What Many Liberals Don’t Understand About Health-Care Reform

Both liberals and conservative critics have charged that the health reform legislation that President Obama signed this spring focuses mainly on insurance coverage, and does little to rein in the spiraling cost of health care. This isn’t true. But the legislation is dense– and, as usual, the truth is more complicated than a lie. There is no single “fix” that will “break the curve” of health care inflation. The Affordable Care Act (ACA) contains multiple provisions that open the door to cost containment in myriad ways.

 In today’s issue of The New England Journal of Medicine (NEJM), Peter Orszag, director of the White House Office of Management and Budget (OMB) and OMB special health advisor Zeke Emmanuel explain how the bill will make Medicare more affordable:   “Perhaps most fundamentally,” they write, “the ACA recognizes that reform, particularly changing the delivery system, is not a one-time event. It is an ongoing, evolutionary process requiring continuous adjustment. The ACA therefore establishes a number of institutions that can respond in a flexible and dynamic way to changes in the health care system.”

What is most exciting is that under the new legislation, Congressional lobbyists will not be able to block the process: “The secretary of health and human services (HHS) is empowered to expand successful pilot programs without the need for additional legislation.”

Below excerpts from their “Perspective” in the June 16 NEJM:

 “Although the bill has now been signed into law, the debate over its design and intended effects has not abated. As concerns appropriately mount about the nation’s medium- and long-term fiscal situation, critics of the ACA have resurrected doubts about its cost-containment measures and overall fiscal impact. Many commentators have claimed that the bill focuses mostly on coverage and contains little in the way of cost control.

“Yet we would argue that even from a purely “green eye shade” viewpoint, the bill will significantly reduce costs.  . . .  the Congressional Budget Office (CBO)  . . .  has determined that the ACA will reduce the federal budget deficit by more than $100 billion over the first decade and by more than $1 trillion between 2020 and 2030. And the Commonwealth Fund recently projected that expenditures for the whole health care system will be reduced by nearly $600 billion in the first decade.

But these savings will be illusory if we do not reform health care delivery to bring down the long-term growth in costs, and the ACA puts us on the path to doing just that. In fact, it institutes myriad elements that experts have long advocated as the foundation for effective cost control. More important is how the legislation approaches this goal. The ACA does not establish a rigid bureaucratic structure to be changed only episodically through arduous legislative action. Rather, it establishes dynamic and flexible structures that can develop and institute policies that respond in real time to changes in the system in order to improve quality and restrain unnecessary cost growth.

So what are the cost-control elements of the ACA? First, some reforms aim to eliminate unnecessary costs to the system; these include measures against fraud and abuse in the Medicare and Medicaid programs, which the Department of Health and Human Services predicts will return approximately $17 in reduced spending for every dollar invested ($7 billion over 10 years, according to the CBO). Administrative simplification under the ACA will reduce unnecessary paperwork and create uniform electronic standards and operating rules to be used by all private insurers, Medicare, and Medicaid — saving the federal government an estimated $20 billion over 10 years and saving insurers, physicians, hospitals, and other providers tens of billions of dollars a year (according to the U.S. Healthcare Efficiency Index) . . .

“An estimated $1.1 billion will be saved in Medicare by calculating payment for complex imaging studies under the assumption that the machines will operate not just 50%, but 75%, of the time. And about $135 billion will be saved in the first decade by eliminating unjustified subsidies to Medicare Advantage plans.

“These savings are oriented toward reducing the level of health care costs rather than the growth rate of such costs. If that were all the legislation did, it would technically pay for health care reform but would miss an opportunity to put downward pressure on the growth of health care costs — an essential step in reducing our long-term fiscal imbalances. .. .  . .

 “ . . .Bending the curve” of health care inflation  . .  requires a more direct change in the way health care is delivered. Health care costs are unevenly distributed: 10% of patients account for 64% of costs. Many of these are patients with chronic conditions, such as congestive heart failure, diabetes, and hypertension. Sustained cost control will occur only with more coordinated care that prevents avoidable complications for patients with chronic illness. As Stanford’s Victor Fuchs has noted, coordinated care requires three “I”s: information, infrastructure, and incentives.

