Atul Gawande in The New Yorker 1/26/09

Some of you have seen this week’s New Yorker and the piece on healthcare reform by Dr Atul Gawande. He is a good writer, but it is unfortunate that his hi profile piece is an apology for the for profit insurance industry and a call for incremental reform. Here is my reply to him:

Dear Dr Gawande,

“Getting There From Here” is a wonderfully written piece full of good analyses of how broken our healthcare “system” is and how we got into this mess.
Your central hypothesis is that we can use the idea of “path dependence” to understand how other countries achieved universal or national health insurance, and thus chart a route forward here in the US. Of course, path dependence is much better at explaining why things happened than it is at predicting what will be, or, as you put it, “With path-dependent processes, the outcome is unpredictable at the start.”
Your first example, the formation of the National Health System (NHS) in England after WW II, points out the temptation to choose facts to fit the hypothesis. You note that Churchill’s government never intended to coin a national health service, but you skipped over the British electorate turning out the Tories and installing a Labour government in 1945. The birth of the NHS required both political will on the part of the new government and a powerful economic incentive to use the implementation of the system as part of the economic recovery of the post war economy. When you frame the birth of the NHS this way, suddenly the path dependence implications for the US today take on a different hue.

You state that no other major country has adopted the British system, but that is only true if you don’t consider Spain a “major country.” The Spanish did borrow from England when they formed their system in 1986. The next “major” country to change to a universal system after Spain was Taiwan in 1995. Like Spain, they looked at systems all over the world, and they decided to model their new system on the US. Not our system of for-profit private insurance that you seem to be so fond of, but on our universal (single payer) system for seniors, Medicare. Learning from the experience of other countries is perhaps another way to consider path dependency.

Path dependence is one way to explain how history unfolds and systems change. Political courage and leadership are sometimes a better explanation. When Canadians were asked to choose “The Greatest Canadian” a few years ago, the overwhelming winner was Tommy Douglas, the father of Canada’s national health system. Starting in his home province of Saskatchewan, Douglas lead the charge that resulted in the Canadian system which was instituted in the mid-Sixties, right around the same time we launched Medicare and Medicaid in the US.

Finally, you use the example of Medicare Part D and its much maligned drug coverage as an example of the dangers of over-reaching reform that ignores the lessons of path dependence at its peril. Another interpretation of this fiasco is that Part D was an example of a different path, a Republican Congress running amok, a piece of legislation written by lobbyists, passed in the dead of the night, with debate suppressed, and the longstanding rules of House and Senate bent if not broken. There are many lessons to be learned from that debacle, but not that the idea of Medicare helping seniors purchase their medicines is somehow too ambitious a project for our government to tackle.

In fact, Medicare Part D should have been written to have traditional Medicare administer the plan, instead of creating a plan run by the for-profit insurance industry, with a built in subsidy to the pharmaceutical industry. If one reads from sources like the Heritage Foundation, it becomes clear that the goal of the far-right conservatives is to destroy Medicare by privatizing it. They don’t want Medicare to continue as such an appealing path toward healthcare reform.

Is it reasonable to conflate Medicare for all (single payer) with the total free-market crazies, to cast both as being extreme, radical positions that should be dismissed out of hand as impractical?

I think our 40+ year experience with Medicare has been pretty good. We already take care of the sickest, most expensive part of our population, everyone over age 65. The government (taxpayers) already pays for 60-65% of all healthcare spending. Medicare is the financial mechanism for healthcare for the elderly, but the care is delivered privately. After I see a Medicare patient in the ER, I send a bill, just the same as I do if they have private insurance or no insurance.

Let’s embrace path dependence from a different angle: the safest, simplest, most commonsense way to reform our broken healthcare system is to expand Medicare to cover everyone, and continue to deliver healthcare privately as we do now. The logical next step, Medicare Part E – E for Everyone!


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