Newspaper headlines about small employers’ fears of the Affordable Care Act (ACA) make it seem like there will be a major cataclysm in the small employer health insurance market come January 1, 2014. What most of these stories miss, however, is that a cataclysm has already occurred in employment-based coverage and the likely impacts of the ACA on the small employer market will be mixed at worst: beneficial for some and challenging for others. Overall, the ACA’s impact on the small employer market is likely to be smaller than most people think—at least in the early years of its implementation.

The cataclysm that has already occurred is the fact that employers have been dropping coverage for the past decade and relatively few truly small employers offer coverage today. In 2001, 60 percent of Michigan’s small firms offered health insurance coverage. By 2011, that percentage had dropped to less than 40 percent—a greater than 20 percentage point decline over those 10 years.

Employers have been dropping health coverage principally because of the cost of health care—a trend worsened by the recession. And, as large firms have reduced their work force, more individuals have obtained employment in smaller firms, which are least likely to offer health insurance and most likely to drop coverage when faced with financial pressures.

A major question is whether the ACA will improve or further worsen this trend. In order to look at this question, it is important to consider several facts. First, a key piece of legislation concerning employers is what is called the “Play or Pay” rule. Under this rule, employers must offer health coverage or pay a penalty for employees who obtain their coverage with a subsidy through the individual market on the health insurance exchange. The reality is, however, that when it comes to the small employer market, very few small employers will be subject to this penalty. The penalty only applies to employers with 50 or more employees. For example, our center just published a report showing there are 154,488 employers in Michigan with fewer than 100 employees, of which 96 percent have fewer than 50 employees and will not be subject to the penalty.

For employers with 50 to 99 employees, about 90 percent already offer health insurance coverage. And, while there will be new requirements for these employers that go into effect on January 1, 2014, many changes have already been implemented without significantly disrupting this market (such as full coverage of preventive benefits, required coverage of dependents to age 26, elimination of lifetime benefit limits and the like).

Second, it is important to recognize that the ACA has new employer benefits as well as new requirements. The Small Business Health Options Program (SHOP) health insurance exchange is designed to pool small employers together so that they can find more affordable health insurance coverage. And, there are new requirements in this market place for community rating and insurance rating oversight that could help some employers, especially those with an older work force. And, finally, there are new grants for wellness programs and some tax credits for very small employers. So, some could obtain new funding from the ACA to offer coverage.

Our best crystal ball on the impact of the ACA is what has already happened in Massachusetts. Employer-offered health insurance actually grew after the implementation of health reform in that state. And, the market there has continued to be quite vibrant.

The bottom line is that today’s headlines are not likely to be representative of what will really happen with the implementation of the ACA. Or, as some might say, it is time to “cool our jets” and wait to see what happens.

Editor’s Note: This column previously appeared in Bridge Magazine.

Recent reports about a Medicaid experiment in Oregon reveal a major disconnect we have in the health care world: we make a historic —and unwarranted— distinction between “physical health” and “mental health.” Worse, that distinction actually interferes with both our investment in mental health treatment and patients’ willingness to seek treatment.

The Oregon Medicaid study is about the impact that Medicaid coverage has had on a group of low-income individuals who obtained health insurance coverage for the first time several years ago. Researchers have been studying Oregon because of a unique set of circumstances that resulted in some uninsured adults being randomly selected to receive access to Medicaid, while others were not. That circumstance enabled a randomized controlled trial to be done in the “real world” —a rarity in health services research.

The experiment’s initial set of results, which relied on self-reports by the participants, were released last year. In the first year of the study, those with Medicaid coverage reported better health than those who were in the control group. In the most recent report, which includes second-year findings, researchers used actual health measures for cholesterol, high blood pressure, diabetes, and depression. This second set of data resulted in a more nuanced and complicated conclusion than the first-year report. Specifically, the researchers found no impact in the two years with regard to cholesterol and high blood pressure; an increase in diagnosis and treatment of diabetes but no impact on blood sugar levels; a significant reduction in depression; and a significant improvement in financial stability for those with Medicaid coverage compared to the control group.

Because these findings were released while many states are still considering whether or not to expand Medicaid, the Oregon story was reported across multiple media outlets. Headlines ranged from the fairly neutral (The New York Times: “Medicaid Access Increases Use of Care, Study Finds”) to the more judgmental (Forbes Magazine: “Oregon Study: Medicaid ‘Had No Significant Effect’ On Health Outcomes vs. Being Uninsured”).

