The health care reform debate has shifted from the original vision of expanding coverage and finding major cost savings through greater competition and other market forces. Lately, the goal of expanding coverage remains, but for White House officials and congressional Demo-crats costs savings have been replaced by increased taxes as a way to pay for expanded coverage.

By re-labeling health care reform as health insurance reform, President Barack Obama is focusing attention on one area where savings can be found. Other areas ripe for savings include pharmaceutical companies and lawsuits or tort reform, to reduce unnecessary and often expensive medical tests ordered by doctors as defense against potential future malpractice lawsuits.

The financially powerful drug companies and lawyers groups are working to shift reform efforts to other areas. And to protect their financial interests, for-profit health insurance companies are spending millions of dollars on lobbying and campaign donations.

Health insurance companies increase profits by denying coverage to people who are sick or likely to become sick. They also increase profits by refusing to pay for treatment.

Another way they have increased profits is by reducing competition among health insurance companies. And that is one reason they are intent on stopping the so-called public option, which would be a government-run health insurance program, similar to Medicare, that would compete against for-profit companies, but with lower overhead expenses for administration, advertising, lobbying and CEO salaries.

The power of the private insurance industry cannot be underestimated in its determination to avoid such competition that would drive down prices and profits.

Profits at the 10 largest health insurance companies, from 2000 to 2007, rose 428 percent, and reduced competition is one reason for that. In the past 15 years, about 400 mergers have reduced competition, allowing health insurance companies to impose major rate increases, which have gone up nearly 90 percent over the past six years.

According to the American Medical Association, more than 90 percent of health insurance markets in the United States are near monopolies, with one or two companies controlling the market.

Insurance companies typically take 10 to 15 percent of premium revenues for administrative costs and profits. One study found that the top-five health insurers recorded profits averaging $1.5 billion in 2008, and compensation for CEOs at these companies ranged from $3 million to $24 million.

Americans must understand the health care industry's intentions. The insurance companies and the drug companies intend to protect their massive profits and multimillion-dollar salaries — and will spend hundreds of millions to do so. To a lesser extent, hospitals and doctors also will fight to protect their slices of the health care spending pie.

According to the Center for Responsive Politics, health care companies spent more than $126 million on lobbying in the first quarter of this year alone.

When lawmakers in Washington work on health care reform, the lobbying and campaign giving of insurance companies, drug makers, hospitals, doctors and lawyers shape reform legislation in ways that benefit those special interests. When that happens, health care consumers and taxpayers lose.

The drug makers forced a provision into the Medicare Part D program for prescription drugs that prohibited the federal government from using its buying power to lower drug prices. And they continue to keep pressure on to avoid such price reductions. But preventing the government from negotiating lower drug prices costs taxpayers billions of dollars — and protects drug companies' profits. Taxpayers should remember that prices for drugs made by American companies are far cheaper in Canada and other foreign countries where the government negotiates lower prices.

As far as health insurance company motives and intentions, they are quite clear: Prevent increased competition and protect billion-dollar profits.

New York Times columnist Paul Krugman wrote recently that "health (care) reform will fail unless we get serious cost control — and we won't get that kind of control unless we fundamentally change how the insurance industry in particular behaves."

Krugman continued, "So let me offer Congress two pieces of advice:

(1) Don't trust the insurance industry

(2) Don't trust the insurance industry."

But it's unclear whether Americans can trust Congress, given the clout of the insurance industry.

The Washington Post reported that the country's largest health insurance companies, hospitals and drug companies "have hired 250 former government staff members, including former members of Congress, in order to influence the health care debate."

Considering the massive amounts of money involved, Americans should be suspicious of the evolving health care reform debate. Powerful interests have descended on Washington, and the interests of taxpayers and citizens of the country are being pushed aside by campaign contributions and lobbying.

According to the nonpartisan Congressional Budget Office, the current proposals for health care reform in Congress do not reduce overall costs, as Obama had promised. In fact, the costs, based on current proposals, are expected to grow even faster — further evidence that the health insurers and drug companies are winning the battle and shaping reform to their benefit.

Such a massive increase in spending affecting such a large segment of the economy should not be pushed through Congress quickly. Unlike the stimulus bill and the cap-and-trade energy bill, health care reform bills should be read and understood by all members of Congress. And the American people also should understand what is being proposed and fight for their interests, when it comes to costs and care. But that won't happen without sustained public pressure on Washington.