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Commentary

The Obama Health Plan
Atul Gawande, The New York Times, 5-31-07

Gawande, a guest columnist in the New York Times, continues his series on health care issues by discussing Sen. Barack Obama' latest plan. Gawande notes that while there are flaws in all existing plans—and all existing health care systems—reform is imperative.

As a surgeon, I've worked with the veterans' health system, Medicare, Medicaid and private insurance companies. I've seen health care in Canada, Britain, Switzerland and the Netherlands. And I was in the Clinton administration when our plan for universal coverage failed. So, with a new health reform debate under way, what I want to tell you in my last guest column is this:

First, there is not a place in this world that is not struggling to control health costs while providing high–quality, easily accessible care. No one—no one—has a great solution.

But second, whether as a doctor or as a citizen, I would take almost any system—from Medicare–for–all to a private insurance voucher system—over the one we now have. Job-based insurance is bleeding away the viability of American businesses—even doctors complain about the cost of insuring employees. And it has left large numbers of patients without adequate coverage when they need it. In the last two years, for example, 51 percent of Americans surveyed did not fill a prescription or visit a doctor for a known medical issue because of cost.

My worry is less about what happens if we change than what happens if we don't.

This week, Barack Obama released his health reform plan. It's a puzzle how you are supposed to regard presidential candidates' proposals. They are treated, by campaigns and media alike, as some kind of political G.P.S. device— gadgets primarily for political positioning. So this was how Mr. Obama's plan was reported: it is a lot like John Edwards's plan and the Massachusetts plan signed into law by Mitt Romney last year; and it has elements of John Kerry's proposal from four years ago. In other words—ho hum—another centrist plan. No one except policy wonks will tell the proposals apart from one another.

Well, all this may be true. And if what you care about is which candidate can one-up the others, it is rather disappointing. But if what you care about is whether, after the 2008 election, we'll be in a position to finally stop the health systems' downward spiral, the similarity of the emerging proposals is exactly what's interesting. I don't think you can call it a consensus, but there is nonetheless a road forward being paved and a growing number of people from across the political spectrum are on it—not just presidential candidates, but governors from California to Pennsylvania, unions and businesses like Safeway, ATT and Pepsi.

This is what that road looks like. It is not single–payer. It instead follows the lead of European countries ranging from the Netherlands to Switzerland to Germany that provide universal coverage (and more doctors, hospitals and access to primary care) through multiple private insurers while spending less money than we do. The proposals all define basic benefits that insurers must offer without penalty for pre—existing conditions. They cover not just expensive sickness care, but also preventive care and cost—saving programs to give patients better control of chronic illnesses like diabetes and asthma.

The European route, however, also depends on rationing care for the sickest patients, and on cost controls for new medical innovations. While we agree with Dr. Gawande's criticisms of the U.S. job–based system, we think that the consumer–driven solution—powered through a tax credit or tax voucher to level the health insurance playing field between employed and unemployed Americans—would be much preferable to government setting and picking plans for consumers.



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