Atul Gawande on Resisting Health Care Reform - He Misses a Tactic, Lying!

Atul Gawande, thoughtful as always, writes about the "wicked problem" of healthcare reform and the historical similarity between this battle and previous battles to expand fairness to all of our citizens. Opening with the kind of experiences all physicians have had with tragically-uninsured patients, he emphasizes why this was a needed change:

A few days ago, while awaiting the Supreme Court ruling on the Obama health-care law, I called a few doctor friends around the country. I asked them if they could tell me about current patients whose health had been affected by a lack of insurance.

“This falls under the ‘too numerous to count’ section,” a New Jersey internist said. A vascular surgeon in Indianapolis told me about a man in his fifties who’d had a large abdominal aortic aneurysm. Doctors knew for months that it was in danger of rupturing, but, since he wasn’t insured, his local private hospital wouldn’t fix it. Finally, it indeed began to rupture. Rupture is an often fatal development, but the man—in pain, with the blood flow to his legs gone— made it to an emergency room. Then the hospital put him in an ambulance to Indiana University, arguing the patient’s condition was “too complex.” My friend got him through, but he’s very lucky to be alive.

Another friend, an oncologist in Marietta, Ohio, told me about three women in their forties and fifties he was treating for advanced cervical cancer. A pap smear would have caught their cancers far sooner. But since they didn’t have insurance, their cancers were only recognized when they caused profuse bleeding. Now they required radiation and chemotherapy if they were to have a chance of surviving.

Even inexperienced physicians like me, still in my residency, have these kinds of stories to tell. They're tragic. But worse, they're just so stupid. Notice how, in each instance, the problem still ends up being taken care of, only now it's emergent, farther along, more risky, and of course, more expensive to treat. This is part of the ludicrous nature of the opposition to health care reform. There is no way to get out of paying for these things. All we do by denying people coverage for necessary medical treatment is guarantee that in a few days, months, or years, they'll be in the emergency room, only now it will cost ten times as much to fix, at greater risk to the patient. This is also backed up by the international experience of health care. Every other industrialized country has universal coverage, many have far superior care, not to mention superior service (France anyone?) to the United States. Yet every one of the countries pays far less per capita (most less than half) than we do on health care. Data from studies within our own country show it's cheaper for the state to cover the uninsured than to let them stay uninsured. Because of EMTALA, passed by that notorious socialist Ronald Reagan, everybody gets emergency care whether they are insured or not, and fully 50% of emergency care is uncompensated, costs which get transferred to the insured and the tax payers.

For most of us in the healthcare system we see that universal coverage is necessary (unless you reverse EMTALA which will never happen), although we may disagree on how to accomplish it. If anything, the ACA/Obamacare is more of a free-market reform than many physicians would like. Many in my generation (though certainly not in the older generation) would have preferred single-payer, but for reasons I discussed yesterday this is actually not as important as merely guaranteeing universality. Mixed private/public and government payer/private insurance schemes are, if anything, the norm around the world and they work well while still costing less than 50% of what we pay per capita.

So why so much resistance to what should be obvious? There is no way to avoid paying for this stuff, so why don't we do it more sensibly? Why don't we move primary care out of the ER? Why not pay for problems when they're cheap and not emergent?

Gawande suggests the problem is that healthcare is a "wicked problem" and such problems that don't have simple, crisp answers generate more controversy and resistance to change.

In 1973, two social scientists, Horst Rittel and Melvin Webber, defined a class of problems they called “wicked problems.” Wicked problems are messy, ill-defined, more complex than we fully grasp, and open to multiple interpretations based on one’s point of view. They are problems such as poverty, obesity, where to put a new highway—or how to make sure that people have adequate health care.


Solutions to wicked problems, by contrast, are only better or worse. Trade-offs are unavoidable. Unanticipated complications and benefits are both common. And opportunities to learn by trial and error are limited. You can’t try a new highway over here and over there; you put it where you put it. But new issues will arise. Adjustments will be required. No solution to a wicked problem is ever permanent or wholly satisfying, which leaves every solution open to easy polemical attack.

This sounds awfully familiar, and I think it's a good explanation for much of the controversy. I've been emphasizing from the beginning, there is more than one answer to the problem of the uninsured. The only really wrong answer is, "doing nothing". We've been doing that for long enough and it actually costs us more to do nothing than to expand coverage! Gawande then discusses Albert O. Hirschman's studies of the polemical forms of resistance to solving these wicked problems, and how they rely on arguments of perversity, jeopardy and futility. However, I find that a critique of these debates isn't particularly satisfying. Just because one argues that a reform is perverse, or risky, or futile, doesn't necessarily make one wrong, even if it is a frequent pattern of obstinance. Gawande also leaves out the 4th tactic of the current opponents of reform. That is, of course, mendacity.

