lundi 17 août 2009

From Gawande's mouth to Obama's ear: the unlegislation

"high levels of health care spending are not associated
with high levels of health care quality.
The system is screwed up."

I swore I'd give this up. I don't have the time for it, and it is probably the biggest effort in futility in which I have ever engaged.

We voted for Obama. We voted for Change. We voted for Hope. We all did this with our eyes more or less open. Many said, "You're being a little too progressive there. I'm not supporting Obama because he's a progressive, but because he's a pragmatist." I think they meant that he'd get things done, not that he'd trade away the barn.

People are getting nervous, though. On August 8, Frank Rich asked, "Is Obama punking us?" and by August 11 Maureen Dowd was asking where's the "young grass-roots army that swept Obama into office", saying it "has yet to mobilize now that the fight is about something complicated rather than a charismatic hope-monger" and Drew Westin, writing in The Huffington Post, was telling us what the other parents in his neighborhood, the ones who voted for that "charismatic hope-monger", were starting to let lose in criticism of the hope-monger now that he is POTUS.

And the MyBO listservs, as quiet as a mausoleum since the inauguration, were coming alive with murmurings of "This is what I received...", "What do you think..." and "Doesn't this sound like a concession to you all?"

And the foreshadowing of history's judgement:
What Obama and Democrats don't get is that not only are they betraying all of us by not advocating for and passing Improved Medicare for all, but they also are betraying themselves. They are giving away this huge cash cow to powerful corporate interests when instead they could use it to solve the health care crisis for generations to come, save Social Security for generations to come, solve the budget deficit for generations to come, and make themselves out to look like (and be) moral heroes and fiscal geniuses for the history books.

But they are trading all of that (money, mercy and saving lives) for a relatively few lousy campaign donations. The long view of history will judge them harshly, and they will end up looking bought-and-sold-out stupid.
And then, in response to Sibelius' remarks on the public option being "unessential" on CNN's "State of the Union":
I think we are on the verge of either real reform OR a revolution.

And this morning:
Is there any point to [the OFA rally for health care reform in Times Square, NYC August 29] now that the White House has given up the ghost to the pharmaceutical industry and is looking to drop the public option? As far as I can tell, real reform is dead.

This is what we get for voting a centrist into office.

All this, while The Huffington Post leads today with the following 10" banner headline under "Breaking News":


Sebelius: Public Option Not "Essential"... Gibbs: WH Supports Public Option... Douglass: Obama Prefers Public Option... WH Official: Sebelius "Misspoke"

One is tempted to ask who the head chef is.

I have a suggestion. It's Dr. Atul Gawande, but the word's not officially out in the administration.

It's Atul Gawande's June 1 New Yorker article

The Cost Conundrum

What a Texas town can teach us about health care.

that President Obama has been handing out to our senators to read. It's Atul Gawande who has the President's ear, and he has never been for single-payer or a public option. Neither has the President. Not seriously. He's still debating the pros and cons in his head, while everyone's screaming and feeling betrayed.

Presidents used to get time to reflect in private, listening to their own angels and demons, before making a public announcement of intent, having lined up their arguments and support beforehand, and ready to defend their position. Now, the intellectual dithering is all out there for everyone to witness and splinter before it comes to maturity.

This is the part of Obama that wasn't apparent before now. It's the messy part of figuring things out. The part that's better done before you start talking and giving interviews.

Sure, those who said, "I'm not voting for him because he'll defend the progressive ideal but because, on the contrary, he's a pragmatist" had something of this in mind. They knew what many others wished weren't true: that he'd never support single-payer, no matter how many of us were willing to lie down our lives for it, and that he'd drop a "public option" like a hot potato if he felt that it wouldn't get him a bill to sign in the Rose Garden.

They would be satisfied with a little progress.

The fact is that Barack Obama is a centrist. Always has been, always will be. It's how he came to terms with his own identity, for heaven's sake. He wants legislation, almost any legislation, whatever he can get out of congress and make a claim for, like "Hey, it isn't everything we wanted, but we always knew [nod, wink] that we wouldn't be able to get it all, and we got this." [Applause.] He could make Bill Clinton turn green with envy.

