In the December 14 New Yorker, Atul Gawande has another fascinating article on health-care-reform incrementalism. If genius lies in seeing the unexpected connections, it’s surely genius to compare our current broken, fragmented, frustrating medical-delivery systems with the state of American agriculture at the turn of the last century:
According to the Congressional Budget Office, the [proposed Senate] bill makes no significant long-term cost reductions. Even Democrats have become nervous. For many, the hope of reform was to re-form the health-care system. If nothing is done, the United States is on track to spend an unimaginable ten trillion dollars more on health care in the next decade than it currently spends, hobbling government, growth, and employment. Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.
At the start of the twentieth century, another indispensable but unmanageably costly sector was strangling the country: agriculture. In 1900, more than forty per cent of a family’s income went to paying for food. At the same time, farming was hugely labor-intensive, tying up almost half the American workforce. We were, partly as a result, still a poor nation. Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power. We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors. And we had to make farming less labor-dependent, so that more of the population could enter non-farming occupations and support economic growth and development…
Please read the whole article, if only to improve your mood. Gawande goes on to describe the gradual development of the USDA’s “scientific farming” innovations — one farm plot, one county, one pilot program at a time. It was inefficient, clumsy, wasteful, and duplicative. And yet, however slowly and painfully, it worked.
The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county. Transforming health care everywhere starts with transforming it somewhere.
…
Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.
…
Which of these programs will work? We can’t know. That’s why the Congressional Budget Office doesn’t credit any of them with substantial savings. The package relies on taxes and short-term payment cuts to providers in order to pay for subsidies. But, in the end, it contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan. That’s a crucial lesson of our agricultural experience. And there’s another: with problems that don’t have technical solutions, the struggle never ends.
amorphous
Do you schedule these posts, or are you just an insomniac?
Chuck Butcher
Holy shit, to compare agriculture at the beginning of the real industrial revolution and the mechanization of farming to Health Care Reform is one of the stupidest goddam things I’ve ever in my entire life seen attempted. Proper land usage has not an iota of shit to do with taking manual labor out of the picture and in fact those real benefits were realized after the mechanized abuse of land.
No, I won’t read it, the entire premise is too stupid.
If you wan to make me feel better, lie to me and tell me nearly half the US Senate has been arrested for criminal stupidity.
inkadu
Agriculture is labor intensive, and medicine is labor intensive… hmmm…..
Hey, is one of the many pilot programs testing the deployment of Emergency Medical Holograms? That could be a good solution.
inkadu
I also bet John Deere can get an MRI to market a lot cheaper than GE can. As an extra bonus, I’d get a green scale model John Deere MRI to add to my collection of tractors this Christmas.
inkadu
Agriculture also makes a great use of land. Whereas individual hospitals contain almost every specialty, hundreds of acres are dedicated to single crops. So lets try putting all the cardiologists in Iowa, all the general practitioners in Idaho, and all oncologists in Florida. Comparison shopping among opthamologists would be so easy, you wouldn’t even need to be able to see to do it.
inkadu
Let’s get rid of pharmacies. Everyone should come outside of their homes around 5:30 every morning and wait to be sprayed by the twin-prop medicine planes. Dosing will be determined by the needs of the population at the time. After all, not every ear of corn gets its own doctor.
inkadu
4H should start a medical division, so that kids can start learning how to do surgeries early on. County Fairs can compete and display, “Best Vasectomy,” and “Best Hemmorhoid Removal” alongside the usual pies and giant pumpkins.
Fencedude
The missing of the point so far in this thread is profound.
Jack Roy
Prehaps, Fencedude. Prehaps. Yet when I read Gawande’s piece last week (with great interest), I found the whole shot through with tenuous analogies and on the whole a work more of blind optimism than reasoned judgment. It’s hopeful, to be sure. But in this case I think it’s worth a second of reflection just how empty a reassurance is hopefulness.
