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Dr. Atul Gawande on Health Care & the Age of Reform

Dr. Atul Gawande (Photo: Gawande.com)

The new Congress is not even convened yet, and already a vote is slated by House GOP leadership to repeal – roll back – the massive health care reform package just passed last year.

Americans are watching, and wondering “what next”? So are doctors, including Dr. Atul Gawande, the surgeon and writer who has emerged as one of the country’s leading interpreters of what’s going on with American health care.

It will eat us alive if we don’t get it right, he says. And getting it right is still a big challenge.

-Tom Ashbrook

Guest:

Dr. Atul Gawande, general and endocrine surgeon at the Brigham and Women’s Hospital, professor at Harvard Medical School and the Harvard School of Public Health, and a staff writer for The New Yorker. A MacArthur Fellow, he also leads the World Health Organization’s Safe Surgery Saves Lives program.

His books include Better and Complications; his latest, just out in paperback, is The Checklist Manifesto.

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(Photo: WBUR/Jesse Costa)

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  • Peter Smyth

    Can we separate health care reform and reforming the way we pay for it?

  • Ellen Dibble, Northampton, MA

    I’ve heard/seen Dr. Gawande, possibly on The News Hour, and I believe I’ve read at least one article of his in the New Yorker. The fact a well-connected and well-established physician chooses to advance the “checklist” idea in his book rather than directly to the American Medical Association mystifies me. Probably he’s explained it and his methodology for improving care is probably catching on as fast as fax machines and e-mail can transmit, and the book probably explains why the general public still needs to know. Or better yet, this doctor is soaring on to other challenges, with no book yet written.
    Still, the elephant in the room at outset is this: Can’t the medical community fix itself (perpetrate its own checklists for surgical procedures, by word of mouth)? — without all the dirty laundry, so to speak (my recollection, unnecessary lapses in medical care, some very easy to fix)?
    I heard over the weekend that Massachusetts can also apparently improve care by taking more responsibilities from the high-paid specialists and the costly high-tech medical centers like Brigham and Women’s, and make better and greater use of local clinics and nurse practitioners, which is what I believe Governor Deval Patrick is focusing on. Is Dr. Gawande part of a team with him: physicians for quality affordable care?

  • Heidi Nepveu

    Re separating health care reform and reforming the way we pay for it, two things:

    Another great writer on the subject is Uwe Reinhardt, and

    To reduce what we pay, docs and pharmaceuticals will have to reduce their fees; those are two of the biggest drivers in health care costs.

    Looking forward to the on-air discussion.

    Heidi in Burlington, VT

  • Al Dorman

    (Boston, MA)
    Every time I look at the issue, I come to the same solution: get rid of the private insurance market (start with health but go on to car insurance too). I don’t see why profits are involved here. As any good economist would say, the moral hazard of letting profit come into conflict with life and death is juste unacceptable. You don’t have to be a socialist to see that.

  • cory

    No ral reform will occur until you remove the profit motive from medicine.

    Leftfield, Wisconsin

  • Janet in Brentwood TN

    Where is the incentive for people to be healthy? My rates should go down everytime I lose 10 lbs and keep it off. My rates should go down everytime I go for a mammogram and it’s clear. My rates should go down when my kid gets vaccines like Gardasil. My rates should go down when I check in to my spinning class faithfully for 6 months.

  • Zeno

    The media does not cover the issue of EXACTLY where ALL the money is going. The doctors state they are living in abject poverty?, the hospitals say they have only debt?, the insurance companies say they don’t have it either?

    Any answers? Will the corporate media ever do deep and necessary investigative reports on where the money goes?

    I am old enough to remember real insurance, and real pricing of medical services. But now we have a system that is bizarre in the extreme. Try asking what a medication actually costs ( even the people selling it don’t know). Try asking your doctor what a visit costs, or an exam, or a test (no one in the office can tell you). Then enter the most bizarre institution in America (The hospital). In patient, out patient, ER, lab, exam, radiology, etc. Ask anyone in the place what ANYTHING costs and they do not know. If it has value it should have a price…correct? It does have a price in the weeks that follow, as a blizzard of medical bills from dozens of entities that may or may not have had anything to do with your care; medical facilities, corporations, and individuals arrive.

    It is then that you realize that these institutions are completely outside of normal behavior because of the perversion of insurance.

    Health care reform is ALL about insurance reform.

    If ANY industry cannot price something until after the purchase it makes cost control impossible. Suppose automobiles were marketed and sold the same way. You would be terrified to (purchase) a car. Then sitting at home wondering if the car will be free or if you will have to sell your house to pay for it.

    I have been asking what every service at my dentists office costs for years. And guess what. I finally have his office staff aware of every price for every service, and I can decide if I want the X-rays or not.

    I advise EVERYONE to ask what every procedure, exam, and test costs before you get it. It annoys them, but it costs you nothing to help hold the system to realistic pricing, and makes them aware that what they do has a real COST to everyone.

  • camblidge

    No ral reform will occur until you remove the profit motive from medicine.

  • Rick Evans

    @Peter Smyth Posted — “Can we separate health care reform and reforming the way we pay for it?”

    Atul Gawande works at the Brigham which is part of FOR PROFIT Partners HealthCare. Partners Health Care has been partners with the MA Blues in boosting Partners’ bottom line at the expense of other medical providers thus despite four years of RomneyCare health insurance premiums continue to soar. So his employer is hardly part of the solution.

    I do agree with his checklist manifesto though.

    EDITOR’S NOTE: A representative of Partners HealthCare called On Point to correct the record. Partners is in fact a not-for-profit 501(c)(3) organization.

  • John

    Stop subsidizing corn. Make insurance cost less for people who eat moderately and exercise.

  • Lisa

    I agree with getting rid of the insurance industry. I harbor healthcare envy for Canada, France, England, and every other country that takes care of its citizenry.

  • at from a beautiful Santa Cruz morning

    Tom, When I was in middle school, I remember reading a report on the relative yearly earnings for different careers. The average yearly income for an MD was $25k.
    But now everyone who makes it into med school expects to be a millionaire. Why is the incredible greed and egomania of the medical profession never brought into the discussions? They have conspired to keep their product in demand by limiting admissions to schools and maintaining an shortage. Then we have to turn around and hire foreign MDs to service our sick. Why could France develop a system where they have enough MDs and a superior system (the average French MD sees a total of 12 patients a day much better than the couple minutes you get in US)

  • Bob, from Berkshires now Expat in Nassau

    Have any studies been done on the effect on healthcare costs of the wave in converting hospitals, even insurance programs, from nonprofits to for-profits?

  • Dean

    What we need to keep in mind about the present insurance model of US health care is that free enterprise requires that the consumer have the ability to opt out if the price goes beyond his/her comfort point or ability to pay. That is the only way free markets work efficiently.

    Problem is, health care can not follow that model, since those in need of health care can not opt out! Insurers and providers both want prices to go up, but there is no free market mechanism to hold them down.

    Therefore, the only cost effective model is one in which the entire society provides for every member of it.

    Health care should be labeled a Public Good, not an industry. A Public Good can only effectively and morally be provided for by our government.

  • Robbie Burnstine

    The one question I would love to ask all those who oppose the mandate is this: when you become ill or get injured–as we all will at some point in our lives–and you do not have health insurance, should we who are participating in the system choose not to treat you when you show up at an emergency room?

