The people who will really decide whether health-care reform succeeds or fails

By Ezra Klein

The New Yorker isn't allowing Atul Gawande's latest article out from behind the paywall, but you can read the abstract here. The basic point is well worth keeping in mind amid all the arguments over the Affordable Care Act: Health-care costs -- and thus our paychecks, and the federal budget -- won't be decided by how we deliver and structure health-care insurance. They'll be decided by how we deliver and structure health care. And though national policy has a role in that, it's not always a huge role, and it's not usually a controversial one.

Gawande relates a series of stories showing innovation in the toughest corners of the care-delivery system. The most inspiring is about Jeffrey Brenner, a Camden-based physician who began playing with his city's hospital claims data and making maps of where the money was being spent. It turned out that there were two city blocks, containing two particular buildings, where 900 people were responsible for "more than four thousand hospital visits and about two hundred million dollars in health-care bills" over the past seven years. So that's where he focused.

Insurers try to run from the costliest patients. They try to kick them out for having preexisting conditions, or they rescind their coverage, or they price coverage beyond their reach. That just makes them costlier, of course. Inconsistent access to medical care means more medical emergencies, and more medical emergencies mean higher medical costs. Brenner, by contrast, is lavishing them with attention. He's calling them daily. He's checking up on their medications, their lifestyles, their habits. He wants to open a doctor's office in their building. His patients averaged "sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after — a forty-per-cent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after — a fifty-six-percent reduction."

We don't really know if his success can be replicated. But somebody'scan be. And that'll be where policy -- in particular, where Medicare -- comes in. The administration's vision sees things running something like this: A promising experiment or pilot program will come to the attention of the newly established Center for Medicare and Medicaid Innovation. The center will fund it on a larger scale and study it more intensely if. If it proves promising, the Independent Payment Advisory Board will force Medicare to implement it fairly quickly. And history shows that if something works in Medicare -- and, quite often, even if it doesn't -- it's soon adopted by private insurers.

That's if all goes well, of course. And all may not go well. But it's important to keep in mind that we know who costs the system money: Sick people. And we know what costs the system money: Their health care, particularly when it involves catastrophic or chronic conditions. So from a cost and quality perspective, this is where health-care reform will live and die: In doctor's offices, in community health centers, in operating rooms and in people's homes.

Insurers can play a role here, as can Medicare. But for the next few years, cost control is going to be less about setting national policy than about setting up the experiments that allow us to test what national policy should be. The Affordable Care Act's contribution to this is money, a center dedicated to bringing these experiments up to scale and a reform process that makes it easier to seed them in Medicare. But for all that to work, the component pieces need to remain in place, and some of the experiments actually need to pan out.

Photo credit: By Pat Sullivan/Associated Press