Nearly two dozen people stood outside U.S. Sen. Jim Webb's Roanoke County office Thursday demanding a government-run public health insurance option be included as part of a health care overhaul.

Last week, another crowd was at the same office rallying against that very plan, calling it socialized medicine and raising concerns over how Democrats are trying to overhaul the nation's health care system.

As Southwest Virginians seek to have their voices heard in the national debate, Sen. Mark Warner has also tried to make his concerns heard among senior Democrats. Warner and eight other freshman senators signed a letter to Senate Finance Chairman Max Baucus asking that more focus be placed on containing health care costs.

"A lot of the negotiations have been going on with the senior members," Warner said by phone Thursday. "We wanted to say, 'Hold on guys, we just got hired. We want our voices heard.' And those voices are saying we've got to drive down the costs. ... In the rush to extend coverage, I think we may have lost sight of an equal goal, which is lowering costs."

Warner has not taken a position on a public health insurance option. Earlier this spring fellow Democrat Webb signed a letter saying he supported a public option.

Locally, both opponents and proponents of health care overhauls have become increasingly vocal in sharing their thoughts as more events are taking place to bring public attention to their views.

"I think the key to why people are so engaged is I literally have not met anyone who is not touched by this. All of us have a vested interest in the subject," said the Rev. Audette Fulbright Fulson, who was outside Webb's office Thursday to support a government-run public insurance option.

As pastor of the Unitarian Universalist Church of Roanoke, she said she regularly hears stories from her congregation about how people are struggling because of the current health care system. Some can't access care; others are hurt by the financial aspects of health care.

Educating the public and making elected officials aware of their concerns are the top reasons people on all sides of the debate say they are speaking out.

"We really need to be about educating people about the issue," said Chip Tarbutton, who has helped to organize some events for the Roanoke Tea Party group, including last week's protest against socialized medicine. "Some people are blindly flying. I think intuitively they know this is a bad idea, and the more you look at it, the worse it looks."

More events are planned.

Next week the conservative group Americans for Prosperity will be driving through the region urging people to oppose a government-run insurance option. The bus tour will travel throughout the state from Saturday through Aug. 1.

"Senators Jim Webb and Mark Warner along with Congressmen like Tom Perriello have to hear from their constituents and know that a vote for socialized medicine is a vote against the well being of all Virginians," wrote Ben Marchi, state director of Americans for Prosperity in an e-mail to supporters about the bus tour. "Please help us pass along this message! It's THAT important!"

The debate is expected to intensify as details of the Senate bill are revealed and votes in the House and Senate near.

Having spent nearly three months going door to door and talking about health care reform, Ashley Taggart said she is convinced emotions surrounding the topic have intensified.

"When we started in Salem in May people were just blase," said Taggart, a summer intern who canvassed the Roanoke area for the Virginia Organizing Project. "But progressively we've noticed a huge difference in the level of interest people have in the subject."

The nonprofit advocacy group VOP continued its efforts Thursday to encourage people to support a public health option as they tried to talk to people at Thrasher Park in Northeast Roanoke. The group said its local summer canvassing efforts found that 80 percent of residents said health care is a very important issue or the most important issue in their lives and that 70 percent of those people said they supported a public health insurance option.

Today, the group has planned a protest at the Anthem Blue Cross Blue Shield offices in Richmond to ask for a refund of their health insurance premiums that went toward Anthem's lobbying against overhauling health care. Anthem is owned by the parent company WellPoint Inc.

Even as people continue to try to sway public opinion, some people are beginning to ask about the issues not being addressed by health care reform.

The letter signed by Warner emphasized that the debate cannot be just about giving all Americans insurance coverage.

"With 17% of our [Gross Domestic Product] currently being used to pay for health care services, we must get health care costs under control so we can compete and lead in the global marketplace," reads a portion of the letter.

Warner said he thinks payment reform must be part of the conversation so that doctors and hospitals are paid for the quality and not the quantity of care.

Similarly in separate interviews leaders of both Carilion Clinic and Anthem Blue Cross Blue Shield of Virginia said that new ways for paying for health care must be part of the reform.

"Right now we are on a path that is not sustainable," Carilion CEO Dr. Ed Murphy said Monday.

Changes to billing practices must take place, he said, and that includes both in the federal Medicare and Medicaid systems and the private insurance market.

Burke King, Virginia president of Anthem, said Wednesday he believes that payment reform should start with the Medicare and Medicaid programs.

"I had hoped the government would have taken the lead more in moving Medicare away from fee-for-service to some kind of new payment," he said.

King also acknowledged changing the payment method would be complicated and constitute a significant investment for insurers to change their information technology systems and the way they do business.