    In our society, the answer is no. It would be viewed as socially unacceptable to take such a stand, to refuse to treat. However, where is the sense of fairness of these anti-mandate folks? Why should they be entitled to receive care, expensive care, the cost of which they have refused to contribute to and which is being borne by others?

  • http://twitter.com/aubsclark Aubrey

    From Anchorage, Alaska

    Dr. Gawande, we spend more money each year on things like movies and football than on medical research. We so not seem as concerned about access to care and quality of care as we should, given our shared mortality. Why do you think it is that we seem to have our priorities backwards as a society? (I realize this is more of a philosophical question, but I know that you have a degree in philosophy.)

  • geffe

    I’m kind of sick of these discussions. No pun intended.
    The system is broken, period.

  • John (Murfreesboro)

    tom could you please ask the guest his thoughts on the public option or single payer, also the possibility of repeal backfiring on conservatives through opening the door of this option having a second chance if current bill is repealed

  • Lisa

    Robbie Burnstine: who is bearing the costs? I’m paying a huge percentage my income in taxes and I’m not rich. I would be happy to pay these taxes if I got decent services for them rather than unending wars. And we don’t need to go into the medicine needed to take care of the veterans — who are often indeed denied healthcare.

  • http://cyberfumes.blogspot.com Dave Eger

    Universal healthcare for everyone in America could save so much cost and time that is now spent on paperwork and rigamarole. It could allow employers much more freedom in hiring because they won’t have to worry about filing benefits, so people could move from job to job easier, and actually find work that they are interested in doing, rather than being stuck holding on to whatever they can get. This might actually allow people to enjoy their work so that overall morale increases, and the country can start picking itself up by it’s own bootstraps. This would make us less dependent on buying entertainment to stay happy enough to avoid suicide, and actually give people time to appreciate art and history again. Just imagine how health would improve if people were excited about life again. The thing holding this back though is that as long as health care is profit driven, it’s in their interest to keep people sick so they have to keep paying to get better. That’s not a very sustainable model though if you take more than a minute to think about it.

  • Ellen Dibble, Northampton, MA

    Gawande isn’t talking about what I see as necessity: split-level care. It seems to me that now if you buy cheap insurance, you get a high deductible, but all sorts of high-tech drugs and so on that might let you beat cancer but “cheap” means still has access to almost everything.
    With science making VERY expensive care actually possible, don’t we need a basic level, maybe part of the taxes we pay, and a private level of insurance where you could get support for self-caused illness, for instance?
    I’m for two-tiers ASAP (private insurance as an add-on for the rich or life-greedy), with cheap insurance not meaning I pay the first $5,000, and the insurer knowing full well they will generate total profit for themselves for say 20 years.

  • at, from a slighlty chilly Santa Cruz

    Posted by John, on January 4th, 2011 at 11:03 AM
    “Stop subsidizing corn. Make insurance cost less for people who eat moderately and exercise.”

    If everyone was in a single player arrangement then the people who take care of themselves should gain points that they can later spend on optional procedures like plastic surgery, or a stay at a health spa that is payed for by medicare, and the people who smoke and take drugs and blow themselves up in meth labs should get bargain basement care, not the top quality free care they now get when they blow themselves up.

  • Yar From Somerset, KY

    No truth in medicine. No price lists for care to allow for comparison. Insurance and Pharmaceutical kickbacks to hide true consumer costs. Cost shifting of the sick and elderly to the public to maximize profits.
    Regressive funding structures that make the working poor pay for indigent care. Hiding what is actually a tax system under the guise of insurance premiums.

    Why not pay for 80 percent of healthcare through a VAT?
    Regressive, yes, but less so than the current system. And everyone pays something.
    Fund the rest out of pocket. That reduces costs through shared responsibility.
    Don’t pay for care that doesn’t improve health. When you die, the bill isn’t collectible.
    List prices.
    The complexity is intentional, if you take 5 drugs you have 100 percent chance of negative drug interactions.
    We don’t want the solutions to be measurable.

  • Ruth Rosensweig (musicmom)

    I’ve read all Dr. Gewande’s books and completely agree with him, in particular with the checklist. Yet a letter to the Boston Globe last week and a comment from MD above show that many MDs are not on board with it. The letter writer called the checklist more bureaucracy when I see it as something that helps democratize surgery. I.e., everyone on team knows each other and works together, which helps eliminate errors. Letter writer personified perception that MDs are on a higher level and don’t bother me with more things that take my valuable time.
    Re insurance: Profit (insurance companies) must be removed from medical care for real cost savings.
    When you publish and if you broadcast my comment, PLEASE don’t use my name and town (Andover MA) because I am from the town of the letter writer and know him!

  • Marc

    It would be nice if you could address the following:

    How adding 40 million people to the system will not result in skyrocketing costs.
    What controls are in place to separate the demand from the supply. Providers (docs, others) provide both.
    Reduce the costs associated with defensive medicine
    Simply the fact that ObamaCare (I don’t like the term) is a 2700 page document.

    My preference is for single payer, but it would be a mess. However, the pre-ObamaCare system was a bigger mess. But ObamaCare will be the worst of all.

    By the way, ObamaCare was, in large part, based on the Massachusetts model. Mass has the highest premiums in the country. Though there are many reasons for this, it does mean the Mass model is, at least, questionable.

  • Rick Evans

    Gawande’s superintendent of schools can probably blame Blue Cross Blue Shield and Gawande’s for profit employer Partners HealthCare.

  • Ken Salzman

    From Lansing, MI

    The Republican vote to repeal health care reform strikes me as the same as the Gingrich Contract with America… a showboating piece of legislation known from the outset to have no hope of doing anything or going anywhere, but good for capturing headlines and fomenting party fervor. I found the Contract to be a fairly disgusting waste of time and energy, too.

  • Ellen Dibble, Northampton, MA

    I’m curious where environmentally caused illnesses are going to fall in the national debate. I see by the White House site that a new law about lead in water is passed with I think 3 years for compliance allowed. If landlords have to limit the exposure of their water-provision, and therefore health is improved, well, super.
    But lots of environmentally caused problems are barely acknowledged, let alone taken responsibility for.
    If polluting industries paid their fair share for the medical damage they did, that would be, um, interesting. I’m not holding my breath. I still expect to pay for the damage they cause, through my insurance and my taxes, forever, actually. Those industries have lobbyists.

  • Yar From Somerset, KY

    Dr. Atul Gawande, Could you a high school basket ball player the muscle memory to do the operation on that lymphoma? Does a surgeon need to have all the skills of an MD or do they need to know how to cut? You do the diagnosis and supervise ten Surgeons to do the surgery.

  • Peter Bannigan

    The issue is a fundimental debate between those that believe healthcare is a right and those that believe it is a privalage that should be gated by ones ability to pay for it personnaly.

    Our fixation is with the idea that the free market is teh answer. It is not if one believes that a healthy work force is a national asset. Concervatives and those of a like mind view the work force as a low level commodity easily replaced by others around the world and insurance as a business first and formost were dollars are more important than an individuals health.

  • Rick kennerly

    Health care reform. We should remember that the other team sat on any meaningful reform of the system for decades. They had their chance, even though the crisis had been looming for years. All this carping reminds me of the t. Roosevelt ” man in the arena” speech.

    Virginia beach

  • geffe

    Let’s be honest here, the political climate and how the right frames this issue will mean it will be a stalemate.
    As the good doctor just noted. Again, the entire system is broken.

