Cash, Culture, and Health Care Delivery


You really have to go read Atul Gawande’s article on health care in the new New Yorker. Not only does it make some vital policy points, but it’s a real masterpiece of a craft of long-format feature magazine writing on a public affairs topic. To try to excerpt or reproduce it would be pointless. You should read it.

But instead of rehashing Gawande’s points, we can pick up where he leaves off. Basically, providing effective health care and thinking of health care provision as a commercial enterprise don’t seem to mix very well. I’m not sure this should strike us as all that surprising. Lots of important things—the police department, universities, art museums—can’t be provided well on a commercial basis. The role of a doctor and the role of a salesman are just too different.

Which isn’t to say that it would be realistic to start health care reform by totally overhauling the premises underlying the system. But it is to say that I suspect the kind of reforms currently being contemplated by congress are really only going to be the first steps in a substantially longer journey that we’ll have to take as a country. In addition to things being totally screwed up in terms of who gets health insurance and how and from whom, the actual delivery of health care happens in a very screwed-up way. But the common view is that it actually isn’t screwed up, and so short-term politics dictates spending a lot of time reassuring people that no terrible change for the worse is on the way in terms of delivery. Which is fine as far as it goes, since the insurance mess really does need to be cleaned up. But then there’s this other problem, where the actual practice of medicine in America, though perceived to be good, is actually extremely hit-or-miss and in some respects getting worse.