In order to oppose a reform so obviously needed, so completely supported by the data from international experience and studies from within our own country, and in the face of the obvious gob-smacking experience of every physician in the country, one ultimately must rely on just lying. Politifact, both before and after the Supreme Court decision, has demonstrated this phenomenon. Many of the claims against the ACA have been so rabidly false as to deserve their "pants-on-fire" designation, including the fully debunked death panels nonsense (2009 lie of the year!), that it's the largest tax increase ever, it's rationing, or that it is some kind of Obama socialist plot. See the top five lies here. Immediately after the ruling Romney was apparently tripping over his own feet in order to be the first to lie about his own reform package saying it would increase the deficit by trillions, another lie, and Limbaugh reiterated the lie that it was the largest tax increase ever.

I think that's what's most disappointing to me about this current debate, but these days it is no surprise. The outrageous mendacity of the opponents of reform, and the unwillingness of the right to engage in honest debate on this topic, are beyond anything I've seen in my lifetime. But a few facts are undeniable. We spend more on health care than any other country. For that cost we can't even cover all of our citizens. Universal healthcare systems are also universally less expensive than ours. When we refuse to cover people, and allow them to be uninsured, they still receive care, it just costs us more to deliver. Why do people oppose universality when these are the facts?

The simple, sad answer, is they're being lied to.

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I wonder how long it will be before they try to repeal EMTALA....

There's an ad that I've seen on TV far too often lately. Bugs the heck out of me, but I think it may be specifically targetted at posts like this one, which point out the reality of the situation as doctors see it. It features a kindly looking lady in a labcoat who is identified as a doctor (but who, for all we know, is merely an actress), talking about how horrible this will be for her patients, and how doctors everywhere know how awful Obamacare will be. It offers no concrete examples; just vagueness. I suspect it is fairly effective, unfortunately. So yes, mendacity is part of it. It's insane. So many financial decisions made by Congress in the past decade have been downright insane, liable to worsen budget problems, increase the debt, and not solve anything at all.

By Calli Arcale (not verified) on 29 Jun 2012 #permalink

"Notice how, in each instance, the problem still ends up being taken care of, only now it’s emergent, farther along, more risky, and of course, more expensive to treat. "

This is an example of ascertainment bias. The people for whom delay simply kills them don't come back for more medical attention, so doctors don't accumulate horror stories about those people.

For most of us in the healthcare system we see that universal coverage is necessary (unless you reverse EMTALA which will never happen),

A major reason for EMTALA was to preserve the private health insurance industry as it then was.

This is not a controversial thing to say.

There had been a number of scandals due to patients, mainly pregnant women in labor, being "transferred" during labor due to lack of insurance, around that time. Also around that time, the first data showing that the US system was more expensive than universal systems came out.

Although the Indiana case discussed here shows that serious abuse is alive and well, EMTALA put a lid on some of the most crazy stories.

The universal coverage issue was still alive enough that Clinton introduced his now-forgotten effort only six or seven years after EMTALA.

EMTALA is better than nothing at all but it was designed to prop up the status quo.

Of interest, turning emergent patients away is often economically irrational. The incremental cost of treating is often not that great. The legal/insurance risk is typically far greater if you try to evade doing what you know you should do, than if you provide care in good faith. It was often just social bias.

“Notice how, in each instance, the problem still ends up being taken care of, only now it’s emergent, farther along, more risky, and of course, more expensive to treat. ”

This is an example of ascertainment bias. The people for whom delay simply kills them don’t come back for more medical attention, so doctors don’t accumulate horror stories about those people.

1) It isn't an example of such a bias, because it refers specifically the cases under discussion.

2) A claim that it is cheaper to let some people go untreated cannot easily be supported.

In the context of ultimate treatment of emergencies, it is probable, but not definitive, that lack of access to early care and subsequent complex care is a net greater cost to the US system, even if some people simply die from lack of any care and are not noticed.

No rich nation lets emergencies go untreated, when detected. All rich nations except the US have some form of universal coverage. The US does have a patchwork of social programs. All other rich nations have lower health care costs and better outcomes than the US.

3) The costs of outright denying some people any treatment even in emergency situations could be considerable. The first cost would be the public health cost. Totally locking some people out of the health care system would make control of infectious disease exceptionally difficult. Another thing to remember is that enormous marginal utility that people put on not dying or being disabled. A middle class child who might have become an accountant dies of meningitis because an uninsured person wasn't treated or detected and, before dying "cost free", was a nidus of infection. What's the "economic value" of the child's death? Is it the net value of what the child could have produced in a lifetime of accounting? Or is it the value of what the parents and family would do to bring the child back, if they could?

4) As a matter of subjective values, I favor treating all sick people, even if it does cost more. Some may disagree with that. But the question of whether it does cost more is an objective one, and the answer is not necessarily "yes".

David, I would consider "patient died" to be an even greater cost than "patient racked up an $800,000 bill that the hospital had to waive due to inability to pay". After all, this person no longer contributes to the economy or to the federal and state budgets through taxes. I do not see how that contradicts the point.

By Calli Arcale (not verified) on 03 Jul 2012 #permalink