Atul Gawande on Resisting Health Care Reform – He Misses a Tactic, Lying!

Atul Gawande, thoughtful as always, writes about the “wicked problem” of healthcare reform and the historical similarity between this battle and previous battles to expand fairness to all of our citizens. Opening with the kind of experiences all physicians have had with tragically-uninsured patients, he emphasizes why this was a needed change:

A few days ago, while awaiting the Supreme Court ruling on the Obama health-care law, I called a few doctor friends around the country. I asked them if they could tell me about current patients whose health had been affected by a lack of insurance.
“This falls under the ‘too numerous to count’ section,” a New Jersey internist said. A vascular surgeon in Indianapolis told me about a man in his fifties who’d had a large abdominal aortic aneurysm. Doctors knew for months that it was in danger of rupturing, but, since he wasn’t insured, his local private hospital wouldn’t fix it. Finally, it indeed began to rupture. Rupture is an often fatal development, but the man—in pain, with the blood flow to his legs gone— made it to an emergency room. Then the hospital put him in an ambulance to Indiana University, arguing the patient’s condition was “too complex.” My friend got him through, but he’s very lucky to be alive.
Another friend, an oncologist in Marietta, Ohio, told me about three women in their forties and fifties he was treating for advanced cervical cancer. A pap smear would have caught their cancers far sooner. But since they didn’t have insurance, their cancers were only recognized when they caused profuse bleeding. Now they required radiation and chemotherapy if they were to have a chance of surviving.

Even inexperienced physicians like me, still in my residency, have these kinds of stories to tell. They’re tragic. But worse, they’re just so stupid. Notice how, in each instance, the problem still ends up being taken care of, only now it’s emergent, farther along, more risky, and of course, more expensive to treat. This is part of the ludicrous nature of the opposition to health care reform. There is no way to get out of paying for these things. All we do by denying people coverage for necessary medical treatment is guarantee that in a few days, months, or years, they’ll be in the emergency room, only now it will cost ten times as much to fix, at greater risk to the patient. This is also backed up by the international experience of health care. Every other industrialized country has universal coverage, many have far superior care, not to mention superior service (France anyone?) to the United States. Yet every one of the countries pays far less per capita (most less than half) than we do on health care. Data from studies within our own country show it’s cheaper for the state to cover the uninsured than to let them stay uninsured. Because of EMTALA, passed by that notorious socialist Ronald Reagan, everybody gets emergency care whether they are insured or not, and fully 50% of emergency care is uncompensated, costs which get transferred to the insured and the tax payers.
For most of us in the healthcare system we see that universal coverage is necessary (unless you reverse EMTALA which will never happen), although we may disagree on how to accomplish it. If anything, the ACA/Obamacare is more of a free-market reform than many physicians would like. Many in my generation (though certainly not in the older generation) would have preferred single-payer, but for reasons I discussed yesterday this is actually not as important as merely guaranteeing universality. Mixed private/public and government payer/private insurance schemes are, if anything, the norm around the world and they work well while still costing less than 50% of what we pay per capita.
So why so much resistance to what should be obvious? There is no way to avoid paying for this stuff, so why don’t we do it more sensibly? Why don’t we move primary care out of the ER? Why not pay for problems when they’re cheap and not emergent?
Gawande suggests the problem is that healthcare is a “wicked problem” and such problems that don’t have simple, crisp answers generate more controversy and resistance to change.

In 1973, two social scientists, Horst Rittel and Melvin Webber, defined a class of problems they called “wicked problems.” Wicked problems are messy, ill-defined, more complex than we fully grasp, and open to multiple interpretations based on one’s point of view. They are problems such as poverty, obesity, where to put a new highway—or how to make sure that people have adequate health care.

Solutions to wicked problems, by contrast, are only better or worse. Trade-offs are unavoidable. Unanticipated complications and benefits are both common. And opportunities to learn by trial and error are limited. You can’t try a new highway over here and over there; you put it where you put it. But new issues will arise. Adjustments will be required. No solution to a wicked problem is ever permanent or wholly satisfying, which leaves every solution open to easy polemical attack.

This sounds awfully familiar, and I think it’s a good explanation for much of the controversy. I’ve been emphasizing from the beginning, there is more than one answer to the problem of the uninsured. The only really wrong answer is, “doing nothing”. We’ve been doing that for long enough and it actually costs us more to do nothing than to expand coverage! Gawande then discusses Albert O. Hirschman’s studies of the polemical forms of resistance to solving these wicked problems, and how they rely on arguments of perversity, jeopardy and futility. However, I find that a critique of these debates isn’t particularly satisfying. Just because one argues that a reform is perverse, or risky, or futile, doesn’t necessarily make one wrong, even if it is a frequent pattern of obstinance. Gawande also leaves out the 4th tactic of the current opponents of reform. That is, of course, mendacity.
In order to oppose a reform so obviously needed, so completely supported by the data from international experience and studies from within our own country, and in the face of the obvious gob-smacking experience of every physician in the country, one ultimately must rely on just lying. Politifact, both before and after the Supreme Court decision, has demonstrated this phenomenon. Many of the claims against the ACA have been so rabidly false as to deserve their “pants-on-fire” designation, including the fully debunked death panels nonsense (2009 lie of the year!), that it’s the largest tax increase ever, it’s rationing, or that it is some kind of Obama socialist plot. See the top five lies here. Immediately after the ruling Romney was apparently tripping over his own feet in order to be the first to lie about his own reform package saying it would increase the deficit by trillions, another lie, and Limbaugh reiterated the lie that it was the largest tax increase ever.
I think that’s what’s most disappointing to me about this current debate, but these days it is no surprise. The outrageous mendacity of the opponents of reform, and the unwillingness of the right to engage in honest debate on this topic, are beyond anything I’ve seen in my lifetime. But a few facts are undeniable. We spend more on health care than any other country. For that cost we can’t even cover all of our citizens. Universal healthcare systems are also universally less expensive than ours. When we refuse to cover people, and allow them to be uninsured, they still receive care, it just costs us more to deliver. Why do people oppose universality when these are the facts?
The simple, sad answer, is they’re being lied to.

