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With Democrats on the Defensive, Gawande Weighs in on The Senate Bill

By John Reichard, CQ HealthBeat Editor

December 11, 2009 -- On a day when they were derided for producing a 2,074-page bill in the Senate that in the words of Minority Leader Mitch McConnell, R-Ky., fails to do anything about rising costs, Democrats were clearly on the defensive.

Medicare's respected actuary Richard S. Foster weighed in Friday with an analysis of the bill (HR 3590) that cast doubt on whether the measure could squeeze savings out of the nation's health system because 33 million newly covered Americans would receive care they wouldn't have received when uninsured.

Poll results earlier in the week were no source of moral support, with a CNN survey showing only 36 percent of Americans surveyed supporting the Senate Democratic overhaul proposal. Earlier in the week, a Quinnipiac University poll found that only 38 percent of Americans "mostly approve" of the proposed changes to the health care system under consideration by Congress.

On the other hand, 52 percent said they "mostly disapprove." Older Americans, who Republicans said would suffer under Medicare cuts in the Senate bill, expressed an even lower opinion of changes under consideration in Congress. Only 30 percent of those over age 55 said they "mostly approve" and 57 percent of them said they "mostly disapprove."

Republicans fired Friday out of both barrels, armed with lengthy talking points based on the Foster findings. Democrats responded quickly but weakly, failing to provide any comprehensive rebuttal. But at least they could take comfort in a defense of the Senate bill written by Atul Gawande, the surgeon and former Clinton administration official who made a big splash in the health care debate earlier this year with a New Yorker magazine article that detailed waste in Medicare spending associated with medical entrepreneurship.

Gawande was back at it in the Dec. 14 issue of the New Yorker with a piece on the Senate bill.

"Health care costs are strangling our country," Gawande wrote. "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 does the Senate bill do about those costs? Does it end piecemeal payment, replace payment for quantity with payment for quality, adopt structural changes that improve quality? "It does not," Gawande said. "Instead, what it offers is. . .pilot programs.

"Where we crave sweeping transformation. . .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."

His argument relies on an extensive analogy to the agricultural sector. In 1900, almost 40 percent of family income went to food and almost half the nation's work force was tied up in farming. "We were, partly as a result, still a poor nation."

But amid criticism that it was taking over the agricultural sector, "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."

Gawande asserted that "it all started with a pilot program."

The piece cites the example of a U.S. Department of Agriculture employee who convinced a Texas farmer to try out "scientific" methods to see how they worked. Amid the spread of the boll weevil, the cotton farmer turned a large increase in profits, catching the eye of other local farmers. USDA followed with a program of employing "extension agents" who set up other demonstration farms across Texas and Louisiana.

Other USDA programs compared the effectiveness of farming techniques and the department continually evaluated new technologies to provide technical assistance to farmers.

"The government never took over agriculture, but the government didn't leave it alone either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country."

The history of agriculture suggests that transformation is possible "without a master plan, without knowing all the answers up front." Figuring out how to transform medical communities with their hodgepodge of local entities is going to require trial and error according to Gawande — and that's where the Senate bill comes in.

"Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodge-podge. And it should be."

Gawande concludes that if "we're willing to accept an arduous, messy, and continuous process [of improving care and controlling costs] we can come to grips with a problem even of this immensity. We've done it before."

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