The health care debate of 2009 has had so many moving parts that it has sometimes seemed impossible to follow. The crisis behind the debate, though, is about one thing above all: the scattershot nature of American medicine. The fee-for-service payment system -- combined with our own instincts as patients -- encourages ever more testing and treatments. We're not sure which ones make a difference, but we keep on getting them, and costs keep rising.
Any bill that Congress passes this year is unlikely to fix these problems. The lobbying groups for drug companies, device makers, insurers, doctors and hospitals have succeeded, so far, in keeping big, systemic changes out of the bills. And yet the modern history of medicine -- the story that James tells -- nonetheless offers reason for optimism. Medicine has changed before, after all. When it did, government policy played a role. But much of the impetus came from inside the profession. Doctors helped change other doctors.