Old hands in Washington are getting a here-we-go-again feeling about health care these days. Candidates and polls are pushing reform toward the top of the nation’s agenda. Many states are on the march. Realism occasionally rears its head in the right places: Controlling cost growth seems to be recognized increasingly as a priority of the same magnitude as expanding coverage, and there’s not as much wishful thinking as there was in the ’90s about magically transforming the delivery system into an integrated Utopia.

But the underside of all this deja-vu is an edgy sense that we might be fooling ourselves — again — by imagining that fundamental reform is just around the corner. To be precise, the mood and the thinking about reform are not so much upbeat as slightly bipolar. So, for example, Andy Stern of the Service Employees International Union said at a recent Brookings Institution forum that all the ingredients needed for reform are at hand and that only sufficient political will is lacking. But moments later, Bob Reischauer of the Urban Institute argued that the technical and intellectual resources needed to design a credible reform strategy simply don’t exist in the current environment and will take years to muster. A well-functioning health system will require a mature capacity to assess the comparative effectiveness of new treatments and enough information technology to evaluate performance across the delivery system, Reischauer said, and we don’t have either.

If it were merely a matter of politics, such disagreements could be considered negotiable. But the chasm between these viewpoints seemed to reflect cognitive differences rather than run-of-the-mill rhetorical arguments. These pragmatic discussants were not divided over whether the public or private sector should lead the charge, as ideologues are; or whether the states or the federal government should be the locus of change. The question was, Are we ready or aren’t we? And among thoughtful people in the health policy world, there is no consensus on that point.

Another major fault line that has little to do with politics is a lack of consensus among the professionals -– payers, providers, and analysts -– about how the delivery system should or could be reengineered to function more effectively. All seem to agree that regardless of whether Medicare or Blue Cross is paying the bills, fee-for-service, cottage-industry, specialty-dominated medicine seems to get the incentives all wrong. But doctors have stubbornly resisted corporatization, despite the blandishments of pundits and visionaries. Post-Enthovian alternatives to structural integration abound. Episode-based payment, ad hoc or virtual integration at the microsystem level, a spectrum of reimagined physician-hospital arrangements –- all await their moment in the sun. But increasingly bitter competition between hospitals and physicians apparently remains the dominant reality on the ground, belying optimistic scenarios about back-door approaches to defragmenting care. How far can any reform go under such circumstances? It is not a question that can be answered on Capitol Hill, or in Albany or Sacramento.