“Information will come from the spread of electronic health records, a process that will be jump-started by the Recovery Act’s $26 billion investment in health information technology. Electronic health records will supply providers with more accurate and real-time data on their patients, as well as provide checks on drug interactions and decision support to improve the quality of care. In addition, the Patient-Centered Outcomes Research Institute (PCORI) that was created by the ACA will empower physicians and patients with new information regarding the effectiveness of various medical technologies and interventions. The integration of the PCORI’s research findings with decision supports, guidelines, and other aspects of electronic health records should greatly enhance the information that physicians and patients can use in choosing the right tests and treatments for a particular situation.

“Infrastructure reform is evident in the law’s provisions supporting enhanced horizontal coordination among providers and more constant monitoring of patients. For physicians, health care reform encourages greater integration in many ways — for instance, through the redesign of delivery systems such as medical homes and accountable health care organizations. In addition, the law includes a new hospital readmission policy to address the fact that nearly 20% of Medicare patients are readmitted within 30 days after a hospital discharge and that lack of coordination in “handoffs” such as hospital discharges has been identified as a particular problem in the health care system overall. More than half of these readmitted patients have not seen their physician between discharge and readmission, and a recent study suggests that better coordination of care can reduce readmission rates for major chronic illness. The policy provides $500 million over 5 years to manage care for 30 days after hospital discharge and also imposes payment penalties on hospitals with high risk-adjusted readmission rates for certain conditions.

“These changes in information and infrastructure will not spontaneously affect how doctors deliver care; incentives within the system also need to be recalibrated, since the dominant fee-for-service payment system creates disincentives to making the changes necessary for coordinated care. In addition to the hospital readmission policy, the ACA will create incentives for hospitals to adopt proven practices that substantially reduce their rates of hospital-acquired infections and other avoidable conditions; hospitals that still have rates in the top 25% will face reductions in Medicare payments. Similarly, the ACA’s pilot programs involving bundled payments will provide physicians and hospitals with incentives to coordinate care for patients with chronic illnesses: keeping these patients healthy and preventing hospitalizations will be financially advantageous. (These efforts will also enhance physicians’ autonomy by allowing them to devise the best practices for keeping patients healthy.)

“Perhaps most fundamentally, the ACA recognizes that reform, particularly changing the delivery system, is not a one-time event. It is an ongoing, evolutionary process requiring continuous adjustment. The ACA therefore establishes a number of institutions that can respond in a flexible and dynamic way to changes in the health care system. The PCORI will assess new medical tests, drugs, and other treatments as they are developed, thereby providing continuously updated information for physicians and patients. Similarly, over the next decade, the Innovation Center in the Centers for Medicare and Medicaid Services will be developing, testing, and evaluating new policies and programs that enhance the quality of care for Medicare beneficiaries, reduce the cost of their care, or both. And the secretary of health and human services (HHS) is empowered to expand successful pilot programs without the need for additional legislation.

“The most important institutional change in the ACA, however, is likely to be the establishment of the Independent Payment Adviso
ry Board (IPAB), an independent panel of medical experts tasked with devising changes to Medicare’s payment system. Beginning in January 2014, each year that Medicare’s per capita costs exceed a certain threshold, the IPAB will develop and propose policies for reducing this inflation. The secretary of HHS must institute the policies unless Congress enacts alternative policies leading to equivalent savings
. . . .

“The combination of these three bodies — the IPAB, the Innovation Center, and the PCORI — holds the potential for providing up-to-date information and developing policies that can improve the quality of care and the value provided by the health care system on an ongoing basis. Ensuring that these new bodies live up to their potential and earn reputations for rigor and integrity will be one of the most important challenges as the implementation of the ACA continues.

“. . . one of the essential aspects of the legislation is that unlike previous efforts, it does not rely on just one policy for effective cost control. Instead, it puts into place virtually every cost-control reform proposed by physicians, economists, and health policy experts and includes the means for these reforms to be assessed quickly and scaled up if they’re successful.  . . .”

