Surgeon-writer Atul Gawande suggests in a recent New Yorker magazine article that controlling health care costs will be an evolutionary process, a town-by-town struggle, painful in spots, but ultimately manageable because it will take place over many decades. The incentives for delivery system changes contained in the Senate health care bill are, in his view, a significant down payment because they highlight best practices that will be implemented gradually over the next several decades.

The Senate devoted long sections of its 2,074-page health care reform bill to promoting wellness, both in the Medicare and Medicaid populations and among the privately insured. The bill establishes demonstration wellness projects in government programs and asks all insurers to report on what they do to promote better health.

And, in what at first blush looks like a bold use of economic incentives, the bill permits employer-based insurance plans to award premium discounts of up to 30 percent to plan beneficiaries who participate in smoking cessation, stress management, physical fitness, nutrition, weight management, and heart disease and diabetes prevention programs as long as the programs are "not unreasonably burdensome (and) are not a subterfuge for discriminating based on a health status factor." Current Labor Department regulations limit the incentives to 20 percent of plan costs.

Promoting wellness makes sense. An estimated 20 percent of Americans suffer from chronic conditions like heart disease and diabetes that arise from being out-of-shape and overweight. Chronic disease now account for 75 percent of all health care costs.. Nearly half of all cancers are related to smoking and obesity. Reducing chronic disease and adopting significant cancer prevention strategies (as opposed to screening, which is early detection) are key to any strategy that hopes to hold down the rate of growth in the nation's $2.4 trillion health care tab.

But do private insurers, which will add tens of millions of new customers to their 170 million-person base through the new subsidies in the bill, have the know-how that will convince employees and their families to participate in wellness programs? Will financial incentives like those allowed by the Senate bill encourage greater use? And, most importantly of all, will employer-based wellness programs actually succeed in reducing health care costs?

How solid is the evidence behind the new targeted therapies for fighting cancer? Not very, according to a new technology assessment from the Agency for Healthcare Research and Quality.

Safety has become a nagging question for millions of Americans lining up for flu vaccines this fall. While some fear extremely rare events like Guillain-Barré syndrome and others believe there is a connection between autism and trace amounts of the mercury preservative thimerasol contained in some of the vaccines, the bigger worry comes from the increasingly globalized nature of the drug and vaccine manufacturing industry.

The 2007-08 heparin scandal, where nearly a hundred people died from taking a blood thinner made from imported Chinese heparin, has given people ample cause for alarm. As former Food and Drug Administration associate commissioner William Hubbard wrote recently in the Archives of Internal Medicine, the heparin scandal's contributing factors included a "primitive" Chinese raw material manufacturing facility, no regulation by the local authorities, no prior FDA inspections of overseas facilities, and a finding of gross violations of basic "good manufacturing practices" when the FDA finally did show up.

With two Chinese manufacturers now licensed by the China State Food and Drug Administration to produce H1N1 flu vaccine, can the safety of the local supply be trusted? "The U.S. flu vaccine is not coming from China, it is coming from FDA-approved manufacturers in the U.S. and Europe," said Andrew Pekosz, an associate professor of molecular biology and immunology at Johns Hopkins University's Bloomberg School of Public Health in Baltimore. He was responding on an online Washington Post forum last week to someone who had heard from a health care worker that the vaccine was Chinese-made.

Even if this year's supply comes from advanced industrial countries with good manufacturing records, how long will that remain the case? Given this year's logjam in production and the increasingly prominent role foreign manufacturers are playing in the vaccine business because of their lower costs, it is inevitable that more of the U.S. vaccine supply will be coming from abroad, especially Asia. Will the FDA be able to police the vaccine industry's increasingly sprawling manufacturing network?