Systemwide cost control--the missing link in health care reform.

1 gains in insurance coverage. The reform legislation now before Congress , however, cannot be relied on to control spending. The Obama administration and others have emphasized the cost-saving potential of prevention, comparative-effectiveness research, disease management, and health information technology. But there is little evidence that these worthwhile measures would produce meaningful cost control over the next decade. 1 The Congressional Budget Office (CBO) has consequently forecast scant savings from these sources, fueling debate about the affordability of reform 2 and raising concerns among fiscally conservative Blue Dog Democrats, without whom health care legislation cannot pass. In response, the administration has touted a proposal establishing an Independent Medicare Advisory Council (IMAC). The council would, along with the President, have broad authority to change Medicare rules in order to reduce program spending. Yet the scope of the savings that may be achieved through IMAC is impossible to know. And any savings would be limited to Medi-care — a modest part of national health care spending. Other cost-control proposals are more tangible. The Obama administration and Congress have proposed significant cuts in projected federal spending on Medi-care over the next decade that largely involve reduced payments to hospitals and private Medicare Advantage plans. These savings, though, would be partially offset — at least in the House legislation — by the cost of cancel-ing scheduled cuts in physician payments. Moreover, there is a sharp distinction between restraining government spending on medical care and restraining systemwide spending. Slowing the growth of federal Medicare expenditures would not guarantee spending restraint outside Medicare. Indeed, to some extent, medical providers could respond to reduced Medicare income by shifting costs to private payers. Nor would creating a new public insurance program guarantee that national health care spending will be restrained. With lower S uccessful health care reform requires effective control of health care spending — without it, rising costs will continue to strain federal and state budgets, businesses, and families, jeopardizing