Really Smart: Atul Gawande

Getting There From Here (0.00 / 0)

Gawande also wrote this excellent piece on how other nations with universal coverage arrived there.

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by: Jason Wiener @ Thu May 28, 2009 at 04:53:31 AM UTC

Yeah, Gawande thinks that the Medicare Drug bill was (0.00 / 0)

"...in theory, a reasonable approach."

WRONG!

In theory it was stupid which proved to also be the case in practice. It wasn't that hard to see, unless you are Gawande, apparently.

Why? Because the concept of private for profit insurance is an oxymoron. Insurance is a socialistic concept. So why try to force a socialistic concept into a capitalistic framework?

That's lame.

America has a proud socialistic heritage. We were formed by a bunch of communal Christians known as Puritans. They shared their labor, their land, their food, and their profits among the entire group.

Why try to re-invent the wheel, for crying out load. It goes against his whole premise of historical memory.

We instituted Social Security in the 1930s, a single payer retirement insurance system that is still popular to this day. We instituted the VA, which is for all intents and purposes identical to the British National Health system, except it only serves our veterans. It's the largest single payer health care system in the world.

No, the radical experiment is attempting to protect a failed system because one is personally invested in it.

Gawande is right that we need to build on our historical foundations. He just needs to understand what those foundations are.

It's obvious to me that he is more interested in rehabing his theories of managed care from the Clinton elite top down attempt than he is in actually understanding our past and building on it.

While some may believe this guy is somehow visionary, I find him seriously flawed in his arguments in a number of ways. He seems to be hell bent to protect his status quo.

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by: Steve W. @ Thu May 28, 2009 at 06:18:52 AM UTC

[ Parent ]

Context (0.00 / 0)

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. The reality is that leaders are held responsible for the hazards of change as well as for the benefits. And the history of master-planned transformation isn't exactly inspiring. The familiar horror story is Mao's Great Leap Forward, where the collectivization of farming caused some thirty million deaths from famine. But, to take an example from our own era, consider Defense Secretary Donald Rumsfeld's disastrous reinvention of modern military operations for the 2003 invasion of Iraq, in which he insisted on deploying far fewer ground troops than were needed. Or consider a health-care example: the 2003 prescription-drug program for America's elderly.

This legislation aimed to expand the Medicare insurance program in order to provide drug coverage for some ten million elderly Americans who lacked it, averaging fifteen hundred dollars per person annually. The White House, congressional Republicans, and the pharmaceutical industry opposed providing this coverage through the existing Medicare public-insurance program. Instead, they created an entirely new, market-oriented program that offered the elderly an online choice of competing, partially subsidized commercial drug-insurance plans. It was, in theory, a reasonable approach. But it meant that twenty-five million Americans got new drug plans, and that all sixty thousand retail pharmacies in the United States had to establish contracts and billing systems for those plans.

On January 1, 2006, the program went into effect nationwide. The result was chaos...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.

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by: Jason Wiener @ Thu May 28, 2009 at 06:58:21 AM UTC

[ Parent ]

The legislation aimed to provide public subsidies for private for profit drug companies, (0.00 / 0)

in fact the legislation was written by the private for profit drug companies.

So for them (the drug companies) it was a smashing success. It was the ideal realized, and it worked as intended. It transferred money from public coffers into private hands, it outlawed negotiating prices, and it outlawed importing cheaper drugs.

If the drug companies had instead suffered financial losses, then Gawande could make the argument that it hadn't worked as intended.

There has been no move or attempt to repeal the legislation by those responsible for it's passage or by those who opposed it's passage.

Those handful of Dems who crossed the aisle to get that bill passed have instead been well subsidized by the drug companies who successfully picked our pockets. Max Baucus was one of them. Kind of gives you confidence, doesn't it?

Gawande misses entirely what took place and instead casts the authors of the bill as well intentioned, yet misguided.

It is he who is misguided.

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by: Steve W. @ Thu May 28, 2009 at 14:04:49 PM UTC

[ Parent ]

Customer service is the measure of success or failure (0.00 / 0)

Republicans, intent on abandoning what they saw as a fatally flawed public system, attempted to create a program that would wipe the slate clean. Their solution failed because it didn't serve the people it purported to, elderly with prescriptions, in the most basic way. If every elderly person who needed a prescription had been able to get it on day one as efficiently and even more cheaply than before, Medicate Part D would not have been perceived as a flop--even if it still lined the pockets of the industries who hatched it. And if drug companies and the government could have performed the transition seamlessly, no one but budget wonks would be calling it a disaster; that would seem to be in the interest of bureaucrats who want to be conceived as competent and private companies taking a fat cut of the commonwealth. They would have gotten it right if they could.

So you can cynically believe that the system was really just designed to benefit drug companies (and the US government was more than willing to go along knowing that--which really requires a lot of cynicism) and, even then, still take away Gawande's point that anyone who tells you real reform can only be had by junking what we've got, regardless of his or her ideology, is setting us up for a herculean task prone to logistical issues large enough to be characterized as catastrophic failure.

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by: Jason Wiener @ Thu May 28, 2009 at 23:36:22 PM UTC

[ Parent ]

The nice Repos and Max were doing it for their over 65 customers? (0.00 / 0)

If that's what you think be my guest.

i don't see myself as a customer. I'm a citizen.

You want to build on being a customer?

I don't.

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by: Steve W. @ Fri May 29, 2009 at 03:33:12 AM UTC

[ Parent ]

To sum up Atul Gawande; The culture of care providers is the problem... (0.00 / 0)

I found the article very interesting, but i found his reluctance to point out the importance that almost all of his data came from a public payer interesting as well. Why didn't he go to all the private insurers and get their data too? I can tell you why, but please ask yourself that question and ponder it.

I guess it's a good thing that Medicare actually keeps public records on expenditures, otherwise Gawande wouldn't have an article to write. In fact he wouldn't know what place was more expensive and what place was less expensive. he would be in the dark.

He glosses over the profound significance of that fact, IMHO.

One would guess that American care providers are greedier than care providers from other countries, from the article. But I doubt that is the case. What the case is, is that in other countries the government actually regulates the greed of the care providers. And they regulate the  greed of the drug companies, and the greed of the equipment suppliers, and the expectations of the patients that care, drugs, and equipment are in infinite supply.

I fail to see how a private funding mechanism can accomplish that goal when a private funding mechanism can't even supply data for an article.

So how do other countries function? The public payer does the global budgeting, planning, and requires certain things of the people they license to provide care. It isn't done by leaving funding up to whoever.

Why should private insurers be able to indulge in an orgy of greed but the doctors shouldn't? That's not just stupid, it's antithetical to a culture of patient care, of putting the needs of the patient ahead of the bottom line.

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by: Steve W. @ Thu May 28, 2009 at 05:06:44 AM UTC