1. Will healthcare change? Berwick offered a story about the auto industry's reactions in Japan and the US after the passage of auto emissions legislation. In Japan the industry responded by mobilizing to reduce emissions. In the US, the industry mobilized to change the law. "This is the strategy choice that we're going to face" in healthcare, Berwick explained.
2. Will we actually reduce cost? Berwick says we are in a rhetorical phase of cost reduction; we're talking about it, but not yet accomplishing it. He points to Massachusetts, which is now grappling with the costs of implementing near-universal coverage. Berwick's concern is that "as you watch the rhetoric play out, it's a playing field in which the authenticity of reducing costs remains in question."
He says he has considered promoting a national project that he calls the "15% projection" to keep healthcare spending at 15% of the GDP. "That would solve the problem, but is the authenticity there to reduce costs?"
3. Mechanics of coverage. Berwick believes health insurance exchanges are among the most difficult aspects of the PPACA. States are struggling with the mechanics of setting up this new "creative and agile element" of the healthcare coverage system. "It's a serious challenge. We can do it, but we have to be serious about it." The difficulty of the task is "compounded by political polarization."
4. The safety net. Berwick says "we must preserve the commitment and mechanics to make healthcare a human right." He notes that there are "real people really at risk" living at the poverty line. Unfortunately, he says, middle class politics are at the foreground and the political will to maintain the commitment to healthcare for the most disadvantaged is vulnerable.