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
- 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
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
- 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