As I write this editorial, we who practice medicine face many challenges. Our internal and external environments are changing, and we are asked to do more with less, but we have better tools to perform that work. We have health care reform, which has been met with such opposition that our government temporarily shutdown in October and faced potential default on the national debt. Although it is uncertain to what degree health care reform will succeed at its primary objectives – the provision of services to the underserved and cost control – it is clear that there are changes ahead that will have an impact on our care delivery. Because many states did not embrace Medicaid, it remains unclear how meaningful care will be provided. The technical challenges in registering for the health care exchanges partnered with the very small penalty for not enrolling are likely to precipitate lower-than-anticipated use of the exchanges, which could result in adverse selection of a sicker patient population, and increase proportional costs for patients enrolled in the health care exchanges. How will we manage this change better?
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