There is a lot of speculation about how health care reform will affect health care costs. Some think it will reduce them, others fear it will increase them, and still others see little or no effect at all. The Health Care Cost Monitor invited several of its contributors and other public policy experts to give their views in answers to some questions. This is the fifth in a series of responses.– The Editors

In terms of curbing health care costs, is the health care reform legislation a win, a loss, or neutral?

Putting the new law in context of the stimulus investments and the president’s decision to appoint Don Berwick to head the Centers for Medicare and Medicaid Services, it is a big win. It’s the biggest coverage change since 1965, when Medicare was created, and the best potential payment change since 1983, when Medicare changed the way it reimbursed hospitals from a fee-for-service system to a system based on diagnostic groups. There is no going back from here. The status quo is unsustainable. The deficit is too great, the states’ capacity is in decline, the national economy is too important, and the public’s need to balance their costs against their expected reduced income is so great that policy implementation will be welcomed when it is understood.

Are the claims that the legislation will significantly control costs plausible?

Only an optimist will say that the cost claims in the law are plausible. The medical-industrial complex contributed little or nothing by way of policy change that will force behavior change. The opportunity to improve physician payment policy and medical technology policy was missed, but the authority to do so in the future is there and will be seized.

I counted at least 48 “cost curve benders” in the bill. Anyone believe Berwick isn’t capable of using his authority for cost curve bending? Congress can no longer afford to let the health care industry stymie CMS payment reform, or “entitlement reform” will become a joke. A lot depends on keeping Republican “anything goes in markets” types from controlling Congress.

Proponents of the reform legislation say that it is just the beginning. What other cost control measures should the president and Congress pursue?

Insurance reform is critical. It is a key to payment reform and using informed consumers and providers to lead the way to bending the cost curve. In the “mainstream” bipartisan legislation in 1994, we recommended accountable health plans, not accountable care organizations, as step one in systemic change. Nancy Kassebaum offered a National Insurance Benefit Board as a means of getting there and we agreed on national, not state, rules. Republican opponents of change can disrupt reform’s potential by undermining insurance rules and insurance exchanges at the state level, but the industry may well fight back because it knows how well it can perform if everyone plays by the same rules.

How likely is it that Congress or future presidents will undo or modify the cost control provisions in the legislation, particularly since some of them will not be politically popular?

This is the $64,000 question. This congressional Republican Party is not willing to drive Democrats to consensus on an issue that always favors Democrats over Republicans on the “whom do you trust” meter. The Republicans may win one house or the other in 2010. But, don’t count Obama out. He is mastering the details of dysfunction in both the system and its politics, and he will be formidable on an issue he didn’t expect to own, but that the Tea Party gave him. When the medical-industrial complex understands this, the ground will shift and it will be impossible to do anything but improve on this policy by encouraging more innovation and rewarding performance.

David Durenberger was a Republican U.S. Senator from Minnesota from 1978 to 1995. He was chair of the Health Subcommittee of the Senate Finance Committee, as well as author and coauthor of several health reform bills, including the Health Insurance Reform Act, which became Kassebaum-Kennedy health insurance reform bill, passed in 1996.