Building On A Bloated Carcass

There’s a great piece by Atul Gawande (love him!) in this week’s New Yorker on the road to universal health coverage from our vastly imperfect starting point.

Many would-be reformers, including genius boggrrrrl Andrea Verykoukis, hold that ‘true’ reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. … [Both sides] reserve special contempt for the pragmatists, who would build around the mess we have. The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational.”

I may have edited that a little bit.

Unfortunately for firebrands like myself, Gawande has some valid and instructive points about how we can get to universal coverage, though it will look a lot like what we have now. Stressing that we can’t shut the system down “even for an afternoon” while we fix it, he still offers some reason for optimism.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.”

Gawande uses the examples of several other (albeit smaller) nations who built their universal coverage on the skeletons of their older systems. He concludes with the example of Massachusetts, which is the only state to have mandated universal coverage. While the results are imperfect, largely because one state alone cannot control an industry’s costs, it has made a huge difference in the lives of Massholes sick and well, offering “a glimpse of American health care without the routine cruelty.” I guess I could settle for that.


  1. Rob Schofield

    January 27, 2009 at 9:49 pm

    I think Gawande and the N.C. Health Access Coalition are probably on the same wave length. The Coalition’s “Guaranteed Affordable Choice” plan features six pragmatic steps toward getting more people on the boat. Check it out here:

  2. Kimberly

    January 28, 2009 at 7:48 am

    I believe that universal health care is needed and it is the right time for it. I agree with the Coalition’s plan but the language concerns me a bit. Who decides that “affordable health insurance” has been offered to a family and turned down by a family? There are situations, like mine, where we have to maintain income below Medicaid caps to allow our children with severe special health care needs to qualify which in turn doesn’t leave us with the extra cash to pay for private health insurance for my husband and I. Private health insurance for our family right now will run 8k per month, 2,500 per month just for my husband and I. Even High Risk Insurance Pool is too expensive for us to afford. The only solution to families with complicated situations, such as ours, is universal health care based on income with sliding scale fees that are truly affordable.

  3. IBXer

    January 28, 2009 at 10:45 am

    Sounds like a Verykouki idea to me.

  4. AdamL

    January 28, 2009 at 11:19 am

    Kimberly — I’m assuming that you mean the piece that requires everyone to buy health insurance. That would come pretty late in the game once we have a host of affordable options available. Right now affordable plans do not exist for most families.

    Before we could even consider penalizing people for refusing insurance we need to allow parents to buy into public programs with sliding scale premiums, we need to help small businesses extend insurance to employees, we need a subsidized insurance exchange, and we need to prohibit insurance companies from charging outrageous premiums because of preexisting conditions.

    Then we could talk about requiring people to purchase insurance.

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