Forget all the angry shouting about socialized medicine and government takeovers. Health care reform is really all about markets, competition and choice.

That's probably not what you've heard. But as Congress pushes ahead after last week's historic Senate vote, it will become increasingly clear.

Details vary in two competing bills being ironed out in the Senate and three in the House. But the general idea behind reform works like this:

Large markets, called insurance exchanges, would be created. They would be open to small businesses and consumers who now buy insurance for themselves and their families, or those who are currently uninsured.

They would not be open to the majority of Americans who now get coverage through their jobs — more on that in a bit.

The exchanges would allow buyers to shop on the basis of price and quality. That would encourage competition among insurance companies, and that competition should hold down premiums.

Which brings us to the so-called public option. If it's included in health reform — it's not in the Senate bill approved in committee last week — it would be one of the insurance providers competing for business in the exchange.

People pushing a public option imagine that it would be among the lowest-cost insurance plans offered, and they may well be right. That would depend on ground rules that haven't yet been set.

But nobody would be forced to enroll in the public option plan. That's the way things work now; no one has to buy coverage from the company with the lowest premiums.

Unlike current markets, however, consumers would have choices in the exchange. In many parts of the country, insurance markets are controlled by just one or two big players. The more rural or sparsely populated the state, the fewer insurance companies that operate there.

Market concentration has increased in at least 24 states since 2002. In nine states, a single large insurer controls at least 70 percent of the market.

Insurance exchanges aren't just theory. Several states have established purchasing cooperatives.

Massachusetts created one in 2006. This year, it negotiated 6 percent lower premiums for its 180,000 customers. But cooperatives in Texas, North Carolina, Florida and California all failed. They had initial successes, but lacked sufficient market share to keep rates low.

Meanwhile, insurance companies worked to keep small businesses with the youngest and healthiest workers outside the cooperatives, leaving the exchange to cover the sickest and most expensive customers.

As those problems demonstrate, national reforms are unlikely to succeed unless exchanges have the broadest possible enrollment. They should be open to everyone who wants in, not just the smallest employers and the chronically uninsured. They also should be regional or national in scope.

Exchanges must function as more than just a collection point for potential customers. The Senate reform bills envision them as a kind of electronic Yellow Pages, where small businesses and consumers would shop for coverage on their own.

In Massachusetts, the exchange actively negotiates rates with insurance companies, then allows businesses and individuals to select from a menu of plans.

None of these reforms will work without competition. If it doesn't exist or doesn't materialize, a strong public option can and should provide it.

Insurance exchanges will provide a healthy dose of market competition to an industry that badly needs it. We all will benefit from the result.

— St. Louis Post-Dispatch