There’s a great post on the NY Time Economix blog from Uwe Reinhardt explaining the theoretical difference between premium support and voucher systems (and you thought they were the same thing!). Unfortunately it skirts the real problem that those of us playing along at home know too well. Either a well constructed premium support (Ryan done right), or a well constructed voucher/managed competition (Enthoven) system, a mixed public/private system (Germany, Starr, Reinhardt) or even a decent Medicare for all /Single payer system (PNHP, McCanne) needs to be designed holistically to have a chance of working–especially to ensure that all people are in plans that treat them all equally. Note that this very week HHS devolved the choice over plan benefits to the states–meaning that the very notion of Enthoven-like standard plan benefits required in a voucher system gets tossed out the window and even in the exchange plans will likely be able to alter their benefits to risk select. The sad facts of the matter are though–speaking as one who is a lefty but supports the concept of managed competition a la the Enthoven or Dutch model–that the 2009-10 debate shows that no holisitic system can emerge through our political process. And worse, no cost containment device will be left alone by a future Congress, as this weeks extension of the now more than a decade old SGR cuts demonstrates. So my non-Christmas cheery message is that the health care system will continue to promote over spending on the wrong types of people, and rational transformation of our 1950s designed insurance coverage and payment system will remain elusive for decades to come. What we get IF we keep the ACA will be the best we can hope for. Meanwhile, back over at NY Times it’s great to see Uwe Reinhardt reacting to his commenters (even those not paying Princeton tuition fees!).  Kudos from a health care blogger who doesn’t engage with his commenters enough.