Gawande uses the agricultural precedent as a basis to argue that, in reforming health care, the Americans will need to muddle through the policy alternatives, trying out many in order to find those that work. What the analogy is obviously missing is that, unlike farmers a century ago, American providers and consumers of health care are surrounded with thoroughly documented examples of alternatives to our system that deliver better care for less money. Dozens of them, if not hundreds. You want to know how well socialized medicine works, in practice rather than in Marxist or Randian theory? Britain’s NHS provides a complete demonstration. Or single-payer? Take a look at France. The empirical work has been done, over the last half century or so. It’s just that Americans aren’t willing to believe data that contradicts their peculiar free-market way of thinking.
What the present debate has demonstrated is not some particular point about health care policy or agriculture, but rather the general point about American politics that, if a constituency is making serious money on some slice of the economy, the government will have to pay off that constituency significantly before it tinkers with any part of that slice. If you want a narrower thesis, you could add that this is true, even if the fact that this constituency is making money is unsustainable and in fact quickly bankrupting the country.
There’s a systemic political problem, as demonstrated by the Senate’s supermajority and the half-dozen veto points in the legislative process, as well as the orthogonal distractions of Stupak et al. And of course it’s always fun to blame political elites for their cowardice and/or opportunism. (Hey, I don’t like Joe Lieberman or Evan Bayh or Olympia… I don’t like any Republicans, actually.) But it’s only half the picture; Americans really are unwilling to believe that the rest of the world does health care better than we do. Every election campaign a candidate declares “we have the best health care system of the world,” and people applaud. The health country industry has captured (to borrow from the poli sci literature) the formal agenda, but they’ve also captured the informal agenda; they’ve largely captured the issue public, and they’ve definitely captured the mass public.
Where we should be now is adopting at least a few of the multitude of significant health care policy improvements that are developed, tested, proven, affordable, and available, by way of the health care systems of pretty much any other country in the world. Even that small step is evidently impossible, given our political system, so what Gawande offers is a plausible reason to hope that it will become possible in a few years or so. Hey, I hope it’s true, too; but to repeat myself, hopefulness is an empty reassurance at this point.
Fencedude
Oh, I completely agree on those points, but I was just amused by how thoroughly literal everyone was being.
WereBear
I kept thinking that American agricultural practices led to the Dustbowl.
But maybe it’s not germane.
mai naem
Other developing/developed(Taiwan/S.Korea/China) went around the world and looked at other countries to figure out what works the best. But not this country. Oh,nooooooooo, we are exceptional dontcha know? We have to reinvent the wheel. Its like the guy who did the Frontline piece said – Americans wouldn’t put up with this kind of expense/inefficiency in any other situation but somehow in healthcare we put up with this. Why? I dunno.
WereBear
@mai naem: Why? Because someone is making a ton of money that way. That’s why.
There really is a segment of the population who believes we are put on this earth to make as much money as possible.
Period.
Comrade Darkness
I, for one, welcome our new combinatorial overlords.
aimai
Still, I love this thread. Even though I can’t afford to get any more depressed about HCR than I already am and would like to feel good about atul gawande’s optimism and pork bellies, or whatever.
aimai
Fulcanelli
@inkadu:
Yes, and all the Proctologists we’ll already find in Oklahoma if their current political representation in any indicator.
Industrialized agriculture, you say? Anybody see the film ‘Food, Inc.’ yet?
drillfork
Without having read the article, the analogy does seem pretty forced. Wasn’t the development of roads the primary catalyst for efficiently distributing food to the masses?
And it’s not like our current agricultural environment, with its reliance on giant corporate farms spewing tons of pigshit into our groundwater, is anything to write home about.
So ya, everything still sucks. Especially HCR. With that in mind I’ll go back to sucking the food particles from this giant hole in my tooth now.
But, at least B-J has edit. Huzzah…
WereBear
Actually, I expected HCR to be a gutted half-a-loaf, so I’m still okay with it.
I never expected they would legislate away a huge swatch of the economy. I never expected it to be a bill I’d be happy about, and would really address the situation.
Because we don’t do that.
At base, what our enormously important legislation steps are is: cracks in the dam.
For decades, right-minded people hurled themselves against the Jim Crow laws, and bounced right off. Because they wanted to break the dam, and dams are too big to break.
LBJ, dirty rotten scoundrel that he was, nonetheless twisted arms to get the 1957 voting rights bill passed; weak, full of loopholes, and an utter disappointment to many. But it cracked the dam, and paved the way.
