Boston surgeon Atul Gawande has become one of the most acclaimed mainstream media critics of American health care. An elegant writer with first-hand hospital experience, he has pointed out, in many articles for The New Yorker and several books, a number of ways that patient care could be improved. My major concern about his reporting has been its consistent failure to acknowledge the critical role that nurses and other non-physicians play in our health care system. For more details of this critique, see ” The Cure: Can Doctors Change How They Think?” (http://bostonreview.net/BR33.2/gordon.php). I now have another. In his December 14, 2009 New Yorker commentary, entitled “Testing, Testing,” (http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=2) Gawande discusses the fact that Administration backed health care plan about to be enacted by Congress will fail to address medical cost inflation. ”Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality?,” he askss. ”It does not,” is the obvious reply.
The author points out that these fundamental flaws have drawn heavy flak from a right-wing determined to block “ObamaCare” in any form. Progressive economists and single-payer advocates have also sharply criticized both the House and Senate health care reform bills—that are currently awaiting joint-committee “reconciliation”–for their deeply flawed incrementalism.
Nevertheless, Gawande remains quite bullish about this emerging Capitol Hill mishmash because, despite its many troubled compromises, “what it offers is . . . pilot programs.” Gawande reassures New Yorker readers that a watered-down, piece-meal approach to governmental reorganization of private markets (in this case, for health insurance) may not be so bad, after all. To make his case, he takes us down legislative memory lane and recounts the fitful 20th century evolution of public intervention in agriculture.
In the early 1900’s, the U. S. Department of Agriculture began to sort out—for better or worse, depending on your point of view—the problem of food in America. Like health care today, the crisis then involved a big disconnect between widespread social need and affordable private provision.Gawande recounts how a patchwork quilt of federal regulation and costly tax-payer subsidies ended up producing safer, cheaper, more plentiful food stuffs for the nation. Meanwhile, farmers were forced or helped to “innovate,” just like doctors and hospitals must do now, as part of the “reform” process.
Gawande does acknowledge, in passing, that U.S. farm policy has had a few glitches of its own over the years. But that is a political understatement of massive proportions. Our special interest-driven reshaping of agriculture has placed the bulk of it firmly under the control of “agri-business.” Its first cousins include all the big drug and insurance companies now expecting to reap a very profitable harvest from federally-mandated private medical coverage. Just as the medical industry has largely driven the solo physician practitioner out of business, federally supported agri-business driven the family farmer into near extinction. The overall result of what Gawande applauds, down on the farm, has already proved to be pretty disastrous, in different ways, for small family farmers, consumers, and the environment, it has also had disaterous medical side effects. And there is a direct link between this public policy back-fire and one major contributor to rising health care costs—namely, obesity and its myriad medical side-effects. Has the obviously well-read Dr. Gawande never bothered to peruse Michael Pollan’s The Omnivore’s Dilemma , with its a well-documented indictment of the public health consequences of tax-supported industrial agriculture?
For decades, the heavily-subsidized production of corn, corn and more corn has unleashed a sugary flood of Katrina proportions that’s now nationwide in scope. As Pollan points out, our millions of overweight corn syrup, and corn fed meat and chicken (and now farm- fed fish) “survivors” face an epidemic of heart attacks, high-blood pressure, and diabetes—each condition a costly hospital stay waiting to happen. (see Annual Medical Spending Attributed to Obesity. Health Affairs http://content.healthaffairs.org/cgi/content/short/hlthaff.28.5.w822) And, speaking of “testing, testing,” that list doesn’t even include the current and future casualties of USDA-approved meat eating!
Among the threats facing carnivores these days (and I’m one of them) is a stream of contaminated food items, from here and abroad. On December 31, 2009, The New York Times ran a front-page story exposing the failure of federal inspectors to stop Beef Products Inc. from sending large quantities of tainted hamburger to the market. Officials at the United States Department of Agriculture endorsed the firm’s ammonia treatment process as a way of keeping deadly E. coli bacteria “to an undetectable level.” In 2007, they decided it was so effective that the firm should be exempted from routine USDA testing. Unfortunately, some Beef Product burgers turned out to be very unsafe to eat. http://www.nytimes.com/2009/12/31/us/31meat.html. This article followed an even more horrific NYTimes front page story about E.coli tainted hamburgers produced by Cargill that crippled a 22 -year- old dance instructor. http://www.nytimes.com/2009/10/04/health/04meat.html.
Anyone concerned about the overall health and well-being of Americans is faced with a tremendous dilemma when it comes to the current health care bills wending their way through Congress. These bills promise to address the problem of the uninsured. The problem is they do little to protect the American public and American patients from the rapaciousness of the private, for-profit insurance and pharmaceutical industries. That’s why people genuinely concerned about the fate of reform should be wary of hyping the kind of regulatory “reform” and industry restructuring process that helped many of us get heavier and sicker in the first place. But that’s exactly what Gawande does with his ahistorical cheerleading for the two-(or three?)headed calf that’s headed for birthing sometime this month on Capitol Hill. As a lont-time advocate of real health care restructuring, Gawande’s article, ironically, makes me even more worried about the future we face under ObamaCare. If it’s going to be just a replay of America’s costly, century-long, and still out-of-control experiment with “market reform” in agriculture, then will things get better or worse?