Whatever happened to audacity?

At a time when most Americans understand and favor the clear, simple goal of "Medicare for All," President Obama seems to have gone AWOL as a decisive, forceful leader. Instead, we are witnessing the congressional cobbling together of a compromise-laden health-care bill that reeks of having been created in a sausage factory.

The audacity that energized voters and generated such vibrant hope last fall would produce a dramatically different result. Think what an audacious Obama might have insisted on:

o Medicare for All -- one national, universal, single-payer system that would cover everyone, no exceptions. Why? Because it's the right thing to do. Period. He would have dared -- dared -- legislators to deny their constituents a health-care plan as good as the one the legislators themselves enjoy, promising to call them out by name.

o Cessation of the financial burden on employers, who backed into being providers of coverage only as a tactic to lure workers during post-World War II wage-and-price controls -- now utterly irrelevant and massively counterproductive. He would have demonstrated how American competitiveness in world markets would improve, while workers would never again have to worry about losing coverage during job transitions.

o Establishment of "best practices" for treating the most prevalent ailments. These would eliminate the irrational variation in treatment practiced by physicians today, including "defensive medicine" overtreatment. Obama would have shocked us by revealing the inverse correlation between medical expenditures and positive clinical outcomes, inviting doubters to visit the Mayo Clinic, where costs run 20 percent to 25 percent lower than among comparable cohorts of patients.

o Putting the red herring of illegal-immigrant coverage on the back burner. It's a totally different question that only disrupts and delays the challenge of creating a quality-driven, cost-effective health-care system for 300 million American citizens. If we were discussing an urgently needed overhaul of the interstate highway system, we wouldn't waste time and energy quibbling about whether undocumented immigrants could drive on it or not.

How to pay for all this? An audacious Obama would have declared that there is already too much money in our health-care system. Medicare for All would provide every single American with superior care, and for less money than we now spend, because Medicare dollars are demonstrably more cost-effective than private-payer dollars. In health care at least, "the government" gets more bang for the buck than business does. And that bang would get louder when Obama demanded an end to the insanely mendacious congressional legislation that forbids Medicare to negotiate better prices on pharmaceuticals, forcing us taxpayers to ante up whatever Big Pharma chooses to charge. (Didn't know about that one? It passed in 2003, and it's in danger of being renewed.) The savings from a Medicare-managed health-care budget? In the hundreds of billions annually.

And Obama would have shown that the establishment of best-practice standards of care would simultaneously eliminate expensive, defensive-medicine overtreatment and discourage capricious malpractice lawsuits, since a physician's having followed standard-of-care protocols is nearly always a sufficient defense in such lawsuits. Less overtreatment, fewer lawsuits mean more hundreds of billions saved, with better outcomes for patients. What's not to like about that?

Would this be difficult? Of course.

Impossible? Of course not.

Once we decided to put astronauts on the moon, we figured out how to do it. If Americans want Medicare for All, we'll figure that out, too. Sure, the private-pay insurance companies are entrenched and powerful, and dislodging or repurposing them won't be easy. Just essential.

Too late? Maybe.

And maybe not.

When our leaders fail to lead on crucial issues, American citizens step up to tell them what to do. Citizen clamor got women the vote, and got people of color access to good seats on buses and in classrooms. Citizen clamor has ended stupid wars and booted witless incumbents.

So now we have to do it once again -- as individuals peppering our elected officials in Washington, as churches and synagogues and mosques crying out for common decency in health care for all, as newspapers providing facts and rousing the populace to speak their mind, as millionaires and billionaires spending that excess money in support of the voices of true reform. All of us, right now, are called to speak up and insist on what we know is right: Medicare for All.

If we don't, something very sad lies ahead. Not just the continuing quiet brutality of consigning 50 million of our friends and neighbors and relatives to the category of medical beggars. That's tragic enough. But -- in some sense even worse -- we can look forward to knowing that when the moment came to be heard, we remained silent and so will be forever complicit in their suffering.

Eliot Daley writes his observations and opinions from Princeton. He welcomes reader response at eliot@eliotdaley.com.