Posted on January 23, 2009

Gawande's pseudo-pragmatism


Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009

People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.

On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.

The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.

For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.

It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.


By Don McCanne, MD

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.

This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.

Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.

His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.

The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”

What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.

Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road - our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.

He leaves us with an example of a successful application of path dependent reform - the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.

But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.

The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.