    The Republicans want a market based system. Well it seems to me it has not worked. So their solution seems to me to be prepared to die if you get a serious illness as you will be nickel and dimed to death. Literally.

  • Ken Salzman, Lansiing, MI

    Insurance is based on a principle of relatively rare adverse events within a relatively large population at risk. When this is the case, you can spread the risk among the population and everyone pays a small amount to avoid a catastrophic loss.

    Health care does NOT apply to this model! The “adverse event” is general health care which is not only not rare, it is ideally universal. The “risk” is not spreadable. Health care is either a public program for the public good, or it is not. Insurance concepts do not apply. The insurance industry, in an effort to make health care fit their model, seeks to inhibit the utilization of care in order to make the “risk” more rare, but this is antithetical to the goals of health care itself. The insurance industry has NO place in health care, short of, perhaps, coverage for catastrophic events, which are rare.

  • Yar From Somerset, KY

    Repost, with the word train

    Dr. Atul Gawande, Could you a train a high school basket ball player the muscle memory to do the operation on that lymphoma? Does a surgeon need to have all the skills of an MD or do they need to know how to cut? You do the diagnosis and supervise ten Surgeons to do the surgery.

    Sorry about that.

  • http://notyet Charles A. Bowsher

    Insurance sales commissions and incentive bonuses do not contribute anything to our health, period.

    While on vacation in Ireland ten years ago I had a frightening breathing problem, I walked into a local MD, she examined me, wrote an order for me to be seen at the local ER. She charged me ten Euros or so for the exam. I got to the ER, they Xrayed me, administered oxygen, wrote me three prescriptions and charged me nothing because the MD had written the referral. I filled the three prescriptions for about 12 Euros at a local pharmacy and went on to enjoy the following three weeks in my adoptive country. Yes, publicly provided health care works miracles. They didn’t care that I was a US citizen, they cared that I was a patient.

  • Iris from Vermont

    FYI – Vermonters from across the state will converge at the Statehouse January 5th to deliver thousands of petition signatures to lawmakers. The petition, to be delivered on the first day of the new session of the legislature, demands that Vermont adopt a healthcare system which meets human rights principles and leads the nation in the adoption of universal healthcare. This comes in anticipation of the release of the state mandated universal healthcare system options, designed by Dr. William Hsiao, following last session’s passage of the Universal Access To Healthcare Act.

    “The time is now for Vermont to take the lead in creating an equitable healthcare system that recognizes healthcare as a public good,” said Peg Franzen, president of the Vermont Workers’ Center which coordinates the Healthcare Is A Human Right campaign. “Every year in Vermont, our neighbors, friends, and families are suffering and dying because they do not receive the healthcare that they need. Every day we wait more uninsured and underinsured people are losing their homes because of their medical bills, closing their family farm or business from a medical crisis or chronic illness, or are crushed by debt after getting sick. We need to act now to put people over profits.”

  • at, from the most liberal town in the US and the best one to live in

    Wouldn’t it save a lot of money if we allowed people who want to die to die with some gentle drug experience like falling asleep on a heroin od. I mean everyone is gonna die anyway (except maybe some of the super rich who buy black market organs and make it through to the next quantum leap in technology)

  • jack

    Tom,

    Outstanding guest & topic this hour. We need articulate advocates like Dr. Gawande to improve (first save it from the reactionaries who are h-bent on repealing it) our health-care system.

    Btw, I had 4-way open-heart surgery at the VA Hospital in Miami, FL in August 2010. As part of my recovery, my wife asked people not to say the words, “Republican”, “Conservative”, “Tea Party”, “Right-Wing”, “Conservative”, etc. in my presence. I think it helped my heart heal, and now I’m feeling great. Now, I’m ready for the reactionaries coming into office tomorrow…(I hope.)

  • Yar From Somerset, KY

    Is indigent care up for the past year?

    It is a tax increase! Your healthcare insurance is a tax. You should be mad at a 12 percent increase when the wealthy are getting tax cuts.

  • Rosalie Fontana

    As a nurse practitioner, I have prescribed many pharmaceuticals for a variety of conditions, but I have become more and more ‘alternative’ with the passage of time. I think we overtreat people with expensive drugs, all of which have side effects that may require the prescription of yet another drug. I think the best way to improve the overall health of the nation and to cope with costs is to focus more on healthy lifestyles. If we don’t get a handle on obesity, unhealthy eating habits, and sedentery lifestyles we will never be able to afford to provide high quality care to everyone with the chronic diseases that result . Prevention is the key to improved quality of life for Americans, and reduced medical costs at the same time.

  • http://www.yourhep.com Paul Abler for Oconomowoc WI

    I am a health care practitioner. A question was just asked was does private insurance do for health care. I have great empathy for that question, and I have a great deal of frustration with our current insurance system. What I do see that I feel is needed to be maintained is choice. I do not want one entity making all the rules. I want regulation that creates an understandable and level playing field, but not on size fits all.

  • Rick Evans

    McAllen Texas? Hmm. Massachusetts has the highest per capital health care costs in the nation. Why did Dr. Gawande need to go all the way to Texas to find waste fraud and abuse. He could have just wandered around the Longwood area.

  • http://WPLN John Watson

    I am one of the people who refuse to buy in to this whole scheme. I realize the IRS will fine me and when I refuse to pay that fine, and they have nothing to attach to get it, that I am facing prison time. So be it as I feel I am being persecuted for my beliefs because I do not believe the govt has the right to force Americans to pay for PRIVATE anything. It is the responsibility of govt to offer care for the sick lest we end up in a Nazi type society but that care should be via socialized medicine not a money scheme of helping the bottom line in private insurance companies.

    Now if private insurance is the cure for all of this then why is it that if I go to the doctor they offer a substantial cash discount?

  • john in danvers

    On cost growth > 12% annually:

    The major factor our representatives will not look at is MONOPOLY. Everywhere you look in our system are little ensconced monopolies, from local hospitals and insurers through doctor groups, drug companies, major insurers, among others. Not to mention the lobbyists running the legal side for them.

    Obama’s law, for instance, ESTABLISHED further monopoly among the insurers for the additional 30 million covered (we hope).

    There’s your cost, baby.

  • Don A.

    Certainly, rationing has to be a source of cost reduction in medical care. A procedure costing $1 million and having a 1% success rate ($100 million/success), is unacceptable. In the healthcare law, is there anything requiring any form of rationing?
    If people want to pay for extra (possibly) better healthcare, let them pay for it either through insurance or their own funds, but this can not be paid for by government (taxpayer) subsidized healthcare.

  • Rich

    Why do we need insurance at all? It seems to me that insurance is simply a way of skimming money from the system without delivering any added value.
    Please, what am I missing here!

  • Martin Brunswick

    Don’t confuse insurance cost with health care cost. Insurance costs go up because of increasing costs of the services rendered by providers. Cost of individual services * the number of service rendered by PROVIDERS. Insurance is not the driver of the cost of healthcare, it is keeping a cap on it as much possible (with much push back from providers and the governement they lobby). It is not the insurers who are stealing from providers and patients, isn’t it the fee for service paid specialists and technology-centric testing to maximize revenues (MRIs, EKGs, etc.) draining the monetary resources that could be used to subsidize primary care and NPs and improve access to primary care.

    PCPs need to be paid more and specialists less, and all salaried and incentivized with Quality measurement.

