In the 15 years since the Clintons and a few hundred handpicked experts famously failed to reform health care, a lot has changed -- for the worse. Life expectancy in the United States has fallen further behind that of other wealthy nations. Costs continue to rise and are now threatening an already weak economy. And more people than ever before -- some 45 million — are without health insurance.

The uninsured bear a more onerous citizenship, one that often forces them to languish in a medical no-man's land, as illustrated by a couple of recent front-page stories in the Valley News. Workers disabled by illness must wait two years -- yes, two years -- before they are eligible to receive Medicare benefits, The Associated Press reports. Many are uninsured, and one in eight die waiting. Also waiting are those with dental problems who can't afford to see a dentist. Here in the Upper Valley, the Red Logan Dental Clinic in White River Junction is struggling to keep up with demand for its free services, not only because the numbers of uninsured are rising but also because not enough dentists and hygienists are willing or able to volunteer their time.

Even those with health insurance are increasingly dissatisfied with rising premiums and the quality of care. A recent survey reported in the New England Journal of Medicine found that 70 percent of respondents favored major changes to the U.S. health care system. While there may never be a national consensus about how best to finance and deliver health care, the nation finally appears ready to have a more productive debate about what the federal government can and must do to ensure access to effective, efficient care for all.

Leading that debate, of course, will be President-elect Barack Obama and his designated “architect” for reform, Tom Daschle, the Health and Human Services secretary-designate. They cannot afford to repeat the mistakes of their Democratic predecessors, who sequestered 500 experts behind closed doors for months before delivering to Congress a proposal so complex few could understand it. This time around, the Obama team has signaled its desire to collaborate with legislators from the get-go. In addition, the transition team is engaging more broadly with the American people, a useful if unwieldy exercise. Relying on the same kind of Internet-savvy political organizing used during the presidential campaign, Obama and company asked volunteers throughout the country to host small group discussions about health care. Thousands of community meetings took place last month, producing reams of ideas from the grass roots.

This community is well suited to offer a bit of advice, too. After all, health care helps to fuel the region's economy, and knowledgeable people abound. Among them are researchers at the Dartmouth Institute for Health Policy and Clinical Practice, which studies and maps geographical disparities in health care as part of the Dartmouth Atlas of Health Care. Last month, the institute issued a set of priorities addressed to Congress and the incoming Obama administration.

Among the salient observations in the paper titled An Agenda for Change: The United States can afford to extend coverage to the uninsured -- but only if it curbs its voracious appetite for health care services. Thus, the authors advocate a less-is-more approach, arguing against the overuse of expensive high-tech procedures and intensive care, particularly at the end of life when such interventions often do no more than delay the inevitable. In fact, as the Atlas project has demonstrated, more spending on more procedures and hospitalizations does not result in better health or lower mortality.

The argument may sound counter-intuitive, even un-American. This country is unaccustomed to the idea of rationing the supply of health care services. But some rationing and redistribution must occur in order to slow spending that is projected to rise to 25 percent of gross domestic product by 2025. It's not an exaggeration to say that the nation's wealth depends to a large extent on its approach to health. As the Dartmouth report soberly concludes, “The need to reduce inefficiency and costs in health care has never been more pressing.”