Curing the System

By ATUL GAWANDE

The American health insurance system is a slow-creeping ruin, damaging people and increasingly the employers that hire us. Yet there is another truth as well: the vast majority who have decent coverage are happy with the care we get — I am writing this, for instance, as I sit with my 11-year-old son waiting for an M.R.I. to check the cardiac repair that has saved his life for a decade. So most have resisted large-scale change, fearing that it could make some lives worse, even as it makes others better.

And the truth is it could.

There are two causes of human fallibility — ignorance and ineptitude — and health system change is at risk of both. We could err from ignorance, because we have never done anything remotely as ambitious as changing out a system that now involves 16 percent of our economy and every one of our lives. And we could err from ineptitude, underestimating the difficulties of even the most mundane tasks after reform — like handling all the confused phone calls from those whose coverage has changed; ensuring that doctor’s appointments and prescriptions don’t fall through; avoiding disastrous cost overruns.

Health systems are nearly as complex as the body itself. They involve hospital care, mental health care, doctor visits, medications, ambulances, and everything else required to keep people alive and healthy. Experts have offered half a dozen more rational ways to finance all this than the wretched one we have. But we cannot change everything at once without causing harm. So we dawdle.

We don’t need to, though. It is possible to alter our system surgically enough to minimize harm while still channeling us onto a path out of our misery.

Option 1 is a Massachusetts-style reform, which follows a strategy of shared responsibility. Enacted statewide last year, the law has four key components. It defines a guaranteed health plan that is now open to all legal residents without penalty for pre-existing conditions. Using public dollars, it has made the plan free to the poor and limited the cost to about 6 percent of income for families earning up to $52,000 a year. It requires all individuals to obtain insurance by year end. And it requires businesses with more than 10 employees to help cover insurance or pay into a state fund.

The reform gives everyone a responsibility. But it leaves untouched the majority with secure insurance while getting the rest covered. As a result, it has had strong public approval. Experience with delivering the new plan is accumulating. And best of all, it offers a mechanism that can absorb change. The guaranteed health plan may cover 5 percent of the state at first, but as job-based health care disintegrates, the plan can take in however many necessary.

The reform has its hurdles, no question. Some residents are angry about being made to buy health coverage — 6 percent of income is not nothing. Next April, when the tax penalty kicks in (refusers will lose their personal tax exemption), you will hear about it. As enrollment and costs in the guaranteed plan rise, there will also be intense public pressure to increase the minimum employer contribution (currently just $295) and clamp down on the costs. But this is what a real system is for: gathering everyone in and enabling the hard choices.

The approach is not just a crazy Massachusetts idea (though Mitt Romney is running from parts of it). Reform plans recently put forward by everyone from the Republican Arnold Schwarzenegger to the Democrat John Edwards to a major new business coalition take the same tack. People don’t want the mess we have — not families, not employers and not health professionals. This offers a viable way forward.

If it’s still too much for people to accept, however, there is a second option, a fallback: we could guarantee coverage for today’s children — for their lifetime. It could be through private insurance or through a Medicare plan that families must enroll them in. Either way, the subsidies required are very much within our means.

We might even pass the fallback plan first. Then, while we are stymied fighting about how to fix the rest, there’d be at least one generation that could count on something more.

Atul Gawande, a surgeon at Brigham and Women’s Hospital and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.