Ezra favorably cites an OMB’s take on the CBO analysis of PPACA, and he quotes the following section:

* CBO projects that the Affordable Care Act will, unless Congress reverses some of its provisions in the future, reduce the long-term fiscal gap — the amount by which revenues must be raised or spending cut to produce a stable debt trajectory — by 2 percent of GDP over the next 75-years. (Between CBO’s long-term report from last year and its report from this year, the 75-year fiscal gap under the “baseline scenario” has been cut by 2.5 percentage points of GDP. There has been only one major change to fiscal outlook in that period — the enactment of the Affordable Care Act. And, based on both the CBO report’s narrative and backup data, the Affordable Care Act is responsible for about 2 percentage points of GDP of this deficit reduction.)

Of course, the Sustainable Growth Rate would have done the same thing. Once again, the White House is relying on budget identities to make the case for the new health law. Ezra anticipates this objection:

At this point, some conservatives say, that might all be true, but the cost controls in the health-care reform bill are tough, and we’ll never implement them. Unfortunately, there are no policies that will substantially cut the long-term deficit and aren’t tough and difficult to implement. We can either pass deficit-reducing legislation and implement it or we can go bankrupt. There’s no other choice. And the upside for the Affordable Care Act’s cost controls is that they’ve been passed into law, and you’d need 60 votes to stop them, which is better than hypothetical policies where you’d still need 60 votes to stop them.

I actually think this is a slight misreading of the conservative critique, or rather the conservative critique with which I’m most familiar: the problem isn’t that the cost controls in PPACA are tough — rather, it’s that they will not work. For James Capretta and and Clayton Christensen and other analysts, “toughness” is not the relevant metric. The important thing is for competition to happen at the right level.

This, in turn, requires structural reform of providers that goes beyond pilot programs that experiment with bundling, etc. Christensen’s The Innovator’s Prescription (co-authored by Jerome Grossman and Jason Hwang) describes the barriers to business model innovation in the U.S. health system — barriers that are more formidable under PPACA, including a variety of restrictions on the creation of new physician-owned specialty hospitals and much else besides. Ultimately, these are questions about industrial organization that tend to get lost in very abstract debates that center on budget identities.

It should go without saying that lobbyists on behalf of general hospitals don’t like specialty hospitals, for reasons Christensen et. al. outline in vivid detail. As Mike Masnick recently observed, this reflects a classic tactic on the part of powerful, organized incumbents.