Some commentators have said that the study and resulting headlines were almost like a Rorschach test about what one believes about the Affordable Care Act and the Medicaid expansion. But, even articles and publications that are generally favorable to the Medicaid expansion often reported that the study showed that the Oregon experiment had no impact on health.

These headlines are stunning in several ways. First of all, they generalize a few measures over a relatively short period of time to a sweeping conclusion about health insurance. But, beyond that, they seem to entirely discount the improvements in mental health as a “health outcome.”

In the Oregon Medicaid experiment, the rate of depression dropped by more than 9 percentage points and the relative improvement compared to the control group was 30 percent. Why is it that we don’t identify the significantly lower rates of depression as a significant health outcome?

For years, we have had research on the causes of depression and other mental health conditions. While the causes are likely multifactorial, including a combination of genetics, environment, biology and psychology, the National Institute of Mental Health describes “depressive illness” as a “disorder of the brain” —not a personal weakness.

More than 10 years ago, visionaries at the University of Michigan, under the leadership of Dr. John Greden, established the country’s first Depression Center. Dr. Greden reasoned that until we treat depression like we do cancer— as a disease that requires focused, team-based research and collaboration —we will not make the kind of progress in understanding this disease that we need to. Today there is a National Network of Depression Centers that includes 21 of the nation’s top academic institutions.

It is disappointing to realize that 10 years of this kind of work has not erased the distinction between “physical” and “mental” health. If we had, the headlines about the Oregon experiment would have been something like this, “Medicaid Coverage Shown to Have Significantly Improve Health relative to being Uninsured.” We should only be so lucky to find a health impact as large as this in other areas of the Oregon health experiment.

Of the Affordable Care Act’s (ACA’s) many provisions aimed at improving health care access, quality, and efficiency, one has been the subject of considerable recent debate: the hospital readmission reduction program. The program’s approach has some merit, but in the end, doesn’t do enough to address the systemic issues underlying the problems it aims to fix. This policy needs adjustments now and bigger changes down the road.

Hospital readmissions within 30 days of initial hospital stay became a policy focus after a report by the Medicare Payment Advisory Commission (MedPac) in 2007. MedPac identified some types of readmissions—in particular, those linked to diagnoses like acute myocardial infarction, congestive heart failure, and pneumonia—as potential indicators of quality problems in the initial hospital stay.

MedPac recommended a readmission reduction program in 2008, but most hospitals didn’t focus on readmissions seriously and systematically until payment penalties for certain readmissions were included in the Affordable Care Act. Two-thirds of hospitals are now facing readmission penalties totaling approximately $280 million in 2013. We summarized some of the key initiatives underway to reduce readmissions, along with research results to date, in a policy paper.

Recently, readmission rates have been on a downward trend, and some analysts see this as a positive outcome attributable to the ACA’s readmission penalties.

Some hospitals, however, have raised concerns about the wisdom of the policy.

Payers tend to view the program favorably for several reasons. First, there are significant dollars associated with readmissions. In 2008 alone, Medicare spent $15 billion on readmissions for just 18 percent of inpatient patients. Second, readmissions can be measured without too much difficulty. The data are readily available through payers’ claims systems. And third, the issue is a hot media topic. That means health purchasers and decision-makers—both employers and members of Congress—are looking to Medicare and private payers to do something about it.

But the very attributes that make the program attractive to payers are symptomatic of the problems with this policy. For example, claims data are not clinically sensitive measures of care. Recent analyses of readmissions penalties indicate that hospitals treating patients on the low end of the socioeconomic scale generally face higher penalties than hospitals treating more affluent patients. Because there may be clinically appropriate reasons for those with low socioeconomic status to have higher readmission rates, penalizing such hospitals may actually interfere with good care.

Media focus on issues like this one often leads to the over-simplification of the issue into sound bites, which in itself can interfere with good policy. Once the media are involved, calls for quick responses often follow, potentially leading to punitive approaches rather than more complex but longer-lasting strategies involving structural change in the healthcare system.

Certainly, the readmissions initiative has led to some positive change. Many hospitals now have a special focus on helping patients make the transition from inpatient care to outpatient or community settings, and that is an improvement over historical care silos. And there are ways to adjust the methodology of the current policy to mitigate some of its negative unintended consequences.

