Yet while the cost problem is widely understood to be one of the two key reasons health reform is necessary (the other being the large and growing number of uninsured), the Senate bill as presently constituted does not tackle this problem head on. Gawande:
Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality. It does not. Instead, what it offers is… pilot programs.
What follows is not an indictment of the bill for its failure to offer a grand unified strategy, however. Instead, Gawande offers a surprising and spirited defense of a piecemeal, experimental approach by looking at the history of how a plethora of small U.S.D.A. programs transformed American agriculture between 1900 and 1930.
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 experimental 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.
Gawande sees strong parallels between this historical case and healthcare today.
Much like farming, medicine involves hundreds of thousands of local entities across the country- hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers…They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous.
Figuring out how to get from where we are to a more effective and less costly system isn’t obvious, Gawande argues – there are many ideas, but “nobody knows for sure.” But he maintains, that’s OK.
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 healthcare everywhere starts with transforming it somewhere.
Great piece. Read it and take heart that despite its messiness and unanswered questions, health reform may still be able to take us, as long as we can learn from experience and refuse to be discouraged by some false starts, to where we need to go.
Gawande makes such a strong case for action…I’m sick of the coverage question. In the end, I expect that we will have a bill that allows us to approach universal coverage. I don’t care if it includes a public option or not…I want folks to have access to affordable coverage. Whether we have a public option or not, it will not be sustainable if we don’t address the cost curve. His description of the impact that government action had on agriculture, without nationalizing the system was incredibly educational.
Thanks for the link! A good description of one of the positive roles government can play.
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p>Massachusetts is a good example of the impact pilot programs can have. Both bills contain a Massachusetts like “exchange”.
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p>However I don’t agree that there aren’t other important roles for the state, as exemplified by the public option idea.