Tuesday, February 17, 2009

Atul Gawande's Path Dependency Thesis

Writing in The New Yorker in January, Atul Gawande makes a case for a pragmatic approach to health care reform. The thesis of his article, "Getting There From Here", is that reform of the health care system must build on what already exists, because so many people depend on the current system. A single-payer system, in particular, would be too much of a break from the current system either to win approval, or to work smoothly:
Yes, American health care is an appallingly patched-together ship ... but hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions... There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it... If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.
Gawande calls the need to start with what we have "path dependence," and he argues that every major universal health care system around the world was built this way.

His article has generated some strong opposition within the single-payer movement, including one essay entitled "Et Tu, Atul?" that argues (unconvincingly) that Gawande is a shill for the insurance industry, and another entitled "Gawande's pseudo-pragmatism".

This second article, written by Don McCanne, MD, and published by the single-payer advocacy group Physicians for a National Health Program (PNHP), argues that it is possible to make the switch to single payer without "dry-docking health care":
Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.


The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

McCanne makes some good points. I don't think it has to be one way or the other. Couldn't we get to a single-payer system by allowing government-funded insurance (either Medicare or a new, broader program) to compete with private plans and prove itself? In fact, this seems to be what President Obama is proposing.

But many single-payer advocates, such as PNHP, are actually supporting something much more radical. HR 676, the "United States National Health Care Act," which PNHP endorses, would make it illegal to sell insurance that competes with the government program. It would also force all hospitals to become non-profit entities.

The bill has 42 cosigners in the House of Representatives, and there's nothing wrong with what they're proposing, except that it is a pretty radical change. In other words, it ignores path dependency, and therefore it has almost no chance of passing.


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