In his address last night President Obama spoke with force about the need for affordable, accessible, high quality health care for all Americans. It's hard to see how anyone can oppose those goals. But getting there will require tough choices that - notwithstanding his popularity - I don't think he has the political capital to carry out.
The goody goody proposals for reining in health care costs - more information technology, medical homes, and comparative effectiveness research - won't slow down the cost trend on their own. We'll need to confront our own ethic of unlimited choice, autonomy for every doctor-patient dyad, and condemnation of any effort to limit spending on costly marginal benefits as unethical rationing.
All developed economies have come to grips with these ethical challenges more robustly than we have. Their global budgets for health care don't allow the public and political leaders to pretend, as we have done for decades, that limiting health care costs is an ethical abomination.
We've created a climate of entitlement on the part of ourselves (the world of patients) and on the part of all the commercial enterprises that have been able to sell to a health system that refuses to get tough about purchasing.
Most physicians in their heart of hearts understand the situation and the need for change. But we need a strong public voice to tell us the truth and help us move forward.
I think the habits of entitlement and the commercial vested interests are too strong for President Obama to take on. Telling the truth won't be popular, and he has the most daunting agenda imaginable.
Since Medicare has to take the lead in insurance reform, we need voices from the Medicare constituency. And since setting limits on what we will pay for with collective (insurance) funds means forgoing beneficial interventions with small yield for the costs they entail, we need advocates who have looked illness and death in the eye.
That's where Senator Kennedy comes in. He just turned 77, and as the world knows, is being treated for brain cancer. He is uniquely positioned to tell us what we need to hear. It's not hard to know what has to be said - John Kitzhaber wrote much of the needed script in Oregon 20 years ago. We need leadership, not more research.
If Senator Kennedy's health allows him to take on this challenge he will leave a stronger country and a legacy to be proud of.