The readmissions policy will continue to spark changes in the system, but in the end, it will be eclipsed by the more systemic approaches to payment reform and coverage scope also included in the ACA—and that is a very good thing.

Great news! The latest and greatest approaches to reducing health care spending are here: paying primary care doctors more, bundling payments for doctors and hospitals; sharing savings and investing more in systems that integrate care. Hooray! New answers to the cost curve dilemma!

The question is: will any of these approaches actually work?

As it turns out, we’ve been down a similar road before. Remember care management? Back in the 1990s, it was “the” answer to the health care cost problem. Vendors were the ones to promote this particular solution; their sales pitches offered employers and health plans returns on investment (ROI) of up to 5:1. This was an attractive notion to employers and other purchasers who were struggling (as they still are) to contain spending on health insurance.

The problem with these pitches was that they were, at best, misleading. To understand the numbers, you really needed to read the fine print in the studies behind them—assuming that those studies were even made public! And generally, the numbers applied only to very small populations for very limited periods of time. So when we look at the claims for ROI the way most employers would—as they apply to their employee populations—we find at best, these programs generally break even.

Now, breaking even is not a bad thing. Breaking even can still add value, if the services provided actually improve health. But unfortunately, that’s not how those programs were sold, and that led to a lot of cynicism about the value of care management interventions.

Today, we are in danger of repeating the care management story, as every new model gets touted as having a major impact on health care spending.

The accountable care organization (ACO) model is the hot concept today—in the 1990s it was PHOs. The two models have a lot in common: hospitals and physicians working together to better coordinate and integrate care. In the 90s, we saw many hospitals purchasing physician group practices. Later, many of these same hospitals determined their own culture and incentives were just too different from those of the physician groups they had purchased: they vowed not to do that again.

Yet now, we see hospitals re-entering this arena. Today, they say they’ve learned from the past, and now have better data and more aligned incentives from payers. And, of course, some providers have been successful with this model.

Perhaps the providers are right. This time may be different from the last. I don’t want to be so cynical as to say that learning from the past is not possible, and that things can’t be done better this time around.

But I do want to be cautious and avoid repeating the worst mistakes of the past. As we celebrate these new approaches to provider payment, let’s not declare victory too soon. All of these approaches have some legitimate foundation and can improve things directionally from the approaches we are using today. Let’s give them a chance to work, evaluate their strengths and weaknesses, and understand the value they can add before we declare—once again—we have “the” answer to health care in America.

Lisa Rosenbaum wrote a terrific piece in the March 7 issue of the New England Journal of Medicine. Her article is a powerful reminder that views of medical appropriateness—what is “right” in health care—can be very different for physicians, patients, and analysts. She highlights the challenges inherent in a system of incentives that reward “value” without taking into account these differing views, and speaks to something often missing in today’s health care: real communication between physicians and patients.

We live in a culture that over-values “doing things” and under-values doing nothing. Many Americans believe that unless they get tests, drugs, or other interventions when they visit the doctor, they are not getting good medical care.

Physicians often reinforce this viewpoint. I’ve been amazed at the number of times physicians themselves speak to their discomfort at not doing a test, concerned they may be viewed as withholding something from patients rather than simply taking a more prudent approach to health care.

While we often talk about defensive medicine, and how fear of litigation may promote the use of too many medical services, I think an even more pervasive issue is physicians’ concern about being perceived as rationing health care.

In his very fine book comparing international health systems, T.R. Reid discusses how he traveled the world to understand differences in health care systems, using his own shoulder problems for the comparison. Not surprisingly, his American physician was quick to offer a major surgical intervention while those in other countries were more cautious in approach, expressing more skepticism about the value of surgery.

At core, however, unless physicians and patients are on the same page about which medical interventions make the most sense, there will be conflict about perceptions of value. And as long as patients think doing more is better—whether diagnostically, medically, or surgically—payment approaches using incentives to affect physician behavior are not likely to work. In the end, physicians care more about their patients’ reactions than incentives from health plans.

Rosenbaum hints at a solution in an anecdote about a patient’s fear of heart disease. The patient wants a pill or some other intervention to fix his problem. But in the end, the problem needed to be addressed with behavioral changes, like diet and exercise. His physicians perceived him as being resistant to change, but in fact, he responded very positively when a senior doctor sat down and talked him through his issues in detail.

