Atul Gawande On Health Reform: ‘On A Practical Level’ We ‘Would All Suddenly Become Incrementalists’

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"Atul Gawande On Health Reform: ‘On A Practical Level’ We ‘Would All Suddenly Become Incrementalists’"

From January 29 to 30th, I attended Family USA’s 14th annual Health Action Conference. This is the first in a series of posts about that event.

atul2.jpgAtul Gawande, a former senior health policy advisor in the Clinton presidential campaign and White House, didn’t want to talk about health politics. When I asked him about the role single-payer advocates play in fighting for comprehensive health reform — that is, do they create the political space in which multi-payer plans seem more politically attractive — Gawande did not dwell on political strategy.

He didn’t explain away the single payer folks as politically naive or impractical. Nor did he suggest that they broadened the spectrum of debate to include more policy options. No, Gawande didn’t really choose sides in the epic health care debate. Instead, he calmly suggested that if we simply thought about what health reform should look like on day one, we would all become incrementalists:

I can see the argument for saying there is a dialectic here and you see people pushing for single payer and it will come out somewhere in the middle….very few of us have been in the process of trying to think in nuts and bolts: what is it that we want to happen on January 1? What is it we really want to happen? And I think even the most idealistic, whether it is the single payer who wants to make on January 1, 2011 all private insurance illegal to the free marketer who wants to end employer-sponsored coverage, put people in the individual market and have everybody competing. On a practical level when they start thinking about what they would do to people on January 1, I think they would all suddenly become incrementalists.

Perhaps that’s the lesson for the upcoming reform battle. While the current economic crisis has opened the door towards transformational change, we shouldn’t let the perfect be the enemy of the good. Building on our current structures, and focusing on the practicality of workable reform, we can construct a solution that gets us towards a system that covers more people at lower costs without disrupting coverage.

It won’t be ideologically perfect, but it will be something that actually works and something that actually passes.

Transcript:

I can see the argument for saying there is a dialectic here and you see people pushing for single payer and it will come out somewhere in the middle. I think the trouble for me is you want the energy of everybody who wants these goals to be pointed in the direction of fighting as hard as they possible can for them.

And to the extent of fighting with each other, what I did see during the Clinton plan is how much time we spent fighting each other. So no matter how many of the single payer lined up behind the Clinton plan, we were still busy hurting ourselves. It is really important that we figure out whether we have some common beliefs that can push in the right direction.

And I think also that the common beliefs are in these goals and second of all in the practicalities of how you make something real happen without killing people in the process. And very few of us have been in the process of trying to think in nuts and bolts, what is it that we want to happen on January 1? What is it we really want to happen? And I think even the most idealistic, whether it is the single payer who wants to make on January 1, 2011 all private insurance illegal to the free marketer who wants to end employer-sponsored coverage, put people in the individual market and have everybody competing. On a practical level when they start thinking about what they would do to people on January 1, I think they would all suddenly become incrementalists. Because you have to figure out step-by-step forward progress of getting there. It’s almost as though the abstract discussions polarize us too much, because I think when we start imagining what it is we want to happen in week one, that there actually is more common ground there than I think we all understand.

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