February 12, 2009
By Don McCanne, MD
On January 23, a Quote of the Day message discussed an article in The New Yorker by Atul Gawande, Getting There from Here: How Should Obama Reform Health Care? Unfortunately, my response to that article was cluttered with comments about framing, linear polarity and other extraneous concepts that detracted from my primary message.
His theme was that health care reform in any nation is inevitably “path dependent,” building on “its own history, however imperfect, unusual, and untidy.” He applies this concept to the United States stating that we must build on what we have, selecting out features of our current fragmented system of financing health care that he says should be expanded to achieve our goals. It just happens that the features he selects are those in the current leading Democratic proposal for reform.
His article is very well written, and is quite convincing to those who have not been intensively involved in reform activities and have only a limited understanding of health policy. Since it is such a impressive article it now is being circulated widely as a statement that (superficially) seems to make sense as a guideline for reform.
The problem is that Atul Gawande is flat out wrong. He implies that other nations merely made adjustments in their existing systems to expand coverage to everyone. In fact, these were not simple adjustments to systems that weren’t working; they were revolutionary transformations of their health care financing systems. Some residuals incorporated into their new financing systems might be called “path dependent,” but a more appropriate framing would be the antithesis that the thrust of each reform effort was to eliminate the deficiencies and inadequacies of the existing financing system or non-system. This inevitably required new financing systems. The fundamentals of these new financing systems were not based on path dependency, but they were based on path trailblazing.
Gawande dismisses single payer supporters as reformers “on the left” who “reserve special contempt for the pragmatists, who would build around the mess we have.” He explains later that the path dependent, pragmatic approach that we must follow will still be “exasperating, even disappointing,” while still failing to give single payer even short shrift.
In a Common Dreams article, Russell Mokhiber provided a comment by Atul Gawande in which he expanded on his views of single payer, along with a response by David Himmelstein. When you hear people praise Gawande’s New Yorker article, you should provide them with the following comments.
Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis
by Russell Mokhiber
February 10, 2009
As for (Gawande’s) opposition to single payer, he remains steadfast.
In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.
“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations – because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”
Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”
“Patients do not care what their insurance plan is – just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service – eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”
“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”
“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”
“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.
Mokhiber: Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis
Gawande: Getting There from Here: How should Obama reform health care?
qotd: Gawande’s pseudo-pragmatism