All posts by blackfriar

HBR Blog: Preventive Health Care Markets

 

https://hbr.org/2014/11/what-the-u-s-can-learn-from-india-and-brazil-about-preventive-health-care

What the U.S. Can Learn From India and Brazil About Preventive Health Care

NOVEMBER 14, 2014

media companies, automakers, clothing retailers, and other industries have for decades looked abroad to find ideas and innovations they can adapt for the US market. But in one of America’s largest, fastest growing, and sometimes most confounding sectors — healthcare — the situation is different.

Imports like aspirin (Germany) and the heart transplant (South Africa) have become almost as American as apple pie. But in preventive health — keeping people from getting sick, or helping them manage the conditions they do have — we adapt too few of the best foreign innovations and models that have proven to be effective and sustainable at scale.

The U.S. spends far more per capita on healthcare than any other nation. Clearly we need to adopt cost-effective prevention efforts where we can. And we have to do so in a way that fits our health care infrastructure, including reliance on the private sector — a mix of for-profit and non-profit payers and providers — as the bedrock of our system. Two tactics that do fit, and can both lower costs and improve patient care, include more expansive use of mobile technology and of lay health workers. Both can be supported by non-profit intermediaries. Scalable models for these interventions are in use and successful in emerging economies, and are particularly germane where it comes to preventing illness and disease in low-income or geographically or linguistically hard-to-reach patient populations.

India’s Telemedicine

Take telemedicine for example, an approach to getting information to remote populations at a fraction of the cost of circuit-riding physicians. In India, 70% of the population lives in rural areas, but only 3% of the country’s specialist physicians practice in those areas. A nonprofit called World Health Partners (WHP) is working to bridge the gap by identifying informal health providers at the village level and using live streaming over the internet to connect them to highly qualified specialists far away. These lay workers, compensated through consultation fees and a reasonable mark up on drugs sold, measure blood pressure, temperature, heart rate, respiratory rate, and can assess EKGs and transmit the results directly to the specialist physicians.

The University of California at Berkeley has studied the program and reported a dramatic increase in access to reproductive health services among six million villagers at a cost of $5.84 per adult for a couple of years protection from pregnancy. Perhaps the most important lesson for the U.S. in WHP’s telemedicine initiatives in India is its approach to scale. Rather than implementing a program and figuring out later how it might be brought to very large numbers of people, WHP is building scalability into the design through low-cost approaches, and a reliance on for-profit rural practitioners — effectively working with the private sector to build a new market for preventative health.

INSIGHT CENTER

  • Innovating for Value in Health Care
    SPONSORED BY MEDTRONIC

    A collaboration of the editors of Harvard Business Review and the New England Journal of Medicine, exploring best practices for improving patient outcomes while reducing costs.

Brazil’s Integration of Lay Health Workers

More deeply integrating lay workers into our health system offers another path to lowering costs and broadening the reach of preventative health care. Most nations, including the U.S., make some use of lay or community health workers, but Brazil is notable for the scale at which it does this, and its success in integrating such workers into its larger healthcare system. A recent Johns Hopkins study notes that Brazil now deploys over 220,000 Community Health Agents (CHAs) to reach more than half of its 200 million residents. They work as members of health teams, including at least one doctor, one nurse, an assistant nurse and six CHAs to serve approximately 1,000 families. All the team members are salaried, full-time employees, and the CHAs must live in the communities they serve, promoting and delivering preventative health practices such as breastfeeding, prenatal care, immunizations, and screening for diseases including HIV and tuberculosis. In tandem with this approach, Brazil now has one of the most rapidly declining childhood mortality rates in the world, and has made striking gains in immunization coverage and other measures of preventive health addressed by the CHAs.

While the U.S., too, has some promising community health worker models, such as “health coaches” at AtlantiCare in Atlantic City, N.J., and “ promotoras” at Latino Health Access in Santa Ana, CA, Brazil’s experience offers us a path to scale, one that no longer views community health workers as “non-traditional,” but integrates them into the healthcare system, and, ultimately, pays for them in the same way that care in clinical settings is remunerated.

Mindset Before Model

 The “market” for preventive services is almost nothing like the market for automobiles; we can’t rely on market forces alone to increase the flow of global preventive health innovations into the U.S. But we should recall that Japanese automakers had been innovating for a long time before American automakers got serious about exploring and adapting these innovations. The first change may need to be mindset: expanding our view of where we might find powerful models for improving preventive health in the U.S., expanding our idea of who should be involved in identifying, prototyping, and scaling these models, and thinking big — designing for scale — from the outset.


