Health care has emerged as one of the primary areas of focus for the new administration. In this space over the past few months, I have offered arguments as to why this is essential. First, there can be no long term economic recovery in this nation unless we get a handle on the runaway costs associated with our health care system. Our annual over-expenditure on health care now approaches $800 billion dollars. Put another way, we would save about $800 billion annually if we outsourced health care for every American to Norway. Second, the cost of care limits access, as does the structure of our health care system. The current economic recession threatens to provide numerous examples of how vulnerable we are to the loss of health care access, because health insurance in the US is largely tied to employment for those under age 65. Finally, while the US approach offers some of the most sophisticated and highest quality care in the world, the system is also characterized by considerable disparities in access, quality and outcomes. Given what we spend on health care and what we know about improving the quality of care, none of this is necessary. But based on our current reality, how do we develop a health care system that meets our health care needs at a cost we can afford?

The last few offerings on this page have focused on the demand and dynamics for reform in health care. With the promise of a new administration in Washington, it seems everyone has been sending memos to Mr. Obama. The opportunity to join in is just too tempting. Here are my suggestions.

Almost all of the candidates vying for next year's big sweepstakes have a sound bite or bumper sticker for health care reform. Virtually all of these begin and end with a scheme for getting insurance coverage for everyone by some hook or crook. The opinions that are more to the left look to mandatory coverage and a greater role for the public sector in picking up the tab or, at least, a legal mandate that private sector employers must cover all employees. Not surprisingly, those that veer more to the right would look more to individual responsibility and accountability to inch us toward something that has a semblance of universal coverage.

Last month I wrote on the break-up of many parts of the health care system as we know it. As this happens it inevitably puts stress into the system, and that produces conflict. The level of change, the stakes involved, and some of our own unique health care pathology all contribute to the ways in which conflict is handled or ignored. Addressing this conflict in a proactive and informed manner is one of the essentials of successful leadership in health care and will be into the coming decade. Without the skills to successfully manage and at times creatively build on and use conflict, there is little hope that the fanciful plans for redesign will come to much.

Slowly you can hear the ice begin to crack in what has been the locked up American health care system. Driven by continually rising costs, uneven quality and sketchy access, even for the insured, the evidence is beginning to accumulate - from the reimbursement polices for Medicare to benefit packages of commercial carriers - showing consumers' preferences for health care that they perceive to make sense, such as obtaining care at the MinuteClinc or in Costa Rica. The movement will take a few more years to fully catch on, but will then, like all things that have reached a tipping point, rapidly increase the speed of adoption. The reason for this transformation is simple: the system that we have is no longer sustainable for those who pay, those who consume and even those who provide.

In California over 600 community clinics provide an essential set of services to populations that are often most at risk. These clinics serve over eight percent of the state's population, nearly three million people, during a typical year. One in every eight children receives health care services through community clinics as does one in seven of the state's Latino population. Not surprisingly a fifth of the uninsured population seeks care in these clinics, but almost the same number of those insured through Medi-Cal also seek care through community clinics.

It slips away so easily, this concern for workforce. Try to remember it is over 60% of the costs of care. Here are four big reasons not to forget.

One of the biggest and most visible workforce transformations in the US and global economies has been the change in staffing patterns for commercial banks. Two decades ago we were just at the end of a generation where legions of tellers provided the entire set of consumer interfaces to services offered by banks. Today, even for those of us who lived through this era, it is hard to imagine having to wait in lines for service or not having worldwide instantaneous access to our cash in the coin of the realm we are visiting. Along the way we have accepted as our responsibility as customer much of the work which was previously done by the bank's employees. As information technology has become more sophisticated and banking has moved on-line the service has become more sophisticated. Along the way the commercial banking workforce has become smaller, more efficient and better skilled.

The cover of Business Week last year captured it all. Against a familiar cartoon image of Rosie the Riveter, now draped in nursing garb, the headline trumpeted that over the past five years the US health care system created 1.7 million new jobs, while the rest of the US economy had offered up a net of zero growth: as many jobs had been lost as had been created. For those of us who encourage young people to consider careers in health care this was encouraging news. The opportunity would continue to grow in these jobs, most of which afforded a good income, an opportunity to serve, and the ability to learn new skills in order to master the seemingly endless array of new technologies and demands needed to be successful.

In all of the leadership development programs that the Center for the Health Professions runs, there’s an ongoing discussion about the difference between the realm of management and leadership. Inevitably someone offers the old saying, “managers do things right and leaders do the right thing.” True enough; the skills of the manager are more attentive to the tasks that make an existing system run more efficiently and those of the leader are more centered on new initiatives or systems that may require a change to be managed. The line between the two domains is permeable and I know few managers that don’t have a lot of leadership abilities and, vice versa, even the most charismatic of leaders must at least know enough to outsource the management when needed. One new twist to this idea is the observation that the U.S. health care system today is over-managed and under-led.