A Supreme Court decision, surprising to many, has allowed the health reform experiment to proceed, but it doesn't guarantee its success. If President Obama wins re-election, that may still be unclear at the time of the 2016 election and could be an issue then.
As Massachusetts is learning, getting all to buy insurance is relatively easy, but doesn't bring costs under control, which is inevitably more difficult and painful.
Those who created the law the Supreme Court affirmed believe we're consuming more medical services than we need to and that cost worries would abate if we could bring consumption down to an appropriate level. Interestingly, conservative health reformers like Paul Ryan share that perception, but differ on how to best achieve this goal. They think market forces could do the job while supporters of President Obama basically support research to prove what works best and then a campaign to make such care the norm.
They would like to think that providers will voluntarily adopt what experts see as optimal treatment protocols, but our experience with PSA tests for men and mammograms for women suggest changing behavior may require a stick along with the carrots encouraging electronic medical records and accountable care organizations.
While providers are fairly prompt in abandoning remedies proven to be bad, they're slower to replace those that have very marginal positive results that can be achieved with cheaper options.
Patients understandably have more of an interest in the micro picture -- their condition -- than the macro one -- the nation's health bill-- and tend to side with the providers they're closest to in such debates.
That's the central stress point in the health reform debate. Most people are satisfied with the care they're getting and don't want it compromised as part of an effort they perceive as broken. A Washington Post-ABC poll found that 75 percent have a favorable impression of the care they receive and 56 percent have an unfavorable impression of today's health system. In fact while 35 percent have a strongly unfavorable impression of the system, 42 percent have a highly favorable view of their care.
Those numbers may explain why the public tends to prefer the highly decentralized decision-making by individual physicians we have now where personal experience often trumps research. The public is very wary of such a new approach -- which some wrongly construe as the introduction of rationing -- because they see little evidence of overconsumption and often think they're already being denied the care they need now.
That results in a very basic dispute where the experts think we could improve American health status by delivering less while the public thinks the answer is more.
Harvard's Bob Blendon, a longtime astute observer of public attitudes toward health reform, and is colleagues point out in a recent blog that two-thirds of Americans think the issue is shortage rather than surplus when it comes to medical care.
Legislators who voted for this legislation have quietly embraced a conservation ethic in an effort to move the society to view medical care through the same lens used to judge calorie or petroleum consumption -- basically that less is better. But they've yet to sell that view to the public -- or even articulate it. Until that perception changes, reform will continue to be an uphill battle.