While I do have some preferences regarding how the system should move, one could envision either a market or regulatory dominant market depending on whether the right safeguards are in place, and here is the key, whether they work!

As far as a market driven system, how confident are open minded reformers that risk-adjustment schemes will succeed? That health exchanges will be firewalled appropriately? That adverse selection won’t overtake the enrollment process? On the latter in fact, I am very cynical, but who is to say.

As far as a public system, unlike the pundits who pounce away, the program is not an entitlement and it will rely on its own premiums and pay back all start up costs. Is this realistic? Can we really create a viable insurance company, which in essence it is (and make no bones, it will need to be a behemoth out of the box), building a qualified infrastructure with talented people in a culture of excellence? Medicare uses third party support for a slew of functions, and one can speculate that the buy or build strategy will be the next hurdle if we get a public option. How this plays, no one knows. Also, I am skeptical at the administrative operating costs proponents often quote (“3%”). More efficient yes, but not the home run people claim. For sure, registry creation, scale, transparency, etc., and “do well” intent is embedded in the mission and on this front I am highly encouraged, but Uncle Sam execution and Congressional hamstringing are the proverbial sticky wickets. Again, there is theory, and there is reality…

I could go on, and these are fleeting thoughts, but the “success or failure” of reform is contingent on whether you believe in the idealized versions of the different plans and the ideologies folks bring to the negotiating table.

As most spectators are, I am highly skeptical, and at best, whether you deem one approach over another superior, we will measure success in inches, not yards—no matter what path we stumble down. The substrate that is our culture is too darn broken and I don’t see it changing—not until things get truly desperate.

Regardless of the final product though, the process will be a lot of round hole, square peg type of dickering, make no mistake. Moreover, it so dependent on the legislation, and at this juncture, the bills seem a helluva lot more descriptive than prescriptive to me. Speculation on whether an MCO can or will do “x,” or the HHS Secretary can or will do “y” just seems like a big black box—and with that, how can anyone be expected to make a real EBM type choice. I can only say it is all gut at this point, and betting on efficient reform (I did not say no reform) is like betting on a hapless ball club—hope springs eternal.

Brad

Rob