Nidhi Sahni is a Manager in the public health and global development practice with The Bridgespan Group, a nonprofit advisor to other nonprofits and philanthropy.


Michael Myers is Managing Director at The Rockefeller Foundationand leads its global health work.

RWJF: Making Sense of the Medicare Physician Payment Data Release: Uses, Limitations, and Potential – The Commonwealth Fund

Making Sense of the Medicare Physician Payment Data Release: Uses, Limitations, and Potential – The Commonwealth Fund.

PDF: 1789_Patel_making_sense_Medicare_phys_payment_data_release_ib

Overview

In April 2014, the Centers for Medicare and Medicaid Services released a data file containing information on Medicare payments made to physicians and other providers. Though an important achievement in promoting greater health system transparency, limitations in the data have hindered key users, including consumers, payers, and providers, from discerning meaningful information from the file. This brief outlines the significance of the data release, the limitations of the dataset, the current uses of the information, and proposals for rendering the file more meaningful for public use.

Fat adults, fat kids, fat pets: how we’re driving the obesity pandemic

 

http://www.smh.com.au/national/health/fat-adults-fat-kids-fat-pets-how-were-driving-the-obesity-pandemic-20141205-120cbb.html

Fat adults, fat kids, fat pets: how we’re driving the obesity pandemic

 Science Editor

New research finds that obesity has become a major pandemic and looks set to get worse – in animals as well as humans, writes Nicky Phillips.

Bulging issue: Processed foods and climate change are hastening the obesity pandemic.Bulging issue: Processed foods and climate change are hastening the obesity pandemic. Photo: iStock

In the year 2000 when Cathy Freeman smashed the women’s 400-metre record at the Sydney Olympics, showcasing the best of our species’ physical abilities, the physique of many others crossed another, less auspicious line.

In that year the number of overweight people surpassed the number of people who were underweight.

While malnutrition remains a scourge in many parts of the third world, obesity elsewhere is now considered a pandemic – a global epidemic that has emerged in recent decades and costs Australia about $21 billion a year.

But it’s not just people battling the bulge.

The data is showing that pets and companion animals – such as cats, dogs and horses – have also dramatically increased in girth.

“There is something about our shared environment that is generating obesity in both humans and our companion animals,” says Professor David Raubenheimer, a nutritional ecologist at the University of Sydney’s Charles Perkins Centre.

A chief driver is economics, he says. Since the 1980s ultra-processed foods, which are cheaper than whole foods but far less nutritious, have flooded supermarkets and fast-food stores.

Climate change is also a factor, as higher concentrations of carbon dioxide diminish  the nutrient quality of plants and crops, which are the basis of human and many animals’ diets.

The idea that environment plays a major role in the obesity epidemic is not new. But Raubenheimer’s work is trying to unravel the complex mechanisms that make the modern world we’ve created for ourselves an uneasy fit for our bodies, which evolved in a very different landscape more than 100,000 years ago.

“It’s only by properly understanding problems that we can hope to predict, avert or manage them,” says Raubenheimer, who notes that not a single country has yet reversed its obesity epidemic.

To understand the role of the environment on obesity, there are a few things to note about our internal workings.

All animals, including humans, have sophisticated internal appetite systems that influence food intake to ensure the body receives the correct balance of each major nutrient group: protein, fat and carbohydrates.

Research by Raubenheimer and his colleagues found protein to be the most dominant of these nutrient “appetites”. Their studies in animals and people consistently show individuals will overeat fats and carbohydrates in order to meet their protein requirement.

Given that early humans evolved in an environment where meals likely consisted of lean game and root plants, both of which contained little fat or sugars, a strong protein appetite makes sense.

But now think of the modern world, where sugary, fatty and highly-processed foods – such as pizza, muesli bars, cereals, burgers and biscuits – are cheap and plentiful. Eating a greater quantity of those foodstuffs will not satisfy the protein appetite, but they are often consumed in place of protein because “protein costs more”, says Raubenheimer.

Studies in middle- and high-income countries consistently find that people living in poorer communities are more likely to be overweight or obese.

“The global rise of ultra-processed products, largely driven by powerful trans-national corporations, began in the 1980s and thus coincides closely with the period in which there has been a doubling in the rates of obesity,” wrote Raubenheimer, in his study published in theBritish Journal of Nutrition in November.

This may also suggest why dogs have beefed up by a whopping 33 percent, on average, and cats by 25 percent over the past few decades.