Maybe President Obama is going to be happy with whatever travesty of actually doing something the bill becomes. Because the first step is the biggest.
Robin G.
Yeah… I’m happy to cling to any sign of optimism at this point (it’s the Christmas season, goddammit), but it doesn’t make me feel much better when we’re supposed to hope that HCR turns out like Big Agra. (Interestingly, if not for Big Agra and the crap food it produces, we’d probably need less health care…)
Brian J
Yikes, maybe I’m just easy to please, but I thought his article was great.
I have to think a lot of people here are being purposefully obtuse, because there’s nothing to support the idea that he’s claiming agriculture and medicine are that similar. He’s simply building an extended analogy. No, the two industries aren’t really alike, but they don’t have to be for inefficiencies to be damaging. His point was that what seemed like a hopeless situation back then and what seems like a hopeless situation now aren’t reason to give up, because through trial and error brought on by the government, we found a way out.
And yes, other countries have found ways to provide more care to more people, and usually better care at that, while spending less than we do. But they are experiencing similar inflationary problems in regards to spending. We can look to them for guidance, but not for concrete answers.
Lee
Of course that are, they are Balloon Juice commenters.
I have no idea if it is true or not, but I would bet that the Republicans of the day fought every single farming project the government implemented. Then when it was a success, they claimed credit.
monkeyboy
In 1900 the US was not sitting in a world where many countries had high output little labor farming systems whose ideas it could borrow, so it had to invent them itself. Nor was it in a situation where there was strong economic interests opposed to farming improvement.
Yes health care can be developed slowly and incrementally, but it takes a perverse form of American Exceptionalism to say that the US is so unique that the experience in the rest of the world is irrelevant.
Seanly
@Fencedude:
That’s a feature, not a bug.
DanF
You know what reformers to early farming didn’t have to face? Big Phrama and Insurance Companies. One hundred years ago, there weren’t dominant political and economic forces attempting to keep farmers from improving their crop yields. Other than that … totally identical. /snark
Wilson Heath
What kind of dumbass looks at the changes in agriculture in America in the 20th century and says “that’s what we need for HCR”?
snabby
What’s missing in the analogy is the huge impact that cheap oil had on making agriculture so efficient. Run machinery with it instead of manual labor or animals; create fertilizer to increase yields; create pesticides to avoid crop destruction; transport the food cheaply to population centers.
Yeah, government helped make agriculture more efficient, but only incrementally. Oil did most of the heavy lifting.
There’s nothing similar in the healthcare arena.
Cerberus
Actually the Gilded Age is a good example for people feeling frustrated. In the Gilded Age, we were wholly dominated by corporate interests in politics and the people could barely be heard, those who could even vote to begin with as women didn’t have the right to vote and blacks were being denied the rights to exercise their votes. The system was collapsing. People were starving, being thrown out of their homes, losing their jobs, massive abuses against all sorts of communities like the Irish-Americans and Asian-Americans. And the media was in the tank for them. People like Hearst were “tweeking the news” to fit their desired goals up to and including goading the US into an unnecessary war ginned up on false pretenses (Spanish American War) and charismatic leaders found themselves hard pressed to really reform things (even the great Teddy Roosevelt felt at the end of his terms like he accomplished jackshit and even passed a number of bills aiding corporations in union-busting and the like).
And progressives at the time felt like they weren’t mattering to the process, that there was nothing that could be done to stop the massive death, destruction, and despair. They felt as powerless then as we do now and massive protests, movements, and public sentiment seemed ill-served to make a dent in Congress’s actions.
Sound familiar?
But by constant effort, by a thousand cracks and movements and pushes, and efforts, there came something out of it. A number of progressive reforms a little here, a little there. Some trust-busting in the teens, some socially progressive major victories, and a bit of a Great Depression leading to the much needed economic reforms.
We might have to go through another Great Depression, in fact, I would suspect we will, but the important thing to remember is that we’ve been here before in our nation’s history and we got out. We’ll do so again.
Oh, but we will lose our special “ruler of the world” title, but frankly, thank Bob in Himmel for when that happens.
