The U.S. now faces a health care challenge of such consequence that it reaches well beyond the physical and mental well-being of the nation. The cost of care now endangers the economic well-being of the next generation and beyond. While the proposed health care reform has advanced a significant development, it has not been able to identify politically viable recommendations that could shake the health care institutions at their very foundation and leave the nation with a remade arrangement for providing for its well-being.

The US economy and society continue to suffer from an overbuilt, under-performing and too costly arrangement for the organization and delivery of health care services. The costs of this policy and market failure now amount to as much as $700 billion annually, approximately the cost of the banking and financial liquidity crisis and remedy of the past two years. The only difference is that the financial fix was a one-time expenditure and has seen nearly two thirds of the funding returned to the Treasury, while the health care overpayment is an annual expenditure with no end in sight. The uncontrollable costs of health care delivery are now driving deep structural deficits at the state level, the steady evaporation of benefited health coverage by employers of all sizes and the direct exposure of individuals to the financial risks associated with irrationally priced and under-performing health care services. In the medium and long term the growth of health care costs will bankrupt the nation.

 A lot has happened -- or not happened as the case may be -- in the past month. At the time of writing this it is unclear what, if anything, will be advanced in the health care reform bill. Bets and suggestions run the gamut from pushing ahead with everything, to selecting those parts that are most important and least controversial, to starting over. Any piece of legislation is a balance of policy and politics, and this one has been fully swimming in this soup from its first day of consideration. Undoubtedly something will happen, even if the happening is a deep reconsideration. Regardless, with or without a health care reform, a change is needed simply because it costs too much, produces too little, and leads to too much dissatisfaction among providers and consumers alike.

The US Senate has just met the challenge of bringing the health care reform legislation to the floor for a vote. It has endured a month long assault from the right for not having enough detail, being far too lengthy, and endangering America’s health; none of these attacks have been accompanied with constructive alternatives. There were many ways that policies from the right side of the aisle could have strengthened this bill had they been offered. For instance, the nation would be better off with a plan for engaging more individual responsibility around health behavior and financial prudence. But because the right chose to work toward a political defeat for the administration rather than a better bill, these contributions are absent.

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.