“If it’s more expensive to buy protein balanced foods for ourselves, imagine economically stressed families’ response when they feed their pets,” he says.

But it’s not just multinationals affecting food quality.

Climate change is diluting the nutrients in plants, because when exposed to high temperatures and a carbon dioxide-rich environment, the percentage of protein and fibre in plant leaves drops, while the concentration of sugars and starches increases.

“There is an immense amount of research showing that one consistent impact of climate change is the nutritional composition of plants,” Raubenheimer says.

Given that plants make up 80 per cent of the human diet, Raubenheimer predicts that vegetables and crops diluted of protein will become another factor in encouraging humans to overeat fats and carbohydrates to satiate their protein requirements.

Raubenheimer’s analysis suggests the impact of global warming on obesity rates will reach beyond plants to livestock animals that eat the plants, which people in turn consume as a major protein source.

If cattle and sheep graze on grasses with lower concentrations of the nutrient, they in turn will overeat to satiate their protein appetite, increasing their body weight, he says.

And while protein is a major driver of appetite, exposure to too much early in life may do more harm than good.

Numerous studies have found that babies fed formula, which has a higher concentration of protein than breast milk, are more likely to become obese later in life than breast-fed infants.

Raubenheimer says one explanation for this trend is that feeding infants high protein foods may be conditioning them to have a higher protein appetite for life.

“[This] is potentially causing those infants to overeat fats and carbs to a greater extent to satisfy their protein requirements,” he says.

While Raubenheimer and his collaborators at the Charles Perkins Centre know obesity emerges from a complex set of interactions between the environment, genetics and lifestyle factors, new approaches are desperately needed to tackle the problem, he says.

“We need interdisciplinary research, where approaches and concepts from multiple areas are applied to this major global crisis.”

Creating a Market for Disease Prevention

 

http://thevitalityinstitute.org/news/focus-on-pharma-creating-a-market-for-disease-prevention/

Focus on Pharma: Creating a Market for Disease Prevention

SustainAbility Newsletter “Radar” | Oct 30, 2014

Should pharmaceutical companies be in the business of producing pills, or of making people well? The answer is both. Elvira Thissen argues that with diminishing returns in medicines it is time for pharma companies to move away from philosophical discussions on prevention and adapt to new realities instead.

[…]

The Business Case for Prevention

A recent report by The Vitality Institute – founded by South Africa’s largest health insurance company – estimates potential annual savings in the US of $217–303 billion on healthcare costs by 2023 if evidence-based approaches to NCD prevention are rolled out.

At an estimated global cost of illness of nearly US$1.4 trillion in 2010 for cardiovascular disease and diabetes alone, there is a market for prevention. In the UK, the NHS spends 10% of its budget on treating diabetes, 80% of which goes to managing (partly preventable) complications. Reducing disease incidence represents a considerable value to governments, insurance companies and employers.

Some sectors are already eyeing the value of this market.

[…]

For access to the full article and SustainAbility newsletter, click here.

On PSA Testing

http://www.australiandoctor.com.au/opinions/guest-view/why-do-doctors-keep-silent-about-their-own-prostat

Simon Chapman’s ebook: Let-sleeping-dogs-lie

http://www.australiandoctor.com.au/news/latest-news/nhrmc-finally-releases-its-psa-advice

For every 1000 low-risk, 60-year-old men tested annually over a decade:

  • Two will avoid dying of prostate cancer before age 85
  • Two will avoid metastatic prostate cancer before age 85
  • 87 will have a false-positive test leading to an unnecessary biopsy, and 28 will suffer significant side effects as a result
  • 28 will be “overdiagnosed” with a prostate cancer that would likely otherwise have remained asymptomatic
  • 25 will be “overtreated”, 7-10 of whom will be left impotent or incontinent as a result
  • PSA testing has “no discernible effect” on overall mortality

The figures are largely unchanged from a draft version released last

Not sure what to say about PSA testing?

6 comments

The NHMRC has finalised its PSA testing advice for doctors, in what is claimed to be the best summary of the evidence to date.

Released Tuesday, the document provides a backgrounder for GPs to discuss both the benefits and harms of PSA testing with asymptomatic men.

Following an extensive literature review, with input spanning general practice, urology and oncology, the guide provides a list of statistics to use in conversation with patients (see below box).

Professor Ian Olver (pictured), a member of the NHMRC’s expert advisory group, said the group was “as confident as we can be” in the figures.

“We’re trying to say that the reason this can’t be promoted as a population test for everyone is that there are benefits and risks that have to be balanced. Every man has to decide where that balance lies for him,” said Professor Olver, CEO of the Cancer Council Australia.