Brian J
@monkeyboy:
In the article, he talks about how those working for the government as it tried to reform agriculture had to deal with the existing systems, sort of like how any reform effort here will have to deal with the systems already in place. As Gawande himself has written in the past, just because the entire industry isn’t changed right away doesn’t mean reform is failing. As was the case with the systems in Europe some would like us to follow, reforms that build upon themselves can make a difference.
Besides, as I said above, other countries are dealing with problems relating to health care inflation. They may be better than we are now, but they aren’t perfect. The implication that such inflation wouldn’t be a problem if we simply copied the French system is weird.
Brian J
@Wilson Heath:
Um, once again, that’s not what he did. He wasn’t describing the two industries as so similar that the solutions to each problem are the same. Instead, he is suggesting that what seems like small scale reforms to a massive problem that threatens to break us isn’t a cause for concern, because we’ve been in a similar situation before and, through trial and error, gotten out of it.
Lex
As a former journalist who has covered both agriculture and medicine, I found some useful analogies in Gawande’s article and even derived from it a moderate measure of hope (which is something I haven’t done w/r/t HCR in a while). @BrianJ gets it, and I suspect more of you others do than are letting on.
As for the people dismissing the piece out of hand without even reading it, well, Balloon Juice is still a semi-free country, so knock yourself out, but, really, on a day when Lieberman has become an even bigger dick than he was yesterday, which is saying something, why deny yourself a little optimism?
Irony Abounds
We have the pilot programs now. The Cleveland Clinic, the Mayo Clinic, etc. The cost savings AND the better outcomes are obvious. Nationwide versions of those outfits would, by and large solve the cost problems and allow for increased care. It seems, however, that the HCR bills presented don’t provide any particular incentive to emulate those models. The problem isn’t a lack of innovation. The problem is, and what Dr. Gawande seems to ignore, the lobbyists and the money invested in keeping the status quo. There was no huge family farming lobby in 1900.
gwangung
Yeah, but the fact that they ARE better means we should look at them.
One of the dumbest arguements I heard against health care reform was that, well, other countries’ costs are rising, too! Uh, yeah, but which country’s costs are rising fastest? And shouldn’t that country look at other systems to see how they can at least slow it down.
Bill H
Well, accepting his premise that incremental change itself is the point, it probably should be pointed out that the incremental change he uses as an example led to a highly efficient way to produce a terribly crappy product. Part of the health problem we face is food that has had a good part of the nutrient bred out of it, and the rest processed out for transport and storage and replaced with chemicals and artificial sweeteners to make it palatable since the original flavor has been lost in transit.
The problem is that incremental change is, by definition, unplanned change
slippy
Here’s why I think most of what we’re hearing out of the Republicans and Conservadems is not going to matter:
Our health insurance system is flat-out unsustainable. It has become incrementally more and more expensive while delivering less and less care.
They’re working towards a tipping point where the cost for having insurance is astronomical, while the benefit for paying all those staggering sums of cash is so miniscule that it is not even worth having. Here’s an example:
My prescription coverage is through Medco, curse their name everlastingly. Medco lets me fill my prescription at my local pharmacy for “maintenance medications” a few times, then sends me a threatening notice that they will be raising the cost for me unless I use their mail-order service and pay for a 90 day supply. I’m prescribed two very common medicines, one for blood pressure and one for diabetes type 2. I found out that basically Medco stops covering me unless I do it their way. I didn’t agree to this and I don’t like it, but I also found out that the “naked” cost of these medicines is $20 per month. My fiancee has done the 90-day deal with them, and they charged her $100 for a 90-day supply of something that costs, without insurance at all, $20 a month. Do the math.
Instead of saving anybody money, they’re ass-fucking their customers at a 40% markup.
They get away with this kind of garbage temporarily, but I have simply quit even reading the festering dogshit they send me in the mail. If I could drop the prescription coverage out of my plan I would. However, I am still doing better for not taking their ass-raping advice and just doing it my way. How long before my entire health insurance package becomes so junked-up that I decide it’s just better to pay my copay to the doctor “naked” and not worry about what happens if I get hit with hospital bills that insurance won’t pay anyway?