21 thoughts on “What Many Liberals Don’t Understand About Health-Care Reform

  1. Maggie:
    I appreciate your helping us to be aware of the many potential cost saving alternatives, and, more importantly, the fluidity of being able to adapt to changing circumstances.
    What I liked about Obama is that he continually stressed during the campaign that health care costs were our number one problem in getting our deficits under control.
    And, he emphasized we cannot grow our way out of the deficits.
    If peiple really took that message to heart, really believed they could make a difference long past their lifetimes, we would see a collective evolution, which these intriguing ideas could complement nicely.
    But, we must have an individual and collective change of heart, for our sakes, and for the sakes of those to follow.
    And, we have the perfect incentives to change our hearts: love and fear.
    Don Levit

  2. Thanks for the info Maggie! And your continued making us more aware of the situation.

  3. The ability to directly implement pilot projects aimed at reducing and preventing costs without direct congressional involvement is a significantly important part to reform being an ongoing process. In my view without this fundamental ability to adapt, some of the ability to control costs would certainly be lost.

  4. Don, Greg, Wellescent Health Blog, and Dr. Rick–
    Thank you all for your encouraging comments.
    I think Don is right–we have the perfect incentives to begin thinking differently about health care: love (of our children, our country and fellow citizens)and fear (that we, our children and grandchildren will fine ourselves priced out of the healthcare market.)
    And Wellescent is right, the fact that the legislation gives Medicare the ability to implement successful pilot projects is essential. This gives reformers the flexibilty needed to make reform a matter “continuous improvment” trying things, rejecting some, improving others– an ongoing process.
    Dr. Rick & Greg– thank you very much for your “continuous” support.
    Reform is so complicated. From time to time, I become discouraged trying to explain it in the face of so much misinformation, cynicism, and conservative fear-mongering. (This is particularly true when I am cross-posted on other blogs where the level of discourse is far less civil. I’m grateful to be cross-posted on blogs that address a broader audience, but this always makes me appreciate HealthBeat readers that much more.

  5. Maggie:
    I’d like to be a believer, but…as the final paragraph of your excerpt from “Perspectives” says: “it puts into place virtually every cost-control reform proposed by physicians, economists, and health policy experts…” And that may be the big problem with PPACA. The lack of a coherent strategy will make it more difficult—not easier—to contain costs. The quote is especially true of Medicare, where I’m concerned we will see many physicians abandoning the program in the face of death by a thousand bureaucratic cuts, leaving only those who have figured out how to continue to increase utilization and intensity—and costs. And, on the private insurance side, the one really worthwhile innovation—insurance exchanges—is made so complex, with so many choices—that its impact on price competition is likely to be minimal.

  6. Roger–
    First, I agree that as now designed, the Exchanges are too ocmplicated. But I think there will be far fewer choices than you anticipate. A great many insurers are going to find tha they can’t make a profit without cherry-picking patients, and under the new rules, that will be hard. States also are going to be making it much harder for insurers to raise premiums.
    My guess is that a fair number of insurers will get out of the health insurance business –even before 2014.
    Look at their profit margins. Look at the prices of their stocks . .
    Regarding your other comment: I’m afraid that the only way to reform heath care in a rational way (rather than simply taking an axe and rationing it) is to use a scalpel–which means making many cuts aimed at reducing errors and waste while moving phsycians away from fee-for-servce, which reward volume.
    Under reform, Medicare will be providing financial incentives that reward efficiency and better outcomes–doing less and doing it well, providing the right care to the right patient at the right time.
    Also, this is a big country; what will work in one place won’t work in another. That’s another reason that so many different programs are needed.
    If there were a single coherent strategy that would accomplish what we want to do, reform would be easy.
    It won’t be easy– and my guess is that changing the way providers deliver care will take about 10 years.
    But those who aren’t willing to be part of the many programs aimed at higher quality and lower costs will find that they aren’t eligible for bonuses. Their incomes will remain flat to down.
    In addition, hospitals and doctors that are “outliers” in terms of doing more tests and more treatments will find that Medicare will be questioning high volume, asking for an explanation, and ultimately, just won’t pay for unnecessary treatments and tests.
    Over the next 10 to 15 years, doctors who believe in evidence-based medicine will be explaining to their patients that “more care” is not necessarily “better care.” They’ll be explaining the hazards of tests. They be explaining tha a great many seniors are over-medicated and undergo unnecessary surgeries.
    Don Berwick will, I think be very effective in talking to the public– he’s a marvelous communicator.
    Already, Medicare is beginning to refuse to pay for a high number of preventable readmissions and is cutting reimbursements for tests done in the doctor’s office.
    Docs won’t be able to game the system by increasing volume.
    Some physicians may well give up taking Medicare patients–though only relatively young, very succesful docs will be able to fill a practice with non -Medicare patients. (Younger patients tend to like younger doctors. It would be hard for most physicians who are, say, 55 to 70 to fill a practice without taking Medicare).
    Finally, private insurers have already indicated that they plan to follow many of Medicare’s reforms–questioning volume, etc.
    Some physicians who aren’t comfortable with the changes will retire early.
    Surveys show that ounger physicians and women M.D.s are more likely to be comfortable with joining large accountable care organizations, working on salary, collaborating, seeing medicine as a team sport, etc.
    And more and more NPS will be working in teams with doctors.
    Finally, if we achieve what we hope to achive–putting the focus on “prevention” rather than “cure”– we’ll need fewer specialists because fewer patients will be undergoing surgeries and other intensive treatments.
    And you may be surprised–you may like the new Medicare more than you expect.

