New Yorker health care writer Atul Gawande is perhaps the most influential and respected health care writer in the U.S. Liberal bloggers respect him so much that in September, they pitched him as a replacement for Ted Kennedy's senate seat. When he churns out long features on health care policy and practice, typically once every few months, they tend to send shockwaves through the debate. Gawande's latest piece on the cost controls of health care, released today, may or may not do the same. If you work in health care or public policy, you're probably already reading the 5,000 word opus. But for those who want quick version, here are Gawande's key points.

  • The Cost Problem "This is historic, and it is necessary. But the legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease. Health-care costs are strangling our country. [...] The reason the system is a money drain is not that it's so successful but that it's fragmented, disorganized, and inconsistent; it's neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures."
  • Pilot Programs in Cost Control That's all the Senate's health care legislation provides for cost controls, Gawande notes. "According to the Congressional Budget Office, the bill makes no significant long-term cost reductions. Even Democrats have become nervous. [...] 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."
  • How Health Care Is Like Agriculture Pre-industrial American farming was once, like health care today, a national crisis, with food too expensive, land poorly used, and farmers barely scraping by. Gawande thinks the government-led innovations and investments that ended the crisis provide a good model for health care reform. In 1903, the Dept. of Agriculture instituted small "pilot programs" of asking a handful of farmers to institute a farming reform, such as deeper plowing, on a small part of their property. Like today, it was denounced as "government control of agriculture." Successful programs were gradually expanded until, by 1930, 750,000 farms used them. Gawande writes, "The U.S.D.A.'s scientific capabilities grew into the world's greatest biological-discovery machine of the time."
What seemed like a hodgepodge eventually cohered into a whole. The government never took over agriculture, but the government didn't leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country. The results were beyond what anyone could have imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half. [...] There were compromises and concessions and wrong turns. But the strategy worked, because United States agencies were allowed to proceed by trial and error.
Gawande concludes that the Senate health care reform bill, a "hodgepodge" of pilot programs, follows a model like that of agriculture 100 years ago. He surveys the pilot programs and the Senate bill's built-in guidance system that would expand what works and shut down what doesn't.
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 [...] if we're willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We've done it before