It’s amazing how fast a year goes by. Last May, when I met with the selection committee for the Kaiser Media Fellowship, I outlined my project. Several folks on the committee said I shouldn’t wait until fall to begin. The health care reform debate might be over by then — or so we thought.

Of course it didn’t work out that way. My year as a Kaiser Fellow has been amazing because it’s paralleled so much of the legislative debate. I started writing columns (or blog posts, depending on your point of view) on July 6, 2009.

The Patient Protection and Affordable Care Act was signed into law on March 23, 2010. And now a different kind of debate begins. Federal agencies, primarily at the departments of Health and Human Services and Treasury, are writing regulations to implement the new law. There will be fights over words like “quality” and ways to define and measure success.

Heck, the government cannot even talk about the law without generating controversy. Republican Senate leader Mitch McConnell called a new Medicare brochure little more than propaganda. “The flyer purports to inform seniors about what the health care bill would mean for them. Much of it directly contradicts what the administration’s own experts have said about the law,” McConnell said. “So this is a complete outrage, and it’s precisely the kind of thing Americans are so angry about at the moment.”

That anger, however, depends on your point of view. On June 10, the health care reform law will become real to many seniors when they receive $250 rebate checks to fill in the “donut hole,” or the drug-coverage gap in Medicare Part D. Imagine the conversation in even conservative states when seniors start calling their congressional offices after a member proposes repeal. (“You want to take away my coverage?”)

Then again I understand the anger and the angst many Americans feel about health care reform. When I started this project my hope was to communicate some of the lessons about “government run” health care to a larger audience. There is a lot to learn from what the government already manages in the health care arena. But the fact is the country is not ready for that conversation. Indeed, even a simple brochure, one similar to those produced by government agencies everyday, generates a new manufactured controversy when it involves health care reform.

Yet as we rebuild the health system — one that everyone understands is broken — we need to keep focused on the big picture. To me this boils down to two simple themes: the demographic imperative and the cost of health care.

First, let’s consider the demographic imperative. We human beings — in America, in Indian Country and around the world — are living longer. That one trend changes everything in our health care system yet it is outside our political discourse. No one is to blame for longevity — and, indeed, who would not want to celebrate this trend? But a longer life span is costly. For example: Diabetes is the most expensive disease to treat and one of the key risk factors is age.

That leads to the second theme, which is financial. Medicare and Medicaid cannot continue without major shifts in thinking, in resource allocation, and even in tax support. This isn’t politics; it’s mathematics. We have to reduce costs, raise taxes and make sure more people have access to primary care. It's cheaper for all of us when patients can visit clinics instead of emergency rooms for treatment.

The law calls for an Independent Payment Advisory Board to recommend proposals to limit Medicare growth. (The Kaiser Family Foundation offers an excellent summary on the foundation’s website.) The panel’s mandate is tricky. On one hand the recommendations are supposed to be implemented (unless Congress objects to the entire package) to achieve budgetary targets based on the Consumer Price Index. On the other hand, the board is not allowed to suggest rationing, a tax increase or a reduction of Medicare benefits. Practically the only option left for them to consider is cutting payments to doctors.

It’s kind of funny. Other than making real cuts, the panel is free to explore any option. Yet a discussion of possible cuts is exactly the kind of debate we need to have going forward.

But the independent panel, or any step toward implementing the health care law, is not the end but the beginning of a long march. We’ve taken a step. Soon we will take another.

I still believe that at some point the U.S. health care system will look more like the Indian health system than the other way around. But that idea is even more divisive than a Medicare brochure. This is a debate saved for another day.

So, for now, I’ll continue to explore the impact of health care reform on the Indian health system. There are many changes ahead — some intended, and others unplanned. Most of these changes will at least open up the prospect of a better delivery system. I have much more to write about along those lines, and so a little good news: My fellowship has been extended through the summer. I’m grateful for the opportunity — and thanks for all those who read, comment and who send me ideas to explore.