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Most in the Pioneer group achieved quality improvements, but only 18 produced cost savings.

It remains to be seen whether it functions profitably or not," said Alan Miller, chief executive of Universal Health Services, which operates more than 200 hospitals, behavioral health facilities and outpatient centers."There has been a lot of discussion of moving away from fee- for-service to something like this, but we are a long way from there," Miller said.

The big opportunity for cost savings lies in getting preventive care for people before they land in the hospital with illnesses such as heart disease, diabetes and asthma,

She eventually went to the M. D. Anderson Cancer Center in Houston, where she has been treated for more than two months. The bill at the end of August was $650,000. The hospital, he said, called them to ask for a payment for $500,000.

But while Mr. Cantu expects to enroll for coverage for next year, the law won’t help him with his wife’s medical bills, which he estimates now approach $1 million, if not more. “Where am I going to get that kind of money?” he said. “In 20 years, I wouldn’t be able to pay it off.”

Medicare patients, however, are at a disadvantage because there is no cap for out-of-pocket expenses. They "are paying copayments or coinsurance forever," Dr. Newcomer explained.

"What we are already seeing is that patients who are on Medicare are coming to hospital settings; they are not being treated at their doctor's office or their infusion center because the doctors can't afford to do it," said Dr. Swain. The doctors would actually lose money on this, so the patients are coming to a higher-priced facility — a hospital — to get their infusion, she explained. "I think it is really going to have an effect, not on the patients but on the economy in general," she added.

The decline in Medicaid budgets has added challenges to medication access for recipients of this program.