.

Not to mention the fact that the tax revenues mentioned above would be available to reduce the government’s alarmingly gargantuan non-health-care deficits if they weren’t spent on Obama’s health care plan.

• "Nothing in this plan will require you or your employer to change the coverage or the doctor you have." That’s literally true, but misleading. The excise tax and other costs imposed on employer-provided insurance would certainly spur many employers to reduce the coverage they pay for.

• Bashing insurance companies. Obama has been borderline deceptive in beating up on insurance companies that "dropped [people’s] coverage when they get sick," "won’t pay the full cost of care," and "deny you coverage because of a pre-existing condition." As he must know, health insurers — whose profits are far from huge compared with other industry sectors — engage in the latter two practices because current law gives them strong incentives to hold down their costs (and the nation’s). Take away those incentives, and costs will go up.

As for dropping people when they are sick, some abuses no doubt exist. But it’s telling that even in the worst two examples that Obama could find, he garbled the facts of one case and glossed over the other patient’s possible concealment of relevant information in applying for coverage, as detailed by Scott Harrington in a September 14 Wall Street Journal op-ed.

In the spirit of Huck Finn, we may excuse the last two of the seven Obama lines of argument cited above as mere stretches. But the first five seem both deceptive and dangerous to the nation’s economic future.

Correction: The initial version of this column contained two errors. The first was a statement that "Obama’s Republican critics have no credible plan of their own." I have since been informed that there are Republican proposals that I would call credible. The second error was a statement that "Obama has made no effort to restrain" the biggest drivers of health care inflation. I have since been informed that he has proposed significant steps to restrain the growth of health care costs.

This article appeared in the Saturday, September 26, 2009 edition of National Journal.