Here’s the challenge: that senior physician spent 75 minutes talking—just talking—with the patient and his wife. But in health care today, we generally don’t reimburse well for 75 minutes of talking. We do, however, reimburse handsomely for the procedures that physician was discouraging his patient from having.

Until we do a better job of aligning reimbursement systems so patients and doctors can be on the same page, all the incentives in the world won’t get us to a true improvement in the value of health care.

Steven Brill’s article on health care costs in the March 4 issue of Time magazine is the talk of the town in health care. While journalists have generally praised the piece, reactions from those in health care have been mixed. The American Hospital Association critiqued a number of Brill’s major points in a fact sheet, Setting the Record Straight on TIME’s Article “Bitter Pill.”

In general, however, there is little doubt that Brill’s main point is true. To encapsulate Brill’s 36 pages into a couple of sentences: Hospital charges are generally not reflective of costs, and it is those who can least afford to pay them who often bear the burden. His emphasis (though it was not entirely clear) was on individuals who lack insurance or have high copays and deductibles: those who generally do not benefit from contracts established by public payers like Medicare and Medicaid, and must therefore bear the burden of payments based on charges. (Medicare and Medicaid often pay at rates that are at least 50 percent lower than what hospitals charge.)

In many cases, hospital charging structures were developed long ago without much analysis of the actual cost of delivering services. These structures haven’t received much attention because relatively few patients actually pay for health care based on charges. But some states have placed limits on what hospitals can charge the uninsured–a point overlooked by Brill. Uwe Reinhardt wrote in the New York Times’ Economix blog about steps taken in New Jersey; Illinois enacted the Hospital Uninsured Patient Discount Act to limit the amount hospitals can charge or collect from uninsured patients.

Brill also made broad statements about the excessive profitability of hospitals as an industry; these statements, too, are not entirely supported by the facts.

The solution to the charging issue is straightforward: bring charges more in line with costs and/or regulate price more broadly in the health care system (like all-payer rate setting systems in Maryland or public payer systems in the U.S. and other countries).

But will this resolve the health care cost issue in America? Unfortunately, I don’t think so; Brill emphasizes the charging problem at the expense of other critical issues.

Health care spending is a product of the price and quantity of care, and we have problems with both. Looking at one or the other in isolation is problematic. We know from target income research and failed experiments like the Sustainable Growth Rate formula that practitioners are skilled at finding ways to compensate for price cuts with increases in the use or intensity of services.

Brill is somewhat dismissive of the Affordable Care Act’s ideas for addressing the cost of health care. But while its approaches may be flawed, they have a solid foundation. Ideas like bundled payments and accountable care organizations are designed to affect both price and use.

Addressing the unit price of a service alone is not the answer. Linking price and use, and providing incentives for quality and effective care is what we must do if we truly intend to address the “bitter” cost of health care in America.

On February 5, 2013, Congressional Budget Office (CBO) director Douglas Elmendorf testified before Congress on the CBO’s budget outlook for 2013-2023. As reported in the New York Times and elsewhere, the health care outlook was remarkable: projected Medicare and Medicaid spending for 2020 was down 15 percent over projections made three years ago.

Specifically, the CBO noted “net outlays for Medicare… grew by 3 percent… in 2012—a slower rate of growth than any recorded since 2000.” And, “the CBO’s current baseline also shows lower spending per person in the Medicaid program than was shown in August, primarily because of adjustments to account for the slowed growth in Medicaid spending…For Medicare, CBO has reduced its 10-year projections of outlays for Medicare by $137 billion…the third consecutive year in which spending was significantly lower than CBO had projected.”

In a February 2013 spending brief, our colleagues at Altarum noted these trends were applicable to health care spending across the board, not limited to Medicare and Medicaid. National health expenditures grew at only 4.3 percent in 2012, slightly higher than the past couple of years but much lower than historical trends.

Many analysts question whether this moderation in spending is a trend or a temporary outcome of recent, unique events. Some have compared the current situation to the 1990s, when a dramatic slowdown in health care spending lasted only a few years. Some members of the media questioned the accuracy of President Obama’s State of the Union comments crediting the Affordable Care Act (in part) for these trends. Indeed, many explanations for the current slowdown do focus on the impact of the recession.

