Unlike so many, I find myself being more impressed each time I delve into the new law. This is, ultimately, a piece of legislation that WILL achieve many stated and even unstated objectives:

1. It will extend the Medicare Part A trust fund for just long enough to allow BOTH sides to discuss meaningful reforms to make it truly sustainable.
2. It provides a real commitment to our nation's poor; and strengthens Medicaid at the same time. Here, too, there are opportunities for additional reforms, but this makes clear what our priorities are; and, importantly, demonstrates our national humanity and compassion for those less fortunate.
3. It dramatically reforms our understanding of and right to health insurance. We have never had a federal definition of health insurance and this begins that discussion in a meaningful way.
4. It is financially sustainable, as long as our elected officials do not undo the tax and revenue-generating items.

What do we need to wait for and hope for?
1. Tort reform and/or Malpractice reform. This should have been firmly part of this law, but will have to wait.
2. Sustainable Growth Rate legislative reform: This is universally recognized as necessary and putting it off, even for a few months, is a big disappointment.
3. Implementation of insurance regulation and insurance exchange regulation will be the first real tests of the success of the law.
4. Taking the Medicare savings and law changes as a first step; and not ignoring the very real legacy costs that we still have to address. AND working with the private (for-profit and not-for-profit) sector to develop a structure and process for improving the delivery of high-quality health care with consideration of cost.
5. Revisiting the notion of better patient education and not being scared off by hateful rhetoric. Discussions around end-of-life and compassionate care should not be politicized or used for pure political gain.

I remain very optimistic about this country and about seeing our elected officials, of both parties, come together around common goals and purposes. In the mean-time, I am proud of the many elected individuals (and their staffs) for having stood behind their promises and made this a reality.

The passage of the health insurance legislation has two overriding positive effects: it brings more clarity to the health insurance issue and it demonstrates the President's ability to govern.

The legislation also affirms that Americans should not face financial ruin from being unable to afford health insurance. It also makes good progress on prevention, on increasing the supply of health care professionals, on eliminating the flawed "doughnut hole" in the Medicare prescription drug system, and on beginning to address the long term care crisis. These are the good elements of this legislation.

As health insurance system restructuring, the legislation has deep flaws that must be addressed in subsequent legislation. We cannot guarantee coverage, prevent people from being subject to pre-existing condition exclusions, and prohibit insurers from canceling policies for those who become ill during the policy period without significantly increasing costs for all policyholders unless we cause healthy uninsured people to buy insurance, reduce what we pay health care providers, or levy more taxes on people to pay for increased subsidies.

The penalties for healthy people refusing to buy insurance are far too low and do not take effect for several years. Reducing payments to doctors and hospitals either drives them out of the system or causes them to drop Medicaid patients. Raising taxes on everyone to pay for these increased costs worsens our economic situation.

One situation illustrates my point: in the 8th Ward of Washington D.C., there is a severe shortage of specialists, including one urologist for a large population. Most people have health insurance or Medicaid. After this legislation passes, there will be even more people with insurance, but still a severe physician shortage. We have more work to do before our health care system is viable. Health insurance affordability does not produce health care access.

In the 1843 Charles Dickens classic "A Christmas Carol," Jacob Marley comes back to warn his former business partner Ebenezer Scrooge that serving humankind was his business; not business for business's sake. The U.S. health insurance industry seems to have forgotten this important lesson. Since their entry into the marketplace in the mid-1800s, the industry has moved from being more than a simple insurer of coverage. Today, these economic behemoths are the centerpiece of the system that is supposed to provide health security to most Americans. They are beginning to fail in this important task. They are a component of a overall health-care delivery system that is broken and, far too often, does not live up to its potential.

Are insurance companies the only one to blame? Of course not. But their business practices are a major part of the problem. Much of what is proposed in health-care reform is the result of an industry that has not addressed the need to have a system with everyone in and no one out; a system where avoiding providing the needed service to many drives the business model; and a system that pays for the volume of services delivered and not the quality of them. In a truly competitive world, they would go out of business because someone else would serve their customers cheaper, faster and with better customer service. Because insurance companies are essentially monopolies, this does not happen.