  • Ellen Dibble, Northampton, MA

    If health care padding such as Gawande describes (excess profits) are truly winding down, doesn’t that squeeze the economy? Doesn’t that reduce the GDP, cut out “fat” jobs?
    It’s part of steering the Titanic, has to be slow. Squeeze the insurers into their appropriate place.
    I don’t think the congressmen understand how it works, and are planning to repeal it before they have to read the whole 2500 pages (whatever it is).

  • charles conroy

    I love hearing from your guest, Dr. Gawande. But I disagree with his comment that our food quality and production has vastly improved the last few decades. Production has become more efficient, but the quality of food has, arguably, declined. Our nation is now ingesting a diet dominated by processed food-like substances. Obesity and consequential health problems have increased dramatically since this so-called improvement in food production!

  • Andrew Sichel

    Since the Congress (house and senate) receive free health care why not allow them the privilege to select Health care for themselves, like we do – this would also help the Republican agenda lower big government costs!

  • MARY LYNN CRAMER

    I am from Iowa and have personal experience with regard to comparison of health care and agricultural: Government involvement in the “revolution” agriculture is/was very similar to government policies of Obamacare. For example, government intervention in regulations impacting agriculture facilitated the concentration of farming in the hands of large agricultural corporations (that receive the most subsidies, access to financing, etc.) while creating circumstances that made it very difficult for small farm families to get financing and compete even though they were more efficient than the factory farms.

    With Obamacare, $500 billion was cut from the most popular health insurance among low-income elderly—Medicare Advantage HMO (also determined to be the most efficient, and less costly than regular Medicare, according to Congressional Report on Medicare Spending for 2009 and 2010, in exchange for enormous new profits to be gained from expansion of every citizen being forced to purchase private, for-profit health insurance. PS My 2010 Medicare Advantage HMO premium increased by %52%, in order to make up for these government cuts in funding, says the CEO of the large health insurance company that provides me with my Medicare Advantage HMO Insurance plan.

  • Christina in Providence, RI

    My question is why do I have to pay for someone else’s health care – Medicare deductions from my part time job paycheck – but I am denied access to affordable health care myself?

    The only way I can keep my house is to not buy health insurance. When the COBRA subsidy was being paid it really helped me out so I could continue to have health insurance and pay my mortgage while looking for full time work.

    I have a very painful bone growth in my left wrist pressing on the thumb tendon and painful tendonitus in my right arm. If I had health insurance I could get treatment and be able to use my hands all day long so I could get a full time job and pay for my own health insurance.

    - Christina in Providence, RI

  • Martin Brunswick

    How about we add a subsidizing (importance of preventive service) factor to RBRVS for primary care, pediatric, and geriatric preventive services.

  • Andrew Sichel

    Why not allow the Senate and House select and pay for their own Health Care rather than receive the best plan money can buy at Taxpayer expense. This would help shrink big government spending as well.
    Andrew Sichel
    New York, NY.

  • Don Morgan

    I’m discouraged by the political goings on now. Health Care Reform seems like so important a step we need to take. There is so much misinformation around. Can Dr. Gawande or others suggest a focussed bibliography that would help us be better informed citizens?

  • Trudy

    Recently our teenage daughter developed serious emotional problems which required frequent emergency room visits and psychiatric hospitalizations. These long-term placements were in several different adolescent units in the boston area and were very expensive. I lived in fear that BCBS would eventually refuse to pay and they did.

    It wasn’t until she was admitted into the state mental health system when she was finally stabilized and is now, thankfully, doing quite well. One of the extreme costs I was shocked to learn about was ambulance services. Each time she was transported via ambulance the cost was roughly $1000 even for a trip as short as one mile! Added to this there were times when we had to call 911 for support at home. When we did so, police, fire and ambulance personnel were always dispatched. I have no idea the cost but can imagine it was also quite high.

    In all, it would not surprise me if the overall cost of the 2-year period of our daughter’s illness was well over $250,000.

    I learned from this experience that for mental health service delivery, there must be a relationship between private hospitals and the state mental health system that currently doesn’t exist. Emergency response is redundant and costly. And, health care policy discussions rarely include discussion of psychiatric services yet these are very costly and very important.

  • Yar From Somerset, KY

    The hospital charges much more for the ER, but does a seat in an ER really cost that much more than a seat in a clinic? I doubt it, they are just figuring in the costs of indigent care in their prices.
    Get to the real numbers. A hospital is a Walmart of care. But only 25 percent go through the check out.
    The rest are not paying for their care.

  • Boris

    I think its disingenuous to say that medical profession want to limit the emergency room visits. I was just in Florida and saw dozens of billboard advertising emergency rooms, touting the convenience and wait times. ER make a lot of money for the hospitals, therefore hospitals have no interest in people not attending ER and seeing their primary care physicians.

    Boston

  • Pancake, with spots and a fever, in NC

    The old buggy whip argument derived from agriculture does not apply because we are much farther along the technological progression in medicine than we were on food in the early 20th Century. Furthermore, we are a nation with a tragic proportion of malnourished and hungry people and the impending threat of adulterated and contaminated and mislabeled food, along with the risk of industrial agriculture collapse under climate change or pestilence. So agriculture itself needs the same types of reforms as medicine.

    I have excellent insurance coverage and several doctors in my family but am convinced that medical care is being undermined by the profit motive and have lost faith in it. It would now require a life and death situation for me to seek help.

    I have had to undergo medical self-education to manage and avoid the pitfalls of our medical system. If care is going to become a mass produced and diffused product we all need to be our own, and our family’s doctor. No more restraint of trade and exclusive licensing for doctors and specialists.

    And if we are going to cover all our population for medical services and products then why not cover none, for without profit it amounts to the same thing. Why not pay for it all with the same Quantitative Easing the Federal reserve uses to treat ailing banks? The bottom line costs to the fitness of our society can’t help but diminish.

    Human society has reached a plateau, and fearful people want to turn back because they fear changes in organization. Do we change our backward property and wealth conceptions or do we fall back into a dark hole of mass suffering?

    This doctor seems unable to see over the edge of the hole. Maybe his money comes from the dark below.

  • Ajay Chawan

    From Nashville, TN. Member station: WPLN

    Moving away from employer-based health insurance is essential in order for America to remain competitive from a business standpoint. As a self-employed entrepreneur, obtaining insurance has been extremely difficult. Obtaining insurance coverage for workers at a factory I recently acquired has also been costly, as we are a small group.

    Having access to a larger insurance pool would help people like me (self-employed, small business owner) add jobs. I would be able to have health insurance for myself and my employees without having to bear a disproportionate amount of the cost as compared to people with “regular jobs” employed at larger companies.

    Dr. Gawande, I am a big fan of your books and appreciate all that you have done to bring attention to this matter.

    Cheers,
    Ajay

  • at from laughing at your guest

    A friend of mine works in the oncology dept at Geisinger Med center in Danville Pa. The head of her department makes oveer 900k a year in salary. This same guy walked into an appointment with my dieing mother without his white coat, bent down and wiped something off his fine wingtip shoes then touched and examined her infected drug port without washing his hands. No one in the room had the guts to say anything to him.

  • Clara

    It seems that technology innovations in some cases drive up the cost of health care (in the case of over use, use of a much more expensive technique or equipment with marginal benefits…), and in some cases might drive the cost down (less tests that can find problems more efficiently…).