Healthcare Upheld!

It’s good news that the Supreme Court split 5-4 with Roberts (and not Kennedy?!?) as the deciding vote, to uphold the affordable care act. It’s interesting that this was controversial, and certainly Roberts led the court to a very safe middle ground making the issue about taxation and saying the commerce clause could not apply. If anything, I wonder if this weakens the previous commerce powers of Congress as defined by Wickard v. Filburn, I’d love to hear what a lawyer thinks.
What does this mean?
Well in the short term not a whole lot, this healthcare bill requires a very slow roll-out of provisions. This was never a revolutionary law, which is why it was so surprising that people treated what was essentially a free-market giveaway as if it were some act of revolutionary socialism. But it will mean that states will have to go ahead and start implementing exchanges, it means that lots of other cost-control provisions are going ahead, coverage for pre-existing conditions will remain (victory!), and most importantly, we can start a great cultural shift from using emergency rooms or just plain avoidance to deal with necessary health maintenance and primary care needs.
Now, I know many that think single payer is the only way that healthcare can be provided might have been hoping this hodgepodge mix of free-market and social reforms would fail in favor of a truly government-administered system. I would say to them, don’t worry! It’s possible to have highly efficacious universal healthcare based on insurance for all and subsidization for those who can not afford it. Most systems not inherited from the Soviets came to universal healthcare from different angles, and only really the UK, Canada, and New Zealand represent totally government-administered healthcare systems in such countries. In between would be Sweden, Japan, France, or Australia with government-administered payment or mixtures of public and private hospitals with government sponsored insurance options. Even Russia now has a mixture of public and private healthcare spending. Then there are the systems which look a bit more like what the ACA will be. For instance Germany, which has had universal health care since Otto von Bismarck, has health coverage through employer-subsidized sickness funds, a mixture of public and private hospitals and clinics. Finally, the Netherlands system probably is most like the system proposed by the ACA. They describe it as “private insurance with social conscience”, and the Netherlands enjoys metrics of patient satisfaction, short wait times, and access to procedures far superior to that of other systems including ours (which performs quite poorly on almost all metrics including access). On the extreme free-market side of universal health care is Singapore, which relies on universal governmental catastrophic insurance coverage, but an individual mandate on citizens to contribute to personal health savings funds which cover primary care and most expenditures until you go over a yearly limit. The only thing all of these systems have in common is that they spend half of what we spend yearly per capita on healthcare.
So, to those who oppose it because you either don’t want healthcare or because you don’t think it was enough, don’t despair! For those who think it’s the worst thing ever to pay for other’s health insurance, don’t worry! You already are! You have been since Reagan passed EMTALA. That won’t change, the cost might actually get cheaper (or at least stop increasing at such a violent pace). For those who think that anything but single-payer is awful, don’t complain! What’s most important is that we have universal coverage that encourages primary care usage, getting patients out of the ER and subsidization for the poorest among us. The international experience shows that truly single-payer systems are the minority, and most systems are a mixture of public and private hospitals, insurance and personal expenditure. Further, one of the best systems in the world, the Netherlands system closely resembles what the ACA will accomplish and has resulted in excellent outcomes and patient satisfaction in that country. In fact, most single-payer systems perform worse in terms of access, wait times, and satisfaction than the mixed systems, with the possible exception of Sweden (probably because they put so much money into it).
This is a victory for healthcare and the country. Even if it’s not “perfect”, or even if you think people being treated for their medical problems is some kind of sin against capitalism, too bad. It will accomplish a great deal, there is international precedent that such systems work (and may work better than single-payer), and there is no escape from the fact that we have to pay for people’s healthcare. We can do it expensively, wastefully, and emergently in the ER, or we can do it like thoughtful, decent citizens who care about each other’s welfare and provide a baseline of access for all.

Visiting the Nat Geo Overlords

Chris and I have met with our new National Geographic overlords here in DC, and we had a productive and interesting meeting. It was a great chance to put names to some faces and hear about where Nat Geo wants to take Scienceblogs. If any of the other sciblings can wrangle it I can highly recommend it. Also, to those who have commented on the migration to wordpress, the new look etc., they clearly are monitoring your opinions about the change and working to first make the system fully functional, then hopefully we can improve some stylistic elements of the site. In particular I think people miss the links to comments from the sidebars, number of comments visible from the main post, and the size of the lead-in. I also have to figure out why WP doesn’t want to upload my custom banners. Oh well. It’s a process.