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BUILDING ON WHAT WORKS.
Atul Gawande has a nicely turned health reform piece in this week's New Yorker that makes quite a few useful points but ultimately says surprisingly little. His thesis statement is simple enough: Countries do best to build atop what they have. He presents this as a rejection of the single payer utopians on the left and the free market ideologues on the right. He backs it up with a very quick tour of other systems around the world: Britain built atop the medical infrastructure developed during World War II, France built atop some voluntary-payroll tax arrangements that had organically emerged, and Switzerland built atop its private insurance system. It's an interesting history but not a thorough one: Any of those systems could have made very different choices and still have been building atop past successes rather than creating something radically new. What Gawande presents as institutional determinism only works in hindsight, and even there it doesn't work all that well.
Gawande's conclusion, however, is well aware of his argument's weaknesses. "Building atop what works" is a common trope in American health care circles. It tends to mean subsidizing the current system, putting in place some alternative insurance options for those who sit outside the employer-based market, and generally patching some holes and tightening some screws. But that's not Gawande's conclusion. Rather, he smartly notes that our current system is "more flotilla than ship," and we could build off virtually anything. We could build atop the VA, he says, accepting its offer of better care at the price of less choice. Or we could expand Medicare, recognizing tat it offers full choice but has been ineffective at cutting costs. Or we could choose some hybrid. "We could have Medicare for retirees, the V.A. for veterans, employer-organized insurance for some workers, federally organized insurance for others."
That's true, we could. Gawande doesn't say which approach would be most ideal. Rather, he concludes that most any reform will prove preferable. "The system will undoubtedly be messier than anything an idealist would devise," he says. "But the results [will] almost certainly be better." And that's probably correct. Health reform can be very far from perfect and still very much improved over the status quo. But one implication of Gawande's piece is quietly radical: It would be no further from the American experience to institute Medicare-for-All than to strengthen the private market. Indeed, it's actually a lesser leap: Most all Americans will eventually be on Medicare. We are comfortable with that notion. But not all Americans will have private insurance, much less a particular private insurer, much less be required to buy into a private insurer. That, however, is what most people mean when they say we should build on the current system. The center, sometimes, can be far more radical than the fringe.
COMMENTS (7)
Most all Americans will eventually be on Medicare. We are comfortable with that notion. But not all Americans will have private insurance, much less a particular private insurer, much less be required to buy into a private insurer. That, however, is what most people mean when they say we should build on the current system. The center, sometimes, can be far more radical than the fringe.
Something that I haven't said on this argument, but need to be said: People are comfortable with Medicare because it pretty much does one thing: it pays the bills. It has close to no utilization controls, provident payments have been heavily controlled the medical specialty societies-- its been everything to everyone, except that stubborn cost thing. Saying that "Americans like Medicare" is a little disingenuous-- there is nothing not to like, because Medicare really doesn't do that much. Its the sugar daddy of the health care system. The moment the sugar daddy runs out of money, Americans won't like it nearly as much.
Posted by: wisewon | January 19, 2009 12:32 PM
In other words: Medicare-for-All doesn't even closely resemble today's Medicare, pretending that it does is either naive or dishonest.
Posted by: wisewon | January 19, 2009 12:34 PM
In 2007, fifty-seven million Americans had difficulty paying their medical bills... On average, they had two thousand dollars in medical debt.
If we try to envision this like income, we see that very high-dollar individuals must skew the average a lot higher than the median. For more than half of the "fifty-seven million," then, the debt must be less than two thousand dollars.
Considering the cost of Social Security and income taxes, and what is purported to be staggering consumer debt, a rash of sub-$2K debts does not define a crisis. I myself let two $100 copays go to collection in 2008 simply because I was unhappy with the billing terms. I would not want to be counted as a statistic in favor of "reform."
Also, if Massachusetts proves that any significant portion of the "problem" is caused by free people who simply choose to spend their money on things other than health insurance (a reasonable decision for many young, statistically healthy people), then what is the real goal of making those people pay for insurance anyway?
That last one could just as well be rehetorical, since we all know what that goal is.
Posted by: cpurick | January 19, 2009 1:29 PM
Perhaps even more important that what works is what has been shown to not work. We haven't found a way to do away with things that are disfunctional by implementing continual improvment reviews and changes.
We know that not having community rating on healthcare premiums leads to unaffordable insurance for many that need it the most.
We know that Medicare's ability to control costs is minimal to non-existent.
I think we know that the marketplace model (competition) is inappropriate as a basis for improving coverage, controlling costs, and improving outcomes.
A comprehensive list of what works and what doesn't work seems like the starting place for evaluating alternatives for the future. The lack of a general consensus on a specific evaluation list makes the discussion of our choices just a mashup of conflicting, incomplete, politicized talking points. The American Way!
Posted by: JimPortlandOR | January 19, 2009 1:33 PM
Ezra
I came to a totally difft conclusion. Gawande's goal was not so much to offer the right answer to our health system woes, but to point out the historical accidents that led to ours and our compatriots' systems.
I actually thought it was damn good.
Brad
Posted by: Brad | January 19, 2009 8:03 PM
Three elements for a great start (or finish): (1) everyone is covered by the Federal Health Insurance Corporation for all annual costs above $2500 for a family, $5000 for a family (pick a number, improve it when prosperity returns); (2) private insurance for the amount underneath the Federal coverage may be continued, now with capped exposure and therefore 1/3 to 1/2 less expensive, but it may not discriminate for pre-existing conditions; (3) optional Federal policy to compete with private insurance underneath the Federal catastrophic guarantee. It's single payer (on catastrohic claims) AND builds on what we have now: you can keep the same insurance, only now it is far less expensive because its exposure is capped.
Posted by: urban legend | January 20, 2009 2:21 PM
If your answer, patchwork or not, includes for-profit legislated "Death by Spreadsheet" in any way it will continue to be a costly epic fail.
The free market simply cannot compete on a level playing field with single payer plans. Everyone that is paying attention understands this - That would be about 65% of Americans right NOW! NOW! NOW!
http://news.yahoo.com/page/election-2008-political-pulse-voter-worries-highlights
There is no valid point in trying to build on something that will go the way of the dinos anyways. Not a valid economic reason, nor a valid political one.
Posted by: connecticut man1 | January 21, 2009 11:55 AM