Healthcare has had a long history of self-improvement. Hospitals had their own scandals. And nursing homes didn't -- even as scandals and exposes about poor-quality care, abuse, and fraud in nursing homes became depressingly common. The lessons of the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), the reform legislation, are 20 years later still there for all the educations. The Institute of Medicine's 1986 report on "Improving the Quality of Care in Nursing Homes" was both groundbreaking and mundane -- mundane in that so few of its 100-plus recommendations were either revolutionary or even objectionable. Enforcement was and is a critical part of OBRA, a necessary part, if you will. But how people enforce it is critical to the ultimate success of the legislation.