As the national debate about healthcare reform intensifies, South Florida stands out as a place that has a lot to gain and a lot to lose, depending on the details hammered out by Congress next month.

A lot to gain because the region has an unusually high percentage of uninsured and people who seek to buy insurance on the individual coverage market, which is often high-priced and unavailable to those with chronic diseases. The reforms are aimed at helping both of these groups get coverage they can afford.

A lot to lose because almost all experts say the only way the country can afford reform is to reduce its healthcare costs. The United States has the highest healthcare costs in the world, and South Florida is among the highest in the nation. Under reform, quite a few of the 218,000 healthcare workers in Miami-Dade and Broward could lose their jobs.

Healthcare leaders like Brian Keeley, chief executive of Baptist Health South Florida, says these two points are closely connected: The higher the costs get, the fewer businesses can afford coverage, which increases the number of uninsured, who often delay treatment until they are extremely sick and go to the emergency room.

There, they run up big bills they can't pay for, and hospitals compensate by hiking rates for private insurance, causing more businesses to drop coverage, which increases the number of uninsured.

``This is a `death spiral,' '' says Keeley.

``The system is totally unsustainable for all parties. Drug companies, insurance companies, the SEIU [Service Employees International Union], you talk about strange bedfellows -- all agree something has to be done.''

With accusations flying in all directions and much confusion about the details in proposals Congress will be considering when it returns from its August recess, here is a quick primer about healthcare, dealing with the misconceptions and the realities: Where the system stands now, how it stacks up to other countries, what is being proposed and what changes mean for South Florida residents.

What we have now

The United States has a public/private mixture. Fifty-three percent get their insurance at work, according to the Kaiser Family Foundation; 27 percent have a government plan (Medicare for seniors, Medicaid for the poor); 5 percent buy on the individual market.

Fifteen percent have no insurance -- 45 million in 2007 and thought by many to have risen to 50 million during the recession.

In South Florida, one million are uninsured. In Miami-Dade, 625,000 have no coverage -- 30.9 percent of the population under 65. In Broward, it's 408,000 -- 27.1 percent of those under 65. This is Census Bureau data for 2006, which was just released. The numbers have likely increased during the recession.

In one sense, the United States already has universal healthcare. Under federal law, everyone in the country -- including immigrants here illegally -- must be treated in hospital emergency rooms.

Those unpaid hospital bills get passed on to people with insurance.

A study by Families USA released this week found that in the past 10 years, family healthcare premiums rose an estimated 3.7 times faster than earnings for Florida workers.

The one group that has a hard time passing on these costs are the public hospitals, because so many of their patients are poor or uninsured.

That's why places like Jackson Health System are in dire financial shape, which is expected to get worse.

What other countries do

The rest of the industrialized world -- Europe, Canada, Australia -- essentially guarantees the right to basic healthcare, as it does the right to public education.

Many critics of reform point to problems in Canada, where patients often complain about long waits for elective surgery. But experts like Steven Ullmann, director of health policy programs at the University of Miami, say Canada's system is essentially a government entity -- unlike what's being proposed in the United States.

Ullmann and many others say a better comparison is the Netherlands, where employers and individuals pay into the system. People choose among private insurers. Costs are regulated.

The bottom line: The Dutch live to 80, on average, for an average annual healthcare cost of $3,383, according to the World Health Organization. In the United States, it's 78 years of life for $6,714.

Most Dutch doctors have their own private practices. A survey sponsored by the Commonwealth Fund of patients with chronic diseases found that 60 percent in the Netherlands say they can get a same-day appointment with a doctor when they're sick. Only 26 percent in the United States said they could.

Ninety-nine percent of those patients in the Netherlands said they have a doctor that they usually see, compared with 82 percent in the United States.

Even so, many are not entirely satisfied with their system: 46 percent of the Dutch want fundamental changes, and 9 percent say the system needs a complete overhaul.

In the United States, Commonwealth reported, 46 percent want fundamental changes, 33 percent demand a complete overhaul.

Much of the dissatisfaction may be based on not getting everything we want: Unlike buying, say, a television, healthcare in the industrialized world works through a third party: Patients get treated and providers get paid -- by a third-party insurer.

As Keeley puts it: ``We all want the very best healthcare -- and we want someone else to pay for it.'' In such a system, neither patients nor providers worry much about costs.