  7. What a load of bullocks. After you all are done patting yourselves on the back and agreeing that the interjection of another rationing third party is going to be awesome, try asking yourselves one crucial question. When has the United States government ever instituted a plan that has actually bent the cost curve for healthcare or any service without dramatically reducing its quality. It hasn’t. Ever. This is why the majority of practicing physicians, as well as a majority of Americans, are still opposed to ObamaCare 60-40. Furthermore, passing this bill in the manner the Dems did, with bribes, threats, legislative gimmicks, etc will be punsihed by the voters in Nov just as the GOP was punished for getting us into Iraq. And any president who calls his constituents ‘tea-baggers’ deserves a massive midterm defeat. So don’t hubristically sink your teeth into my healthcare just quite yet. Repeal & replace.

  8. What is it with Randians and poor spelling?!?!? The word DrGalt was probably seeking (amidst the invective and pejorative labeling) was”bollocks”. “Bullocks” are probably what actress Sandra’s neighbors’ exclaim when her pooch digs up the flowers on the adjoining boundary for the umpteenth time…

  9. By reducing Medicare payments, all the ACA will accomplish is reducing the number of Medicare providers. We know where that leads: increased costs from increased emergency hospital admissions.
    Marginally increasing funding for fraud detection will yield marginal increases in fraud detection.
    Prediction: As long as the government funnels taxpayer dollars through private providers for Medicare, we will see no savings. Similarly, as long as the rest of us are mandated to pay private insurers for healthcare, we will see no savings.
    It is nice though that we’re giving private industry a $26b subsidy so that they can more easily cherry-pick desirable health consumers.

