In the last week, a daunting prospect arose for the nation's troubled health-care system - namely, that it's too expensive to keep running as is, yet also may be too costly to fix.
In other words, the 800-pound patient of health-care reform - its cost - has taken a seat in the waiting room and is refusing to leave until the doctor arrives.
President Obama understands reform is critical to the nation's well-being. But it's both inevitable and important to face the reality of the cost. It's a hurdle that each of the many overhaul plans being drafted by Congress will have to clear.
First out of the blocks was a proposal from Sen. Edward M. Kennedy's health committee, and the results weren't pretty. The nonpartisan Congressional Budget Office said the plan would cost $1 trillion over a decade, while covering only one-third of the 46 million uninsured.
Other plans were being priced even higher, at upwards of $1.5 trillion for 10 years.
On the cost-savings side of the ledger - a critical element of success for Obama's hoped-for reforms - CBO director Douglas Elmendorf warned last week that health-care economies can be elusive.
Elmendorf's outlook wasn't quite as pessimistic as the Republican senator who called the health industry's pledge of savings "fairy dust," but the note of caution was just as strong.
Little wonder, Democrats in Congress last week were scrambling over various plans to finance the sought-after goals: getting everyone covered, improving quality, and controlling runaway spending growth on patient care and rising insurance premiums.
So far, though, the fiscal options being kicked around don't look promising from the perspective of this region or its key health-care stakeholders.
Axing more than $600 billion from Medicare and the federal low-income health insurance program, Medicaid - with most of those cuts absorbed by hospitals - would be a tough nut for health-science centers like Philadelphia. As for using the cuts to drive reform, the CBO was right to characterize them as blunt instruments of reform just as likely to "create risks for providers and patients."
On the tax front, the continued march in Congress toward some form of taxing employee health benefits would be unfair to regions - like this one - where employers have provided comprehensive benefits. Even a nuisance-style tax like the House idea to tax soda and other high-sugar drinks would be preferable.
The fairest means of paying for health-care reform would be a broad-based revenue source that doesn't produce winners and losers. Combine that with targeted controls on health spending tied to quality and efficiency. That would give all Americans a stake in seeing reform succeed.
Confronting the cost issue is a real hurdle that everyone in Washington must grapple with if there is going to be bipartisan support for any real reform.