President Obama set out a long list of worthy goals in his healthcare speech to Congress last week, but at least one of them was utterly unrealistic. "I am not the first president to take up this cause," he said, "but I am determined to be the last."
If Obama succeeds in winning a comprehensive healthcare bill, he will have established, for the first time, a federal government obligation to make some kind of health insurance available to every citizen. That's a monumental achievement.
But it will be only the first step in a process of designing, launching and improving a new healthcare system for a nation of some 300 million. That's a monumental task.
And it won't be completed in a single presidency -- not even a two-term presidency that would run until 2017. If Obama succeeds, most of the new program won't even be launched until 2013, so his successors will inherit the job of managing the system he builds and -- when flaws reveal themselves, as they inevitably will -- the obligation to make adjustments.
"The repair is going to be a process, not a one-time event," Atul Gawande, the celebrated physician-journalist at the New Yorker, wrote last week. "Reform will have to be more like a series of operations, with X-rays and tests in between to see how we're doing."
Whatever bill gets through Congress this fall -- and it seems increasingly likely that one will -- is almost certain to obligate citizens to obtain insurance, require insurance companies to offer "affordable" basic policies and impose taxes and Medicare payment cuts to help pay the insurance bills of low-income families.
But no matter how specific the bill gets, it can't guarantee that the president's proposals for funding the plan will generate enough to cover the costs.
And the bill won't reshape the medical system to focus on overall care instead of individual procedures -- at least, not yet. It only launches a series of experiments and studies to see what works and what doesn't.
The most intriguing question the bill can't answer is this: How will the practice of medicine -- the way doctors, nurses and hospitals actually treat their patients -- change to make all this work?
There's no question that it will have to change. "If you talk to doctors, they'll tell you, 'Yeah, we're practicing inefficiently, and we know it,' " said Dr. Mark McClellan, who ran Medicare under President George W. Bush and supports the basic thrust of Obama's plan.