  10. Gene, Dr. John Galt, Cassandra, John
    Gene–It seems to me that somene who so vehemently opposes the legislation should at least read a summary of the bill.
    If you did that you would know that the legislation ELIMINATES THE OVERPAYMENT TO MEDICARE ADVANTAGE INSURERS.
    IF you bothered to check your facts by Goggling, you would know that the legisaltion does NOT CUT MEDICARE PAYMEntS TO ANY PHYSICIANS.
    In fact it provides a 10% pay increase to many docs– primary care docs, geriatricians, general surgeons, family practioners . . .
    The SGR cut in doctors’ fees that Congress is refusing to implement has NOTHING TO DO WIHT REFORM LEGISLATION. This was a formula passed in 1997 and Congress has never implemented it–and never will..
    See my recent post on why
    MEDICARE WILL NEVER SLASH PAYMENTS Across the Board to physicians.
    As for Medicare patients winding up in ERS, the legislation doubles the capacity of community clinics that will be open after hours. People who show up at the ER with something less than a medical emergency will be sent to these clinics.
    Who will staff the clinics– physicians and Nurse-practioners. (The legislation provides funding for many more NPs in the form of pay hikes for their teachers as well as loan forgiveness, scholarships and pay hikes for the NPS.
    Gene, when you don’t try to get your facts straight you wind up spreading misinformation. . . . I realize that’s not your intention, but if you’re not sure of something, it would be more helpful to raise the question in your comment (doesn’t the legislation continue to pay an enormous bonus to Medicare Advantage insurers?) rather than assert something that just isn’t true.
    Dr. John Galt–
    Please see Cassandra’s comment right above yours.
    I’m afraid she has a point. When people are ranting, their English tends to fall apart. (“Don’t hubristically sink your teeth into my healthcare”???)
    Btw have you ever tried the post office’s overnight of 2-day mail?
    Much less expensive than Fed Ex and more reliable than UPS. I’ve used it many, many times and find it affordable and very efficient.
    Finally, Cassandra’s right– on this blog we try to avoid “invective and pejorative labeling”–it only undermines your credibility.
    Cassandra– nice riff on bullocks!
    Clearly you haven’t looked into who is on the Independent Advisory Board or what it is charged with doing.
    I suggest you Google “Independent Advisory Board” -you might learn something.

  11. I wish you all well in coming to grips with this difficult issue, but there is an elephant in the room you are not willing to speak of. It’s the problem of Science Progress creating more and more possibilities for medical analysis and treatment. Soon, if not already, the nation’s budget would be spent many times over giving everything to everyone. If you won’t COME UP WITH A SYSTEM OF RATIONING, you’ll just have to go on hiding the need for it.
    In a world run by engineers instead of humanitarians and diplomats, a solution would be worked out roughly like this: First the president would announce we need to have a sense of our nation’s ethical sensitivities. We need to know how people feel about some tough questions, and finding out how they feel, we need to come up with some kind of consensus. Engineers and statisticians know how to do this. The kinds of tough questions we need to ask are: What proportion of our health dollars should we spend for the young versus the old? For convicted criminals versus working citizens? For those contributing financially to the health care system and those who are not? Who is more worthy for a heart and lung replacement, the one who will benefit the most? or the one who has been waiting the longest?
    Once we have sorted out the facts on the moral sensitivities of our population, engineers and statisticians will be able to define a SYSTEM OF RATIONING that best represents it. We don’t need to abandon our system of political fights among lobbied elected representatives. We simply need to have defined the SYSTEM OF RATIONING and then let the voters choose between that and what our politicians come up with.

