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By Ira Sharkansky
 JERUSALEM—Obama's health initiative provides its lessons about politics generally, as well as being a fascinating effort to remake a major public policy.
Whatever is happening has not been smooth, and will not produce a mega change. The whole flurry may end with a presidential defeat, or with additional features added to what is already a complex array of pieces fashioned over the course of 40 years. Simple and centrally managed is not in the cards. Insurance companies and HMOs will remain in place. It is doubtful that Americans will be spending more time with care givers than with learning what they can receive, how much they must pay, and what forms they must submit.
Among the insights apparent in the torrent of commentary, politicking, public meetings and e-mails is that many Americans like what they have. In this they resemble residents of other western democracies. Few are experts in the policies offered by other countries. Parochialism and patriotism are part of public opinion and politics, whether or not they are tapped directly by surveys.
Among those opposed to change there is a preference for choice, opposition to socialized medicine, and opposition to providing health coverage to illegal aliens. The realities are that there is not a great deal of choice currently available to the average citizen, with collective policies dominated by insurance companies and HMOs. There is a choice of insurance companies and programs, but it is hard to believe that many citizens probe the complexities, get something that matches specifications they define for themselves, and know for sure what is covered.
Appreciation for what exists shows up in stories of successful treatment experiences. The cost and medical inefficiency of using emergency rooms for primary care should be a major target of reform, but many people perceive justice when they see or hear of poor people being treated in emergency rooms.
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Euthanasia, coverage of abortion or fertility treatment, aliens, rationed care, and uninsured children are hot buttons capable of generating mass mailings and adding to the provisions that individual legislators will demand as their price of support. None of these need be all or nothing. Assisted suicide is not euthanasia. Coverage of fertility treatments or other treatments can be made available a limited number of times, or rationed with co-pays. A final bill will include criteria to be used in deciding about treatments and cost sharing, with considerable work left for administrative rulings and the courts.
The subject of aliens taps unresolved issues no less complex and emotional than health.
Any proposal a thousand pages in length does not generate coherent debate. Legislators and activists talk past one another, each focusing on what they perceive as essential points to support or oppose. There are contentious claims about facts, myths disguised as facts, and facts said to be myths.
Comprehension may be pointless insofar as the discussion in two house of the legislature and several committees quickly gets to amendments and counter proposals. What emerges at the end may be described as a work of compromise, but is also a crap shoot. If few understand the original proposal and all its implications, fewer still will understand what comes out of the grinder.
There is no such thing as once and for all time health policy. Soon after the president signs whatever emerges and proclaims his victory, there will be proposals to fix defects, and to add what is missing. Medical innovations will provoke advocates, while others take another shot at cost containment.
What happens to a patient's existing opportunities and expenditures will not be apparent for some time. Deliberations may last longer than the patient.
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