As candidates for president unveil their plans for universal health coverage, it is also an appropriate time to reflect on broader issues, and to separate reality from political rhetoric. Let me try to do this by sharing some material from my in basket last month:

The New York Times highlighted a new trend of rehabilitation units in nursing homes. These units offer a more informal alternative to postoperative care at hospitals or affiliated rehab facilities. The article talked about competition in the medical marketplace. Rehab units offer nursing homes a new patient pool to counter loss of patients to home-based care and assisted-living facilities. The article talked about economic incentives. Rehab units give nursing homes access to younger and better-paying patients, and allow them to draw on higher Medicare, rather than Medicaid, reimbursement rates.

The Times noted that while nursing home rehab units can offer less expensive, more patient-friendly care than hospitals, they do so with a decrease in available medical services and equipment. The result, according to some data, is a reduction in quality of care. But most of the article was not about patient well-being. It was about enterprise and profit. It was about fragmenting care into commercial segments, not coordinating care or assuring quality.

The Times article coincided with the release of “The Illusion of Coverage: How Health Insurance Fails People When They Get Sick,” a study from The Access Project. That report examines extensive financial and medical problems resulting from high premiums and deductibles, co-pays and co-insurance, caps on coverage, uncovered services, out-of-network fees, and confusing provisions and administrative disputes and errors. The report coincided with a Kaiser Foundation webcast noting that most private medical insurance fails to meet the three essential criteria: that it be available, affordable and adequate.

Here again, underlying issues jump out. For one: With private insurance, the seller picks the customer, rather than the other way around. Hardly a free market! Secondly: Insurance companies make money not by providing care but by denying it. And finally: The object should not be to provide insurance, but to provide health care. And even then not just to provide care, but to assure the maximum possible quality of life.

That same week, Harvard Business School professor Michael Porter held a press conference in conjunction with an article in the Journal of the American Medical Association. Porter has an international reputation in the fields of competition and strategy. He puts forward a plan to reform the U.S. health-care system by focusing on the value of care to patients. Porter argues that improving the quality of medical services can by itself save money and provide a road map to a national health plan. “As important as insurance coverage is, insurance is just the beginning,” Porter claims. “If we just fix insurance, but don’t fix the delivery of health care, we might have a greater crisis than we have today.”

In his earlier book, “Redefining Health Care,” Porter points out that the goal should be health, not treatment, and that the value (outcome per cost) must be measured over the full cycle of care, not as a series of discrete procedures and interventions. He insists that the present system is based on the wrong kind of competition, at the wrong level, and on the wrong things. Instead of focusing on value to the patient, it focuses on competition between providers for a greater share of existing money, and on shifting the costs of care from one group to another.

As I was reading these reports, a friend brought me files from a daylong Health Care University for legislators held as part of a West Virginia Health Care Reform Project in 1994. Recommendation 1.1 called on the state to “implement and coordinate all health-care services into community care networks by July 1, 1997.” The goal was to create “a coordinated system serving the health-care needs of the whole individual, rather than a fragmented series of encounters or episodic treatment.” It is not as though this is an impossible task. This past session, the Legislature gave the go-ahead to Charleston Area Medical Center’s Program of All-Inclusive Care of the Elderly, which will provide comprehensive, community-based care for a small group of disabled and nursing-home eligible patients. For months I had been working on a paper: “We Know What to Do, Why Aren’t We Doing It?” As I read more and talked to more people, the title changed: “We Know What to Do and We’re Doing It. So Why Isn’t It Working?”

It’s not working because we are only playing around the edges. Pilot studies and demonstration projects do not have to confront the economic forces at play in health care today. When stakeholders come around the table to discuss health-care reform, to achieve a consensus, to “balance the needs of all,” they do so to protect their fiduciary interests, to assure the perpetuation and profitability of their share of the market.

Reforming health involves reforming health care, and reforming health care requires reforming the business of health care. While true reform will offer new opportunities to many, it will, of necessity or simply inevitability, hurt vested interests.

As things stand now, it does not appear that we will get true health-care reform until things get bad enough to embolden politicians to confront those interests, until the potential health benefits of reform outweigh the political risks of inaction. It will be a difficult political judgment call to know when we’ve reached that point. The Leadership Prize will go to the political figure who first makes that call, and gets it right.

Kurland is health action coordinator of Covenant House and creator of the Web site www.criticalreading.com.