(Louisiana Blue Heron--James Audubon)Each looked for an easier triumph, and a result less fundamental and astounding.
--Abraham Lincoln
Second Inaugural Addresss
The New York Times today publishes a letter from Atul Gawande, who, we are reminded, is not only a surgeon at the Brigham and Women's Hospital (one of the three big Harvard Medical School teaching hospitals) and but he is also an associate professor at the Harvard School of Public Health.
Now, with that set of bone fides here is a man who ought to know of what he speaks.
It seems Dr. Gawande is concerned we know criticism of the Dartmouth Health Atlas appearing in the New England Journal of Medicine which criticized the way the authors of the Atlas collected and analyzed data about the quality of care rendered by different hospitals does not taint the way he used that data in a New Yorker article which so impressed President Obama he made it required reading by anyone at the White House engaged in efforts to overhaul healthcare.
Dr. Gawande was honest enough to say in an interview it was a sort of journalist's dream come true to think something he wrote might have such impact on the forces of government and on the formulation of policies controlling health care, so it is understandable he might be sensitive when criticism or backlash comes his way.
The truth is, many of us who viscerally desire a fundamental overhaul of our health care system winced more than once at Dr. Gwande's article and the response to it by President Obama's people (including Peter Orszag) at the White House, who could not see through it.
The basic premise of Dr. Gawande's article was you could use Medicare data to see that there are radically different health care practices out there in the country--there are those who are more expensive and less successful at what they do and then there are the heroes, who practice the highest quality care and couple that with lower cost. So now we have the villains and the good guys, neatly presented. Those wonderful docs at the Mayo Clinic, the Geisenger Clinic, who generally speaking are salaried and not motivated by the profit motive functioning in a fee for service private sector, versus the bad guys in McAllen, Texas, who send in exhoribitant bills and rape the system.
What Dr. Gawande implied, which was not lost on the White House, was this is where the cost savings could be found to fund the Healthcare Reform Act. Just rout out all that waste and over charging by bad docs doing bad medicine and send the patients to the good guys.
The problem, and what made so many docs who sympathize with President and who want to see him succeed in restructuring the system, is Dr. Gawande depicted a few outliers, a few exceptional cases and he suggested there are enough docs like them to make a difference. He had them saying, over beers at a bar how they knew they were running up costs, and he painted a picture of the guilty "knowing" full well they were responsible for the runaway costs in Medicare.
Those beery docs may have believed that, but as many of us out here in the trenches (as opposed to the rarefied place Dr. Gawande practices) as we know--there aren't enough outliers out there to eliminate to save enough money.
It's difficult for anyone to know what is really going on by examining data and numbers, because the way those numbers are collected is simply too difficult to understand and to analyze. So the average doc can only know what he sees from his own particular hole in the ground, and even when Dr. Gawande hops a plane to Texas, he goes back home to Boston and writes from his own hole, even if he's stopped off briefly at Rochester, Minnesota to be wowed by what he sees at the Mayo Clinic. He expresses an honest astonishment at how easily a cardiologist at Mayo could be called out of his office to hear a case presented and render an opinion--and what that vignette meant to the medical (as opposed to surgical) docs reading the article was how callow Dr. Gawande really is. What he was exclaiming about is something that happens in a variety of settings among physicians (not surgeons) all the time.
In fact, the big picture is often hard to see. It's like that scene from one of the Indiana Jones movies where Indie is looking for a big X but he cannot see it because the X takes up the entire surface of the floor he's standing on and it's only the person standing on the railing near the ceiling who can perceive the X.
The big picture was enunciated not by a surgeon from Harvard, but from a more modest source, a Congressman from New York named Weiner, on The Daily Show. What he said was so simple and so obvious it could hardly be seen by those close to it. He asked, "What fifty year old when asked if he would like to have Medicare would not say, 'Yes'? Or what about the kid who has graduated college and can't be carried on his parents' policy? He wants Medicare, too."
The fact is the government option is too radical a choice, a result too fundamental and astounding, for anyone faint of heart to embrace. Only the bravehearted can face it.
As much as we love President Obama, he has not shown himself to be bravehearted. He has not said, "Look, the Republicans are determined to dig in and prevent real reform. What we need is to make Medicare an option for every American, cradle to grave.
Given the slice of the federal budget fixed expenses claim, extending the option of even a bare bone Medicare to the whole population is a real revolution in the idea of what our government is all about. When you look at that pie, Social Security and Medicare already look like the lion's share. That leaves everything else which is not a fixed expense, including military/defense/Homeland Security struggling for the rest. And then there's the need for infrastructure repair and expansion and all the other things we need to do.
The Republicans may be correct about one thing: If a nation decides to provide medicare care for all its citizens instead of simply allowing them to be culled by the relentless progress of disease and inevitable injuries, then it has made a fundamental choice about what the government owes its citizens and about what its citizens owe each other. In the land of the free and the home of the Brave, we have, until now, chosen to allow our fellow citizens to die without helping them. We'll help our family members; we'll even help our co workers, but we do not feel an obligation toward our countrymen.
So that is what we are talking about: a result more fundamental and more astounding than we are willing to contemplate.
Universal healthcare would fundamentally change this country. People would not have to remain at jobs they hate for the health insurance. Big companies like General Motors would no longer be at a competitive disadvantage competing against Japanese, German and other foreign companies who do not pay the freight for their employees' health insurance. The Veterans Administration would no longer be saddled with the longterm care of Vets who eventually enter the phase of life where their coronary artery artery disease, which has nothing to do with their service as twenty year olds, catches up with them. They would be taken care of, but not by the VA any more.
Restructuring our healthcare system would fundamentally restructure our economy and unlike any other government program save Social Security and the IRS, it would touch us all.
Are you read for that America?
Or, asked another way, do you think we can really remain the dominant nation we once were if we are afraid to make the same committment to our own people other nations have made to their own?
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