Thursday, May 10, 2007

Atul Gawande: Curing the System

From the New York Times editorial page:

There are two causes of human fallibility — ignorance and ineptitude — and health system change is at risk of both. We could err from ignorance, because we have never done anything remotely as ambitious as changing out a system that now involves 16 percent of our economy and every one of our lives. And we could err from ineptitude, underestimating the difficulties of even the most mundane tasks after reform — like handling all the confused phone calls from those whose coverage has changed; ensuring that doctor’s appointments and prescriptions don’t fall through; avoiding disastrous cost overruns.

Health systems are nearly as complex as the body itself. They involve hospital care, mental health care, doctor visits, medications, ambulances, and everything else required to keep people alive and healthy. Experts have offered half a dozen more rational ways to finance all this than the wretched one we have. But we cannot change everything at once without causing harm. So we dawdle.

Gawande then suggests two possible public policy initiatives: a Massachusetts-type plan or cover every child starting right now for their lifetime.

Personally, I think each fail -- but for different reasons:

First, a state-by-state plan fails because it fails to take into consideration that people move all the time for jobs. The market needs portability of labor to where it is most beneficial. You won't have that if some workers won't move due to loss of health coverage and we don't want to create first-class and second-class states (rich states that can afford health care and poor ones that cannot). The founding fathers felt it necessary to create a national economy. Health care needs to be uniform throughout the country. This is not an issue of technology, this is an issue of money.

Secondly, the problem of only providing health benefits for children might be more politically palatable, but, on the whole, the real cost of health care is not the young and healthy -- it is the old, sick and frail. Dr. Gawande said he wrote his piece "as I sit with my 11-year-old son waiting for an M.R.I. to check the cardiac repair that has saved his life for a decade." So I can see how helping children is personal to him.

But it isn't just the 11-year sons that are suffering because of our lack of health care coverage, it is all of us. It is the millions of Americans who have filed for bankruptcy over the last 10 years because of their unique health care story. And, ultimately, we all pay for it one way or another: health care costs will rise on everyone else anyway due to the ones who cannot pay. But -- and this is an important point -- creating a national funding system that guarantees payment is far more efficient, fair and humane than the patchwork system that we have now. No more denying of coverage due to "pre-existing conditions" or because a patient goes "out-of-network." The fact is that DNA science is teaching us that we are all born with a "pre-existing condition." And, being an American citizen and seeing a licensed doctor should automatically make you "in network."

The health of our country requires a national health care system.

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