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Health-care help from the rookies

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Friday, December 11, 2009

Finally, there is some good news on the health-care front.

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The headlines went to a possible compromise on the contentious issue of the public option, but the greater victory may lie in less-publicized Senate action that might actually cut the costs of our impossibly expensive health-care system.

This week, the outlines of such a change emerged in a package of amendments proposed by 11 freshman Democratic senators -- who have an abundance of common sense that more than compensates for their lack of seniority and renown.

Since they returned from their August recess, with the angry words of their constituent town meetings ringing in their ears, the nine men and two women who were newly seated in the Senate majority have been meeting weekly to see what they might contribute to moving the process forward.

As Virginia's Mark Warner, one of the leaders of the informal group, told me, "We knew we were seated at the kids' table," not being members of the elite Finance Committee. But many of them were accustomed, from their jobs in state and local government, to working out similarly snagged policy disputes.

So they reached out to some of the major players outside Congress and, as several of those interest-group experts told me, did the hard work of exploring for themselves how the emerging legislation might be improved.

The product of their exercise is a series of amendments that they argue will "broaden and accelerate efforts to encourage innovation and lower costs for consumers across the U.S. health care system."

Many of the proposed changes come with the endorsement of business, labor, consumer and provider organizations. While the drafters were all backbench Democrats, they were operating with the blessing of Majority Leader Harry Reid and their package was immediately endorsed by Sen. Susan Collins of Maine, a moderate Republican. Republican Sen. Robert Bennett of Utah, who had been skeptical of other Democratic amendments, said this one "moves in the right direction."

By keeping their goals modest and focusing on changes that can have practical benefits, the freshmen greatly improved the chances that their proposals will survive in any legislation that reaches the president's desk.

Their work was praised by many who helped develop it for recognizing that parallel changes must come in Medicare and Medicaid, as well as in the private sector of medicine. They also grasped that we need to make more robust use of field experiments in how to do that.

This builds on a growing awareness of the fact that buried in the thousands of pages of the legislation passed by the House and pending in the Senate are authorizations for pilot programs testing a wide variety of changes to coordinate care and reduce costs.

They have been there all along, but until recently were obscured by the fight over the public option, abortion and other headline-grabbing issues. These pilots would test such approaches as offering a comprehensive fee, rather than billing for each doctor or test when, for example, a heart attack or diabetes patient is first treated, or rewarding or penalizing a hospital depending on its rate of hospital-incurred infections.

Coincidentally, just as the freshmen were preparing to introduce their package, expanding significantly the scope of the pilot programs, the New Yorker magazine published a piece by Atul Gawande in its Dec. 14 edition highlighting the potential of such experimentation. Gawande, a Boston-based physician-journalist whose work is often cited by President Obama, has become perhaps the most influential outside voice in the health-care debate, especially on the issue of curbing ruinous medical inflation.

Gawande argues that the historical example for spreading cost-cutting innovation through government-sponsored pilot projects can be found in the Agriculture Department's extension system. In the first decade of the 20th century, county agents persuaded a handful of farmers to use modern scientific methods of cultivating land and raising crops, and their success quickly spread to thousands of others. We are still reaping the benefits of a transformation that was facilitated -- not ordered -- by government.

We badly need a similar transformation in health care, and the freshmen's amendments may help bring it sooner.


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