>It seems that for this to work we'd have to maintain some intestinal fortitude to say "no" - and that to me sounds like a serious culture change in this country.

I'd argue that the culture is currently overwhelmingly biased toward saying "no," usually under the guise of "freedom" -- if we couldn't say "no" to the chronically homeless, we probably wouldn't have a half-million of them on the streets. If we couldn't say "no" to low-income mothers, we wouldn't have the highest maternal mortality rate in the developed world.