Prediction is hard . . .

. . .especially when it comes to the future. Marcia Angell takes a shot at it anyway  . (I try not to link to the Puffington Host, but that's where this is so what can I do? Do not rely on the site as a source for health advice or scientific information!)

Dr. Angell wishes the Supreme Court had thrown out the Affordable Care Act because a) she thinks it's going to be a train wreck and b) if they'd thrown it out, we all would have been "energized" and gotten the universal, comprehensive, single payer health care we actually need.

As I have been saying, yes, it won't work without additional reforms and what will be a very tough political struggle to move the development of the system along the right path. But why that's supposed to be more difficult than blowing the whole thing up and magically passing a single payer plan is mysterious indeed. Angell worries, as do I, that costs will simply continue to soar and that even with subsidies too many people will decide they can't afford insurance and will just pay the penalty. The problems of adverse selection will just get worse and meanwhile, the rates paid by Medicare and especially Medicaid will be so low that lots of people just won't be able to find doctors, while people who do have private insurance will have crappy plans with unaffordable co-pays and deductibles so they won't even be able to use them.

Okay, that could well happen if everybody just hits the champagne and then goes home, like I said the other day. But let's you and I and Dr. Angell all agree not to do that. We have now an opportunity for Barack Obama and non-wingnut politicians and even the occasional, rare journalist to explain to people how the market for health insurance works and why it fails; what the act actually does and how it isn't going to force your doctor to fill out a form in triplicate and get permission from a mid-level civil servant in Bethesda before writing you a prescription, nor will it put Granny on an ice floe; and what we still need to do to make the thing work properly.

Insurance companies won't like those reforms but guess what: other employers will. So will most of the physicians' organizations, that really do want the system work for their patients even if interventional radiologists won't make a million dollars a year. So will lots of people who are actually knowledgeable. The Koch brothers, by the way, don't actually give a shit one way or the other, they just want to use this as a blunt weapon with which to cudgel Barack Obama and Democrats, as a means to their entirely unrelated ends. The only people who are truly against the Affordable Care Act and the payment and delivery system reforms we still need are health insurance companies, and to some extent perhaps drug companies and medical device makers, and ignorant far right ideologues who would have been for it if a Republican president had signed it.

I still think we have a chance. But waving a magic wand and passing single payer? Not going to happen.