If You Read Only One Thing This Week


It Should Be This

In it, Dr. Atul Gawande of The New Yorker pens possibly one of the most informative articles on healthcare this year. It’s quite lengthy, but if you’re even remotely interested in universal healthcare (either for or against)then this will probably become required reading as it addresses some of the inherent problems in the US model of healthcare delivery. Problems that must be addressed regardless of whether healthcare reform is passed later this year.

Full article is here, and is well worth your time. My quick synopsis is below the fold:


Dr. Gawande’s focus throughout the article is on McAllen, TX, which apparently is the 2nd most expensive city in America for healthcare (Miami is 1st), and the factors that led to this distinction. I can’t say this immediately surprised me however, due to the often cited loophole in our current system being that illegal immigrants and the uninsured receive “free” healthcare by frequenting the ER. This argument is quickly debunked however when the author compares McAllen to El Paso, demographically identical cities except that El Paso’s Medicare cost/enrollee is roughly half that of McAllen.

The author later asks the $1 trillion question to a local physician about whether switching to a single-payer government model would work. Here’s his response

“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.

So it seems, as Dr. Gawande’s opus describes, that one of the key problems in our current healthcare system is yet another example of a misalignment of incentives (something we've all seen play out in the financial world over the past nine months):

When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

If you’re interested in learning why patients in Grand Junction receive higher quality care at less than half the cost, or why there is an inverse relationship between cost and quality of care across the board then click here to get your learn on (as the kids like to say). Personally, as many universal healthcare advocates smarter and more informed than I am often cite the cost savings inherent in a European style system, the section of the article describing how the Mayo Clinic already manages to accomplish this is more than enough of a reason to do so.


Leah on 3/6/09 said...

Good article. Thanks for sharing!

I think the situation in McAllen is unfortunate. If all clinics took personal responsibility to operate like the Mayo Clinic, we'd clearly be in much better shape. Unfortunately, many have neglected their own personal responsibility and the price for that is not just unaffordable healthcare, but also freedom.

I think this article illustrates the paradox of freedom - the main issue I think America is dealing with today. If our nation as a whole forsakes responsibility and due diligence in the workplace and at home or wherever, the government will step in and regulate and grow bigger and try to fix things - not that I think it should, it just will.

Immorality is becoming more and more common in America - greed and the love of money, the disintegration of family, etc... it has become acceptable to act irresponsibly. (People acted irresponsibly 30 years ago, but it was not acceptable.)

The result of this is that we have a ton of problems that we have caused that need to be fixed. As you already know, my preference is that we the people fix them, that we take the responsibility and burden for our own moral decline, help the helpless and punish those that act irresponsibly. We take responsibility and we get to keep our freedom, but if we make our problems the government's responsibility, we lose our freedom.

I personally think a government-run health care system would be a punishment for everyone - mainly because it wouldn't solve the real problem of greed or laziness in a man's heart, and in the meantime, it might just put another sleezeball in control of your health care decisions - a politician or a bureaucratic monster in general.

I agree that the current system sucks though. :)

Mike on 3/6/09 said...

Leah as always, thanks for the response (you should write a guest post someday). Clearly I don't have the answer to this problem, but the Mayo Clinic example struck me as a crucial example of how the cost savings that the public option crowd thinks will happen, are already attainable. If however, this is the model that proves most effective, the problem will be very similar in that it requires all healthcare providers to willing reduce their earnings (as the article points out even the Mayo Clinic struggles with this). So should someone require them to do so? And if so, who would that be?

Also, the reform currently on the table doesn't involve the government running everyone's healthcare (you can keep what you have), it rather provides a public option to lower the cost so that everyone has access. This path however has a much higher price-tag however, and paying for it seems to require some sort of alteration to the employer based healthcare model we enjoy today (which some, mostly older, people would argue actually infringes on their freedom as they feel stuck to their employer due to the fear of obtaining healthcare individually).

And though I don't necessarily agree that it wasn't acceptable to act irresponsibly 30 years ago (e.g. the disco era!), I do agree that we'd be in much better shape if we all took a little more personal responsibility.

Leah on 4/6/09 said...

I am opposed to the government requiring health insurance companies to reduce their earnings... the freedom thing again. Don't have a better solution though...

