CS: The NHS has had boatloads of cash flowing into it. Its funding has more than doubled over the last decade. Many people would justifiably argue this was a much-needed investment after years of neglect, but that’s meant it has been easy to solve problems with lots of money. The key problem going forward is that money, the cash increase, has now stopped and there will be years of flat funding and demands are increasing for reasons that are common to the whole developed world.

TL: So what you’re saying is that the health system has to do more with less. In some ways that sounds like the American system. Our reforms basically moved money around in the federal budget, with a little bit of new money coming from new taxes on the very wealthy and on insurance companies and makers of medical devices. The reform law is not wildly popular. The support is less than 50 percent depending on which poll you use, and that number hasn’t changed in two years. So it’s probably doubtful there is going to be a groundswell of popularity for this act, even when it’s implemented.

CS: What occurred to me might happen, is that once it is implemented and people see that they have coverage where they didn’t before, or they see that they’re not denied coverage for preexisting conditions, people will start to value it in a way that they didn’t before, and it’ll become like Medicare or Social Security. And then it will be much harder to take away.

And just to finish. In Britain, by comparison, these reforms will come into effect and no one will notice the difference because essentially, they are behind-the-scenes reforms. If the reforms do what they say they’re going to do, patients will notice a slight improvement. In fact, what might happen is that things carry on very much as they always have, which tends to be the pattern in NHS reorganizations.

TL: To come back to your point that the Act could become more popular as people see the benefits: Most Americans aren’t going to be affected by it. They will still maintain their employer-provided coverage, and that’s 150 to 160 million people.

What those people are going to see is insurance with higher and higher deductibles and more cost sharing and higher premiums. They are going to find that they’re paying a lot more for less coverage. That has been happening aside from the Affordable Care Act.

CS: Do you think the Affordable Care Act will worsen the problem?

TL: We don’t know, because it depends on the extent that employers stay in the game. A lot of employers may decide to give up health insurance and send their workers to the exchanges, those state-run shopping services where people can buy policies. Coverage in the exchanges is going to be expensive for some people, and, depending on what you buy, benefits may not cover much. It hasn’t been widely publicized that the so-called “bronze policy”—which will most likely be the lowest-priced policy in the state exchanges—is designed to cover only 60 percent of your costs. People may not be happy when they find they can only afford a bronze plan. Some people shopping in the exchanges may come to like it. Others may not. It all depends on what the insurance companies offer at that point.

CS: Some of the more optimistic, liberal supporters of the Affordable Care Act say it starts all these experiments on cost control and puts all these pilot schemes to work. And that may not solve the problem, but it will start a process by which the best practices will be more widely adopted and something will be done about costs. Is that a plausible or probable scenario?