Last August, when the health care debate was one disrupted town hall after another, I had the pleasure of talking to Dr. David Howes, the president of Martin’s Point Health Care.

In calm and measured tones, Howes explained that there were things about the bill he liked, and things he didn’t, and he made it clear that he didn’t think it was either as good — or as bad — as did the antagonists on either side.

After President Obama’s campaign-style visit to Portland last week, I talked with Howes again.

As a former primary care physician who runs a nonprofit company that sells insurance and operates clinics, Howes has a unique perspective on the health care scene. Nine months after our first conversation, he still sees plenty to like and plenty to be concerned about as he looks at post-reform health care in Maine.

The biggest changes, such as the individual and employer mandates and the state-run insurance exchanges, are still four years away. But there are many more small changes that could have an impact much sooner.

“It’s already begun,” he said. “It’s driven by the employer community, who are facing real challenges on the business side providing health benefits. They’re saying, ‘This is not working for us. We want better value for our health care dollar.’ “

Changes that are already under way will be accelerated, Howes predicts. The trend of doctors choosing to work for clinics or hospital-managed practices rather than operating their own practices will likely continue. Financial pressure on small rural hospitals may force them to change their missions to more limited roles.

The biggest changes, Howes said, are likely to come from demonstration projects, which are the part of the health care law that has gotten the least amount of attention.

The law creates opportunities for states and providers to experiment with different ways of financing health care that would cut costs and improve outcomes.

One way is to provide incentives for hospitals to prevent infections, which are both avoidable and expensive to treat. Another would stop payment for costs associated with readmissions for the same condition, giving hospitals a reason to make sure that a patient is well enough to be discharged even if that means keeping him an extra day or two.

Other projects would change the structure of the way physicians get paid. “Accountable care organizations” is a catchall term for several different kinds of practices in which providers are paid by the patient instead of by the procedure, and they get to keep more of the money if the patient is healthy.

“In the current system, it’s like going to a restaurant and ordering everything ‘a la carte,’ ” Howes said. “This would be more like ordering ‘prix fixe,’ and that can be a much better deal.”

One model organization, Howes said, is the Kaiser Permanente’s Denver project, where an interdisciplinary group of doctors selected the people covered by their plan with the greatest risk of heart disease and focused on making them more healthy.

“They reduced the cardiac death rate by 70 percent,” Howes said. “It’s possible to get in front of the risk, and the payoff comes very quickly. It plays out in the quality of people’s lives and saves costs.”

Under the new law, there will be an unprecedented $10 billion invested in helping new projects get started and keeping them going until it’s clear whether they can work.

If successful, a demonstration project can spread very quickly. The law allows the secretary of health and human services to make a successful demonstration into standard practice without having to go back to Congress for approval.

Howes said there is still a lot of uncertainty that has providers concerned.

Maine’s hospitals are struggling to pick up the costs that are not paid by government plans such as Medicaid and Medicare, and that could grow worse if the numbers of people who qualify for those plans increase. But under the current system, hospitals haven’t really had an incentive to decrease overall costs, because they could shift them among different payers.

“This is an awfully difficult time for hospitals,” Howes said. “It’s a big challenge for them.”

With the passage of the law, Maine remains an expensive place to provide health care.

It’s a relatively poor state with a large elderly population, and people suffer from a lot of chronic diseases related to obesity and smoking. The right mix of incentives could bring costs down by making people healthier, but Howes doesn’t know if the right mix has been found yet.

“This is a very good day,” Howes said after the passage of the bill. “But there is so much that has to be sorted out.”

Greg Kesich is an editorial writer. He can be contacted at 791-6481 or at: gkesich@pressherald.com