If our Senate were honest they would be looking at the business practices of health insurers and deciding that they needed to apply RICO statues, not agricultural solutions. The people running these companies need to be arrested, fined, their companies dissolved, their shareholders told to gag on it, their employees told to find another job. just fucking dissolved. They are a gigantic organised criminal scheme and they don’t seem to care that they are violating several core principles of business that any blithering shit-for-brains moron can grasp: don’t make your business so expensive to use that nobody can afford it, don’t shit all over your customers, and don’t act like you’re irreplaceable.
The insurance industry is headed for a cataclysm. If our fake reform fails, and I’m increasingly of the opinion that it is going to just fall flat on its face, the result will be an industry-wide orgy of profit-taking until the public simply says “enough” and unsubscribes from their plans en-masse. Because what the hell is the point of spending $20,000 a year on insurance that doesn’t fucking cover anything?
Then the government will institute Medicare for all. Because if you do the math, no other choice actually makes sense. So, screw Joe Lieberman and his whore wife. They don’t matter in the long run. History will steamroll over their con game and crush it flat.
Brian J
@gwangung:
I’m not using these points to argue against health care reform. I hope you don’t think that.
Like you, I think we should look at them, but I’d be willing to guess that Gawande feels the same way. His article doesn’t go against the idea we need to look at successful systems. If anything, his tone suggests he’d support that.
What he’s saying is that the bills in question call for are experimentation: we need to see what works, what doesn’t work, and then move on while trying new things to keep working to improve the system. Instead of thinking that the bill is crappy because it tries a lot of things, he says we should be comfortable because such trial and error are to be expected. It’s what happened in the past when a major industry was in trouble.
Brian J
@Bill H:
You make a valid point that what we eat has a big effect on our health, but I don’t think that’s entirely the fault of the system being dominated by a few big players.
Steerpike
I like the “cracks in the dam” analogy. At this point, any form of public option will be so wildly popular that future Congresses will have no choice but to expand and improve it, to make it more efficient and more widely available, which will make it even more popular, and so on. What the entrenched health care
denialproviding industry is trying to do is to make sure that any public option will be so expensive, constrained and unpopular that future congresses will be more inclined to kill it off, rather than improve on it.And yeah, the posters here have been a bit disingenuous about the health care/agriculture analogy. The point is not that these sectors are remotely similar, only that the best approach to reforming them both may be a slow, incremental one, rather than a sweeping, mandated upheaval. Agree or not, but pointing out that farmers don’t set broken bones and doctors don’t grow wheat, and therefore any comparison between the two is invalid is a bit dense.
CalD
Democracy at it’s most functional produces sub-optimal, compromised solutions that no one is happy with. That’s by design. If anyone is completely happy with anything the government does it usually means someone else is got it shoved down their throat and that’s something the system is specifically designed to try and minimize. I tend to think this is what prompted Winston Churchill to characterize democracy as the worst possible form of government, except for all the others.
But because no one is ever really happy with most of what the government produces even — even when operating as functionally as its competing design objectives will allow — things do tend to be refined over time through a slow and often painful succession of baby steps. That’s not even necessarily such a bad thing because you usually learn a lot in the process of trying to solve a problem that you didn’t know at the outset.
Tom Hilton
@Jack Roy:
Yes, there are examples of systems that work a whole lot better than ours–and it makes sense to look at aspects of each of them to see if they would work here.
The idea that any of those systems could be transplanted here and work as well as it does in its original form is a pipe dream (politically, for starters, but also operationally). As Gawande pointed out in an earlier piece that is well worth seeking out and reading in its entirety, each of those systems developed incrementally, building on whatever was in place at the time. That’s a messier and less satisfying process for progressives than just waving a magic wand and establishing a Single Payer system, but it’s how these things work.
Notorious P.A.T.
You have no idea what you are talking about. The industrial revolution happened at the beginning of the 20th century? Good one. And tell a sharecropper in 1910 that American agriculture was fully mechanized.
Notorious P.A.T.
Actually, better agricultural practices might have prevented that.
LOL. Read the article.