“We’re providing an evidence-based tool for practitioners to be able to have that discussion.”

For every 1000 low-risk, 60-year-old men tested annually over a decade:

  • Two will avoid dying of prostate cancer before age 85
  • Two will avoid metastatic prostate cancer before age 85
  • 87 will have a false-positive test leading to an unnecessary biopsy, and 28 will suffer significant side effects as a result
  • 28 will be “overdiagnosed” with a prostate cancer that would likely otherwise have remained asymptomatic
  • 25 will be “overtreated”, 7-10 of whom will be left impotent or incontinent as a result
  • PSA testing has “no discernible effect” on overall mortality

The figures are largely unchanged from a draft version released last year, although the NHMRC has now stressed that the document “is not a substitute for relevant clinical practice guidelines and therefore does not contain recommendations”.

Meanwhile, GPs will have to wait until December for full consensus clinical practice guidelines, which are currently being developed by the Cancer Council Australia and Prostate Cancer Foundation of Australia.

These guidelines also have broad, multidisciplinary representation, and it is hoped they will provide some resolution to a debate that has divided Australia’s medical colleges in recent years.

731/8 Point Street

 

PDF: 731_8 Point Street, Pyrmont _ Feldi Property Agents – Pyrmont

http://www.feldiproperty.com/6304865

731/8 Point Street, Pyrmont

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Those looking for one of the most dramatic harbourbrige and city views available combined with huge living and entertaining balcony must inspect this property.

Boasting Mirvac quality interiors framed in floor-to-ceiling glass and surrounded by a wraparound balcony, this stunning penthouse captures harbour district and Bridge views from the prestigious Promontory building.

Close to restaurants and cafes in waterfront precinct.

Open plan living and dining flooded in all day north east sunshine.

-Marble kitchen with Miele appliances -featured bathroom and deluxe ensuite
-Three bedrooms, all bedrooms have built-ins, with high ceilings throughout.
-Huge, is the only way to describe the vast entertainers terrace, the backdrop will ensure you and your guests gaze across one of the worlds most dynamic harbour panorama
-Internal laundry and pet friendly building.
-Occupying the entire top floor giving you direct lift access to your own private foyer and entry.
-Video intercom and double security parking plus storage.

Facilities include pool, gymnasium, spa and sauna.

A stunning location with amazing views in every sense of the word,

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*Whilst we make every endeavour to ensure the information provided is correct, we do not guarantee or give any warranty as to the accuracy of the details provided, interested parties must rely on their own enquires.

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Bedrooms 3
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Dr Atul Gawande – 2014 Reith Lectures

Lecture 1: Why Do Doctors Fail?

Lecture 2: The Century of the System

Lecture 3: The Problem of Hubris

Lecture 4: The Idea of Wellbeing

http://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atul-gawande-2014-reith-lectures

Dr Atul Gawande – 2014 Reith Lectures

Atul Gawande, MD, MPH is a practicing surgeon at Brigham and Women’s Hospital and Professor at both the Harvard School of Public Health and Harvard Medical School.

In his lecture series, The Future of Medicine, Dr Atul Gawande will examine the nature of progress and failure in medicine, a field defined by what he calls ‘the messy intersection of science and human fallibility’.

Known for both his clear analysis and vivid storytelling, he will explore the growing importance of systems in medicine and argue that the future role of the medical profession in our lives should be bigger than simply assuring health and survival.

The 2014 Reith Lectures

The first lecture, Why do Doctors Fail?, will explore the nature of imperfection in medicine. In particular, Gawande will examine how much of failure in medicine remains due to ignorance (lack of knowledge) and how much is due to ineptitude (failure to use existing knowledge) and what that means for where medical progress will come from in the future.

In the second lecture, The Century of the System, Gawande will focus on the impact that the development of systems has had – and should have in the future – on medicine and overcoming failures of ineptitude. He will dissect systems of all kinds, from simple checklists to complex mechanisms of many parts. And he will argue for how they can be better designed to transform care from the richest parts of the world to the poorest.

The third lecture, The Problem of Hubris, will examine the great unfixable problems in life and healthcare – aging and death. Gawande will argue that the reluctance of society and medical institutions to recognise the limits of what professionals can do is producing widespread suffering. But research is revealing how this can change.

The fourth and final lecture, The Idea of Wellbeing, will argue that medicine must shift from a focus on health and survival to a focus on wellbeing – on protecting, insofar as possible, people’s abilities to pursue their highest priorities in life. And, as he will suggest from the story of his father’s life and death from cancer, those priorities are nearly always more complex than simply to live longer.

