Atul Gawande, the surgeon and writer, has a keen eye, and his prose reveals a very good ear. He has a thoughtful piece in the January 26 New Yorker on health care reform. In it, when he thinks we aren’t looking, he reveals himself as Dr. Smarty Pants. Gawande takes what I would call the “meliorist” position, rejecting structural changes in favor of an adaptive approach. He makes a big deal of the principle of “path-dependence,” enlisting Paul Krugman to appear to be supporting an evolutionary position that Krugman, in fact, does not hold. Krugman wants a single-payer plan. He praises the Massachusetts reform plan. Then, almost at the end of the piece, he notes that “The Massachusetts plan didn’t do anything about medical costs, however….” And that’s about it. End of discussion.
My take on health reform is that a decent policy needs to be universal (everyone is covered) comprehensive (all reasonable procedures are included) and affordable (co-payments are reasonable AND the overall cost to taxpayers is reasonable). That’s where Gawande, like so many other meliorists, looks the other way. Costs are absolutely critical elements that need equal weight along with universality and comprehensiveness. Otherwise any reform plan won’t work (which Massachusetts is rapidly discovering).
Charles Baker, CEO of Harvard Pilgrim and a non-doctor, follows a similar path. Near the end of a piece, he forthrightly says of the Massachusetts plan, “Finally, the health care cost problem wasn’t addressed by the MA health care reform plan.” Note that very first word: “finally.” Why “finally?” This, too, comes near the end of his piece. Costs? No big deal.
A big percentage of health care costs are driven by the administrative costs of private insurers. These costs pay for the tens of thousands of insurance company employees whose job it is to find ways to deny or reduce coverage. Come on, Dr. Smarty Pants, let’s deal with it. If you won’t acknowledge the importance of controlling costs (along with, presumably, your costs as a physician), then your views need to be discounted.