    What a conflict for an engineering researcher in health care like myself! What can be done with technology to drive down the cost?

    I’m sure the costs are much more driven by politics, companies, and a few powerful people making a lot of money, but I hold some naive hope that I could do something to contribute to the problem just by going to work everyday…

    Does anyone have any thoughts to keep my naive hope alive?

  • Rex Henry, Washington, DC

    When your guest speaks of doctors who keep people out of the hospital, it’s like saying “When you do things right, people won’t be sure you’ve done anything at all.”
    I wish it would happen but it’s nothing to yell and argue over…or to make money with

  • HS in Natick

    Hi,

    I am interested in hearing about Dr. Gawande’s thoughts on the Patient Centered Medical Home model and what he thinks about the potential for the use of “Nudges” in healthcare – choice architecture, defaults, and libertarian paternalism as outlined by Thaler & Sunstein.

    Thanks!

  • http://fago9@hotmail.com john fago

    Does Dr. Gawande think it’s possible for Vermont to become the first state to demonstrate single payer health care delivery?
    Thanks.
    John Fago
    Bethel, Vermont

  • http://Www.cornerstoneprivatepractice.com Dr. Christopher Dowd

    I’d like to hear some discussion about innovative practice models like direct care and concierge care, now called private medicine. These models have increasing amounts of data demonstrating significant cost savings while improving care quality. And it is being done in ways that are accessible to almost everyone, not just the wealthy. I have teachers and retired teachers on fixed incomes in my practice.

    Thanks for covering this topic today–very timely.

  • Ellen Dibble, Northampton, MA

    I agree with Gawande, Waxman’s prediction that we will come to like the law is a bit off. I say we won’t like it more. But plenty of ramifications will not be made very clear, because those who profit from the changes won’t WANT to get that out.
    So it is the ability to adapt and change that law that is crucial to me. It has to stay in our sights very hotly for many years.

  • Janice Evans

    If the Congress and the state governments would spend their time and energy AND our tax dollars on finding SOLUTIONS as recommended by the fabulous Dr. Atul Gawande in fixing and reforming health care instead of re-litigating it in Congress and shoving it through the courts, we would all benefit.

    It’s complicated people!! Get smart – and demand more than platitudes and political reindeer games from your elected representatives.

    Demand innovation from your doctors or change doctors.

    Your life may depend on it – your healthcare already does. Read everything and anything Dr. Gawande has written. He makes the complex easy to understand. He rocks!

    Janice Evans, Salt Lake City

  • David

    Is Canada going bankrupt from healthcare?

  • Jim in Charlotte

    Tom,
    Good conversation but both you and your guest are stuck in the paradigm that gov’t is the answer. An earlier guest correctly pointed out the scepticism that gov’t can really enact these solutions across the country – and yet we have successful private industry examples of complex processes being reliably implemented nationwide and even worldwide! Fedex, UPS, phone companies, data providers – heck, even food franchises! While we would have to search far and wide to find the same success in ANY gov’t program (TSA – don’t think so, VA – nope, etc).

    The protest is not against reform but against THIS reform! Give us real reform that spurs on the private competitive market place and watch cost come down and coverage expand. Look what happened when we remove gov’t control from the old Ma Bell and force private competition! Not advocating total abandonment of gov’t oversight in Health Care but its goal should be to encourage competition, not strangle it.

  • Hoshiar Abdollah

    Hello:

    I am a Canadian cardiologist and great admirer of your guest. My question is why Obama administration turn to people like Dr. Gawande to lead the national discussion regarding health care reform? If I were Obama I will inite Dr. Gawande to join his administration.

    Hoshiar

  • Rick Evans

    @Rich “Why do we need insurance at all? … Please, what am I missing here!” — What you and policy makers are missing is the purpose of insurance. Individual mandate advocates love to use the example of car insurance saying “Everyone has to have car insurance.” WRONG. Only drivers need car insurance. But more important, car insurance does not pay for incidental wear and tear or car maintenance. You have mandatory car insurance to protect others from your bad driving.

    OTOH health insurance pays all routine health care because Americans would rather pay their cable company $100 instead of their doctor $100 to see them. It also pays for all kinds of dubious procedures and meds that have nothing to do with keeping us healthy. Why should I help some horny geezer pay for ED pills. What’s next? Do I also pay for romantic dinner and wine for two?

    In Massachusetts insurance will pay for fertility treatments helping a women get pregnant with triplets then pay for the premature birth of those triplets. That’s like a car insurance company paying crooks to steal your car then paying you to replace it.

    Insurance should pay for catastrophically expensive unforeseen health events.

  • ThresherK
  • Ann, Barrington, RI

    WHY can’t re just IMITATE everything that the individual Scandinavian countries do? Investigate which of those countries does things the best, then just DO THE SAME THING!

    When I say “everything”, I also mean add childcare, eldercare, disability care and/or disability work programs — add those programs to health care — an American health care that was just like that of those countries.

    Please do NOT say that their countries are uniform genetically speaking. People say that so often that I want to SHOUT, “but WE are supposed to be a country that believes in liberty and equality for ALL!!! WHY would the relative homogeneity of the Scandinavian countries make any difference?” Hearing the guest say that people originally fought medicare because of racism, makes me wonder if that homogeneity issue is more of THAT??!!!

    Ahh — yes, the Scandinavian countries have high taxes. But, guess what?!!, the individual there GETS something for their taxes — their taxes do NOT go toward profits for the war industrialists!

    We do NOT have to re-invent the wheel. Other countries HAVE tackled these issues and solved them with elegance, not exotic complexity! The Danes are said to be amongst the happiest people on earth, along with the people of Bhutan, who also have universal health care! Our country is run as if it were still part of the British Empire with its WRETCHED CLASS SYSTEM!!!!!

    Thanks!

  • ThresherK
  • geffe

    A friend of mine works in the oncology dept at Geisinger Med center in Danville Pa. The head of her department makes oveer 900k a year in salary. This same guy walked into an appointment with my dieing mother without his white coat, bent down and wiped something off his fine wingtip shoes then touched and examined her infected drug port without washing his hands. No one in the room had the guts to say anything to him.
    Posted by at from laughing at your guest, on January 4th, 2011 at 11:47 AM

    900K a year for a department head! You want to know why health care is so messed up in this country that man is one of the reasons.

    Nothing will be done. It’s going to be ideological based arguments that drive this and our nation will slip further down into the abyss of a third world country or banana republic.