Five things to know about Dr Atul Gawande

Find out about Atul Gawande ahead of his 2014 Reith Lectures…

1.

In 2010, Time Magazine named him as one of the world’s most influential thinkers.

2.

His 2009 New Yorker article – The Cost Conundrum – made waves when it compared the health care of two towns in Texas and suggested that more expensive care is often worse care. Barack Obama cited the article during his attempt to get Obamacare passed by the US Congress.

3.

Atul Gawande’s 2012 TED talk – How do we heal medicine? – has been watched over 1m times.

4.

Atul Gawande has written three bestselling books: Complications, Better and The Checklist Manifesto.

The Checklist Manifesto is about the importance of having a process for whatever you are doing. Better focuses on the drive for better medicine and health care systems. Complications was based on his training as a surgeon.

5.

In 2013, Atul launched Ariadne Labs – a new health care innovation lab aiming ‘to provide scalable solutions that produce better care at the most critical moments in people’s lives everywhere’.

 

Professor Guy Maddern’s tips on protecting yourself in surgery

1. If you are away from a major hospital, get yourself to one. A particular problem, Professor Maddern says, exists when rural patients resist transfers to major hospitals because they don’t want to leave their families.

2. Lose weight and don’t smoke.The proportion of deaths where obesity was a factor increased slightly this year. “An operation done on a thin person relative to a fat person can have a completely different outcome,” Professor Maddern says. This is particularly important for older people, who have the most operations.

3. Go to a hospital that performs a lot of the type of surgery you are going to have, particularly if it is complex. Remember, practice makes perfect.

http://www.canberratimes.com.au/national/health/one-in-10-surgery-deaths-due-to-flawed-care-or-injury-caused-by-treatment-20141203-11z5y1.html

One in 10 surgery deaths due to flawed care or injury caused by treatment

Date December 3, 2014

Health Editor, Sydney Morning Herald

View more articles from Amy Corderoy

Dangerous: Surgery risks can outweigh benefits.

Dangerous: Surgery risks can outweigh benefits. Photo: Nic Walker

More than one in 10 deaths during or after surgery involved flawed care or serious injury caused by the treatment, a national audit has found.

The Australian and New Zealand Audits of Surgical Mortality shows delays in treatment or decisions by surgeons to perform futile surgeries are still the most common problems linked to surgical deaths.

But surgery also appears to be getting a little safer, with the audit, which covers almost every surgery death in Australia, finding fewer faults with the medical care provided to patients than it has in the past.

Audit chair Guy Maddern said of the deaths where there were concerns, about 5 per cent involved serious adverse events that were likely to have contributed to the person’s death.

In about 8 per cent of cases, the audit found some area of care could have been delivered better.

“These are the sorts of deaths where it was a difficult surgery, and instead of going straight to an operation, maybe additional X-rays and imaging should have been pursued, or maybe the skill set of the team that was operating could have been more appropriate,” he said.

“Sometimes, of course, the result would have been exactly the same.”

Professor Maddern said some surgeons, particularly in general surgery, orthopaedics, and, to a lesser extent, neurosurgery, still needed to work on deciding not to proceed with surgeries where the risks outweighed the benefits.

“People are thinking a little bit longer and harder about whether an operation is really going to alter the outcome,” he said. “These are the types of cases where you know before you begin that it is not going to end well.”

However, in some areas with many patients with complex conditions, things were just more likely to go wrong.

The report, which includes data from nearly 18,600 deaths over five years, found in 2013 the decision to operate was the most common reason a death was reviewed.

Overall, delays in treatment, linked to issues such as patients needing to be transferred or surgeons delaying the decision to operate, were still the most common problem, and in about 26 per cent of the deaths no surgery was performed.

Between 2009 and 2013, the report shows a decrease in the proportion of patients who died with serious infection causing sepsis from 12 per cent to 9 per cent, while significant post-operative bleeding decreased from 12 per cent to 11 per cent. Serious adverse events halved from 6 per cent of deaths in 2009 to 3 per cent in 2013.

Every public hospital now participates in the audit, along with all private hospitals in every state except NSW. However, Professor Maddern said he was pleased NSW private hospitals had agreed to participate in future.

Doctors are now provided with regular case studies from the audit, in which de-identified information about the death is provided, so they can learn from any mistakes.

“What we are seeing is an overall decrease in deaths associated with surgical care, which may be due to many things, and we think the audit is helping,” he said. “It’s making people think twice.”

