Bill Keller

Bill Keller

Unless you’ve been bamboozled by the right wing, you know that the Affordable Care Act has begun to accomplish its first goal: enrolling millions of uninsured Americans. You realize those computer failures that hampered sign-ups confirm enormous demand. You have probably figured out the real mission of Republican extortionists ais to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable.

What you may not know is that Obamacare is also beginning to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system.

Irony of ironies, the people who ought to be most vigorously applauding this success story are Republicans, because it is being done not by government decree but almost entirely with market incentives.

These systemic reforms potentially touch every patient, every taxpayer.

Since the law was signed three years ago, more than 370 innovative medical practices called “accountable care organizations” have sprung up, with 150 more coming. At these centers, Medicare or private insurers reward doctors financially when their patients require fewer hospital stays, emergency room visits and surgeries — exactly the opposite of what doctors have traditionally been paid to do.

These organizations have invested heavily in information technology so they can identify the most at-risk, those overdue for checkups, those who have not been taking their meds. They then deploy new medical SWAT teams — doctors, health coaches, care coordinators, nurse practitioners — to intervene and encourage patients to live healthier lives.

Advocates of these reforms say they are transforming medicine from treatment of disease to treatment of patients.

This is not the heroic medicine that turns surgeons into gods and emergency rooms into Hollywood. Don’t expect to see a toenail-clipping episode on “Grey’s Anatomy.”

But these services address the embarrassing fact, reiterated in study after study, that Americans pay much more for medical care than other developed countries, with no better results.

Obamacare addresses this problem by going where the money is. It concentrates resources on the unhealthiest.

According to Kaiser Health News, the sickest 1 percent of patients account for 21 percent of all costs; 5 percent account for half of the total costs.

There are organizations that are bringing emergency room visits down by 15 to 20 percent. That can make a huge difference not only in the cost of care but also in the quality of care.

The best sign these innovations are beginning to go viral is that they have caught the attention of giant businesses. Drugstore chains like Walgreens and CVS are now joining hospitals or accountable care organizations to give patients convenient points of access and to coordinate treatment.

Obamacare has also had some important indirect consequences.

According to Catherine Dower of the Center for the Health Professions at the University of California at San Francisco, since the Affordable Care Act, states have become more aggressive about challenging protectionist laws that prevent well-qualified medical professionals — pharmacists, nurse practitioners, physician assistants, emergency medical technicians — from offering some kinds of primary care. Letting pharmacists perform services that don’t require seven years of medical training makes those services cheaper and more convenient, increasing the chances consumers will take better care of themselves.

Dower said that while the formal doctor lobby continues to resist this as a threat to the M.D. cartel, many physicians have embraced it, recognizing that outsourcing some services leaves them more time to do what only doctors can do. And with an estimated 29 million new clients expected to join the ranks of the insured, there is a lot of work to share.

The emerging system is far from perfect. Congress buckled to drug company lobbying and refused to let Medicare use its purchasing power to bring down inflated drug prices. And like any upheaval, the reform of health care will produce some losers. Since hospitals account for about a third of our health care bill, they are a particular target of cost-cutters; some will fail to adapt and will go out of business.

What Obamacare has wrought is the kind of market-driven reformation that Republicans pretend to believe in. Which makes you wonder how much of their opposition rests on the merits, and how much is just a loathing for anything associated with Barack Obama.

BILL KELLER writes for The New York Times News Service.

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