Health insurance companies are the target of public ire because everyone knows they are the one group with the capacity to make the most dramatic changes to the fragmented system as we know it today and have not done so. They control more than premium costs. They control costs through provider payments; they control access to care through the decisions they make on which practitioners to include on their provider panels; they make coverage decisions through the design of benefits; and impact quality through payment and other program strategies.

As a product in the marketplace, health insurance costs too much and is becoming increasingly undependable. It seems like the business of insurance has overtaken the reason for providing it: health security. They are certainly not the only problem in the health care delivery system, but they are a major component that needs fixing.

While insurance companies have enjoyed unprecedented profit and growth, they have failed to do anything to address or prevent the problems we are facing with health insurance today. Instead of finding a way to include those in America that can't afford their own insurance, they established rates and policies to eliminate them. Instead of showing they are willing to extend a cooperative and inclusive hand to reform, they arrogantly raised their premiums for millions of Americans. The insurance industry has had decades to get it right and instead they decided to get as much as they could.

The problem with health care in America is not the health care itself. We are all agreed that it is among the best in the world. The problem is access to this great health care because of the cost of insurance. Even those that have insurance are deluged with co-pays and exclusions. Practices that limit treatment aren't because of providers but because of insurance policies. Health care is an essential service, without options outside of insurance companies they have all the power to weigh our access against their profits.

Insurance companies have already spent hundreds of millions of dollars lobbying against health-care reform and the public option. Next, I expect we will see millions of dollars poured into advertising to urge Americans to keep them in business; big business. The question Americans really face is whether their health care should be about profits or about people.

Huge rate increases by health insurance companies are largely caused by market conditions and misguided government laws and regulations, but insurance companies also have to bear responsibility for being resistant to change. I disagree with those who blame insurance companies for major rate increases:

• As people get sicker and use health care more frequently, health care costs go up and insurance goes up with them.
• Large providers with market power are all raising prices significantly.
• State governments worsen the problem by increasing coverage requirements under every state-regulated insurance plan.
• States also limit the ability of insurance companies to reduce costs by limiting wellness incentives and other tools that could take overall health care costs down.

The proposed health insurance reforms, such as guaranteed insurance policies, prohibitions against pre-existing condition limitations, and terminations when someone gets sick, are all good ways of expanding access, but they will drive up costs. Limiting price increases, profit margins and medical loss ratios are all bad ideas, since they will prevent insurance companies from making enough money to improve their customer service and improve efficiency.

However, insurance companies are partly at fault. While insurance CEOs like Ron Williams (Aetna), Angela Braly (Anthem), and Dave Cordani (CIGNA), and Jay Gellert (HealthNet), to name a few CEOs I know, are inspiring, caring, and brilliant leaders, they sit atop organizations transitioning to new ways of making profits, but sometimes resistant to change. The insurance industry is not as supportive of patients or doctors as it needs to be, and often has antiquated information systems and business processes, which contributes to its image of being highly insensitive or uncaring. However, the proposed health insurance reforms, unless significantly modified, could make the situation considerably worse.

My charge is to say whether I agree with President Obama's comments about health-care reform.

Yeah, I do agree with him, particularly his admonition to Democrats: "We still have the largest majority in decades, and the people expect us to solve some problems, not run for the hills."

I do wish he had been more directive in asking the House to pass the Senate bill, and in asking the Senate to address that bill's major flaws through the reconciliation process. (I and 50 other health policy experts recently signed a petition that advocated this course.)

As I listened to the State of the Union, I was less impressed with what President Obama should do than I was with we--his listeners--should do to help get this done. He can't do this alone. Neither can Harry Reid or Nancy Pelosi. They need grassroots help.

