The day after trinity. Just as nuclear threats continue to influence foreign policy, the ghosts of past efforts to improve the U.S. health system still trouble us.

BY EMILY FRIEDMAN Ms. Friedman is an independent health policy and ethics analyst based in Chicago. On July 16, 1945, the first atomic bomb was detonated near Los Alamos, N.M. The explosion was code-named "Trinity" by the project's lead physicist, J. Robert Oppenheimer. He later said that the name, ironically, was inspired by the poetry of John Donne, a 17th century Anglican priest and author of the famous sonnet, "Death Be Not Proud." Within weeks of the explosion, Hiroshima and Nagasaki were devastated. Today, the legacy of Trinity still haunts humankind, as we worry about which nations have the capacity to produce these weapons and what they might do with them. It is not much of a stretch to see the parallels to what is generally being referred to these days as health care "reform." (Personally, I don't like the term; it seems to imply that the health care system has committed some criminal act, as in reform school.) Whatever we call it, the idea is to control costs, achieve access and coverage for most or all Americans, and reconfigure the provider and insurance sectors. Beyond that, there is little agreement. Proposals run the gamut from "keep things pretty much as they are and give tax credits to the uninsured" to "let's have a government-controlled single-payer system," as many other countries do. What are the parallels with the nuclear threat? For one thing, we've been kicking this particular ball around for decades, with limited results. There have been successes — Medicare, Medicaid, the State Children's Health Insurance Program, a few state initiatives — and there have been failures, including the Clinton health plan. We produce studies, hold conferences, publish articles. But the number of uninsured continues to grow, as has membership in the club of nuclear nations. Furthermore, just as the nuclear threat still influences foreign policy, the ghosts of previous efforts to improve our health system haunt us. We do not seem to have learned the lessons of the atomic age any more than we have learned much from previous attempts to bring rationality, and justice to health care. So although there is great hope right now, there is also great anxiety about what "reform" will bring. Policymakers are busily formulating "reform" proposals, jockeying for power goes on, lobbies prepare their assault. Yet, most of those involved in the effort are too busy furthering their agendas to ask the most difficult and controversial questions.