As for the ACA's other cost controls, they're mostly fluff. One idea is "accountable care organizations" (ACOs), which link payment to better coordination of medical treatment. The administration says its ACO proposal might save $470 million from 2012 to 2015, a period when projected Medicare spending exceeds $2 trillion; savings would be a rounding error. Then there's the Independent Payment Advisory Board (IPAB), a body of 15 experts charged with limiting Medicare spending if it passes certain targets. But the law handcuffs IPAB. It can't increase patient cost-sharing, restrict benefits, modify eligibility requirements or — in any one year — cut spending by more than 1.5 percent, reports the Kaiser Family Foundation.
Limits must be imposed on the health sector. There are no pleasing ways to do this. Still, the increasing evidence from large-scale experience is that market mechanisms offer the best chance of reconciling Americans' desire for personal choice with cost control. If there are better ideas, let's hear them. Otherwise, we shouldn't reject the obvious merely because it's unfamiliar.
Voucher plans are not right-wing, extremist ideas. They enjoy support in both parties. Ryan would permit continuation of fee-for-service; if it's more efficient and effective, it would survive. If not, its decline would be no great loss. The Ryan plan's greatest defect may be that it doesn't start for a decade. We can't wait that long.
Robert J. Samuelson is a Washington Post columnist.
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