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So what is Machiavelli's Law of Reform? From The Prince:

He who desires or attempts to reform the government of a state... must at least retain the semblance of the old forms, so that it may seem to the people that there has been no change in the institutions, even though they are in fact entirely different from the old ones.
Still, a major asset to reform hopes is the possibility of same-party control in DC. That has to improve chances of reform but as noted, also in Health Affairs, by William L Roper (dean of the University of North Carolina at Chapel Hill (UNC) School of Medicine and chief executive officer of the UNC Health Care System):
The 2008 election will focus renewed attention on fundamental health care reform. Lessons from past politically driven reform efforts show that although fundamental reforms may make for good politics, a systemic shift in how health care is financed and delivered is unlikely to occur. Calls for fundamental reform over the past twenty-five years have prompted incremental changes that have had a major impact on the U.S. health care system. Many of these changes were driven from outside the political system. The forecast based on past experience is not radical change; it is more of the same.
That resistance to change is something we've covered here. It's partly a function of the resiliency of the health care system, and partly a function of a lack of political pressure to make changes.

Nonetheless, change is in the air. Single party rule in DC is possible (more so for Democrats than Republicans, and Democrats rate health care a higher issue than Republicans do). Costs are driving business and consumers alike to consider health reform. The NY Times this month:

The American carmakers’ problems underscore the need for a government-backed system of universal health care, which would relieve some of the costs that have made competing so much harder.
Who knows? With a Democratic victory in November, and a leader in the White House, a recession in the economy and business pushing to reduce costs, we may just get the perfect storm of events that'll move the ball down the field.
Friday, Feb 29, 2008
A new poll on health care from NPR, the Kaiser Family Foundation and the Harvard School of Public Health finds that a majority of Americans are backing key elements in the health reform proposals of Democratic presidential candidates Hillary Clinton and Barack Obama.
But even if that happens, check the conclusion from the NEJM authors:
Looking forward, the ranking of health care as a top issue in the primaries and plans for serious health care reform proposed by both Democrats and Republicans are major steps toward a larger debate in the 2008 general election and beyond. However, the intensity of the debate, and whether it engages the nation the way the last great health care debate did in the early 1990s, remains to be seen. In addition, the prospects for actual health care reform are tempered by two factors: the wide differences in the two parties' views of what health care reform should look like and the current level of satisfaction that majorities of both parties have with their own health care situations.
Reform needs to happen. Just don't expect it to all happen at once (childrens' coverage has more consensus than adult), or at the expense of what people already have, or even to necessarily look radically different (see Machiavelli), whatever anyone promises.

Sources
This is a follow up on Daily Kos posts here (Medical Crisis: The Shape Of Things To Come), here (Perspective on Health Care Reform), here (What's The Effect Of Recession On The Health Care Safety Net?), and here (Health Stories: HR 5449). The posts use public opinion polling from Kaiser, here with a summary tutorial, narrative supplied by Claudia Deane (formerly of the Washington Post polling unit). Further elaboration appears here in more academic form published in the January 24 New England Journal of Medicine with co-authors from the Harvard School of Public Health and John F Kennedy School of Government). The latest poll from NPR/Kaiser/HSPH is dated 2/28/08, and available here.

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Originally posted to Daily Kos on Sun Mar 02, 2008 at 05:32 AM PST.

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