Successful enactment of health reform legislation using the Senate bill as the foundation would suggest that America remains a centrist country and that progress is a possibility as long as a majority of our elected officials are open to compromise and a few leaders have the patience and skill to find the center.
The Senate health care bill does an impressive job of reducing the uninsured population, but is tentative about how to create a more efficient system that will make medical costs tolerable. How to translate the legislative vision of creating a more unified, cost-effective delivery mechanism remains a major challenge that underlies much of today's debate from the periphery about the flaws of the bill.
The parameters of the translation problem have been outlined by Atul Gawande, a polemicist and physician, who's probably had a bigger impact on the current debate than any other writer-activist, and Alain Enthoven, a retired Stanford economist, who can be called a founding father of the health reform debate because he's been writing about it for more than three decades.
Gawande puts forth the "hundred flowers" argument which holds that we don't know what works best but that providers will inevitably gravitate toward efficiencies that are discovered as a result of the many pilot projects contained in the bill. He likens this process to the way American agriculture's efficiency grew explosively thanks to efforts of the Agriculture Department's Cooperative Extension Service.
He relies on good old American ingenuity.
Enthoven, by contrast, continues to argue that we know what works but are imprisoned by a system with perverse rewards. This is not unlike the argument made by Mayo Clinic which suggests it makes more sense to get things right than to pay a low price and then finance a lot of rework to fix what goes wrong. Mayo, which is seen by many as a poster child for reform, says it has an integrated system with relatively high initial costs that tends to deliver a cure at a good price, perhaps because doctors talk more with patients rather than immediately resorting to tests and procedures that have high price tags.
Capitation, where a health care provider like Kaiser Permanente receives an amount per patient negotiated in advance, is a mechanism that should promote efficiency. Profits are dollars unspent at the end of the year. In such a system providers have an incentive to do less. Suddenly the provider has an incentive to minimize the number of tests and procedures. Theoretically, there could be a danger that such providers would stint on patient care and thus be less likely to solve any given problem.
But Enthoven and those supporting capitation in Medicare [a program known as Medicare Advantage that wins broad GOP applause] say this threat can be constrained by oversight and a realization that providers who deny cheap care today will often be confronted by sicker patients who require more expensive care tomorrow.
If Enthoven is right that his structure is the sole solution, then you can fault the health reform for failing to get us there directly. But imposing it would be painful for many providers and more than a few patients. It would create a world that probably looked a lot like the Kaiser HMO, where some drugs and procedures that are common elsewhere are used rarely, if at all. Kaiser delivers quality care driven by protocols that limit treatment options.
In short, it restricts choice.
Gawande seems to have a more optimistic view of human behavior, arguing that providers will make the right choices once they're provided with data proving what type of treatment is optimal. If research clearly shows a $50 injection is better than a $5000 procedure, he says, providers will migrate in that direction.
Excess medical personnel will become surplus and find new jobs, just as the thousands of American farmers forced to migrate to the cities did more than a century go. It is an interesting theory. My cursory view of history is that doctors, drug firms and hospital administrators have greater sophistication and control of their markets than farmers ever did and will not embrace the transition. They'll fight it in a more deft fashion than was used by supporters of William Jennings Bryan.
That doesn't mean they'll win. Ultimately the logic of Nixon economic advisor Herb Stein - who allegedly opined that no situation deemed intolerable lasted very long - will come to the fore. The final lesson of today's debate is that most of us don't find health costs intolerable --- yet.
But if the Gawande scenario doesn't come true, we soon will.