  12. Jon–
    The U.K. is the only country in the developed world that rations as you describe– making descisions about what surgeries should be available to people over 85, etc.
    The UK must do this because while Margaret Thatcher was prime minister, she slashed the healthcare budget.
    In recent years, they’ve been allocating more money to healthcare, but still spend less per person than most countries in the developed world.
    The U.S., by contrast, spends about 50% more. We have to put a lid on our spending, but in order to do that, we don’t need to ration.
    We simply need to cut out the totally ineffective care.
    Much research shows that 1/3 of our health care dollars are wasted on tests and procedures that provide NO BENEFIT for the patient. And often these treatments do the patient harm. WE also over pay for drugs, devices and some services.
    For example, more than half of the bypasses and angioplasties that we do offer no benefit: mortalisties are not reduced; patients don’t live even one day longer.
    Most back surgeries offer no benefit.
    The same is true of PSA testing and treatments for early-stage prostate cancer.
    Over 80,000 Americans over the age of 80 receive pace-makers. Unfortunately, a large share of people in their 80s suffer from Alzheimer’s or another form of senile dementia.
    They are easily identified.
    Their body has already outlived their mind. By putting in a pacemaker, you all but guarantee that that the body will live another 10 yaers, while a mute, uncomprehending person is trapped inside.
    Most of us would agree that we wouldnt’ want our life–or the life of a loved one– prolonged at that point.
    But some hosptials and doctors insist. (See the NYT magazine story that I just posted on– “ONe Family’s Story”)
    If Americans knew the facts about bypasses, angioplasties and back surgery, most wouldn’t want them.
    We don’t need engineers to help us make dispassionate hard choices about who deserves health care.
    We need more physicians who are totally honest with patients about the risks vs. benfits of treatments, and the reasons why, in some cases,
    they would be better off without the treatment.
    Some people think that in the future, human geonome reserach will lead to “customized medicine” that everyone will want and that society won’t be able to afford.
    This is mainly hype.
    See this recent NYT story which begins:
    “the primary goal of the $3 billion Human Genome Project — to ferret out the genetic roots of common diseases like cancer and Alzheimer’s and then generate treatments — remains largely elusive. Indeed, after 10 years of effort, geneticists are almost back to square one in knowing where to look for the roots of common disease.
    “One sign of the genome’s limited use for medicine so far was a recent test of genetic predictions for heart disease. A medical team led by Nina P. Paynter of Brigham and Women’s Hospital in Boston collected 101 genetic variants that had been statistically linked to heart disease in various genome-scanning studies. But the variants turned out to have no value in forecasting disease among 19,000 women who had been followed for 12 years.
    “The old-fashioned method of taking a family history was a better guide, Dr. Paynter reported this February in The Journal of the American Medical Association. ”
    In the 1960s and 1970s medical science was making progress by leaps and bounds. This is no longer the case.
    Over the past 20 years we have made relatively little progress in extending how long people live.
    The things that we could do that would make a real difference are low-tech:
    get people to stop smoking; launch a war on poverty so that fewer people lead lives that are so hopeless that they self-medicate (drugs, alcohol, etc) and really don’t care about their physical health; make sure that poorer people have safe places to exercise and access to nutirious foods– fresh fish, fruits and vegetables–both in public schools and in their neighborhoods so that they don’t become obese.
    At this point, we’re over-spendign on high-tech medicine, surgeries,etc.
    We need to use the comparative effecticness research that we have to cut back on treatments that do patients no good–and often hurt them.

  13. I would like for the reform to work, but I’m afraid it is about 15 years too late.
    These links tell me that US medical care is way, way overpriced, & that healthcare is the next sector to be outsourced.
    Personal note: In 2006 my wife walked into a Baylor hospital in Dallas, Texas & said: “I’ve got blood coming out of my rear end”. They kept her 5 days, never figured out what was happening, & the 1st bill was for $27,500.
    Two weeks ago she walked into an NHS hospital in Coventry, UK & said: “I can’t breathe”. We were out in 90 minutes & they didn’t charge me a penny, even though we don’t live there.

  14. Bob–
    Your wife’s experiences pretty much sums up the difference between healthcare in our for-profit system and healthcare in most of the developed world . ..
    And it certainly would have been much, much easier to do this about 15 years ago, when the Clintons proposed it.
    But now we will do it– because we have no choice.
    If we don’t reform health care, 90% of Americans won’t be able to afford even “good” (not excellent) care in the not so distant future.
    That isn’t politically acceptable, so at last, politicians will stand up to the lobbyists.
    I learned a great deal about for-profit health care while I was senior editor at Barron’s from 1986 to 1998. And for the last 7 years, I’ve studied health care and health care reform full-time.
    So please believe me when I say that
    a) health care in the U.S. is overpriced and
    b) Americans are overtreated.
    About 1/3 of our health care dollars are spent on unncessary, unproven and sometimes unwanted tests and treatments.
    This can be changed– the health care legislation sets out to do that.
    We’ve been living in a health care “bubble”– not unlike the stock market bubble or the real estate bubble. Many of those who make a profit on heatlh care have been making indecent profits that the rest of society cannot afford.
    The bubble will be popped. This will be painful. Those whose oxen are gored will howl. (Mainly drugmakeres, device-makers, hospitals that over-charge and over-treat –and some, very well-paid specialists (those earning over, say, $400,000 a year– sometimes $1 million or more)
    They won’t be happy, but they represent a minority, and we just cannot afford to keep the bubble afloat.
    As for “outsourcing” medical care–I’m assuming you’re talking about medical tourism.
    This is a possible alternative for the wealthy –but it’s risky.
    First, it’s expensive becuase while the treatment is much cheaper, you’ll need to fly there and stay in a hotel before and after.
    If you are sick you really, realy don’t want to fly to India or Thailand coach. Do you know what 1st class airfare to these countries costs?
    Secondly, in develping countries that have good health care for their wealthier citizens and tourists (India, Thailand, etc.) hotels are very, very expensive. I’ve been there. There are no middle-class hotels –just luxury hotels and low-priced hotels for young back-packers (not for someone recuperating from an operation.)
    Figure $300 to $600 per night.
    In addition, you would be crazy to go into a hospital either here or abroad without a friend or relative to serve as a patient advocate.
    Double the cost of airfare, and raise the cost of the hotel and other expenses.
    Finally, the risk: if something goes wrong with an operation in another country, you have no recourse.
    You can’t sue for malpractice–even to recover money lost payiing for a botched procedure.
    The doctors and hospitals there won’t re-do the operation at no cost. In most cases, they won’t want to admit a mistake was made. (Bad for medical tourism).
    And chances are, by the time you figure out that something is very wrong, you’ll be back home. And no one here is going to want to try to re-do an operation done aboad.If they do, they will charge you royally. (They’re not sure what they are getting into.)
    A great many people are hyping medical tourism as an alternative, but it’s just that–much hype.
    For healthy, wealthy people who want to combine a luxury vacation with a knee implant, this might make sense. (Though I don’t like the lack of recourse.)
    Moreover, if you have good insurance, you won’t save that much by going abroad.

