The countdown to the health care reform debate on Capitol Hill is underway, and the long knives are coming out. Today's Wall Street Journal editorial page marshals the arguments against reform by revealing the anti-reformers ace-in-the-hole:

More health information technology; emphasizing prevention and healthy living; rejiggering reimbursement policies so doctors and hospitals are paid more for quality care; and funding federal research that compares the effectiveness of medical treatments. These are the lovable bromides of all politicians, and some of them may or may not improve health overall. But there's scant evidence that any of them will ever save real money. There's a reason the Congressional Budget Office can't score them.

Aye, there's the rub. The Obama administration and the leadership on the Hill say health care reform must be paid for. That means the soon-to-be-unveiled legislation needs to identify an estimated $1 trillion in new money over the next ten years either through increased taxes or health care savings to pay for insuring the nation's 47 million uninsured.

The Obama team plans to unveil about $300 billion in savings. It will be interesting to see what approaches they take. Last December, CBO all but scoffed at the cost-saving potential of most of the delivery system reforms cherished by reformers.

Comparative effectiveness research? Will cost more than it saves, CBO (then under Budget chief Peter Orszag's direction) declared. Organizing physicians into so-called accountable care organizations receiving bundled payments (thus eliminating the perverse incentives to deliver useless care fostered by the fee-for-service system): savings of less than $1 billion a year in the early years and just $24 billion over ten years. Ditto for penalizing hospitals with high readmission rates (a negative incentive) or paying for meeting quality standards (a positive incentive). Either way, it saves less than $1 billion a year and about $10 billion over the next decade. 

One major area where there is CBO buy-in is expanded health information technology (although there's plenty of skeptics on that front who claim that HIT has been a cost fiasco in some if not many of the hospitals and physician offices that have already moved in that direction). Still, the optimists at CBO say that could only save Medicare $34 billion over the next decade 

The real money comes from either increasing taxes or across-the-board cuts in payments to providers. Reduce payments to physicians for productivity improvements (is there an eight-minute office visit in your future?) would save $16 billion a year or $200 billion over a decade. That alone is a fifth of the reform tab. There's another $7 billion a year or $92 billion over a decade for imposing a one percent cut in hospital payments.

Drug and insurance companies can be forced to cough up real money, too, according to CBO. Demanding drug rebates for Medicare beneficiaries could save $10 billion a year or $110 billion over the next decade, while eliminating the costly Medicare Advantage program (the extra payments to insurers for setting up health maintenance organization plans for seniors) could save $6 billion a year or $61 billion over the period.

There's real money in higher "sin" taxes: $5 billion a year for taxing soda pop for the first time; $10 billion from a new dollar-a-pack tax on cigarettes; and $6 billion from raising alcohol taxes. That's over $200 billion over 10 years or, again, a fifth of the total.

But each of those sin taxes is dwarfed by the option of eliminating the income tax exclusion for health benefits. Even if capped so 75 percent of benefits are excluded, a health benefits tax would raise $39 billion a year or $452 billion over the next decade. That's nearly half of what the reformers need, which is the only reason why reformers (and the Obama administration) have said they are open to this politically risky proposition. Compare that to a new "pay or play" rule, which would force all employers (except very small businesses) to either provide insurance or pay a fee into a national fund. That would raise just $6 billion a year or $48 billion over the next decade.

My guess is that the Senate Finance Committee will propose a smorgasbord of tax increases and spending cuts in an effort to hold onto the votes of Blue Dog Democrats, who insist that any new entitlement be paid for. The problem with this nickel-and-dime approach is that each item on the menu turns a constituency that now supports reform into its opponent. The doctors, the hospitals, the drug and device companies, the insurance companies, the home health providers -- their lobbyists will offer lip service for reform even as they work to undermine their own contribution to its financing.

The challenge facing the president's team is twofold. First, they must craft a proposal that only asks for a little sacrifice from everyone. Then the president must use his powers of persuasion to to create a political environment where refusing to sacrifice for the common good is simply unacceptable.

However, if they ask that the middle class pick up the lion's share of the tab in the the form of higher taxes and taxable benefits, they'll be taking a huge political risk. Imagine a scenario where health care reform died because the special interests refused to take a hair cut. Voters who care about reform could decide at the next election that they preferred representatives willing to ignore those special interests.

But imagine that reform gets defeated amidst a middle class backlash. Or, worse, it gets repealed by a new, more conservative Congress elected because of anger over higher taxes to pay for the uninsured. Either scenario would set back the cause of reform for another generation.