So, is the current slowdown a similar situation to what happened in the 1990s, or not? While the answer to that question won’t become clear for some time, I believe what we are seeing now is quite different from what we saw then. I think the President may have more truth on his side than the media credits.

Most analysts believe what happened in the 1990s was the result of changes in health care financing. Specifically, over a several year period, employers shifted from indemnity health insurance plans to managed care. This meant much of the care priced at “charges” began to be paid at lower, contracted rates. While that change was substantive and good, it did nothing to address the underlying fundamentals of health care delivery. The savings were one-time, and once those costs were wrung out of the system, the upward trend resumed.

Today, the health care delivery system is engaged in whole-scale change and restructuring. While some of this change predated the Affordable Care Act, much has been sparked by it.

Three years ago providers, health plans, and others started anticipating changes coming with the Affordable Care Act by gearing up for affordable care organizations, patient centered medical homes, bundled payments, readmission payment reductions, and value-based purchasing. The scope of change occurring now in the health care delivery system is stunning.

So, the President and the Affordable Care Act can take some bows.

But, more importantly, we all have reason to be optimistic about the changes we are witnessing today are are not one-time phenomena. The actions health systems and health plans are taking is exciting: we are seeing things now that we simply haven’t seen before.

Why does health care cost so much more in America than in any other country in the world? One major reason is that our system is really a non-system. That is, in America we have many different payers, financing mechanisms, benefit designs, and structures. Every health plan has its own ways of doing things, and every health purchaser wants a customized benefit plan that meets its own specific goals.

All of this fragmentation leads to higher administrative costs. As cited in a New England Journal of Medicine Perspective, the Institute of Medicine has estimated the U.S. spends $361 billion on administrative costs annually, half of which may be unnecessary. Health care fragmentation in America comes with a hefty price tag.

Another cost of health care fragmentation is harder to quantify but undoubtedly contributes to higher health care spending in the U.S.: The multiplicity of health plans in America makes it difficult to intervene with providers of care to reduce health care spending. When any one payer represents a relatively small percentage of a provider’s practice, it is difficult for that payer to identify clear opportunities for intervention. Indeed, a study in the American Journal of Managed Care comparing variation in Medicare and private sector spending showed some spending patterns to be directionally the same and some to be different.

The Affordable Care Act contains some positive steps designed to make dents in health care fragmentation. The Multipayer Advanced Primary Care Practice demonstration project is one such effort. In that initiative, Medicare, Medicaid, and private sector health plans are working together—with aligned incentives and strategies—to implement a patient centered medical home approach to patient care.

Another positive step in this direction was taken on November 21, 2012, when the Centers for Medicare and Medicaid Services announced the first three participants in the Medicare Data Sharing for Performance Measurement program. The collaboratives included in this program (in Cincinnati, Kansas City and Oregon) will pool information between the private sector and Medicare to enable a fuller picture of provider health care use. The information is intended both to raise consumer awareness and to be available for quality improvement and cost intervention by payers.

In most developed countries in the world, governmental agencies, commissions, or other such groups monitor total health care spending in a region and/or country as a clear part of their mission. This gives these countries a process for developing new policies or procedures when the picture of health care spending becomes concerning.

But in the U.S., there is no such entity, and health care spending issues are generally addressed through strategies initiated by either Medicare, Medicaid, or individual health plans in the private sector. Generally speaking, these initiatives are not coordinated. Indeed, at times, the different payer strategies can send conflicting messages to providers.

At its core, the Affordable Care Act does not address this issue. Indeed, one indicator of the incremental nature of the ACA is how fragmented the American health care system will be even after the ACA is fully in place.

But America is a country in which most policy changes occur incrementally. The steps taken by the ACA, as evidenced by the Multipayer Advanced Primary Care Demonstration Project and the Medicare Data Sharing program, are steps in the right direction. Reducing fragmentation to save health care costs and improve quality of care is a goal we should all be able to support.

The Supreme Court’s June 2012 decision on the constitutionality of the Affordable Care Act made the Medicaid expansion—a cornerstone of the coverage expansion included in the law—an option rather than a requirement for states. To help Michigan policy makers make an informed decision on that expansion, we published a brief on the economic impact of the Medicaid expansion in Michigan. That brief noted under the most likely scenario, Michigan would save almost $1 billion over 10 years if it chose to expand Medicaid as contemplated in the ACA.