It’s funny how reading an article makes it easier to appreciate the article.
Notorious P.A.T.
Right. No one speculated on agricultural futures back then. In fact, I don’t think we even had a stock market.
/snark
Read the article.
Read the article.
For Christ’s sake, read the fucking article.
Notorious P.A.T.
Was that happening in 1910, when this article begins? Did our great-grandparents live on Twinkies and Famous Bowls? Was genetic engineering a feature of Guilded Age agribusiness?
Read.
the.
fucking.
article.
Tom Hilton
@Notorious P.A.T.:
This.
Notorious P.A.T.
Has anyone who dismissed the article read it yet?
I’ll admit, when I started reading it I was deeply skeptical. Gawande’s last article warned of the grave perils of skyrocketing medical costs, yet now he doesn’t seem to mind that this Senate reform proposal lacks strong measures to contain those costs. But by the end of the article, I was convinced he was on to something.
As many have said, there clearly is a lot wrong with how our country does agriculture these days. But most of that traces back to decisions made during Nixon’s time, not the time featured in this New Yorker piece. And a lot that has happened since Nixon has undone the kinds of reform Gawande talks about. For instance, 100 years ago we began encouraging farmers to rotate crops, but since Nixon changed the way our federal government handle crop surpluses it’s in a farmer’s best interests to raise only corn, or raise only pigs. Someone mentioned the use of petroleum in modern farming, and that is definitely a quantum leap, but as is explained in the article it took a while to convince farmers to try these new-fangled oil-based fertilizers and gas-driven machines. Is that hard to believe, that people might be resistant to change?
Gawande’s last piece about health care reform was a major focus of discussion in this debate, and this one looks to be the same. So read it! What else are you going to do, head to the beach and sunbathe?
Tax Analyst
@Notorious P.A.T. –
So you think maybe it’s a good idea to read the article?
That’s a very bold idea. I think you ought to emphasize it a little more, though.
Tax Analyst
Notorious Pat – OK, I read it…bu..bu…there’s no Magic Wand…waahh!!!
Seriously, it’s a thoughtful piece with some good points. And hey, I learned some stuff about agriculture, too. But you must realize that asking people, particularly Americans, to actually read SIX WHOLE PAGES is rather a presumptuous demand.
Brian J
@Notorious P.A.T.:
Did I miss something? I doubt he’d describe the bill as perfect, but I don’t know of anything that he has written to support your statement. If you don’t mind, please link to what you are referring to.
John Sears
Well, I did read the article, and I read his last big article on why healthcare costs dramatically more in some areas than in others.
What always comes across for me, reading Gawande, is that he is an ideologue trying to mask his deeply unpopular position. In this article, for example, he compares major systemic health care reform (say, single payer) with Soviet ‘experiments’ in improving agriculture, which of course led to millions of deaths.
In the article on costs in a small Texas town (The Cost Conundrum), Gawande attacks single payer repeatedly by claiming that Medicare can’t bring down costs in our current system. He does this by finding the sickest, poorest possible community he can, with the most venal, corrupt doctors imaginable, and then points to what they charge Medicare and jumps up and down, giddy with excitement. He proved single payer can’t work! Oh, if only the Mayo Clinic can save us from ourselves!
Then in this article, he tries to say that tiny, tinker around the edges pilot programs saved American agriculture (as opposed to making it completely dependent on chemical fertilizers, made from petroleum, and mechanical farming, driven BY petroleum), and that, therefore, tiny, tinker around the edges pilot programs will save medicine too. He claims, repeatedly, that NO ONE KNOWS what will work to contain costs, and therefore, as painful and slow as it is, the ONLY WAY to fix the system is to experiment, while 45k people die a year.
Only, as Jack Roy pointed out way toward the start of this thread, while we Americans sat on our asses letting the HMOs rob us blind for the last 30 years, the rest of the world did something. Not just something, but a half dozen different somethings. And each and every major system they tried worked better than ours. We have half a dozen major models with decades of hard data to choose from; we don’t need pilot programs and endless tinkering and pleading with doctors who hate Medicare reimbursement rates to know what works, we just have to swallow our American ego and look at the data from the rest of the planet.
