09/24/2009 05:12 am ET Updated May 25, 2011

The Modesty of Hope

The debate over health care reform has rapidly morphed from a discussion of the risks and rewards of proposals to improve our health care system into a much larger, broader debate that has very little to do with health care. In town hall meetings and on cable networks, in blogs and over dinner tables, we are now arguing about our hopes and expectations for the American Dream.

Since the dawn of the Industrial Age, and even before, there has been a deep strain of exceptionalism in the American character. The idea is that America and Americans are somehow special, masters of our own destiny in a chaotic and uncertain world, able to exert both our moral leadership and economic might to lift humanity to a higher place. With the misguided war in Iraq and the economic missteps that lead to the greatest economic meltdown since the Depression, American exceptionalism -- and with it the American Dream -- has been brought sharply into question.

Even President Obama's "audacity of hope" rings with echoes of American exceptionalism. "We are a great people" was the implication, "and if we simply recommit ourselves to the American Dream, we can again triumph over adversity and despair." After a rough month in which the health care debate escalated into a screaming match and Americans began again to view the national glass as half-empty, questions about exceptionalism and the American Dream have resurfaced.

The health care debate has become a microcosm for those questions. Essentially, there are three critical issues at play in the health care discussion -- equity, efficiency and quality of care. The health care system is clearly inequitable -- only those who can afford insurance or who have no pre-existing conditions will be given full access to medical care. The system is also clearly inefficient -- we spend more on health care than most nations and have poorer results. And the quality of care is uneven -- it ranges from unrivaled Cadillac treatment for some conditions and individuals to extreme neglect in areas like preventive care and care for the uninsured.

Each of these critical issues has its advocates on both sides of the political spectrum. While some want more equity in the system, others would like to see more efficiency, and still others fear a loss of quality care. But what few of the proponents of the various policy positions acknowledge is that there are not many realistic, affordable options that address these issues. Universal, single payer coverage is likely beyond our means, certainly at the level of care we now provide. The European nations and Japan have discovered this and are facing their own health care crises. Efficiency in the health care system is unlikely to come quickly and will certainly not provide the cost savings that many people -- including the President -- envision. And, finally, the high quality health care that has been delivered in the past, albeit inequitably and inefficiently, is no longer affordable.

What this means is that we, as Americans, must accept at some level, an unequal, inefficient, lower-quality health care system. Right now, most people are not willing to do that. They want to cling to what they have, even if it means an expensive, cumbersome system. In the end, it is the devil we know rather than the devil we don't know. However, America's corporations and businesses have announced with great clarity that they are no longer willing to pick up the tab for an expensive and inefficient system. At that point, the only other payer is the American government, i.e. taxpayer, who will pay either in the form of subsidies or a direct government program.

We are, therefore, at one of those peculiar moments in history when our destiny is clear, but we are unwilling to embrace it fully. The American Dream has been diminished, and we can no longer rely on American exceptionalism -- or even the audacity of hope -- to restore it. What we can do, however, with modesty and humility, is to accept our somewhat diminished circumstances and, counting our many blessings, proceed to forge a path forward that preserves our fundamental American values of equality, integrity and common sense. Perhaps it is audacious to hope -- as President Obama did in his campaign -- that we can come together to forge a common solution to adversity. But we must begin with modest hopes and modest goals.