If you haven't already, read Atul Gawande's piece on health reform in the New Yorker, largely centered around McAllen, Texas, the community in America with the highest health care costs. It's hard to quote the heart of the article, because it's so good, so I'll just quote the conclusion:
Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.
In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.
And he's right. If we don't get health care costs down, health reform will not work. People will still go bankrupt, we will still ration care based on ability to pay, and we will still have a health care crisis. And when you get down to it, health care costs are about how much and what medicine your doctor orders for you.
Conservatives will accuse those in favor of health reform of taking the easiest way out, in a sense. Health care costs are up? Ok, let's ration care and drive those costs down. But that's not what we're proposing. And, as Gawande so eloquently points out, driving down health care costs and increasing the quality of that care actually can be one and the same. So that's some pretty good news.
One thing about this article leaves me puzzled, though. Gawande seems to set up a conflict between advocacy for a public health insurance option and what he apparently considers "real" health care reform, which is setting up incentives for doctors to provide better care, not just more care. Maybe he's just reacting to the media coverage around health care reform, which has been largely centered around a public health insurance option. And maybe I'm biased, seeing as I've been working to shape that media battle. But I really don't think it's either/or. Actually, I think Gawande's point makes the public health insurance option more critical.
I agree with Gawande that we could end up with a public health insurance option that doesn't foster the right incentives to control costs, and that wouldn't be a big victory. But while Gawande is proposing some kind of outside board to control these incentives, I wonder if the public health insurance option isn't the place where these reforms are put into action.
Think about it: One advantage to a public health insurance option is that it is transparent. Private insurance doesn't tell you what they pay for services, how often these services are used, and whether these services have improved patient outcomes. A public health insurance option could make that data available and work with it to improve care and control costs. This data would put the public health insurance option in the perfect position to figure out why some places in America cost so much more and why their outcomes aren't any better, and how to fix that.
We must get costs down, that much is clear. We need the tools to do it. I'm pretty convinced the public health insurance option can be at least a crucial part of that toolset.