The reform won't go from personal/private healthcare to govt rationed healthcare overnight, but this reform is the first step, and I think a slippery one...

As far as acting irresponsibly, I was mostly referring to what is acceptable in the media, on television in movies, etc. The Brady Bunch was the 1st TV show where a married couple slept in the same bed together on TV, and apparently that was a big deal. Totally different story now. Maybe I should have said 40-50 yrs ago.

I don't think you want me to guest post for you. BTW, like the new look!

Andrea on 6/6/09 said...

I am glad to see the two little bloggers in my life communicating/disagreeing via...well a blog!

Yet another reason I quit my job doing medical device sales. Working in that capacity in the health care industry was a very disturbing and eye-opening experience. It's always interesting to discuss policies and issues such as this on a macro level, but Leah, I like where you went with it on a micro level. I see it as a challenge to us, as educated young people (especially ones who are involved with health care), to be the change you want to see. What can you do at a personal level?

Gosh, that was inspirational...

Mike on 9/6/09 said...

@ Andrea, finally after about a year! I knew I'd turn you into a blogging nerd eventually.

@ Leah, my original intent with this site was to flesh out my own views in light of whatever scrutiny readers would offer and new information. Therefore I welcome anyone who's open-minded and willing to put their own thoughts out on display.

Plus I don't think we differ all that much on the end goal (lowering costs and increasing access), just on the idea that government can or should play a role in this process.

My main takeaway from this article however is that simply adding a public plan on top of the current system will seemingly only make things worse. Conservative economist Greg Mankiw makes a valid point when he asks if the public plan will have access to tax payer dollars unavailable to private insurance providers. If so then that is not competition, it is the slippery slope you referred to.

But Obama at least acknowledged this dilemma recently by stating that, "As we move forward on health care reform, it is not sufficient for us simply to add more people to Medicare or Medicaid to increase the rolls, to increase coverage in the absence of cost controls and reform. And let me repeat this principle: If we don't get control over costs, then it is going to be very difficult for us to expand coverage."

I think this provides a stark contrast from the far left who want universal coverage no matter the cost.

Leah on 11/6/09 said...


:) You choose to believe Obama. I choose (careful wording) to believe that he knows the only way to get a far-left health care agenda passed is to clothe it in moderate language. Par for the course as far as I am concerned in regard to his campaign and policies so far. Somehow the approval rating on Obama's policies is far, far, FAR lower than it is on Obama himself - I blame it on the silver tongue.


By "we" I mean private companies without the "help" of government. So I myself may not play a specific part in this, but I CAN, choose to live a healthy lifestyle. Some people don't choose to do that - once again, lack of personal responsibility comes at a cost.

However, w/ govt in control of healthcare, many people could possibly lose the freedom to choose in regard to lifestyle decisions - Obama himself said something to the effect of that today in a townhall meeting in Green Bay, referring to a theoretical diabetic, I believe. Don't quote me on that.

I think this problem is really ginormo scale because, as we all know, health is a lifestyle issue - all-encompassing...

Also, another issue is that we as a society no longer embrace the fact that there is right and wrong, or truth and falsehood, and so it has become increasingly impossible to hold anyone accountable for bad behavior. Everyone pays for that.

I realize that pretty much all I have done today is comment on your blog. My excuse is ... My friends either 1 - don't care or 2 - hate talking with me about this stuff (though I can't see why???), so thanks for the outlet. :)

And we will be seeing you guys on Sat! whoop!

Mike on 12/6/09 said...

Glad to provide a sounding board for issues that you clearly care about. Hope I keep you coming back.

To your point, I don't believe much of anything that comes out of Washington (or cable news), but I do give the Obama administration the benefit of the doubt here as they undoubtedly knows that a "far left" agenda would not pass through Congress (no matter what Sean Hannity says).

Here's Peter Orzag's commentary on the issue:


From what I've seen, very few people want government run healthcare (i.e. the VA system or Great Britain) so your fears may be a bit premature. More people want single-payer (i.e. Medicare and France), but that doesn't appear to be what we're getting either. Here's a better analysis:


Personally, I'm just trying to figure out what makes the most sense as I look at the fact that we have the 37th best system (WHO estimate) and the 2nd most expensive. It seems logical to think there might be a better model somewhere, that doesn't involve threatening someone's freedom.

More on that next week.


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