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.

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.