We are a bit late getting to Atul Gawande's New Yorker article on health reform, and we wondered whether to post, or whether many of you had read it. But then we remembered a lesson from a complicated pregnancy: even during three months of strict bedrest, it's impossible to keep up with the New Yorker. So for those of you who still have the magazine with this excellent piece on your bedside table, here goes:

The essay, "Getting There From Here," starts with the obvious: people who don't have health insurance have sad stories to tell, and sad stories can compel a society to change. At least it compelled every other major industrialized democracy (and some non-industrialized, non-democracies, but Gawande doesn't dwell on those) to make sure people get health care. But maybe we are at the point finally when we, as a society, with a new leader, will find those stories not just sad but unconscionable.

Gawande makes the case for pragmatism, for building on the current system. Not because the current system is flawless. It is deeply flawed. But it works well for some people. And it's what we have. And contrary to what many believe, other countries including postwar France and Britain built their health systems on what they had, not through radical changes imposed by a bold legislative stroke. Their systems evolved because of the peculiar quirks of history, geography and circumstance, what social scientists call "path-dependence."

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

In our country, however, we get sidetracked in part because we get polarized, caught between different visions of an ideal system.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn't mean that ambitious reform is beyond us. But we have to start with what we have.

In the real world, radical change isn't always better; Gawande reminds us of the mess at the start of the Medicare drug benefit, which was a complicated market structure rather than a natural graft onto existing Medicare. He reminds us that our modern phone system is a jerry-rigged antique, "shaggy" and convoluted. It keeps getting fixed and patched, but it "made the twenty-first century possible. A health care system built on the current one, dependent on our own historical path, "will undoubtedly be messier than anything an idealist would devise," he says. "But the results would almost certainly be better."

Gawande lives and practices medicine in Massachusetts. And we all know the strengths of that state's experiment (it is covering people) and the weaknesses (it is costing more than expected, due in part though not completely to health cost trends outside the control of a single state.) It is imperfect. But since it was implemented Gawande has not had a single patient put off cancer surgery because he or she was uninsured. "That's a remarkable change: a glimpse of American health care without the routine cruelty."

"We're not going to get perfection," he writes. "But we can have transformation—which is to say, a health-care system that works. And there are ways to get there that start from where we are. "