Building on What We Have

Dr. Atul Gawande, author of “Complications: A Surgeon’s Notes on an Imperfect Science”, and its follow-up, “Better: A Surgeon’s Notes on Performance“, is also a staff writer for the New Yorker, and in the January 29 issue has an article titled “Getting There From Here“.

Gawande laments the factions that have formed in American health care reform circles, and suggests that no solution will come from either camp.

…[factions] 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.

Indeed – we have had some of that at this little blog. Gawande suggests that other industrialized countries have been so successful at building their systems because they took what they had and made it more expansive rather than starting over from scratch.

In Britain, for example, the National Health Service came about as the government was forced to move millions of people out of the cities and into the countryside in the face of bombing by the Nazis. The government found the then-existing health care system inadequate, and had to build clinics and hire doctors, in addition to subsidizing private hospitals.

Churchill’s government intended the program to be temporary. But the war destroyed the status quo for patients, doctors, and hospitals alike. Moreover, the new system proved better than the old. Despite the ravages of war, the health of the population had improved. The medical and social services had reduced infant and adult mortality rates. Even the dental care was better. By the end of 1944, when the wartime medical service began to demobilize, the country’s citizens did not want to see it go. The private hospitals didn’t, either; they had come to depend on those government payments.

By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone. So, while the ideal of universal coverage was spurred by those horror stories, the particular system that emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day.

France had a similar story. Labor unions and employers had built a private, not-for-profit insurance system (“not-for-profit” being the key to success) through a self-imposed payroll tax. In 1945, when seventy-five per cent of the population paid cash for medical care, the de Gaulle government built on what it had, expanding the payroll tax and private insurer system to cover the entire population. The 2000 World Health Organization survey found this system to be the best in the world. The U.S. ranked 37th in that survey. (U.S. conservatives have taken the survey to task.)

Switzerland has a similar story, but had built a system of private for-profit insurance coverage. But the system had so many gaps and inconsistencies that in 1994 they passed universal coverage. But they built on what it already had, electing to cap household insurance expenses and subsidize insurance companies.

Contrast this with the U.S. attempt in 2006 to extend drug coverage to senior citizens via “Medicare D”. The congress opted to forego Medicare itself as the disbursing agent, and used private insurance companies.

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.

Medicare is prohibited from bargaining for lower prices – private sector competition was to take care of that. Since it took effect, drug prices have gone up, the system has become no less stodgy and confusing, and pharmaceutical companies, luxuriating in subsidy, are wont to change anything.

What does Gawande propose for the U.S.? That we build on what we have – he thinks we could move seamlessly from over fifty million uninsured to universal coverage by leaving the existing private system of employer-sponsored coverage intact, along with Medicare and the very efficient and effective VA system. Massachusetts oft-derided system offers an example (Gawande practices there):

It didn’t organize a government takeover of the state’s hospitals or insurance companies, or force people into a new system of state-run clinics. It built on what existed. On July 1, 2007, the state began offering an online choice of four private insurance plans for people without health coverage. The cost is zero for the poor; for the rest, it is limited to no more than about eight per cent of income. The vast majority of families, who had insurance through work, didn’t notice a thing when the program was launched. But those who had no coverage had to enroll in a plan or incur a tax penalty.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close. Despite the requirement that individuals buy insurance and that employers either provide coverage or pay a tax, the program has remained extremely popular. Repeated surveys have found that at least two-thirds of the state’s residents support the reform.

Like every universal system everywhere, the Massachusetts program is very popular, and will be improved. However, an individual state cannot control runaway nationwide medical costs, and that state is facing increased costs without cost controls. But as a laboratory experiment, it’s had impressive results.

So we won’t get single-payer. We might not even get anything, as President Obama is yet to mention health care reform since taking office. Whatever happens, to be successful, has to come about by pressure from below and build on what we already have for seamless transition. Gawande seems to favor opening up Medicare for more clients, and opening up the VA system to the general public. If this were done, these systems might eventually force private insurers out of business. It might even force them to institute much-needed reforms.

But something’s gotta give. What we have isn’t working. What we will have will be better … but

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.

Note: I hope anyone who wants to read Gawande’s article can access it in its entirety. As a New Yorker subscriber, I have web site privileges. I don’t know if the New Yorker site is open to the public.