From a very good article regarding Obama’s legacy in Politico found here:

  1. First, through the use of the stimulus money, his administration  created the infrastructure necessary for change:

A $25 billion incentive program in the stimulus for health information technology has helped drag a pen-and-paper medical system into the digital age, with adoption soaring from about 10 percent of hospitals and 20 percent of doctors in 2008 to about 80 percent of hospitals and 80 percent of doctors today. E-prescriptions are ubiquitous, and digitization is already reducing fatal errors and unnecessary tests caused by sloppy handwriting and inaccessible files. There have been problems getting electronic systems to talk to each other, sparking a backlash of sorts from irritated doctors, but Farzad Mostashari, Obama’s former health IT czar, is confident online medicine will inevitably produce the efficiencies common in online banking and dating.

2. Then, with the ACA,  a plan to improve access was implemented to address the game of uninsured “hot potato”:

It has already extended medical coverage to some 18 million uninsured Americans. It also closed loopholes that insurers used to deny coverage to insured Americans when they got sick. And it eliminated co-payments for quit-smoking programs, birth control pills, certain cancer screenings and other preventive care. As Obama has suggested, it’s what he was talking about when he talked about change.

3. Despite the reality that the right had no stomach for system change and the left had no stomach for cost controls, the majority of the ACA was about those two things. Improving the care delivery system was attempted by putting every idea, good or bad, tried or not, into the law and incenting folks to “don’t just stand there, do something.” Amazingly, it is working. First, the cost side:

Less than one-fourth of the bill was devoted to access. The rest was stuffed with almost every cost-control idea in circulation, from new competitive bidding rules for wheelchairs to a government Innovation Center to test new payment models to a “Cadillac tax” on pricey employer-sponsored plans. “We did a smorgasbord of just about everything people thought could conceivably help,” says Peter Orszag, Obama’s former budget director.

And so far, the cost curve is bending even faster than White House officials had dreamed. Health care is still getting more expensive, but since 2010, the growth rate has slowed so drastically that the Congressional Budget Office has slashed its projection for government health spending in 2020 by $175 billion. That’s enough to fund the Navy for a year, or the EPA for two decades. “We wanted to throw a whole bunch of stuff against the wall to see if any of it would stick, which probably sounded bogus,” Orszag says. “But if these results continue, they’ll fundamentally change the fiscal trajectory of the country.”

And on the quality side:

One recent report found that infections and other “hospital-acquired conditions” have declined 17 percent since 2010, when Obamacare created financial incentives for hospitals to avoid them. That reduction saved an estimated 87,000 lives and $20 billion. A similar effort to incentivize better management of discharged patients has coincided with a decline in hospital readmission rates that’s keeping 150,000 more Medicare patients at home every day, according to Meena Seshamani, director of the administration’s Office of Health Reform.

When put together, it is leading to a much more rational system. Maryland, for example, is experimenting with an “all payers” system:

A recent New England Journal of Medicine article found the state’s hospital costs increased at less than half the expected rate in the program’s first year, saving Medicare $116 million.

And everywhere there are changes to change the payment from one of paying for volume to paying for value:

There are signs that Obama’s convoluted jumble of changes may be starting to rationalize an irrational system. Patrick Conway, the director of the new innovation center, told me about a new Independence at Home experiment that coordinates nurse and doctor visits for frail and disabled patients—and saved Medicare $3,000 per beneficiary in its first year. One elderly diabetic who had 19 hospitalizations the previous year had only one after enrolling in the program.

When Medicare was signed into law, I guess they could have called it LBJCare. Today, no matter what it is called, no one is calling for us to put Grandma back in the attic and let her die. Medicare is here to stay. I suspect that 20 years from now, no one will even think about going back to volume based care delivery with rationing based on income and willingness to pay. Wonder what we will call our care delivery sustem?