  • geffe

    Is Canada going bankrupt from healthcare?
    Posted by David, on January 4th, 2011 at 11:55 AM

    No. They spend half as much as we do and everyone is covered. They spend about 10% of GDP on health care and we spend over 15%.

    http://www.visualeconomics.com/healthcare-costs-around-the-world_2010-03-01/

  • at, from the most leftist town in America and the best place to live

    It was fun getting up in time to interact with you fine folks during the show this morning. Even though I am in my sixties I must now take your leave to play a little Modern Warfare 2 which is now a healthful substitute for a morning cup of coffee (actually makes me more awake than coffee) then its off to the gym so I don’t become a burden in my old age — when ever that will come around.
    Live Long and Prosper (in the higher realms)

  • Ellen Dibble, Northampton, MA

    Obama wanted a public option. He said Americans wanted to keep the current system that links insurance to employment.
    Am I wrong about that?
    It seems so obvious that DETACHING health insurance from employment would make it MUCH EASIER for businesses to initiate new jobs. To solve the jobs-in-America issue, take the expectation (or requirement?) of health insurance out of the definition of a “good job.”
    Also, if you don’t feel tethered to a bleak job outlook because of the health insurance involved, you might actually get on with your life and contribute more fully in our economy. (And if you don’t feel tethered by an underwater or sinking homeownership situation.)
    Who are these Americans who “want” health insurance to be part of their benefits package?
    Oh, those would be the ones who realize that dealing with getting their own insurance is REALLY complicated, and that it takes a whole corporate human services department to get a really good deal.
    So it would be certain employers hanging onto high value employees (high value because paid mostly by super health insurance deals that large corporations can finagle). If insurance were an American even-handed prerogative, the employers would have to offer fair wages rather than special-deal benefits. (Obama’s administration apparently figured that out, and caved.)
    Oh, the insurers like dealing with Human Services offices rather than all 300 million of us individually. As do the insurers. If you are an entity of One, and you call the MA Blues, they are very polite and helpful, but they would be more profitable if you called on behalf of say 300 employees.
    If you are calling about a Medicare glitch in payment, who then do you call? I’ll soon find out.

  • Yar From Somerset, KY

    Anne, on imitation it will take more than a generation for a positive outcome. Education and health are closely related. I wonder the number of Meth labs busted in Sweden? A cold climate may also have an effect on health as well.
    We are obese, lazy, addicted, and poorly educated.
    We exploit a large segment of our population. Our nation is built on a model of exploitation.
    How do we change tracks of history that feeds the system we currently have?
    Yes, the idea is good, but how to get there?
    I would start with universal coverage for contagious disease.
    Buy the rest of health insurance by pound, or at least by the BMI.
    A heart disease rider, or a diabetes policy as additional coverage but basic health is covered for all.
    I prefer single payer.

  • AJ North

    We Americans have a fundamental choice we need to make (sooner than later): whether quality health care for every citizen is in the national interest (not to mention our “national security”), or whether health care is merely another industry that sells a product to those who can afford to pay for it.

    Rather than a health care system that holds the well being of us citizens as the ultimate goal, we have one that places profit above all else – and insures that status quo by spending lavishly on on our elected officials. (Recall, for example, the prescription drug legislation forced through the GOP-led House under Denny Hastert that explicitly FORBADE the government from negotiating prices.)

    The disinformation campaign by the GOP and their “Tea Party” allies has been spectacularly successful, in no small part because most Americans are woefully ignorant of the facts, in particular on how other nations deliver health care to their citizens; as merely one example, they are still referring to “Death Panels” – when in fact the ONLY real “Death Panel” is in the GOP-controlled state of Arizona.

    In terms of actual health care delivery, outcome-based medicine, as Dr. Gawande has stated, should be the ultimate measuring stick, rather than the number of medical interventions performed (or the amount spent) – that is, quality over quantity. An integral part of this would be paying physicians (and other providers) a straight salary, rather than a per-procedure fee.

    Those (mostly on the Right) who extol American health care as “the best in the world” are either woefully ignorant of the widely available facts or delusionally living about half a century in the past – unless, of course, they are only considering the health care of the very wealthy.

    The for-profit health insurance cartel has an overhead on the order of thirty percent, while Medicare’s overhead is about four percent. A single-payer health care system n- national indemnification – would save an extraordinary amount of money, beginning immediately and accruing in perpetuity. Placing every citizen in the same [risk] group provides THE lowest actuarial costs.

    If private health insurance is ultimately retained, then it should be refashioned after systems that deliver much higher overall coverage at substantially lower costs; the Netherlands is an excellent example (largely because of strict government regulation and oversight).

    Then there is the matter of the pharmaceutical cartel and their outright thievery. The amount they spend on advertising is at least as much as they spend on actual research – as the U.S., after all, is only one of two nations (the other being New Zealand) that permits direct advertising of prescription medicines to consumers.

    Those who wish to inform themselves with the wisdom of others whose lives have been devoted to the selfless betterment of humanity would do well to read “Health Care: The Disquieting Truth” , by Arnold Relman, M.D., former Editor-In-Chief of The New England Journal of Medicine, as well as other articles by him – and also his colleague Marcia Angell, M.D., both widely available on-line.

  • at, wait a darn minute usa

    Posted by at from a beautiful Santa Cruz morning, on January 4th, 2011 at 11:07

    Tom, When I was in middle school, I remember reading a report on the relative yearly earnings for different careers. The average yearly income for an MD was $25k.
    But now everyone who makes it into med school expects to be a millionaire. Why is the incredible greed and egomania of the medical profession never brought into the discussions? They have conspired to keep their product in demand by limiting admissions to schools and maintaining an shortage. Then we have to turn around and hire foreign MDs to service our sick. Why could France develop a system where they have enough MDs and a superior system (the average French MD sees a total of 12 patients a day much better than the couple minutes you get in US)

    Well Tom asked this question on the air, even read a good deal of it. And, ok the doc sort of gave it short but kindly shrift, then there I am in the flavale of Rio fighting against insurmountable odds when I realize (I am getting old — darn) His answer was that the problem wasn’t greedy docs, and his proof was that most docs wanted to go into specialty surgery like him because there wasn’t enough money in pediatrics and such. Listen to it. THIS IS UNBELIEVABLE — we are so enmired in a culture of smoke and mirrors that this kind of doublethink goes unnoticed by almost everyone. — according to the doc The proof that greed is not the problem is that we are greedy and act accordingly. — UNREAL, they have us, we are lost.

  • jason from santa barbara

    Why are the republicans wasting money legislating something that will not pass(repealing healthcare). They talk about wanting to cut the deficit. So why waste time and money with this legislation???

  • Ellen Dibble, Northampton, MA

    at, I think people have heard for so long that doctors want to become specialists because specialists make significantly more money, heard that for so long that it is not, as you say, remarkable, worthy of pointing out.
    This has been the case — I am mid-’60s — for most of our lives. I recall in the early ’80s that an MD who was smart picked a specialty for the financial promise associated with it.
    In the last couple decades, you can add on top of the financial factor the additional complexities of running a staff that can handle insurance billing and to some extent insulate the physicians from the kind of triage that insurance foists upon the consumers (us). A primary care physician who in the allotted 15 minutes manages to get a good “read” on a person’s condition should probably also get a good read on the fact that the necessary care is completely beyond the capacity of the particular patient to afford, at least not outside of Medicare. It’s a race to get to the safety of that net. The costs will still be there, but at least the costs will not be ON TOP of the cost of private insurance. Of course it varies person to person, but I suspect there is an underlying truth to it by virtue of about 15 years of noticing this Tyvex shield between providers and the reality of what care is costing their patients. It would probably be much easier on the human psychology of an actual concerned MD to care exclusively for those on MassHealth (the subsidized care for low-income people in my state) or Medicaid or Medicare. I remember seeing a physician circa 1972, and the fee was $5, and the doctor (personally) told me he would not accept that money. He somehow knew without being in any way hinted at that I would be forgoing other needed things if I paid him. He knew he had other patients who would keep him whole. Nowadays doctors don’t have any sensory organ that tells them, “I can’t see this person because money issues might get in the way.” So bizarre things happen, and a physician wrings the hands and says “I’d need more than three appointments to address this and that,” or the equivalent. And “three appointments” also means there are “other issues” that would be hand-wringingly forbidding (the patient’s time and money; the physician’s office’s resources and parameters). To a 25-year-old, a physician can maybe “misrepresent” about something, because a 25-year-old’s body may still be mostly a mystery to the patient (with no spouse there to complain, no parents to be pestering, no dependent children either), but older people, can we be dismissively skimmed-over? Not so much. We are more savvy.
    Life is like that, we have to conclude. Or for now, it is. (Who would WANT to be a primary care physician under these circumstances, even without the cost differential? Actually, there are some. Would you rather be a used-car salesman or a caregiver?)

