During the heady early days after Barack Obama’s election, oncologist Ezekiel Emanuel, now a health care adviser to the president, wrote a blog for the New York Times with the headline “Think Big.”

The blog item, not surprisingly, foreshadowed what the Obama administration would attempt to do. Thinking very big indeed, Emanuel noted:

“Health care reform cannot be considered in isolation. The new administration must remember that health care is so big — $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform.

“Consequently, if the heart of Mr. Obama’s economic policy is job creation, then it is contradictory to have a health care reform built on an employer mandate or to fund reform with a payroll tax. Employer mandates and payroll taxes stymie job formation.

“Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration’s health care reform effort. This builds grass roots support.

“Since 1913, the United States has been trying to achieve comprehensive health care reform. If the Obama administration finally does it, it will truly be history making. The challenge is huge, but the rewards — for the administration and every citizen — will be even ‘huger.’”

Skipping over Mr. Emanuel’s strange notion that coercion is a component of building grassroots support, the problem is: Emanuel’s big thinking. It is not necessary to restructure the whole of society and government to reform healthcare. A good piece in Fortune magazine proposes ways in which, thinking small, we really can improve our health care system.

“Unlike the House bill that fills 1,100 pages, my proposed health-care plan can be expressed in four simple bullet points. The marketplace, with more than 100 million consumers writing their own checks, will take care of the rest,” writes Shawn Tully.

I urge you to read the piece, as I am going to address only one of the four points: people with pre-existing conditions, a particular challenge for a free-market system.

The person with pre-existing conditions is in the most difficult situation: If one thinks of it in strictly insurance terms (and this is my analogy, not Tully’s), this person’s demand to be unconditionally insured would be like the owner of a boat with a hole in the bottom demanding a policy from the old Lloyd’s of London for a policy—I think Lloyd’s finally insured a few too many great ships that went down, and the outcome was a disaster.

But the medical needs of such people are heart-rending. Can society really accommodate them without restructuring?

Tully says yes:

“It’s clear that to make a mostly free-market plan work, those with chronic illnesses need to be protected. Fortunately, the template is already in place. About 30 states, usually those without requirements for community rating or guaranteed issue, have high-risk pools that automatically enroll people with pre-existing conditions. Their premiums generally can’t exceed 150% of the average plan within the state, even though the patients may actually cost far more. The full costs of the high-risk pools are covered from state income- and sales-tax revenues.”

The key to Tully’s suggestions is thinking small—or, at least, a lot smaller than Mr. Emanuel. But Tully seeks not to make history but to reform healthcare. Which, come to think of it, would be historical.