The answer, say leading groups of businesses, hospitals, doctors, labor unions and insurance companies - as well as senior lawmakers on Capitol Hill and members of the new Barack Obama administration - is unprecedented government intervention to create a system of universal protection.
At the same time, these groups, which span the ideological and political spectrum, largely have agreed to preserve the current employer-based system through which most Americans obtain their health insurance.
The idea of a federal, single-payer system patterned on those in Europe and Canada, long a dream of the political left, is now virtually off the table. Rejected as well is the traditionally conservative concept, championed by Sen. John McCain, R-Ariz., during the presidential campaign, of reforming health care mainly by giving incentives for more Americans to buy their own insurance.
There is also a widespread understanding that any expansion of coverage must be accompanied by aggressive efforts to bring down costs and reward quality care. And key players in the debate increasingly back a massive investment of taxpayer money for health-care reform, despite the burgeoning budget deficits.
Beyond these areas of basic agreement, the details of what would be one of the most momentous changes in domestic policy since World War II remain vague. As a presidential candidate, Obama embraced both expanded insurance coverage and preservation of the job-centered system, but he has provided few specifics about his plans.
Disagreements over specifics could lead to stalemate again. Even the most hopeful advocates of sweeping reform concede that difficult negotiations lie ahead.
But what is taking shape is a debate very different from previous discussions about what America’s health-care system should look like.
“A lot has changed,” said Karen Ignagni, president of America’s Health Insurance Plans, a leading trade group whose members helped kill the Clinton administration’s health-care campaign in the early ’90s.
AHIP is participating in talks with other interest groups to build consensus before Obama takes office in January and Congress begins debating any health-care legislation.
Among the issues to be decided as more concrete proposals emerge in the months ahead is whether the roughly 46 million uninsured people in the U.S. will be pushed to buy private coverage or be enrolled in a government insurance program, as some consumer groups want.
Hospitals and doctors fear another public program would reduce what they are paid, as Medicare and Medicaid have done. Insurers worry they could lose customers to the government.
Also unresolved is what mechanisms might be created to force individuals or businesses to obtain insurance, both potentially contentious subjects.
And few have tackled how the government will control costs and set standards of care, proposals that raise the unpopular prospect of federal regulators dictating which doctors Americans can see and what drugs they can take.
“There are some very big questions and some very big stumbling blocks,” said Stuart Butler, vice president for domestic policy at the conservative Heritage Foundation, who has been watching the health-care debate for three decades.
“Once you get into the details, the consensus is going to vanish pretty quickly, I suspect,” he said.
At the same time, advocates for a single-payer system, including the California Nurses Association, have vowed to continue pushing the idea next year along with many Democrats on Capitol Hill.
And Republican lawmakers, though still reeling from their losses last month, have signaled discomfort with a major expansion of government spending, a position many in the GOP hope will help return the party to power.
“Increasing access for the uninsured is not going to come cheap,” Sen. Charles E. Grassley, R-Iowa, said at a recent hearing on health-care reform. “And it’s clear to me that our economy cannot stand much further deficit spending.”
Nonetheless, the current agreement on principles contrasts markedly with previous reform efforts. Today, many of the key players in the debate see the importance of preserving those elements of the current health-care system that many Americans say they like.
“There is a growing understanding that you have to give people choice and you can’t take away what they have,” said Ron Pollack, head of Families USA, an advocacy group for health-care consumers that is working with a diverse collection of interest groups to build consensus. “One of the big no-nos is that you must not ever threaten the coverage that people have.”
Many involved in the debate, including Democratic lawmakers and key members of Obama’s team, also see health-care reform as part of a broader economic picture.
Democratic leaders on Capitol Hill have begun sketching out plans for health-care reform that, like Obama’s plan, preserve the employer-based system and create a new system for those without insurance. Last month, Senate Finance Committee Chairman Max Baucus, D-Mont., outlined such a plan in an 87-page white paper he titled a “Call to Action.” Similar approaches have been endorsed by House Democrats.
In contrast, the Clinton administration drew up its health-care reform plan with little involvement from congressional Democrats. In the Senate, then-New York Democrat Daniel Patrick Moynihan, who chaired the finance committee at the time, actively resisted the idea of sweeping change in health care.
There are no signs of a similar rift today, said Jacob Hacker, a political scientist at the University of California, Berkeley who has written a book about the failed Clinton effort.
“Possibly more important than policy agreements,” Hacker said, “is the fact that the political forces now are in alignment.”
