Congressional Democrats have seen the future of American health care. It looks a lot like Massachusetts, and a little like John McCain, George W. Bush and Barack Obama.

House Democratic leaders spelled out their prescriptions for reform last week. Their colleagues in the Senate are circulating draft legislation with similar ideas. The plans would:

• Provide universal coverage. Every American would have health insurance.

• Share responsibility for getting and paying for coverage between individuals and their employers. Everyone would be required to obtain insurance, either through their job or by buying it. Companies would be obligated to provide insurance for workers or pay part of the cost of coverage they get elsewhere. All are key elements of the 2006 Massachusetts health reforms, approved by a Democratic-controlled Legislature and signed by Republican Gov. Mitt Romney.

• Create a so-called public insurance option, which would compete directly with private insurance companies. It could function as a kind of insurance co-op, or it might operate more like Medicare. This public option was a key to health reforms Obama proposed during the presidential campaign.

The challenge for Democrats is how to pay for those reforms. Some advocate taking a cue from their political opponents by taxing the value of health insurance provided by employers.

That idea has been championed by Republican leaders for years. Arizona Sen. John McCain, the GOP presidential candidate in 2008, and former President George W. Bush both have proposed it. But it remains controversial even among many Republicans.

Workers currently pay income, Social Security and Medicare taxes on their wages but not on the cost of benefits like health insurance. Insurance costs are considerable; average premiums for family coverage provided by an employer in 2008 were $12,680.

Benefits have been tax exempt since World War II, when wage controls were put in place to prevent inflation.

Last year, the exemption cost an estimated $225 billion, an amount that grows every year as premiums rise. Over the next decade, it will cost a projected $3.2 trillion.

Removing the exemption means workers would pay higher taxes. The sharpest increase would be felt by those with the highest incomes.

The nonpartisan Kaiser Family Foundation calculates that a family earning about $50,000 a year would pay about $1,800 more in income taxes, a 15 percent increase, if health benefits were fully taxed. A family earning $200,000 would pay about $3,360 more, a 28 percent increase.

In theory, covering the uninsured would help slow rising health costs and keep premiums from rising as quickly as they otherwise would. But that's only a theory.

Some proposals for taxing health benefits — Bush's, for example — would have capped the health care exemption instead of removing it entirely. That would lessen the impact on taxpayers and reduce the amount of revenue it would raise.

It's still not certain that Democrats will propose ending the tax exemption. That change would be a big risk.

Most Americans now get health insurance through their jobs. Taxing health benefits could discourage companies from providing them. That would raise the cost of health reform and disrupt coverage for many families.

A better way, in the long run, would be to remove financial incentives for doctors to provide more care regardless of its value, and base their pay on better outcomes.

Some experts estimate health spending could be cut by 30 percent simply by eliminating care that provides no real benefits to patients. But most of those savings would be realized years in the future; many doctors, hospitals and health providers can be expected to oppose such reforms.

For now, Congress is wise to find a middle ground on health reform. That means adopting ideas that have been shown to work, regardless of who first proposed them.

— St. Louis Post-Dispatch