Last weekend's historic vote by Congress for health care reform is a beginning. Access to affordable health care will be substantially expanded. Financial projections by the non-partisan Congressional Budget Office indicate that savings will be realized while care is extended. Substantial challenges remain if we are to offer opportunities for improved health to all Americans.

* New technology. Breath-taking advances in diagnosis and treatment abound. New technology enters the medical place continually, often before the possible advantages and risks can be properly evaluated. We assume that what is new will inevitably be better. Investors rally behind new technologies. Hospitals and clinics rush to purchase and to install the newest and latest instruments and therapies lest they be left behind by competitors. No rational system exists to determine how much of which new technology will be needed by a community. We have the equivalent of a medical "arms" race within many municipalities.

Just over the horizon are exotic new therapies based on our expanding knowledge of the human genome. Researchers speak of an exciting new era of personalized medicine in which our individual genome can be analyzed for possible risks for many diseases and for therapies that would work best for us in any circumstance of illness. This new technology will not be cheap.

Who will ultimately determine which new technologies will be deployed? Who will make the complex cost-benefit analyses? And will these be enforceable? Will every hospital feel compelled to invest in new tests and equipment? Will everyone have access to new therapies or only people with money and connections?

* End-of-life care. Years ago, I laughed when a lecturer at a national medical meeting stated that we were approaching a time when death would be optional. We may be there. Systems of life support are quite sophisticated. New organs can be transplanted or mechanical organs substituted for failed organs, in many instances without regard to the age or condition of the recipient.

If family members insist upon futile care--support of vital functions in the absence of any prospect that meaningful life can be restored, care-givers have little choice but to continue treatment. This is a complex area of the law, medicine, and religion that must be addressed lest we endlessly expand intensive care units to sustain vital signs in people whose brains have perished.

* Primary care. If health care is to be affordable, it must be carefully coordinated. Coordination is most readily achieved when each of has a personal care-giver who can interpret our health needs and make appropriate referrals for tests and consultations. Despite a slight increase in the number of senior medical students who chose primary care residencies (family medicine, internal medicine, pediatrics, obstetrics-gynecology) this year, the number does not come close to replacing an aging primary care workforce. As our workforce becomes progressively top-heavy with subspecialists of medicine, who will assume the tasks of making sure that care is relevant, safe, and affordable?

* Medical error and malpractice litigation. The two topics are closely linked. Too many preventable errors still occur in all locations where medical care is delivered. Tens of thousands of deaths result annually. Countless patients are injured and their hospital stays extended by such mistakes. When accidents occur in public transportation, we promptly dispatch teams of investigators to determine causes and to design corrective measures. We need similar mechanisms to investigate and thereby to prevent medical errors.

Once real medical error is defined, we need to evaluate timely, just, and efficient mechanisms for compensating victims. Our present system of litigation can impose delays of years and mammoth expenses in determining if, indeed, medical errors occurred.

* Disease prevention. Children and young adults are becoming more obese and sedentary. This will translate into a worsening epidemic of diabetes, heart disease, sleep apnea, and malignancies that could drive future health care costs through the roof.

I will address each of these issues in greater detail in future columns.

E-mail Clif Cleaveland at Cleaveland1000@comcast.net.