In Europe, governments generally have price controls. In the United States, private and government insurers have tried to control costs -- generally without success.

Plans for reformThe proposals now before the House and Senate are complex. Some highlights:

• In all proposals before Congress, private health plans provided by employers will remain the fundamental form of insurance for most Americans. One key issue creating bitter debate is whether to add a ``public plan'' -- a government alternative to compete with private insurers.

• Most proposals require all Americans to have health insurance. Individuals who can not afford the premiums could be eligible for subsidies, a provision that will cost billions. This would enlarge the insurance pool -- and make private insurers happy. In return, the insurers promise not to reject people because of preexisting conditions, although this provision would be phased in slowly over time.

• One of the biggest uncertainties: What happens to small businesses. Should businesses of a certain size be forced to provide insurance or pay a tax? How big a tax? If there was a public plan, many small businesses might be better off paying a tax and putting their employees in a public plan, where a large risk pool would spread costs.

Some small-business owners that don't provide coverage,like Miriam Vilariño of Las Vegas Cuban Restaurants, warn that one proposal -- a payroll tax of 8 percent for companies that don't offer insurance -- could destroy the family business.

• How to pay for all this? This is the toughest part: Proposals include new taxes on the wealthy, and/or businesses that don't offer healthcare, and/or insurers that offer ``Cadillac plans,'' which offer unusually rich benefit packages.

But what makes a Cadillac? Laurie Amber, a South Miami lawyer, worries that her $1,700-a-month policy might qualify, even though it includes a $2,000 deductible. ``We really have a bare bones. It's just expensive.'' Expensive because healthcare in South Florida tends to cost far more than elsewhere.

Cutting costs

Republicans and Democrats agree that any reform must be funded in part by cutting costs. But they say that doesn't mean denying care or simply cutting payments to doctors or hospitals.

Dartmouth researchers and the Midwest Business Group on Health have said about 30 percent of current health spending is completely wasted -- duplicative or unnecessary tests, too many trips to specialists, too much reliance on expensive drugs when cheaper generics could do just as well.

Dartmouth studies show that South Florida is a poster child for such high costs: A Miami senior costs Medicare twice as much annually as a senior in Minneapolis, but lives no longer and gets no healthier.

``That difference is so big that if you got rid of it, you could afford to lease a Lexus 400 for every senior in Miami,'' says Becky Cherney of the Florida Health Care Coalition. Of course, policy makers want the money saved to help the uninsured, not another car program.

One major issue lost in the present debate: With or without reform, Medicare is in financial trouble. ``At the year 2013, Medicare starts going broke,'' warns Tommy Thompson, George W. Bush's secretary of Health and Human Services.

Reform critics say that Medicare's problems are a good reason why Congress should not add another ``public plan.''

Politics of reform In the past month, the rhetoric of the debate has escalated so much to include even an accusation that the government is planning ``death panels'' to decide who should live and who should die.

There's nothing like that in the proposed legislation. Ullmann says the fear comes from a benign provision that, if a senior wants a consultation with her doctor about end-of-life decisions, insurance should pay for this.

But with more than a thousand pages of proposals, there's the possibility for a lot of argument. Insurers don't want a public plan. Big Pharma is preparing to spend millions on ads supporting reform -- as long as the government doesn't set drug prices.

The intensity of the debate has clearly split voters. A Gallup Poll conducted about the time of the ``death panel'' accusation found that 35 percent of the nation wants Congress to pass a reform bill when it returns from its August recess, 36 percent recommend a vote against and 29 percent have no opinion.

Talk of controlling costs has many frightened. A Gallup Poll last month showed 42 percent of those over 65 believed reform will ``worsen medical care in the United States.''

Many critics have concerns not about what is in the legislation, but implications about what the reform could lead to later: A public plan could open the door to ``socialized medicine.'' Cost controls might lead to euthanasia.

The healthcare coalition's Cherney, who has read the entire 1,000-page House bill, says euthanasia is nowhere in the legislation. ``There's a lot of misconceptions out there.''

She says the thick package has many valuable provisions -- such as the government helping doctors pay for converting their offices to electronic records.

But Ullmann at UM says the ``very complex'' proposal ``by itself causes anxiety about what might be hidden in there.'' He suggests that policymakers may have erred by including too many details. ``There's something to be said for that old saying: Keep it simple, stupid.' ''

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