  15. Maggie,
    You are right, of course.
    Besides (1) data on the moral sensitivities of our population, we need (2) cost effectiveness estimates of medical procedures. This is not rocket science, but many practitioners, drug companies, etc will not agree with the effectiveness estimates. Next is the process of “modeling”. Scientists, engineers, and statisticians do this all the time. A health care system model can be assembled that best matches the data of (1) and (2).

  16. Maggie:
    You may be optimistic about the new legislation, but the conservatives are even more optimistic about their prospects under it. And for reasons opposite to yours. See this report from a meeting of the Health Enterprises Network (try to get past the single payer source). http://seminal.firedoglake.com/diary/55674
    GOP Health Expert: Medical Industry to ‘Boom’ Under New Law

  17. While these cost savings of a few billion here and there over 10 years are nice, they are peanuts because we currently waste $1 trillion per year (310 m people x $3500/yr) compared with every other developed country.
    Being a little more efficient here and a little better there won’t do much to change the waste that goes on by the health care price gougers.
    What we need is single payer health care, not overpriced health insurers and self-funded corporate health plans, who are nothing more than expensive middlemen. There needs to be government control over the drug prices, hospital charges and overhead that costs us $1 trillion per year.
    They have no incentive to significantly change the system, which is why they buy up Congress to keep the status quo.
    The Obama plan is a miniature band aid on a profusely bleeding patient. The biggest cause of future budget deficits is the continuing, unjustified rise in the cost of health care.

  18. Foon the Elder–
    All Western European countries have exactly what you are suggesting: ”
    control over the drug prices, hospital charges . . .
    In these developed countires, gov’t also has control over the cost of medical devices adn doctors’ charge. And they regulate private insurers.
    No Country in Western Europe Has a “Single-Payer System” Run by the Gov’t.
    We don’t have to go to singe-payer (which would mean asking everyone who has employer-based insurance to give it up– very complicated)
    in order to enjoy all of the savings that other developed countries have discovred.
    But we do need to regulate private isurers. The healthcare reform legislation lays out some pretty strong rules to do that. Now we have to make sure that insuerers don’t try to cheat and “game” the rules.
    I’m pretty confident that the Obama administration won’t let that happen. See the statements that Obama has made about the insurance industry, after passing the legislation.

  19. ACarroll–
    I wouldn’t worry too much about what Scully says.
    Take a look at health care stocks on Wall Street.
    Many are not doing very well. This is because investors are skeptical about reform legislation marking a “boom” for the for-profit health care industry.
    Of course, Wall Street is often wrong. But usually, it’s wrong when it’s too optimistic (everyone wins if stocks go up), and less likely to be wrong when it is dispensing bad news (which Wall Street customers do not want to hear.)