Democrats have made impressive gains via an inside game that moved us closer to a final bill than we have ever been. Unfortunately, as political scientist James Morone reminds us in the Jan. 27 Los Angeles Times, Democrats have been less successful telling their story to the American public. All that legislative sausage-making was done for worthy purposes. These purposes were too often left unexplained. Surprisingly and inexcusably, health care proponents have been outworked and out-talked by conservative opponents, who were often able to frame public debate:

Every big piece of legislation is a contest of ideas about what the nation needs. The Republicans told their story with exquisite skill. "Death panels," socialism and "government takeover" were all colorful ways to opt for private markets over government policy.

Those of us who know better must provide a more compelling alternative, one that emphasizes the inherent shortcomings of any "private market" solution that lacks proper government backing and oversight.

My own family is connected by fate with many others affected by cognitive and developmental disabilities. Over the past six years, we have borne primary responsibility for a cognitively disabled adult facing multiple challenges arising from fragile X syndrome. He requires hundreds of thousands of dollars in medical and social services. Although I have an excellent job as a University of Chicago professor, we could not have cared for him without a lot of help from Social Security, Medicare, and Medicaid. We are very grateful for this help. Hundreds of thousands of others are intimately affected by fragile X and similar disorders. Many are effectively uninsurable.

There are many good arguments for health reform. The simple argument for social insurance may be the best: Acting together, we can protect each other from burdens that would crush any one of us, if we were forced to bear it alone.

That's a good message to deliver to your Senator and your Representative as you urge them to get this done. If you or a loved one has benefited from government help at a crucial life moment, make yourself heard. People need help.

This Sunday, the Detroit Free Press ran a story about a mother and daughter who had both been diagnosed with breast cancer and neither had health insurance. The story told of their subsequent battles: the mother's with cancer and the daughter's with finding funds for surgery and treatment without which she will die. The mother qualified for a program that covered her surgery and treatment. The daughter, at 31 years old, was too young for federal aid programs and she couldn't qualify for Medicaid. This is bittersweet for the mother who will win her own battle but may have nothing to live for if her daughter loses hers for lack of insurance.

In the next three years, we will hear a lot more of these stories. Many Americans will die while waiting for coverage. Our representatives are so worried about costs they are trying to find a way to either kill some sick people off or prevent them from getting coverage. Sen. Judd Gregg (R-N.H.) lead me to this theory when I heard him on a Sunday news program discussing the bill they were working on at the time. He was against lowering the age for Medicare recipients to include 55 year olds. His reason was that too many sick people will apply thus making it too expensive. You think? Generally healthy people don't use health care. Even the insurance companies know that, just check out their policies that make it impossible for sick people to buy into.

It was the daughter's doctor who finally figured out a way to help her. He is doing the surgery for free. Now if only our representatives worked for free we could all afford health care.

Looking back over the past year of health-care legislation, I would make the following observations:
• The Obama Administration made remarkable progress on health information technology, prevention and wellness and health-care quality in the February 2009, stimulus legislation.
• Although the House and Senate health-care reform bills were not bipartisan and some of the compromises were not particularly good ones, I am pleased that the Senate discarded the public option, the logic for which was never compelling.
• Relative to what the bills attempted to accomplish, the goal of enabling universal health insurance would be achieved. However, there are some structural flaws in the design of the insurance systems that, if not corrected, will put our country at serious financial risk.
• Structural health-care payment and delivery reform could avoid a financial crisis, but it is not clear that any level of government has the political will to tackle these issues, and they were addressed in these bills. Raising taxes to fund health insurance will cripple the economy, and cutting Medicare payments in our existing flawed system will simply drive doctors and other providers out of the system, which will create shortages. At this stage, it is unclear how we will create universal insurance that is affordable and financially sustainable.
• I commend Senators Harkin and Dodd and their colleagues for some excellent work on prevention and wellness. I also believe that the foundation has been laid for supporting more community health centers, a vital tool for health care delivery. Nevertheless, the good pieces of the legislation are relatively under-developed nuggets, not full-blown health care transformation solutions.