  • at, at the same place

    Would you rather be a used-car salesman or a caregiver?)
    Posted by Ellen Dibble, Northampton, MA, on January 4th, 2011 at 2:38 P

    I hear you Ellen, it is the community docs who are the heroes. Mine told me that his little family practice group had to resort to high school loyalty and such to entice new docs. They really do deserve a break.
    Outahere

  • LYN

    Let everyone choose from govenment run clinics that provide complete wellness programs. Total care from head to toe, and this should include dental/eye care. On site specialists would be available as needed daily. All care is based on sliding scales that is addressed quarterly based on total of income proved by IRS records. The mecical, and business employees are all trained by the goverment in a Manhatten project type program to get medical cost on non-profit basis only, and quality care for all available. From first intake of a new patient they are tracked with their own electronic medical record. One is kept on site of clinic, one record will be back-up at cloud location set up by government, and the other could be as simple as a flash drive that would be kept with each person as they go about their life. This will stream line all care, and help with medical errors. Also, put a lot of people to work with training, and grants to set these clinics/workers are trained ASAP. If individuals want to keep the helth care they have now let them, but they will see that no one can afford what we have now for much longer. Help make medical care a human right just like all other well off countries on the earth.

  • william

    The “minute clinics” and “urgent care clinics” in my city are a very good idea. Much cheaper than the emergency room. I would like to see some of those useless gov. agencies like the depts of labor,energy, education eliminated and the money used to support these type of clinics.

  • Jerry Gustafson

    My email to many:
    I saw a news bleb that said Atul Gawande, MD would be on “On Point” on NPR this afternoon for one hour and I found him on U. of Tulsa’s, KWGS, HD 3, at 5PM. Could not record it, but here it is for you to hear. I share his concerns, 300 million people in the US, spend 8K each in 2007 or 2 trillion 400 billion for health care, wow this will destroy our budget. It was expected to rise by 6-7%. OH NO!!! The Census says we are now 310 million, in 2010 and health care experts expect costs to be 9% per person in 2008, we are rising like a rocket. If you use the the “rule of 72″ this means if you divide 9 into 72, the number compounded is the number of years for the original number to double, thus in 8, yes in EIGHT years, by 2020 conservatively, the individual cost of health care will double. So, go figure a financial plan to take care of paying for our U.S citizens health care, and save us. Thanks, Jerry
    Click below to hear Atul.
    http://www.onpointradio.org/2011/01/atul-gawande-health-reform

  • http://none Lisa

    For me, a VERY easy improvement to managing health care costs would be for doctor’s, hospitals, clinics, and other providers to post their prices clearly. I have undergone several tests this year that were probably not necessary. Had I known what they would cost me personally close to $2000 and my insurance provider much more than that, I never would have agreed to the tests.

  • http://notyet Charles A. Bowsher in KY

    A simple but factual number to keep in mind for all who are concerned about health care costs. Our nation spends 17.2% of its GDP on Health Care and we have 40,000,000 (forty million!) uninsured. Other countries with universal Health Care spend 10.5% of their GDP, have better outcomes (lower infant mortality, longer lives, etc.) and everyone is covered! It’s called a no-brainer.
    In the words of Earl Pitts- “Wake Up America!”

    Ellen @ 12:34 _ I believe you will be very pleased with your Medicare experience. My parents loved it. My trouble is I am at the exact age that now makes me a target of the “reformers” of Soc Sec and Medi (54!). I don’t mean to be paranoid, but this is getting ridiculous. Also FEMA wants to tear my house down this year! Any suggestions?

    AJ North @ 1:09 It is my Senator McConnell who is fond of saying “We have the best health care in the world”, what no one seems to realize is that he is the most self-centered person in the world. He is correct in saying it, it is just that his world of “We” is the members of Congress.

  • Marjorie

    The conversation should be about the cost of technology, not the usage. If MRI’s and CT’s were $1 we would be in a different place today. The lack of free market forces on medical technology is the cost driver. If plasma screen TV’s have dropped from $10,000 to $500, why not MRI. Insurance is the barrier. Just think of a world where you get technology insurance for your household and how that would affect cost. The Disconnect between technology and cost is the problem!!!!

  • Caleb from Somerville, MA

    The clear and rational solution, already implemented across the civilized world:

    Establish a single payer health insurance system, with universal coverage in order to reduce costs, expand coverage and improve quality. A single, public health insurance system would allow the US to spend, in line with the world’s top 10 health systems (all of which provide universal coverage), about 1/2 to 2/3 per capita of what we currently spend. In 2009, the US federal, state and local governments, corporations & individuals, together spent $2.5 trillion, $8,047 per person, on health care. This amount represented 17.3% of the GDP, up from 16.2% in 2008 (Jones, Brent. “Medical expenses have ‘very steep rate of growth’”. 4 Feb 2010. USA Today). Canada and most of the G20 nations, contrastingly, spend around 10% of GDP on Health Care (OECD Health Data, June 2009; 2010) and pay, on average, 1/2 per capita of what the US spends on Health Care. Yet in Sept 2010, the US Census Bureau reported that 50.7 million Americans (16.7% of population) are now without any form of coverage (up from 46.3 Million of 15.4% of the population in 2007). Many millions who are “insured” have high deductible plans with coverage caps which, should any serious procedure be required, result in bankruptcy (the leading cause of personal bankruptcy in the US, though non-extant in the civilized world). All of the other G20 nations, contrastingly, cover all of their citizens for most treatments and procedures. Even when adjusted for obesity and life-style related mortality, our comparatively low life expectancy bears testimony to this disadvantage. The ‘one size fits all’ criticism is addressed with the provision of supplemental, private insurance plans – something available for those who desire it in Canada and France, to list two examples.

    If we were to establish a single payer insurance system with price controls in the USA (like every one of our competitors, including Singapore, which rigorously controls supply of medical services and institutes a sliding payment scale), we’d be able to drastically lower costs via monopsony and drastically expand and improve coverage. If the government is the only or at least the major buyer in every town, then provider costs must adapt to the reasonable rates that buyer is willing to offer. In terms of cost & efficacy, all the systems of Western Europe, Canada, Japan, NZ, Aus, etc. are superior to that of the US. USA healthcare under-performs the majority of developed nations’ systems on every measure (including the treatment of preventable diseases), such that the WHO ranked us 37th in 2000. Even when completely removing the equity parameter, the conservatively-biased WSJ reckoned that we’d still be at 15th place in 2009.

    Why is it that the US is the only industrialized country on earth to require everyone to learn how to read and do sums but refuses to ensure that they and their working parents are treated for life-threatening or debilitating illnesses without entering into bankruptcy? No one, except on the ultra, ultra-right is calling for the end of the public school system, the removal of public sewage systems, the end of public road, highway and train maintenance or the repeal of traffic laws, yet these were all impositions on individual “choice” and “liberty” enacted to achieve the obvious, collective benefit. Health care is no different, whatsoever: we all have bodies, they have common characteristics and there are common solutions to ailments, which can be provided for in common. In certain areas, Socialism is good: health, education, transport, retirement security, unemployment and disability insurance.

