This installment of the Director’s Report is coming online as the Senate has reported its version of reform to the floor for debate. While there is much work to be done to have some version of the bill leave the Senate and perhaps even more in reconciling it with the House bill in conference committee, there seems to be a growing demand for beginning the change. The detractors and outright opponents of this legislation rightly point out that it does little to reduce the cost of care in the US. But it does begin the process and provides some essential foundations to move toward that goal that has remained so elusive.

As we continue to move slowly toward health reform legislation, it is important to remember what it is and what it isn’t. It will create a pathway to move toward a plan for universal access. It will pay for this with some combination of direct taxes or indirect requirements that cause people to buy insurance. It may provide some much needed reforms in the insurance market including the guarantee issue and non-cancellation for illness. It will not reduce health care costs, at least not initially.

August started off badly. Congresswomen and men seeking a broader understanding of the proposed health care legislation returned to their districts and asked for a dialogue over this very difficult and contentious issue. What they received were, for the most part, screamed questions/statements, followed immediately by orchestrated efforts to shout down any effort to answer the question. It wasn’t civil dialogue, it wasn’t even dialogue. That is too bad, but just what those opposed to significant reform wanted to accomplish. Shouting and attacking works if one does not have an alternative strategy or is protecting a special interest which runs counter to the real interests of most others -- or if the hypocrisy of the position being advanced is just so absurd that only the ensuing cacophony could cover its trail. As the President took his case for reform to Congress, the incivility only got worse.

Every day seems to bring a new article or news story about health care reform and change. Consumers are reported to be ready for change, fearful of altering what they have, anxious about the cost of care and trusting in their physicians. Eric Hoffer, the American longshoreman philosopher once said something like “when one doesn’t know what one wants or needs, one can never have enough”. I might add: especially when there are few costs charged up front.

We are well on the way to significant reform of the health care system. There are of course major battles to fight, but those who advocate for the status quo are finding it increasingly difficult to find a way of defending a system that taxes every citizen an extra $3000 or so to pay for health care that is radically uneven, unsafe, exposes everyone to potential financial ruin and simply underperforms.

Soon the nation will have to face the reality that our system of health care, evolved over the past fifty years, is financially and clinically unsustainable. After the financing discussion has progressed and the silos of service that cost so much and underperform so often have begun to re-integrate, then the public will begin to look for new ways to consume health care.

It is a big challenge redirecting health care. There are many informed people who have concluded that significant change is not really possible and that the best that we can hope for is more modest changes on the margins. These assessments are from people inside the system who don't really see any way to go about doing this work other than the way we have gone about it for the past sixty years or so. Until very recently there were similar theories held by the banking and automotive industries.

This is a time of tremendous challenge and change in our country. On only three other occasions in our history have we faced problems that are as wide and complex as those that now confront us. The Revolutionary War and the creation of the new constitutional government; the Civil War and its aftermath; and the Great Depression and the Second World War offered challenges of similar scope and scale. In each of these crises there was a serious question as to whether the country would continue on its path of political and economic freedom. As a nation, we met these challenges by creating new political and economic arrangements that made significant breaks with the past while comprising structures and organizations that sustained the core values, beliefs and vision of the country.

As I write this the Obama Administration has just appointed a new Secretary of Health and Human Services. Last week I heard someone ask how we could possibly go forward with extensive economic reform without knowing how health care reform would inform the President’s policies. The commentator needn’t have worried. Even without a person in the HHS position, the scenario for health care reform was already in place.

The inauguration is over and our new president seems very busy. Appropriately, there is a lot of attention on the economy, critical international issues, and whether civility can sprout in DC. Everyone I know has read the new HHS Secretary’s book [1] and everyone has great confidence that we will soon be moving forward. So it must be time for us to get back to the status quo in the clinic, ward, practice, dispensing counter, or operatory. Haven’t we learned anything? Are we blinded to the fiscal realities of our circumstances? Or are we, perhaps, actually satisfied with the way things are? Real change is needed, but not here, maybe over there at that other place, with them, those other people. Or, knowing that we need to change, do we know where to start? If not, we are defeated before we begin.