Amid all the post-election crystal-gazing, one of the few safe inferences so far is that voter worries about health care were a powerful source of discontent; and that if the war in Iraq de-escalates over the next two years, affordable access to care is likely to emerge as a major issue in the 2008 elections. Even the chairman of the insurance industry’s largest trade organization warns of a “growing crisis.” But Democratic pollster Celinda Lake said last week that exit polls suggest the voters’ desire for change is tempered by caution. Not all change is good, the voters thought. And according to Lake, mixed emotions about the Medicare Modernization Act fueled their ambivalence.

Undaunted by the obvious fragility of post-election good will, America’s Health Insurance Plans unveiled their ambitious, sensible, 10-year, $300-billion plan for universal coverage within days of the Democrats’ victory. The Service Employees International Union has a plan too, as will others. But in the short run, the new Democratic congressional leaders have unfinished business to settle over the MMA – provisions viewed as unduly favorable to the insurance and pharmaceutical industries – which are sure to have partisan ramifications. It will be difficult to move forward with this kind of baggage.

During the early debates over Medicare, John F. Kennedy liked to quote Thomas Jefferson’s adage that “great innovations should not be forced on slender majorities.” In 1974, House Ways & Means Chairman Wilbur Mills gave up on national health insurance when he could muster no better than a one-vote majority for NHI on his committee. The MMA, as we know, passed by the merest whisker.

It will take more than political showmanship to subdue health care’s twin crises of cost and access. One positive sign from post-election polling is that voters seem increasingly aware that costs are their problem, too, not just their insurer’s – an unanticipated and perhaps benign consequence of increased cost-sharing under the rubric of “consumer-directed” health care. If the voters are getting smarter, perhaps politicians can learn too.

SEIU’s Anna Burger said last week that the health care challenge is not an issue of policy but of political will. She is welcome to her opinion. But the nation’s propensity for overconsuming health services – like its overconsumption of many other consumer goods – will be excruciatingly difficult to rein in. Very smart strategies will be needed, as well as serious, adult collaboration among stakeholders, of a kind that has not been seen in this generation – except perhaps during the passage of SCHIP and prospective payment in Medicare. The time for policymakers to roll up their sleeves and start studying is now.

We hope our readers will make the most of Health Affairs’ archives as they pursue this duty. In recent months we have published valuable papers on long-term cost trends in Medicare, reform in Massachusetts, recent trends in medical costs and insurance premiums, and consumer-directed care. This week, we release a special issue on the future of employment-based insurance. Evidence first; conclusions to follow.