Atul Gawande: Will Obamacare bankrupt Boston's Children's Hospital?

Our fanboyism on ATUL GAWANDE is well-established: we think he should be surgeon general. Brilliant medical writer. Brilliant medical thinker. One of the very few essential voices to emerge out of the bar-brawl of the health-care debate. Local guy. Knows what it's like for someone to yell "FUCK YOU" at him in the middle of a reading.

He commandeered this week's New Yorker "Comment" to weigh in yet again on health care, and once again resists the temptations of politics and ideology to raise a red flag about the just-passed reform legislation. His larger point is a comparison to the enactment of Medicare by LBJ: after the law was passed, the American Medical Association "waged war to try to stop the program, and doctors weren’t about to abandon the fight against 'socialized medicine' simply because it had passed into law."

If you'd like to get a taste of what that debate sounded like, here's a recording made in Boston in 1965, in the middle of the dogfight over Medicare. The outgoing president of the AMA and the architect of its opposition to Medicare, Edward Annis, staged a public debate against Dean Schottland, at the time a Brandeis educator who'd been the commissioner of Social Security under Eisenhower. That debate, entitled "Medicare: Is It The Best Solution," will inspire a shocking dose of deja vu. And yet you may also be shocked by the notion that, 45 years ago, it was politically acceptable to suggest that compassion was a legitimate goal of a just society.

LISTEN: Medicare: Is It the Best Solution? [Ford Hall Forum, Boston, 1965] (mp3)

To get back to Gawande: most of the people echoing his New Yorker column this week are focusing on his broad goal: a warning about the dangers of assuming that the work of health reform is over. But they seem to be glossing over the narrow example he gives, which is a terrifying warning that when all is said and done, health reform may simply not work -- or may work, and then have horrific unintended consequences. In this passage, he gives a real-world example of how improving health care at Boston's Children's Hospital resulted in cut costs . . . which has had the paradoxic effect of occasioning a financial crisis. Here's the relevant passage:

Recently, clinicians at Children’s Hospital Boston adopted a more systematic approach for managing inner-city children who suffer severe asthma attacks, by introducing a bundle of preventive measures. Insurance would cover just one: prescribing an inhaler. The hospital agreed to pay for the rest, which included nurses who would visit parents after discharge and make sure that they had their child’s medicine, knew how to administer it, and had a follow-up appointment with a pediatrician; home inspections for mold and pests; and vacuum cleaners for families without one (which is cheaper than medication). After a year, the hospital readmission rate for these patients dropped by more than eighty per cent, and costs plunged. But an empty hospital bed is a revenue loss, and asthma is Children’s Hospital’s leading source of admissions. Under the current system, this sensible program could threaten to bankrupt it. So far, neither the government nor the insurance companies have figured out a solution.


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