It seems a truism in democratic societies that only a crisis of a social institution will lead to fundamental change even when the institution is the source of considerable harm. The vested interests are so strong, the chances through a democratic process of rectifying the institution without causing still further harm are small, and the existing harm is so often to those without much of a voice in the political process. In effect, it is only when a crisis has occurred of such proportions that it cannot be ignored that the body politic is forced to act. The health care system seems to be such a social institution—backed in its current configuration by all the vested interests that make money from it as it is and that could see significant losses were any fundamental change to occur. In its current configuration it harms a great many people, those without any health care coverage for instance, but not enough people, or not enough people with loud enough political voices, to push the system to a tipping point that would require change.

One reason for no one's having grasped the nettle of the health care problem is conceptual. “The health care system” seems a simple description, but refers to a complex institution composed of so very many different kinds of players, from hospitals to the American Medical Association to insurance companies to federal, state, and local governments, etc., that it is difficult to grasp. We are brought up short by even such a seemingly simple question as “What is its structure?” What is its structure? We can understand how unpredictable any attempted change in the system might be when, without being able to articulate clearly its structure, we consider how any change would affect so many different constituencies: from the elderly to the poor to the middle class to the rich to all the usual categories used for discrimination like African American, Hispanic, and so on. It would also affect so many different kinds of institutions that work within the system, from nurses to physicians to adjusters to administrators to suppliers of drugs and hospital equipment, technicians, and so on. So even someone with the best of intentions might well hesitate to grasp the nettle.