Prospects for the enactment of some reform look good, but comprehensive, sustainable reform of the health care system must wait for another day. Republican support for President Barack Obama's ambitious agenda is fading fast, if it ever existed. An imaginative, truly bipartisan approach that moves the system away from employer-sponsored insurance - the Wyden-Bennett plan - has failed to gain any traction. Within the Democratic majority, sharp disagreements in each house, and between the House and Senate, do not augur well for coherent legislation, even if political compromises can be struck.

Disappointment with the reaction of some of the public and gridlock in Congress might lead to the abandonment of reform this year. With the need so great, and with so much effort having been put forth by so many people, that would be a crime. Almost everyone agrees that the present U.S. health care system is dysfunctional: it is too costly, too incomplete in coverage, and too prone to avoidable lapses in quality of care. A true remedy would require major changes in the financing and organization of care; such changes currently have little support from either politicians or the public. But a start must be made.

Although comprehensive change is probably beyond reach this year, several specific reforms should and could be enacted: the creation of insurance exchanges, the elimination or limitation of the tax exemption of employer-sponsored health insurance, the appointment of an expert commission to devise changes to the way Medicare pays providers, and the provision of ensured funding for a quasi-independent institute for technology assessment. Each of these changes alone has a high probability of doing some good. Taken together, they reinforce each other and lay a foundation for further reforms.