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In his address to a n audience of Robert Wood Johnson Foundation funded community-based health alliances, former Office of Management and Budget Director Peter Orszag sounded a fairly optimistic note on prospects for implementation of health reform despite the Republican surge. He also emphasized provisions of the law that address cost and quality, areas that have received comparatively little attention in the general press.

Outright appeal won’t happen, as others have also said, but Orszag went beyond that, emphasizing the power of the Center for Medicare and Medicaid Innovation and the Independent Payment Advisory Board to scale up successful pilot programs and take action to curtail Medicare spending growth without additional legislative approval. Congress would have to work hard to stop these entities, and with gridlock the likely order of the day in Washington for a while, “The power of default and inertia may be key” to keeping health reform implementation rolling along.

Orszag expects that implementation will be underfunded by Congress –not completely defunded. That will slow things down and make implementation sloppier but won’t be a highly effective blocker. He quite rightly pointed out that the locally-based innovations being piloted by the Robert Wood Johnson Foundation’s Aligning Forces for Quality communities and others can counteract –to some extent– the effects of defunding of government programs.

I thought it was an effective and inspiring talk and agreed with most of what he said. On the flip side, there may be other vulnerabilities –such as the difficulty in selling PPACA to the American people and Republicans’ willingness to block appointments– that were brought up in the Q&A session but downplayed by Orszag.

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