Since we published that brief in October 2012, policy makers have raised other questions related to the possible expansion. Most notably, Governor Snyder had concerns about whether or not providers in Michigan would have enough capacity to serve an expanded population. His concern was if Michigan lacked primary care capacity, newly eligible Medicaid recipients could end up seeking care in the emergency room, thus driving up costs for the state.

As it turns out, a survey of primary care physicians we had fielded in the fall of 2012 (from October through December) shed light on that very question. We now have, hot off the press, an answer to the Medicaid capacity question from our survey of primary care providers.

The survey results were enormously heartening on the readiness of primary care physicians to serve patients who should be getting coverage in 2014: 81 percent of primary care physicians overall in the state said they have enough capacity to expand their practices to take patients who will be newly covered by private coverage and Medicaid.

Of primary care physicians in the state, 55 percent said they take Medicaid patients today. Almost all of those said that they had capacity to serve new Medicaid patients in the future.

But what was particularly encouraging was this: of physicians who said they had capacity to accept new patients but don’t take Medicaid today, more than 80 percent in every practice category (family medicine, internal medicine, and pediatrics) said that they have the capacity to serve newly eligible Medicaid patients.

This is exciting news and should give policy makers confidence that as a state, we will be ready for a Medicaid expansion in 2014.

As I discussed these findings with reporters in the run up to the public release of our issue brief, I said I thought the state should indeed expand Medicaid. After I made that statement, a reporter asked me if we were changing our mission and becoming an advocacy organization. We are not. Our commitment is to provide non-partisan, factual information that is useful for policy makers. Our economic analysis and provider survey were powerful pieces of data. Those data, combined with what we know about the positive influence of health insurance on health and a recent American Cancer Society funded survey that showed that 63 percent of Michigan registered voters want the expansion, paint a compelling picture.

In this particular case it is hard not to conclude, based on the facts, that an expansion of the Medicaid program would be good for the state of Michigan.

When the Affordable Care Act passed in March of 2010, 2014 (the year when the most fundamental coverage changes resulting from the ACA occur) seemed a long way off.

Well, 2014 doesn’t feel so far away now, does it? In fact, for those who are most immediately affected—the uninsured, small businesses, and individuals who buy their own health insurance in the private market place—enrollment for new coverage will begin later this year.

And 2013 will be a year of enormous activity for those who actually have to implement the law. President Obama, we are told, believes people will understand and appreciate health care reform when it goes more fully into effect. Whether or not that happens depends on how well the reforms are implemented this year.

To help people and policy makers understand the changes that are occurring this year, our center published a timeline that can be used to anticipate, plan for, and follow along with key events in the health reform journey. Some notable changes include:

• Primary care providers who take Medicaid patients should already see a difference in the amount they are paid to care for them. Starting January 1 and for two years (2013 and 2014), the federal government will provide 100 percent of the funding required to bring primary care payments for Medicaid patients up to Medicare levels. That’s a big change in Michigan (and most other states), where those providing primary care services for Medicaid patients are generally compensated well below the actual cost of care. The federal government hopes states will continue to pay physicians at these higher rates after 2014. It will be interesting to see how many do.
• Many employer health plans must include contraceptive coverage with no cost sharing starting in 2013. While some employers are challenging this provision in the courts, so far there have been no stays of this requirement that would affect implementation in any significant way.
• States that implement state-based exchanges (now called “health insurance marketplaces” by the U.S. Department of Health and Human Services) must have them up and running before October 1, 2013. Sometime before then, states must decide on rates and publicize plans to be offered—even if they are not running their own exchanges.
• Health plans, employers, some higher-income individuals, and some providers will see tax and fee increases, to begin to fund the expansion of coverage.
• The “donut hole” in drug coverage for seniors will continue to shrink in 2013.
• And, though not on the timeline itself, governors across the country will be deciding whether or not to expand Medicaid coverage, now that it is an optional part of the law as a result of the decision by the Supreme Court in June of 2012. Most governors will make this decision in conjunction with their budget proposals, so look for lots of announcements over the next month or two.

All these changes and more will take place over the next few months. And while some opponents of the Affordable Care Act are hoping these key implementation steps fail in some way, most Americans should be hoping they succeed. The promise and the hope of health reform is that access to care and population health will both improve. 2013 is an important year in the effort to get us there.