Actually, he did already.

And here comes Atul Gawande, already "unfriended" by the single-payer movement and committed progressives, with the perfect solution: just do like some successful areas in the United States are already doing all on their own, and we'll be fine, and we've totally missed it. Dr. Gawande tells us in "1o Steps to Better Health Care" in the NYT August 13 OpEd pages:
We have really discussed only two options: raising taxes or rationing care. The public is understandably alarmed.
[Understandably? Did you explain to them how single-payer works and why? No? What are you afraid of exactly?]

There is a far more desirable alternative: to change how care is delivered so that it is both less expensive and more effective. But there is widespread skepticism about whether that is possible.

Yes, many European health systems have done it,
[Yes! Yes! Europe! Here it comes...]
but we are not Europe.
[Oh. The let-down: get over it. I have been trying, from my vantage point here in Europe, where I know how right we've got it.]
If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).
[Now this sounds like Nirvana... but he does mention a caveat: "Because we relied on Medicare data for our selections, it is possible that some of these regions are not so low-cost from the viewpoint of non-Medicare patients. But overall data strongly suggest that most of these regions are providing excellent care for all patients while being far more successful than others at not overusing or misusing health care resources." They couldn't do a little checking of that strong suggestion of the data?]
... better, safer, lower-cost care is within reach. Many high-cost regions are just a few hours’ drive from a lower-cost, higher-quality region. And in the more efficient areas, neither the physicians nor the citizens reported feeling that care is “rationed.” Indeed, it’s rational.

Many in Congress and the Obama administration seem to recognize this. The various reform bills making their way through the process have included provisions to protect successful medical communities by incorporating payment approaches that reward those that slow spending growth while improving patient outcomes. This is the right direction for reform.

See? Obama agrees with him. This is what Obama wants, but how are they going to do this?

I'm not saying that it won't work. The three key ingrediants for success (not the 10 promised by the OpEd's authors) form a part of the fabric of the European, Canadian and Japanese single-payer systems:
  1. The "Mayo model, with salaried doctors employed by a unified local system focused on quality of care".
  2. "with several medical groups whose physicians are paid on a traditional fee-for-service basis" incorporating "ways to protect patients against the damaging incentives of a system that encourages fragmentation of care and the pursuit of revenues over patient needs."
  3. "a collaboration of doctors, state officials, insurers and community leaders to improve care. For more than four years, physicians have been tracking some 60 measures of quality, like medication error rates for their patients, and meeting voluntary cost-reduction goals."
So, Dr. Gawande and President Obama, is this a voluntary system and our representatives on Capitol Hill can just heave a sigh of relief and turn to another issue you'll be able to find a way not to legislate to improve, or will this involve legislation the AMA can accept to make heath care so inexpensive and successful that insuring it will be like calling Geico for your old wreck?

We're dying to hear the details.

And you'd better hurry before you have to do more of the damage control we saw in today's HuffPo and you look even more like a band of amateurs.

Meanwhile, what discussion of nearly anything would be complete without Paul Krugman's input?
So where does Obamacare fit into all this? Basically, it’s a plan to Swissify America, using regulation and subsidies to ensure universal coverage.

If we were starting from scratch we probably wouldn’t have chosen this route. True “socialized medicine” would undoubtedly cost less, and a straightforward extension of Medicare-type coverage to all Americans would probably be cheaper than a Swiss-style system. That’s why I and others believe that a true public option competing with private insurers is extremely important: otherwise, rising costs could all too easily undermine the whole effort.

But a Swiss-style system of universal coverage would be a vast improvement on what we have now. And we already know that such systems work.

So we can do this. At this point, all that stands in the way of universal health care in America are the greed of the medical-industrial complex, the lies of the right-wing propaganda machine, and the gullibility of voters who believe those lies.

Thank you, Mr. Krugman. Italics mine.

You don't get this done, and there's reason to be worried, very worried, for 2010. Ask Nate Silver.

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