That first step, it's a doozy

It’s tough times for those of us in the blogosphere who are focused on health reform.  After all the frenzied activity this year so far, we’re now in the position of wondering what deals are being cut behind closed doors as the Senate debates its version of a bill.  Oh, you still hear the occasional hand-wringing about whether [INSERT PREFERRED VERSION OF BILL] will cover enough people, do enough to control health care spending, or, if you want to believe the extremists, end up funding amoral behaviors, but for the most part, we’re all waiting to see if a signed bill will be in our stockings, or not. 

I have two innate characteristics that tend to war with each other over things like health reform legislation—one, I’m a rules-driven person, and I believe in process to the extent that it allows for fairness and for a range of perspectives to inform the debate, but two, I’m also naturally impatient, and I hate process when it is subject to numerous wrangling and gaming attempts until it no longer looks like a process anymore, it just looks like...a bureaucracy.  So part of me wants to find value in this hurry-up-and-wait period that Congress and the Administration have been engaged in all year, with respect to health reform legislation, but part of me wants to say, let’s just get this part over with, already, and move on to the next part.

Some of my impatience, I think, comes from what I learned in law school (on top of learning that I didn’t, actually, want to practice law), and it’s this:  the law, or rather, the compilation of statutes and legislative acts and regulations that we understand to be the law, is a really blunt instrument for change.  No matter how many pages of legislation you pass, legislation alone will not change the behaviors and practices that have led us to our current health care woes.

Don’t misunderstand me—there are times when you really need a blunt instrument to do the job.  Sweeping legislation might be very useful to get more people into the health care system, for example, by creating mandates for health insurance.  Legislation might also be useful in terms of setting examples—like, getting federal agencies like CMS to model some practices for how we might deliver and pay for high-quality health care, which shows up in the legislation as pilot or demonstration projects, mostly run through Medicare (Atul Gawande writes about the concept of pilots in this week’s issue of the New Yorker magazine).  But legislation cannot, in one fell swoop, change all of the good and bad behaviors—not all of them intentional, by the way—that we by turns praise and bemoan in health insurance companies, doctors, patients, and others.  

Transformative, long-lasting changes in how health care services are delivered in this country—and how we understand, access, and adapt to these services—will take much more concerted effort on the ground, than what can possibly be accomplished with any one piece of legislation.  If you think about where we are right now, with very few Americans even understanding or caring how health care is bought and paid for, or what care helps them get better and what care doesn't, it becomes clear how much harder we will need to work at creating change, well after a bill gets signed into law.  This is why I’m feeling so impatient that this legislative step is taking this long—because we need to let the blunt instrument of the law do its work, so we can move on to the finer, more detail-oriented finishing work that may take even longer to complete.