You could try a Single Provider system, like the NHS, or a Single Payer, like Canada. You could use a national, minimum coverage plan with optional supplemental insurance (like France), or you could go with a large government run and heavily regulated exchange (Germany). You could even keep private insurers intact, but regulate every decision they make, down to what plans they offer, to whom, and at what price (Switzerland). Or, if you want to be really wacky, you could be like Japan, and set up single payer models for each major industry.
All of these models work, to varying degrees, but better than ours. Prices are lower, outcomes are better. When Gawande pretends that we live in ignorance of a better way to do things, what he means is that we live in ignorance of a better way that keeps everybody rich, and the eeevil big government out of his business.
Brian J
@John Sears:
Um, what the fuck? Where are you getting this stuff? Only the most casual, careless reading of his articles could make you write such statements.
I don’t think his point in “The Cost Conundrum,” for instance, was that Medicare is horrible. It’s that fee-for-service appears to be a big contributor to rising health care costs. Why did he use Medicare as an example? My guess is, the information is readily available and easy to figure out if you’re knowledgeable like him. Perhaps he could have used private hospitals, but must they release their information to anyone who asks? I’d guess not, but if you have some information to the contrary, please let me know.
But more generally speaking, his point isn’t that a series of proposals to experiment is the best way forward. It’s that it’s an acceptable starting point, as demonstrated by other countries, like any of the ones you are apparently referring to, in the move towards universal coverage.
Besides that, other countries are experiencing similar issues with health care inflation. Their overall costs may be lower, which is no small feat, and something we should try to follow, but they are rising, too. Like us, they need better ways to control costs, regardless of how small their base is. That’s where the experimentation comes in.
John Sears
@Brian J: Hmm, let’s see where I’m getting this:
Now you tell me what the hell basis he has, other than pure fearmongering, to compare the lunatic collectivization schemes of Stalin with the current healthcare reform process? It is clear, to anyone who reads the piece honestly, that Gawande is trying to paint a parallel between health care reform and agriculture, and argues for a government hands-off approach, where, much like the agricultural reforms he spends five pages praising, they offer only help, advice and money, not rules or regulations. Where PRIVATE businesses, insurers and providers are left intact.
Which is his highest concern. He states, over and over again, that we have to be deeply concerned with the welfare and individual liberty of the providers, that we have to convince them of each reform and get them to take it of their own free will, much like he imagines farmers were convinced.
As for bashing Medicare, in The Cost Conundrum he states conclusively that (he feels) it is no better to have a public insurer than a private one for cost containment:
Note the message: public health insurance won’t work. Nevermind that Medicare is far more efficient and has far less overhead, don’t try expanding public health insurance, just give big sacks of money to doctors and hospitals for 10 years and we’ll see what shakes out.
Yeesh. I think I read his articles a lot closer than you did.
Brian J
@John Sears:
You are simply misreading what he wrote. Whether this is intentional or not isn’t clear, but Gawande most certainly did not compare the current effort to reform health care to collectivization. He discussed Soviet farms to establish a context for the severity of the crisis many nations around the world were facing. There’s simply no other way to interpret that, unless you are trying to bastardize what he says.
Really? Where does he do that? I’ll admit, I read his latest piece last week and the others a couple of weeks ago, so they aren’t that fresh in my mind, but I think I’d remember such an high-spirited comment, particularly one that is made as many times as you claim. So please, provide me some links.
Why don’t you try reading a few paragraphs above? Here:
“Empirical, not ideological.” Those don’t sound like the words of a man who is committed to any one particular plan. Indeed, he’s not. He wrote an eight-page article describing the problems with fee-for-service medicine and how seeking more and more revenue was bad for everyone but those earning high incomes. His solution was start trying new things and to see what works. One of the big points of things like effectiveness research is that if something starts working for a program like Medicare, the private sector could follow suit. He talks about making recommendations for certain systems, but that’s expected, because we can’t necessarily force one insurer to do things a certain way. We can regulate them, sure, but we unless we completely nationalize them, we don’t own them.
If by “read” you meant completely twisting his words and inserting your own bizarre interpretation, then yes, you are correct.