Atul Gawande, Transforming Health Care
Is Atul Gawande on to something in what he asks in a recent New Yorker article, “The health-care bill has no master plan for curbing costs. Is that a bad thing?”
Can we, as he suggests, usefully and justifiably compare the place of health care, in particular the escalating cost of health care today, with the place and high cost of agriculture in the economy some 100 years ago?
And more important can we apply the example of all that we learned from our successful efforts to reform American agriculture in the 20th. century to our present attempts in the 21st century to reform health care?
I think so. What Gawande is saying is both highly interesting in itself and highly relevant to the national debate now going on over health care reform.
What Americans are most afraid of, at least those who work and pay taxes and who are ultimately responsible for providing the revenues that pay for all government programs, are the escalating costs that they now, and later their children and grandchildren, if nothing is done, will have to pay for their health care.
Gawande points out that, ‘Medical care now absorbs eighteen per cent of every dollar we earn, that between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900.”
These numbers ought in themselves to be enough to push our leaders to act. So far they haven’t done so.
Americans are asking if the health care bill, now before Congress, will help to make health care affordable. And more and more they are of the opinion that it won’t. Gawande, however, says there is a good chance that it will, and he bases his argument on the agriculture/health care comparison.
Everyone agrees that sooner or later costs will have to be substantially lowered, that the present health cost trajectory is unsustainable, and that if nothing is done, to cite Gawande’s words: “Health-care spending will essentially devour all our future wage increases and economic growth. State budget costs for health care will more than double, and Medicare will run out of money in just eight years. The cost problem threatens not just our prosperity but our solvency.”
While Gawande admits that the Bill doesn’t directly confront the problem of escalating costs (“we crave sweeping transformation [but] all the current bill offers [are] pilot programs, a battery of small-scale experiments”) he strongly suggests that the many small pilot programs in the present Bill, as earlier in the case of agricultural reform, may be the very best way to reform our medical practices.
In 1900 food costs consumed some 40% of the American family’s income, considerably higher than the cost of health care today. At the time agriculture was notoriously inefficient and whereas some might have called for huge federal programs to reform the nation’s farms the government instead went about reform piecemeal, supporting hundreds, perhaps thousands of pilot programs meant to show the farmers how things could be done differently and more efficiently.
At the time it was clear to almost everyone that only by improving the productivity of farming could the living standard be significantly raised, and the U.S. emerge as an industrial power. As Gawande writes, “We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors. And we had to make farming less labor-dependent, so that more of the population could enter non-farming occupations and support economic growth and development.”
And that is what we did and what happened, while admittedly “in the attempt to reform how we grew our food there were compromises and concessions and wrong turns, ultimately we were successful because the government agencies leading the reform efforts were allowed to proceed by trial and error, continually adjusting their policies over time in response not to ideology but to hard measurement of the results against societal goals.”
So today it’s clear to everyone that in order to compete successfully in the global economy we have to reduce the amount of our wealth now consumed by the health care industry. And to do this we ought to follow the agriculture example.
In a section of the Bill, entitled “Transforming the Health Care Delivery System,” what is offered are, pilot programs, piecemeal efforts to change things locally, or in particular segments of the health industry, such as medical record keeping and the greater use of these records by clinicians. And for Gawande these programs are our best chance of bending the cost curve down to something well within our means to handle.
There are, in fact, as on the millions of small farms earlier, any number of inexpensive improvements that might be made in the way we deliver health care in our hospitals and clinics, and that, if copied nation-wide, as in the case of the earlier agricultural improvements, could result in significantly lower costs, as well as better treatments, just as the agricultural reforms resulted in more and better food at lower costs.
Health professionals, just like agricultural workers, will need to be shown in order to learn, and then, without pressure from without, proceed themselves to make the desired changes and deliver better services at less cost to their patients.
Again, in Gawande’s own words, “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 health care everywhere starts with transforming it somewhere.”
