Evaluating Obamacare: A Guide for the Perplexed

Any serious effort to evaluate Obamacare must begin with a basic question: Compared to what?

Once today's administrative glitches are resolved, the basic goal is to provide Americans with an improved relationship with the nation's health care system. There are many ways to do so.

The dream standard, which Obamacare does not aspire to meet, is a system that provides any care requested from any provider without worrisome costs. Such care would include eyeglasses, hearing aids, dental work and unlimited physical and mental therapy, all conveniently available at sites where cost was never a barrier.

There is no existing insurance plan in America that provides such a broad menu of services. While these services may solve real problems, insurance typically limits or excludes them.

And very few plans will pay full reimbursement to any provider picked by the patient. Those who demand service from a doctor or hospital not in their plan -- or an uncovered drug or procedure -- are out of luck unless they're willing to pay for it. That will continue to be true under Obamacare.

So critical stories explaining how someone enrolled in Obamacare may have to switch physicians or drugs miss the mark. They're comparing the new program with a fantasy that will never come true.

Their criticism is as misguided as the alarm sounded because a few physicians (under 10 percent) don't participate in Medicare, effectively denying their services to most Medicare beneficiaries. A more realistic benchmark is private insurance, which relies on networks that include less than two-thirds of physicians practicing in any area.

Many of the Obamacare plans include even smaller networks. But the key question -- alike with both Obamacare and existing plans -- is whether you can get service from a competent urologist or neurosurgeon when you need it, not whether you can pick any such specialist anywhere.

That's what President Obama meant when he repeatedly promised the plan would guarantee the medical care people need -- which is not necessarily the same as the care people want. An efficient system inevitably relies on protocols that rely on preferred medicines and procedures. Today that would suggest a bias against immediate spine surgery, angioplasties or any drug that has a generic equivalent. There's a wealth of data available on what works. One challenge for Obamacare is getting providers to stop ignoring it.

Ever since the Nixon administration, there's been a bipartisan consensus in Washington that the most efficient way of delivering care is through a protocol-driven health maintenance organization like Kaiser Permanente, which has a standard, default answer for nearly any diagnosis. Government efforts to push medicine in this direction haven't been wildly successful. Obamacare provides another opportunity.

Ultimately, we'll probably find that Obamacare mirrors the current system, with both its strengths, frustrations and imperfections. That's not accidental. It will closely resemble the existing employer-linked coverage that most Americans enjoy and not be totally different from Medicare.

For those who lack affordable coverage today, it will be a big step forward. For those with adequate coverage today, the changes will be nearly invisible and features that frustrate patients -- and providers -- today will continue.

Obamacare backers over promised. Politicians always do. Cancer and the common cold will still be with us. The difference is that nearly everyone will be able to get the care they need in either situation. That's a big step forward.

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