Professor Guy Maddern’s tips on protecting yourself in surgery

1. If you are away from a major hospital, get yourself to one. A particular problem, Professor Maddern says, exists when rural patients resist transfers to major hospitals because they don’t want to leave their families.

2. Lose weight and don’t smoke.The proportion of deaths where obesity was a factor increased slightly this year. “An operation done on a thin person relative to a fat person can have a completely different outcome,” Professor Maddern says. This is particularly important for older people, who have the most operations.

3. Go to a hospital that performs a lot of the type of surgery you are going to have, particularly if it is complex. Remember, practice makes perfect.

Blumenthal on Health Reform: Foolish, Courageous, or Both

http://www.commonwealthfund.org/publications/blog/2014/dec/health-reform-foolish-courageous

Health Reform: Foolish, Courageous, or Both

Thursday, December 4, 2014

Some supporters of the Affordable Care Act (ACA) are worried they’re paying a political price for health care reform. The political fallout should come as no surprise.

The history of comprehensive health reform shows unequivocally that it’s a short-term political disaster. That’s why so many political leaders have either avoided the issue, or regretted engaging it. Franklin D. Roosevelt, arguably one of our most politically adept presidents, turned his back on national health insurance in 1934 when advisors argued for including it in the Social Security program. He continued to dodge it for most of his long presidency. Both Jimmy Carter and Bill Clinton paid heavy political prices for their proposed national health care programs.

Health reform’s political toxicity is all about math and voting.  Even prior to the ACA, more than 80 percent of Americans under 65 had health insurance, and most were satisfied with their coverage and regular care. These are people—better educated, employed, with middle to higher incomes—who vote, especially in mid-terms. The elderly, of course, have Medicare and they too are generally satisfied with their insurance and care. The 20 percent who didn’t have insurance before the law was passed were—and are—much less likely to show up at the polls. They tend to be younger, less-educated, and less well-off.

Then there’s the nature of health care as an issue: highly personal, highly consequential, and incredibly complex and confusing. Health care is about people’s deepest hopes and fears, for themselves and for their loved ones. And the health care system has become a multi-layered maze of huge insurance chains, enormous and acquisitive provider organizations, government regulation, and constantly changing therapeutics.

This makes it easy for opponents of health reform to stir opposition by arguing—fairly or not—that any new program will make things worse for people who are satisfied with their insurance and their care. This is precisely why President Obama felt the need to promise, inaccurately as it turned out, that every American who liked their insurance plan would be able to keep it under the ACA.

And supporters of reform have difficulty explaining any new program and motivating its beneficiaries to take advantage of it. Witness the large numbers of uninsured Americans who remain unaware of the availability of subsidized insurance through the ACA marketplaces.

So, to put it crudely, why would any sane politician push a program likely to scare and confuse large numbers of people who vote, in order to help small numbers who don’t?

There are two possible responses. One is that it’s the right thing to do, since a lack of insurance is essentially a death sentence for millions of Americans. Doing the right thing, however, can be politically costly: when Lyndon Johnson pushed through the Civil Rights Act in 1965, he gave away the southern United States to the other party for a generation.

A second argument for braving health reform is practical: it simply has to be done to make our health system viable. The private health insurance industry in the United States, and our health system as a whole, have been in a downward spiral that threatens the interests of all Americans, including the now contentedly insured. Prior to the ACA’s enactment, more and more people were losing insurance, or being forced—because of huge premium increases—to purchase coverage that offers less and less protection.

For some years now, insured Americans have been the proverbial frog in the cooking pot, barely noticing as the water slowly approaches the boiling point. A health care system in which, year after year, the cost of insurancerises faster than workers’ wages is not sustainable for anyone.

Relatively little attention has been paid to ACA reforms that attempt to make the system sustainable by tackling fundamental problems with the health care delivery system and with the structure of the private insurance markets. The reason may be that insurance markets and delivery systems—their problems and solutions—are complex and much less interesting than the political battles surrounding covering uninsured Americans, and whether currently insured Americans may face cancellation of their plans. While the major long-term political gains to supporters of health reform may lie in these delivery system and insurance reforms, President Obama and many current congressmen and senators will likely be long gone when and if those gains materialize.

So ACA supporters have every right to be concerned about the politics of health reform. Each will have to decide for themselves whether health reform was foolish, courageous, or both.

In the meantime, millions of Americans now have health insurance who didn’t before, and the cost of health care is increasing at the lowest rate in 50 years.