Atul Gawande's Latest on Health Care Reform

By John Ballard

His name will be synonymous with health care reform. Dr. Gawande may have influenced more thinking than any other individual. In this latest piece he compares changing the way we do medicine with the way America changed the way we do agriculture.

Brilliant. I feel reassured.

What seemed like a hodgepodge eventually cohered into a whole. The government never took over agriculture, but the government didn�t leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country. The results were beyond what anyone could have imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half. By 1930, food absorbed just twenty-four per cent of family spending and twenty per cent of the workforce. Today, food accounts for just eight per cent of household income and two per cent of the labor force. It is produced on no more land than was devoted to it a century ago, and with far greater variety and abundance than ever before in history.

This transformation, though critical to America�s rise as a superpower, involved some painful dislocations: farms were consolidated; unproductive farmers were winnowed out. As the historian Sally Clarke, of the University of Texas at Austin, has pointed out, it�s astonishing that the revolution took place without vast numbers of farm foreclosures and social unrest. We cushioned the impact of the transformation�with, for instance, price supports that smoothed out the price decline and avoided wholesale bankruptcies. There were compromises and concessions and wrong turns. But the strategy worked, because United States agencies were allowed to proceed by trial and error, continually adjusting their policies over time in response not to ideology but to hard measurement of the results against societal goals. Could something like this happen with health care?

There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. Problems of the second kind, by contrast, are never solved, exactly; they are managed. Reforming the agricultural system so that it serves the country�s needs has been a process, involving millions of farmers pursuing their individual interests. This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country�s needs. No nation has escaped the cost problem: the expenditure curves have outpaced inflation around the world. Nobody has found a master switch that you can flip to make the problem go away. If we want to start solving it, we first need to recognize that there is no technical solution.

Much like farming, medicine involves hundreds of thousands of local entities across the country�hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous. Our fee-for-service system, doling out separate payments for everything and everyone involved in a patient�s care, has all the wrong incentives: it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is�well, plenty of people have plenty of ideas. It�s just that nobody knows for sure.