Health Care’s Moment in History

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.

In each of these periods the nation was well served by great national political leaders. The founding was formed by Washington, Jefferson, Adams, Hamilton and a host of others. The Civil War vaulted a young man from Illinois into the nation’s premier leadership role and Franklin Roosevelt confronted world wide economic panic and war. But each of these headliners was surrounded by talent that also rose to their challenges. Lincoln’s now famous “team of rivals,” was an amazing generation of revolutionary and constitutional leaders. Both they and the “brain trusters” that remade Washington physically and intellectually for Roosevelt played critical roles in resolving their respective crises. It remains to be seen if the current national leadership can rise to today’s challenges with equal fortitude and success.

During times of crisis, we have tended to focus on the challenges that thrust our leadership into the fray and the immediate response to these challenges, often failing to notice how the nation has changed following the crisis. In each of the eras discussed here, new political and economic frameworks were born which realigned both the democracy and the economy in the following decades. After the Revolution and Constitution there were over forty years of democratic experimentation and consolidation, particularly at the local level, coupled with economic expansion and growth among small farmers, businessmen, and industrialists. The Civil War knit the nation back together immediately, but also marked the beginning of fifty years of industrialization, consolidation of capital and the rise the modern urban landscape, which was accompanied by a similar consolidation of political power in the two national parties. While America had always been a nation of immigrants, this period also witnessed a growing heterogeneity that was made possible in the anonymous dimensions of a growing mass society. To confront the challenge of world wide depression and war, Roosevelt recast the role of the federal government and harnessed the political power of the teeming diversity of the nation. What followed in the fifties was US domination of the world economy, the great rise of the American population to the middle class, the beginning of our transition from a production-based industrial economy to a knowledge-based service economy, and the slow transformation of the American public from activist to consumer as the population shifted from the cities to the suburbs.

For each of these great epochs of our past there was a war. But curiously enough each war was different: one a revolution, one a civil war and one a world wide conflagration of previously unseen proportions. And each of the economic and social changes that followed was also of a distinctive character, maintaining some continuity with the past, but reshaping existing institutions and creating new ones.

We are now engaged in another economic crisis of unique dimensions. We are also engaged in a war that has its own distinctive character. And the consequences of the actions that will be taken over the next few years are likely to imprint the nation’s social, economic and moral character for years to come. New ways of understanding our public and private lives will emerge, institutions will be born and some will pass away, our children’s understanding of what it is to be an American will differ from past ways of understanding this role.

Our tendency will be to focus on Washington and the high profile leaders that are stretching to meet the demands and challenges of this yet unborn world. But the character and working mechanisms of this country have always been remade by countless leaders of communities and institutions at all levels, while engaged in the business of everyday life. This has always been the American genius. Through each of the three previous challenges, these leaders took the time to understand and in part shape broad national movements and to translate these into new ways of doing business at the local level. The focused and dedicated work of these leaders is what led to the phenomenal growth, expansion and remaking of American life following each of these past three epochs.

America’s response to the current crisis will be a product of the individual and collective efforts of leaders that weave the fabric of our nation. The need for change in health care is rapidly approaching center stage. Some of our current activities in the health care arena, and our ways of doing them, must be given up. New ways must be invented. Consistency with American values and traditions must be preserved, but likely in forms that are not currently familiar to us.

As we go about this work, if health care leaders look to Washington to make all of the changes that will be needed, we will beggar the process. The necessary changes will require curiosity, creativity and a large dose of courage. To be successful, everyone must be prepared to stretch to meet these new realities.