Politically, this legislation went as far as Congress could probably go, but much remains to be done.

In the iconic tale "The Little Engine that Could," a disabled train needs a forceful push through rough terrain and onto its final destination. It inquires of the larger, more equipped and powerful engines but they all refuse. It is not until a small blue engine volunteers and dares the impossible, does the stranded train ascend the mountain and arrive at its promised end.

Faced with a more daunting task, we've entered a new year and a new decade. Not only do we have the chance to be reflective, but also to be forward thinking and deliberately hopeful. Typically, around this time we find ourselves in a "can do" fury and fleeting resolutions abound. What we need is not a spurt of momentum, but an impassioned push and the steely resolve to win at a Herculean feat.

The little blue engine succeeded at something that others confessed could not be done or risked too much. And it did so while repeating the famed affirmation, "I think I can. I think I can."

What is it that we think we can do? While the health-care debate has dragged on for a year, it is unclear whether the objective is to transform the health-care landscape or to initiate change and achieve a down payment on meaningful reform. Frankly, reform does not culminate in any legislation's passage. Rather, reform only begins. While no one should be the enemy of incremental progress, we must realistically frame short-term and long-term goals, which has yet to be done.

The "summer of discontent" crippled the health reform agenda. With latent hostilities made painfully apparent, the message was hijacked and health-care legislation became less about securing a better health covenant and more about salvaging political wins in a frayed and contentious atmosphere.

With political proselytizing at an epic frenzy, the perceived winners and losers have selfishly sidelined the interests of the American consumer and a weary public has grown suspicious and reluctant. Still, inaction is a reckless alternative for the millions suffocating under the status quo. Access and cost, the two hot button issues, have made for strange bedfellows in the health-care debate. Both are worthy causes, and in light of recent economic woes, both are crucial to the conversation, but good legislation hinges on a compelling mix of good policy and good politics, and these two have been cast as opposing corners in the ring.

True and radical change will surface when we confront the care culture where health promotion, wellness and prevention take a back seat to cure and disease management. In that far-away utopia, not quite in our immediate grasp, cure and care should receive equal billing and likewise creative strategies and dollars should be aimed at making health and well-being a more cogent issue for the masses.

Thus the more truthful question is do we think we can challenge that cultural behemoth. And to that, I say I know we can. But we must be willing to enlist in what is likely to be an uncomfortable battle, and a marathon indeed. So kudos to the landmark legislation, which is likely to pass the Congress but in retort, "now what?" With whatever health-care bill emerges from conference, imperfect at best, we simply live to fight another day.

And to that fight we must invite all stakeholders -- patients, families, caregivers, physicians, nurses, private industry, public health, clinical and research scholars, social and political scientists and all big thinkers who honestly believe in the can-do spirit.

Negotiation and compromise has left us with a bill that doesn't even begin to meet the health-care needs of this nation. Every day many Americans wake up to the nightmare of battling cancer or other critical conditions without health insurance. I am all too familiar with living this nightmare. We had health insurance through my husband's employer when I was diagnosed with stage three breast cancer. I had only completed two out of six months of chemotherapy after surgery when my husband's job was cut and we lost our health insurance.

We even had to fight to get COBRA. I remember standing at the reception desk of a clinic using the phone to reach someone at my husband's ex-company who could confirm we had COBRA so the radiologist would see me. We had to pay thousands in COBRA payments and still thousands more in co-pays. Fighting for health coverage was as brutal as fighting for my life.

We need health-care reform so this doesn't continue to happen to people who live and work in America. We need the public option so private insurers don't have all the say about our coverage, but the public option has been negotiated away in an effort to pass the bill. The goal, Senator Reid tells us, is to pass the bill. Funny, I thought the goal was to ensure everyone in America had access to health care, just like the senators have. With all of the compromise and negotiation to win 60 votes, the most significant part of health-care reform was lost.