Writing in this week's New Yorker, Atul Gawande, a doctor and justly celebrated health care scribe, is hopeful that the health care reform will leverage local experimentation in order to bring down costs:
The major engine of opposition, however, remains the insistence that health-care reform is unaffordable. The best way to protect reform, in turn, is to prove the skeptics wrong…The reform package emerged with a clear recognition of what is driving c
osts up: a system that pays for the quantity of care rather than the value of it. This can't continue.
…The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn't pretend to have the answers. Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.
That's the one truly scary thing about health reform: far from being a government takeover, it counts on local communities and clinicians for success. We are the ones to determine whether costs are controlled and health care improves—which is to say, whether reform survives and resistance is defeated.
Well, one hopes, though I'm not sure there's much reason to. Gawande's notion that the Affordable Care Act might work, although we can't really say how, is superficially appealing to those of us who see benefits in widespread experimentation. But it isn't all that convincing when compared to John Cassidy's more skeptical view, which appeared on The New Yorker's website last week. Cassidy offers a rather blunt assessment:
The official projections for health-care reform, which show it greatly reducing the number of uninsured and also reducing the budget deficit, are simply not credible.
1. The cost and revenue projections rely on unrealistic assumptions and accounting tricks. If you make some adjustments for these, the cost of the plan is much higher.
2. The so-called "individual mandate" isn't really a mandate at all. Under the new system, many young and healthy people will still have a strong incentive to go uninsured.
3. Once the reforms are up and running, some employers will have a big incentive to end their group coverage plans and dump their employees onto the taxpayer-subsidized individual plans, greatly adding to their cost.
The rest of his post expands on these criticisms, and it's worth reading in full. But the contrast between the two pieces and their respective outlooks is worth underlining. Gawande's cautious hopefulness comes down to a belief that, given our system's flaws, something had to be done to change it. The ACA is something. It might work. It might not. We don't really know. But it was better to pass it and try than do nothing. Cassidy, on the other hand, agrees that the system is a mess, but notes that, historically, the types of reforms it enacts have not produced their desired effects, and there is little evidence that should cause us to believe that this time will be any different. I suspect Cassidy and I would disagree on what sort of system would be more likely to work, but on this, I think he offers what is clearly the more compelling case.