It's clear that 2009 could be the year that we make real progress in health care reform. All the Democratic candidates are putting a lot of emphasis on this issue, and are showing some real understanding that access to health care is diminishing, quality is deteriorating, and costs are rising. This is affecting low-income families, and broad swaths of the middle class as well. Republican candidates are talking about health care too - even Mitt Romney, who is now opposing key elements of the health care reform plan he signed into law here in Massachusetts with much fanfare in 2006. Another interesting development is the significant number of Republicans who have abandoned President Bush and support renewal of the SCHIP program that funds coverage for low- and moderate-income children.

Different candidates have differing plans and emphases, but the specifics don't matter too much at this point. The fact that there is such a strong focus on health care now, during the Congressional and Presidential campaigns, is a good sign that in the year after the 2008 elections we will see a push for comprehensive reform at the federal level.

The strength of the commitment to real reform, especially among Congressmembers, is an important factor. When Hillary Clinton was in the White House, the health care reform plan she and the President advocated was stymied by Congressional infighting and a strong push against it by the insurance industry lobby.

There are currently a number of "strange bedfellow initiatives," in which corporate interests are teaming up with activist or union groups to offer alternatives. This is because companies are tired of paying for health care, a system that grew up by accident as an artifact of worker shortages during World War II. The success of these coalitions could lead to a flip in how Americans get their health care. Economists agree that since one way or another, health care costs come out of workers' salaries, if employers are phased out of the system then these costs would be covered by an increase in taxes. Would workers' salaries then rise? Most economists say they would eventually - but not right away.

Promising Innovations

One of the landmark features in the Massachusetts reform law is that it allows individuals buying health insurance to qualify for group rates, instead of the astronomically high price that has typically been charged to individuals by insurers. That change builds on others in insurance law, like requiring insurers to cover everyone regardless of health status, and requiring them to guarantee renewal (instead of withdrawing coverage from people whose health care needs increase). This innovation has been picked up by several presidential candidates as part of their plans.

At the community level, there is a role for the public to start demanding better quality from health care providers. In Massachusetts, we've been experimenting with giving people tools to manage their own chronic conditions, like diabetes. There is good evidence that these programs, administered through community-based groups, can give people better care and save money.

An Organized Opposition

Drug companies and the insurance industry are well-organized and they will be out in force this year, promoting their agenda. They will be using the fear factor ("The reformers want ësocialized medicine' - you'll lose what you have!") and trying to build on the fact that the majority of voters are reasonably happy with their health care coverage to dissuade people from demanding change.

We must continue to educate our communities about these issues - especially the issue of disparities in health care. Studies show that within the same socio-economic levels, even with the same health care coverage, black people & Hispanics get lower quality care. We need to push our states to study these differences and take action. There are opportunities for action at a number of different points - from causes (the environmental justice movement has done important work in showing which environmental health care risks are situated in communities of color) to care. Improvement in health care can include the provision of appropriate language services, and the training and promotion of community health workers.

While we work to maintain the election year momentum towards reform, we should also speak up to keep other key health care issues from falling off the agenda. The national commitment to public health has been woefully ignored recently. It is in the public interest to worry about water and food quality, and to cut down smoking. Some of the diseases that have raised alarm in the past are still dangers, even though they no longer receive front-page attention: a flu pandemic, for instance, is still a very real risk. The pressure point for activists and voters is to persuade states and municipalities to commit financial resources to public health. It's seen as a luxury to set money aside for something that might not happen, and of course the huge budget deficit at the federal level influences these decisions as well.

Over this year we must take every opportunity to bring more progressive politics to the White House and to Congress. One tangible goal should be for health care needs to be raised as a topic at the last presidential debate before the election - and the candidate with the strongest position on health care needs to give the strongest response.