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Gawande and Hope for Health Care Reform

December 10, 2009

Atul Gawande has an interesting article in the New Yorker about the current reform bills circulating through Congress.  Like everything else Gawande has written, this piece is insightful, concise, and inspiring.  He draws a parallel between American agricultural reform during the early part of the 20th century and the current debate over health care.  Given I am not well-versed in agricultural reform in the US (I did see a PBS special on it once), I’m not exactly certain of the appropriateness of this analogy.  What Gawande does accomplish in this piece (and why you should read it) is a sense of hope in our collective ingenuity to actually accomplish effective health care reform.  He believes this goal will be achieved through provisions in the current Senate reform bill for dozens of pilot programs to test new payment structures and delivery systems.  Although Gawande makes a strong, eloquent argument, I am only partially convinced.  How will these pilot programs generate substantial change?  How long will it take for these programs to demonstrate substantive value and then how much longer would it take to scale up their lessons?  I actually like the idea of pilot programs, but they need to have scale to make an impact.  As I have argued many times before, different approaches should be tried at the state level (like Massachusetts) and then scaled up when appropriate.  Such larger programs offer two distinct advantages: (1) their relative scale means evidence of effectiveness (or ineffectiveness) will be generated more quickly and (2) scaling such programs to multiple states or  the national level will take less time and effort since the original scale is more proximate to the end goal.  But read Gawande’s article, it really is quite good (despite my skepticism).


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