THE PRESIDENT AND THE REPUBLICANS

I’ll link to Friday’s give-and-take – in case you missed it – again tomorrow.  As one of my friends put it, “The level of skill, intelligence, expertise and political sophistication the President demonstrated throughout was incredible.”

Today, though . . .

WHAT’S THE MATTER WITH DEMOCRATS

Here’s a pretty plausible explanation of mistakes we Democrats make in communicating our message.  We use numbers and logic; they use stories.  We’re generally right; they’re generally effective. ("Mr Gore was talking sense and Mr Bush nonsense – but Mr Bush won the debate. With statistics, the voters just hear a patronising policy wonk, and switch off.")

I blame myself

If I weren’t always so far behind*, I would have read Atul Gawande’s piece in the December 14 New Yorker the first week in December, and I would have linked you to it and you would have linked all your friends, and, along the way someone would have persuaded Martha Coakley to campaign (and told her who Curt Schilling is, though it obviously couldn’t have been me, having just learned myself … though I did once meet Bobby Orr, which I know is different, but not that much different), and we would have “passed health care” before the State of the Union.

*For that, I blame Mad Man and Modern Family and The Office and 30 Rock and 24 and – well, I don’t blame Rachel Maddow or Jon Stewart or Steven Colbert or 60 Minutes, because, zooming past the commercials with Tivo, there is no better use of time – you know the kind of shows I mean. Dexter, Desperate Housewives, Law and Order, CBS Sunday Morning. It is a golden age.

So it’s on me, but now it’s on you to read the piece yourself. 

Gawande, by the way, is the same guy who did the pieces previously linked to on hospital checklists (using them makes a dramatic difference in the quality of care) and, later, on McAllen Texas versus El Paso (the demographics are similar, yet health care costs in McAllen are much higher because most McAllen docs view their calling as a business).

His overall point is that the myriad pilot programs in the health care bill are just what the doctor ordered – and can lead to the same kind of dramatic improvements in U.S. health care as they did, a century ago, in U.S. agriculture.

See what you think (and subscribe to the New Yorker!) . . .

Testing, Testing

The health-care bill has no master plan for curbing costs. Is that a bad thing?

by Atul Gawande

December 14, 2009

Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. Those gaps have widened to become graves—resulting in an estimated forty-five thousand premature deaths each year—and have forced more than a million people into bankruptcy. The emerging health-reform package has a master plan for this problem. By establishing insurance exchanges, mandates, and tax credits, it would guarantee that at least ninety-four per cent of Americans had decent medical coverage. This is historic, and it is necessary. But the legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease.

Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.

What have we gained by paying more than twice as much for medical care as we did a decade ago? The health-care sector certainly employs more people and more machines than it did. But there have been no great strides in service. In Western Europe, most primary-care practices now use electronic health records and offer after-hours care; in the United States, most don’t. Improvement in demonstrated medical outcomes has been modest in most fields. The reason the system is a money drain is not that it’s so successful but that it’s fragmented, disorganized, and inconsistent; it’s neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.

At the current rate of increase, the cost of family insurance will reach twenty-seven thousand dollars or more in a decade, taking more than a fifth of every dollar that people earn. Businesses will see their health-coverage expenses rise from ten per cent of total labor costs to seventeen per cent. Health-care spending will essentially devour all our future wage increases and economic growth. State budget costs for health care will more than double, and Medicare will run out of money in just eight years. The cost problem, people have come to realize, threatens not just our prosperity but our solvency.

So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.

This has provided a soft target for critics. “Two thousand seventy-four pages and trillions of dollars later,” Mitch McConnell, the Senate Minority Leader, said recently, “this bill doesn’t even meet the basic goal that the American people had in mind and what they thought this debate was all about: to lower costs.” According to the Congressional Budget Office, the bill makes no significant long-term cost reductions. Even Democrats have become nervous. For many, the hope of reform was to re-form the health-care system. If nothing is done, the United States is on track to spend an unimaginable ten trillion dollars more on health care in the next decade than it currently spends, hobbling government, growth, and employment. Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.

At the start of the twentieth century, another indispensable but unmanageably costly sector was strangling the country: agriculture. In 1900, more than forty per cent of a family’s income went to paying for food. At the same time, farming was hugely labor-intensive, tying up almost half the American workforce. We were, partly as a result, still a poor nation. Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power. We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors. And we had to make farming less labor-dependent, so that more of the population could enter non-farming occupations and support economic growth and development.

America’s agricultural crisis gave rise to deep national frustration. The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of coördination led to local shortages of many crops and overproduction of others.

You might think that the invisible hand of market competition would have solved these problems, that the prospect of higher income from improved practices would have encouraged change. But laissez-faire had not worked. Farmers relied so much on human muscle because it was cheap and didn’t require the long-term investment that animal power and machinery did. The fact that land, too, was cheap encouraged extensive, almost careless cultivation. When the soil became exhausted, farmers simply moved; most tracts of farmland were occupied for five years or less. Those who didn’t move tended to be tenant farmers, who paid rent to their landlords in either cash or crops, which also discouraged long-term investment. And there was a deep-seated fear of risk and the uncertainties of change; many farmers dismissed new ideas as “book farming.”

Things were no better elsewhere in the world. For industrializing nations in the first half of the twentieth century, food was the fundamental problem. The desire for a once-and-for-all fix led Communist governments to take over and run vast “scientific” farms and collectives.  We know what that led to: widespread famines and tens of millions of deaths.

The United States did not seek a grand solution.  Private farms remained, along with the considerable advantages of individual initiative. Still, government was enlisted to help millions of farmers change the way they worked. The approach succeeded almost shockingly well.  The resulting abundance of goods in our grocery stores and the leaps in our standard of living became the greatest argument for America around the world.  And, as the agricultural historian Roy V. Scott recounted, four decades ago, in his remarkable study “The Reluctant Farmer,” it all started with a pilot program.

In February, 1903, Seaman Knapp arrived in the East Texas town of Terrell to talk to the local farmers.  He was what we’d today deride as a government bureaucrat . . . he worked for the United States Department of Agriculture.  Earlier in his life, he had been a farmer himself and a professor of agriculture at Iowa State College.  He had also been a pastor, a bank president, and an entrepreneur, who once brought twenty-five thousand settlers to southwest Louisiana to farm for an English company that had bought a million and a half acres of land there. Then he got a position at the U.S.D.A. as an “agricultural explorer,” travelling across Asia and collecting seeds for everything from alfalfa to persimmons, not to mention a variety of rice that proved more productive than any that we’d had. The U.S.D.A. now wanted him to get farmers to farm differently. And he had an idea . . .

☞  It’s a wonderful story, filled with hope, and worth reading to the end.

(And tort reform?  Sensibly done, with very high caps, if any, on the worst pain and suffering, I’m for it.  That will come, too, but likely not this year.  Except maybe some pilot programs.)