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.
How do we get from our current patchwork system to one that works better? Reformers want to nudge doctors in the right direction by changing the way they're paid.
The Democratic proposals include bonus payments for doctors and hospitals that coordinate care, for example, so patients don't bounce from specialist to specialist, repeating the same tests at every stop. But the bills are still too tentative, in McClellan's view. "We need more carrots, more incentives on the positive side -- but we need more disincentives, more sticks too."
For one thing, some doctors won't be willing or able to move into new payment systems. The government currently plans to wring savings from them the old-fashioned way, by cutting Medicare fees across the board. But that kind of cost-cutting doesn't do anything to make doctors more efficient or effective.
One answer, McClellan said, is to track doctors' practices more closely, to offer targeted rewards for those who improve both service and efficiency -- and targeted penalties for those who don't.
This is called "provider payment reform," a term you'll hear more often as 2013 nears. Does it mean a more intrusive government role in medicine? Sure. But federal, state and local governments already pay almost half of all the healthcare bills in the country. Government is already involved. And with increased scrutiny will also come a beneficial side effect: more transparency.
Right now, the U.S. healthcare system is a patchwork of different systems -- Medicare for the elderly, Medicaid for the poor, military and veterans' medicine, private insurance for the fully employed, and a lot of cracks in between.
Decisions about how much to spend on health, and how, have often been made through backroom battles among big institutions: employers, insurance companies, drug companies and hospitals. Doctors and patients have been among the least influential players.
By expanding the federal role in healthcare, and by setting up a system that guarantees all citizens access to affordable insurance, Obama's plan gives everyone a stake in its success. Voters will want to know that this system is working well at a reasonable cost. They'll demand -- even more than they do now -- evidence that their money is being well spent. Future Congresses and presidents, far from being relieved of the issue, will find themselves debating it year after year. American medicine is being politicized -- and that may not be a bad thing.