Learning from the Past

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Atul Gawande has a fascinating piece in the New Yorker with an unusual argument on how to do health reform. I see the piece as also an insightful window on any of our “big” problems, like climate change, or even sustainability. He argues, against all the talk coming out of Washington, that the present messy Senate bill is built on a sound and successful precedent, although not deliberately or maybe even without any sense of the past. His reference is the history of reforms to our (and other) agricultural systems.

His central message is

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… 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.

Gawande then leads us through a detailed history of how the United States dealt with a somehat similar situation starting around 1900—an agricultural system that was acting as a drag on the whole economy. Food prices were very high relative to family budgets, consuming about 40% of income. Even present health costs haven’t gotten that high, except for a few families. Other structural problems, like extremely low labor productivity, differ in specifics from those affecting today’s health system. One set of possibilities ran headlong into another, just as in today’s context.

For many reasons, out of this impasse, small experimental efforts were put into play, eventually ending with, for example, the Department of Agriculture’s extension program that introduced manifold improvements in the way farmers went about their business. Gawande’s point, which I strongly adhere to, is that, in such complex messes, it is folly to expect that the solutions that emerge from political and academic expertise will produce the results that their proponents claim. The more prudent approach is to try small experiments: keeping and improving the successful pieces, dropping the failures along the way, until the system begins to perform as desired. Complexity demands that we pay lots of attention to local knowledge, that is, knowledge coming from practice, rather than from theory. Such was also the theme of the New Deal designers and practitioners.

The Senate bill, Gawande points out, is crammed full of just such “experiments.” These do not and cannot provide the certainty about the future that gives politicians safe harbors. The same is true for climate change and sustainability in general. The problems arise out of a faulty system with many of its components malfunctioning and out of synch with others. Prudence and an understanding of such complex systems warns against a hubristic set of solutions, based on what our models and experts tell us will happen when we apply bandages or replace organs here and there. He sees the bill as promising because it, by and large, avoids a narrow framing philosophy. Obama let the Congress muddle through rather than present them with a more narrowly constructed program as did Clinton. It’s time, however, to move along, get a new set of experiments going, stop the political haranguing, and give those that play in the field the opportunity to create the system we want and need. He ends with:

Getting our medical communities, town by town, to improve care and control costs isn’t a task that we’ve asked government to take on before. But we have no choice. At this point, we can’t afford any illusions: the system won’t fix itself, and there’s no piece of legislation that will have all the answers, either. The task will require dedicated and talented people in government agencies and in communities who recognize that the country’s future depends on their sidestepping the ideological battles, encouraging local change, and following the results. But if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We’ve done it before.

(Photo credit to: ©Tom Weigand, Inc., www.thewinningimage.com)