    We don’t need another “testing ground” or “experiment” when every other nation in the industrialized world has already successfully completed the experiment. Their uncontested verdict? Establish a single-payer public health insurance system with universal coverage in order to cut costs, expand coverage and improve quality.

  • Caleb from Somerville, MA

    @ AJ North, on January 4th, 2011 at 1:09 PM: Excellent summary, persuasively written. Now if only you could go back and add a bunch of citations and statistics in foot-notes, we’d have a platform. While the masses are indeed easily deceived into believing anything they are spoon-fed over and over – and can you blame them when they have no access to quality education, a decent wage or even mandatory sick? – it is to the great credit of the otherwise odious American people that:

    “Between 2003 to 2009, 17 opinion polls showed the majority of the public supports a single-payer system.[66] These polls are from sources such as CNN,[67] AP-Yahoo,[68][69] Quinnipiac,[70] New York Times/CBS News Poll,[71][72][73] Washington Post/ABC News Poll,[74] Kaiser Family Foundation[75] and the Civil Society Institute.[76].” (See the Wikipedia article “Public opinion on health care reform in the United States” for citations).

    But when did public opinion ever matter when it came to decision making of our elected officials? Though most Americans, misinformed as they may be by the profit-backed noise machine, supported public insurance, Obama and the Republidems scrapped the Public Option from the table before even debating it on the House or Senate floor, after giving it lip service throughout the campaign.

    Indeed, our Republican-in-chief, Barack Obama, himself openly admitted during the Dec 6, 2010 press-conference prior to machine-feeding his plutocratic, Social Sec. destroying tax bill through Congress, “The polls are on our side on this” – “this” referring to the position that tax cuts should NOT be extended to the wealthiest Americans. Gallup reported in a Sept. 10, 2010 poll that 59% of Americans favored letting the Bush tax cuts expire for those earning over $250K per annum. But what does the opinion of the citizenry matter when it comes to buttering the bread of the Plutocracy through public policy initiatives?

    That’s why this “center” left pill pusher, Dr. Atul Gawande, is simply another bought hack ignoring the obvious evidence for a single payer universal insurance system alternatively dubbed “the G20,” “the developed world,” etc. and pushing the attractive soundbite of “experimentation” and “innovation” to achieve what every other system has achieved via the only obvious ways to achieve it: Monopsony reduces provider and supply costs, advances access, improves quality. Don’t expect NPR to question this Scrooge-fabricated “centrist” stance any time soon (a stance which 40 years ago would have fallen squarely in the center-Right) with anything intellectually rigorous, honest or responsive.

    We notice that Tom is getting rougher on his obfuscating, side-stepping guests who time and time again refuse to answer the direct challenges of callers – examples: Glenn Hubbard & Alice Rivlin (Nov. 18, 2010); Tom Friedman (Dec. 20, 2010); Robert Shiller & Jeremy Siegel (Jan. 4, 2011). Yet, like an unwavering torrent, these right-wing foot soldiers parading as “centrists” keep coming. Who is in charge of scheduling? Can we please get a single Progressive on the show – say someone like Chris Hedges, Charles Kernaghan, Bernie Sanders, Robert Reich, or Ralph Nader?

  • Jayko

    Republicans want the poor to DIE! Period!!

  • Rachel

    Interesting that he’s a guest today. He might like to know that his name came up at our monthly staff meeting. At each meeting, one staff member gives a d’var Torah – a little note on the weekly parsha. Today, the presenter shared his book as an example of “inside-out Torah” – wisdom from other sources that meshes with Torah ethics.

  • http://www.beccar.wordpress.com Eugenia Renskoff, Brooklyn, NY

    Hi, Tom, I have given up on health care reform. The insurance companies are always in the way, always more interested in making money than in helping people care for their health. Eugenia Renskoff

  • geffe

    Caleb from Somerville, MA. With all due respect Bernie Sanders, Robert Reich, and Ralph Nader have been on the show. Reich has been on numerous times.

  • Rachel

    I second what geffe said – the system is broken and needs to be fixed. We need to stop saying America is the greatest place in the world to live. That is an outdated statement. Our health care – or lack of it, sucks. Period.

  • Ryan

    Once again I here the liberals, progressives, and left wingers in this discuss claiming medical companies should NOT make a PROFIT. Are profits evil to you people? Why stop at the medical industry? What about food, water, clothing, housing, eletricity, etc.? Damn those companies for making a profit off helpless middle class people on the basic needs of life. You guys are living on another planet.

  • brendan

    why not have undergraduate medical school like most other countries? that would reduce education costs and medical doctors wouldn’t have the excuse to charge us so much.

  • http://www.hopestreetgroup.org/community/healthcare Joy Twesigye

    Although primary care is only six to eight percent of annual health care spending, its role within the health care system (1)—as often the first and most frequent point of patient contact and its effect on downstream costs—make it a point of high leverage for overall reform (2). This leverage has the potential to drive system-wide change and fundamentally improve cost and quality by changing both the nature of demand for health care services and how the supply from health care providers responds to that demand. Through investments in enhanced primary care, some employers claim net cost savings of up to 20 percent for their employees with chronic diseases (3).

    We are proposing a conceptual framework to generate policy solutions for using primary care to address the shortage of resources in U.S. health care. This framework will standardize primary care policy options so that we can evaluate them consistently within the opportunity of the microcosms that exist in our health care system. Our framework is built on several principles. First, we need to learn through research and development by finding creative solutions that are better, faster, and scalable. In its simplest form, part of the answer is to drive a top-line increase in capacity by finding new ways to create health care workers. However, because there is not nearly enough time even if we had unlimited financial resources, we also need to substitute traditional methods with alternatives. Then, we need to amplify the entire resource pool through increased productivity. Lastly, this process will be most successful if we are able to modify consumer behaviors that lead to poor health. Clear incentives should be structured to support each of these activities.

    Based on projected capacity requirements, we know that there is a large provider gap, but we do not know to what extent each of the levers——LEARN, CREATE, SUBSTITUTE, AMPLIFY, or MODIFY——can contribute to an overall solution. We believe some combination of these five levers could be pulled to achieve large-scale innovation in primary care that meets our needs as a country.

    We lay out specifics on how to foster an environment in which innovative practice models, payment structures, and advances in technology can be tested, measured, and diffused more rapidly at http://www.hopestreetgroup.org/docs/DOC-2476

    1. Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community; Institute of Medicine, Defining Primary Care: An Interim Report (Washington, D.C.: Institute of Medicine, 1994).

    2. A.H. Goroll, R.A. Berenson, S.C. Schoenbaum, and L.B. Gardner, ““Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care,”” Health Policy 22 (3): 410–415 (2007).

    3. A. Milstein and P. Kothari, “Are Higher Value Models Replicable?” Patient-Centered Primary Care Collaborative Blog (2009). Accessed November 24, 2010, http://www.pcpcc.net/ Þles/health_affairs_blog_1.pdf.

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Attorney General Eric Holder talks with Capt. Ron Johnson of the Missouri State Highway Patrol at Drake's Place Restaurant, Wednesday, Aug. 20, 2014, in Florrissant, Mo. (AP)

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