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Atul Gawande: This kind of health care can save your life, but reform could take it away

Atul Gawande
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Atul Gawande

Surgeon, bestselling author and MacArthur Foundation "genius" Atul Gawande took the stage at the New Yorker Festival on Saturday to say that seeing a primary care physician on a regular basis is relatively cheap and easy, yet it can save your life. But Medicaid cuts, he warned, may strip you of that opportunity.

Gawande echoed a key point he has also made in writing: "Incremental care — regular, ongoing care as opposed to heroic, emergency care — is the greatest source of value in modern medicine."

In June, when Senate Republicans first unveiled their plan to cut Medicaid and end the mandate that guarantees Americans health insurance, he explained why that posed such a danger: "There is clear evidence that people who get sufficient incremental care enjoy better prevention, earlier diagnosis and management of urgent conditions, better control of chronic illnesses, and longer life spans."

Getting a regular physical is vital, in other words. Even life-saving.

Some people who don't realize this assume primary care physicians are dispensable. After all, compared to a specialist, they seem less knowledgeable.

On the festival stage, Gawande told the story of a surgeon friend of his who spoke on the phone with a primary care physician about a patient. The surgeon told the physician that the patient had a glioma, a brain tumor, and the physician responded, "What's a glioma?" — a term anyone with a Bachelor's of Science degree should know.

Sometimes "there's just too much to know," conceded Gawande, who is himself an endocrine specialist.

So how can it be that the physician providing incremental care offers the most valuable service in health care?

For one, Gawande explained, your regular doctor offers something unique: long-term relationships. If you see the same doctor over the course of many years and need a diagnosis, that doctor will be able to integrate all of the information she knows about you from throughout the years you've visited her.

Additionally, when you get to know your doctor and grow comfortable with her, you have a "lower threshold for seeking attention." If you think something might be wrong, you'll be more inclined to go in for a visit and, in many cases, address the issue before it becomes more serious.

This is called the Primary Care Paradox. "For any given situation, specialists are better," said Gawande, "yet having a primary care physician is better for long-term life."

Cuts to Medicaid threaten access to this type of incremental care.

The Senators wary of signing the Graham-Cassidy Bill, the Republicans' recent effort to repeal Obamacare that collapsed late in September, criticized how it rolled back protections for people with pre-existing conditions, and also how it proposed deep cuts to Medicaid.

According to the Congressional Budget Office, the repeal would've left millions more Americans without coverage — which would have meant millions more unable to afford incremental care.

Some reform of America's health care system is needed, Gawande agreed. In its current state, it's flawed.

For one, its poor performance doesn't justify its enormous expense. In an analysis of the health systems of 11 Western high-income countries, the Commonwealth Fund ranked America 11th. "These results are troubling because the U.S. has the highest per capita health expenditures of any country and devotes a larger percentage of its GDP to health care than any other country," the report notes.

Gawande has also pointed out that access to healthcare is unfairly distributed.

"In the American health care system," he writes in another piece for the New Yorker, "different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another."

While everyone might not agree that health care is a right, he said, among those he's talked to, liberal and conservative alike, the consensus is that all Americans should be able to access health care, as long as they can somehow contribute to the cost.

So any reform, Gawande said, should bear this perspective in mind. Because, as he put it, "it's really about understanding that all lives have equal value."

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