Yesterday the American Medical Association came out against a public option for health care. And yesterday the President reaffirmed his support for it. The next weeks will show what Obama is made of -- whether he's willing and able to take on the most formidable lobbying coalition he has faced so far on an issue that will define his presidency.

And make no mistake: A public option large enough to have bargaining leverage to drive down drug prices and private-insurance premiums is the defining issue of universal health care. It's the only way to make health care affordable. It's the only way to prevent Medicare and Medicaid from eating up future federal budgets. An ersatz public option -- whether Kent Conrad's non-profit cooperatives, Olympia Snowe's "trigger," or regulated state-run plans -- won't do squat.

The last president to successfully take on the giant health care lobbies was LBJ. He got Medicare and Medicaid enacted because he weighed into the details, twisted congressional arms, threatened and cajoled, drew lines in the sand, and went to war against the AMA and the other giant lobbyists standing in the way. The question now is how much LBJ is in Barack Obama.

The big guns are out and they're firing. All major lobbying firms in Washington -- many of them brimming with ex-members of Congress -- are now crawling all over the Hill. Lots of money is on the table. AMA's political action committee has contributed $9.8 million to congressional candidates since 2000, and its lobbying arm is one of the most formidable on the Hill. Meanwhile, Big Insurance and Big Pharma are increasing their firepower. The five largest private insurers and their trade group America's Health Insurance Plans spent a total of $6.4 million on lobbying in the first quarter of this year, up more than $1 million from the first quarter last year, and are spending even more now. United Health Group spent $1.5 million in the first quarter, up 34 percent from the $1.1 million it spent in the first quarter last year. Aetna spent $809,793 between January and the end of March, up 41 percent from last year. Pfizer, the world's biggest drugmaker, spent more than $6.1 million on lobbying between January and March, more than double what it spent last year. It also spent nearly $3.3 million lobbying in the fourth quarter of 2008. Every one of them is upping their spending.

Some congressional Democrats are willing and able to stand up to this barrage. Many are not. They need cover from the White House.

The President can't do this alone. You must weigh in and get everyone you know to weigh in, too. Bombard your senators and representatives. Organize and mobilize others. And let the White House know how strongly you feel. This is one of those battles that define a presidency. But more importantly, it's one of those battles that define the state of American democracy.

Here's the latest contortion from Senate Dems trying to win over a few Republicans to a "public option:" Let nonprofits create health-care cooperatives, and call them the public option. Kent Conrad came up with this bamboozle. Finance chair Baucus is impressed, and some Republicans -- even Grassley -- seem interested. Watch your wallets.

Nonprofit health-care cooperatives won't have any real bargaining leverage to get lower prices because they'll be too small and too numerous. Pharma and Insurance know they can roll them. That's why the Conrad compromise is getting a good reception from across the aisle, just as Olympia Snowe's "trigger" (whereby no public option until some time down the pike, and only if Pharma and Insurance don't bring down and extend coverage a tad) is also gaining traction.

The truth is that there's only one "public option" that will truly bring down costs and premiums -- one that's national in scale and combines its bargaining power with Medicare, and is allowed to negotiate lower drug prices and lower doctor and hospital fees. And that's precisely what Pharma and Insurance detest, for exactly the same reason.

Whatever it's called -- public option or chopped liver -- it has to be able to squeeze Pharma, Insurance, and the rest of the medical-industrial complex. And the more likely it is to squeeze them, the more they'll fight it. And the greater the opposition from Republicans, and from Dems who either believe any bill has to have some Republican support or who have sold themselves out to the medical biggies.

As long as single payer is off the table, then we need a real public option. Don't be fooled by labels. Demand the real thing.

It’s the kind of thing I expect to hear from deficit hawks and chicken littles -- from the self-described "fiscally responsible" right, from the scolds Ross Perot and Pete Peterson, from my former cabinet colleague Bob Rubin. But yesterday I was shown slides developed by the putatively liberal Center for American Progress intended to make the point. And today’s front page story in the New York Times, by the eminent David Leonhardt, entitled "Sea of Red Ink: How It Spread From A Puddle," puts the issue right before our progressive noses, so to speak.

The Great Debt Scare is back.

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In an interesting piece in Sunday's New York Times Magazine, Matt Bai suggests that the White House has learned the main lesson of Bill Clinton's failed attempt at universal health care, which is not to deliver a finished product to Congress but instead give Congress a set of goals and let it decide how to reach them.

The question to my mind is whether the Obama White House has over-learned that lesson. Without strong White House leadership, individual members of Congress are particularly susceptible to the threats and promises of powerful lobbies. A statement of White House goals that leaves the details to Congress will likely result in legislation that superficially meets those goals but whose details undermine them. That's the biggest danger now with the inchoate healthcare legislation.

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