Dr. Gawande says the ultimate measure of leadership is to take a health plan and persuede people to find common ground in it. Mr. Kristof is in Weihai, China, writing on the rule of law in China. Here’s Dr. Gawande:
As a surgeon, I’ve worked with the veterans’ health system, Medicare, Medicaid and private insurance companies. I’ve seen health care in Canada, Britain, Switzerland and the Netherlands. And I was in the Clinton administration when our plan for universal coverage failed. So, with a new health reform debate under way, what I want to tell you in my last guest column is this:
First, there is not a place in this world that is not struggling to control health costs while providing high-quality, easily accessible care. No one — no one — has a great solution.
But second, whether as a doctor or as a citizen, I would take almost any system — from Medicare-for-all to a private insurance voucher system — over the one we now have. Job-based insurance is bleeding away the viability of American businesses — even doctors complain about the cost of insuring employees. And it has left large numbers of patients without adequate coverage when they need it. In the last two years, for example, 51 percent of Americans surveyed did not fill a prescription or visit a doctor for a known medical issue because of cost.
My worry is less about what happens if we change than what happens if we don’t.
This week, Barack Obama released his health reform plan. It’s a puzzle how you are supposed to regard presidential candidates’ proposals. They are treated, by campaigns and media alike, as some kind of political G.P.S. device — gadgets primarily for political positioning. So this was how Mr. Obama’s plan was reported: it is a lot like John Edwards’s plan and the Massachusetts plan signed into law by Mitt Romney last year; and it has elements of John Kerry’s proposal from four years ago. In other words — ho hum — another centrist plan. No one except policy wonks will tell the proposals apart from one another.
Well, all this may be true. And if what you care about is which candidate can one-up the others, it is rather disappointing. But if what you care about is whether, after the 2008 election, we’ll be in a position to finally stop the health systems’ downward spiral, the similarity of the emerging proposals is exactly what’s interesting. I don’t think you can call it a consensus, but there is nonetheless a road forward being paved and a growing number of people from across the political spectrum are on it — not just presidential candidates, but governors from California to Pennsylvania, unions and businesses like Safeway, ATT and Pepsi.
This is what that road looks like. It is not single-payer. It instead follows the lead of European countries ranging from the Netherlands to Switzerland to Germany that provide universal coverage (and more doctors, hospitals and access to primary care) through multiple private insurers while spending less money than we do. The proposals all define basic benefits that insurers must offer without penalty for pre-existing conditions. They cover not just expensive sickness care, but also preventive care and cost-saving programs to give patients better control of chronic illnesses like diabetes and asthma.
We’d have a choice of competing private plans, and, with Edwards and Obama, a Medicare-like public option, too. An income-related federal subsidy or voucher would help individuals pay for that coverage. And the proposals also embrace what’s been called shared responsibility — requiring that individuals buy health insurance (at minimum for their children) and that employers bigger than 10 or 15 employees either provide health benefits or pay into a subsidy fund.
It is a coherent approach. And it seems to be our one politically viable approach, too. No question, proponents have crucial differences — like what the individual versus employer payments should be. And attacks are certain to label this as tax-and-spend liberalism and government-controlled health care. But these are not what will sabotage success.
Instead, the crucial matter is our reaction as a country when the attacks come. If we as consumers, health professionals and business leaders sit on our hands, unwilling to compromise and defend change, we will be doomed to our sliding global competitiveness and self-defeating system. Avoiding this will take extraordinary political leadership. So we should not even consider a candidate without a plan capable of producing agreement.
The ultimate measure of leadership, however, is not the plan. It is the capacity to take that plan and persuade people to find common ground in it. The politician who can is the one we want.
Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He has been a guest columnist this month.
Here’s Mr. Kristof:
Every evening in a little village near this coastal city, peasants gather in a private home and do something that used to be dangerous. They pray.
They are Christians gathering in a little “house church,” reflecting a religious boom across China. But their story also underscores another trend: the way the legal system here offers hope of chipping away at the Communist Party dictatorship.
The tale begins a year ago when the authorities here in Shandong Province raided this house church and carted 31 Christians off to the police station. Such crackdowns are the traditional way the Communist Party has dealt with house churches in rural areas, and some Christians have even been tortured to death.
But this incident ended differently.
Tian Yinghua, a 55-year-old evangelical Protestant who runs the church in her living room, was outraged after she was ordered jailed for 10 days.
“We had done nothing wrong at all,” explained Ms. Tian. “We weren’t criminals.”
So Ms. Tian contacted a prominent Christian and legal scholar in Beijing, Li Baiguang, who traveled to Shandong Province to do something that once would have been unthinkable: Sue the police.
Even more unthinkable, Ms. Tian won. The police settled the case by withdrawing the charges. The police also formally apologized, paid symbolic damages of 1 yuan (a bit more than a dime) and promised not to bother the church again.
It was a historic victory for freedom of religion in China — and, even more important, for the rule of law.
“The police don’t bother us at all,” said another church leader, Wang Qiu. “They just stay away.”
That seems to be a growing pattern. The central government’s policy toward religion is much more relaxed than a few years ago, and in coastal areas the government usually lets people worship freely.
“In most places, it’s no problem today,” said Mr. Li, who himself was imprisoned for more than a month two years ago for his legal activism. “It’s just a problem in backward areas, or if you directly attack the Communist Party.”
Mr. Li, who enjoys a bit of protection because President Bush invited him to the White House last year, says that last year he filed suits like this one in eight provinces. The other he lost, but even in those cases the authorities were shaken enough that they have stopped harassing Christians, he says.
“On the surface we lost,” he said. “But in reality, we won in every case.”
Han Dongfang, a Chinese labor activist now exiled to Hong Kong, says that he has also found that suing the authorities is often an effective way to increase labor protections. Mr. Han was a leader in the Tiananmen protests of 1989, but now he is trying to bring about change from within. “I believe this is the way to develop a civil society, not through a revolution,” he said.
Of course, the legal system is still routinely used to oppress people, rather than to protect them. China imprisons more journalists than any country in the world, and one of them is my Times colleague Zhao Yan. Judges never go against the Communist Party; what they can do is rectify local injustices where the higher party officials are indifferent.
Moreover, even when lawsuits are allowed to go forward, many Chinese police and judges are so corrupt that they sell themselves to the highest bidder.
A common saying, which I even saw in an illegal poster pasted on a government building in Beijing, goes: “The bandits used to hide in the hills. Now the bandits are in the courthouses.”
Still, the rule of law has gained immensely since the 1980’s, when a defense attorney was imprisoned for having the temerity to claim that the police had arrested the wrong man and that his client was innocent. If the Chinese government continues to nurture the rule of law, China could increasingly follow the path of South Korea and Taiwan away from autocracy toward greater democracy.
Easing the repression could also change the religious complexion of China. Estimates of the number of Chinese Christians vary widely, but the number may be approaching 100 million, many of them evangelical Protestants who aggressively recruit new believers. And with the more relaxed policy, the numbers are soaring.
“In 20 to 30 years China will have several hundred million believers,” said Mr. Li, the lawyer who helped the Shandong church. “That will make China the biggest Christian nation in the world, with more Christians than the entire U.S. population.”
You are invited to comment on this column at Mr. Kristof’s blog, www.nytimes.com/ontheground.