Back in December, the New Yorker published a really great article by Atul Gawande on reforming the health care system and reigning in health care cost growth over time. Gawande drew lessons from the activities of the USDA’s Agricultural Extension Service in the early 1900s, which, in combination with a variety of other relatively small-bore initiatives, succeeded in transforming American agriculture to be much more productive–paving the way for further economic growth. Even though the article’s been out there a while, I’m posting about it now, because I think it has tremendous relevance to our current debates about education reform that has been under-recognized and discussed. Key grafs:
There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. Problems of the second kind, by contrast, are never solved, exactly; they are managed. Reforming the agricultural system so that it serves the country’s needs has been a process, involving millions of farmers pursuing their individual interests. This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country’s needs. No nation has escaped the cost problem: the expenditure curves have outpaced inflation around the world. Nobody has found a master switch that you can flip to make the problem go away. If we want to start solving it, we first need to recognize that there is no technical solution.
Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous. Our fee-for-service system, doling out separate payments for everything and everyone involved in a patient’s care, has all the wrong incentives: it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.
A few of these issues are unique to health care, but most could also be said about our education system. Generating improvement in educational outcomes requires changing the behavior of thousands of local entities that provide complex services. Knowledge about effective practices diffuses too slowly. Information and other critical systems are primitive. Education spending, like health spending, has increased dramatically in recent decades, and given current state and federal fiscal challenges, and the fact that we no longer have rising property values fueling predictable increases in state and local property tax revenues, education, like health, is going to need to identify ways to become more productive with relatively flat resources. Perhaps most important, while some of our educational challenges are amenable to technical solutions, many are not.
Some further thoughts on this:
First, the Agricultural Extension Service model that Gawande is talking about here is worth looking at as a potential model for efforts to improve education. One of the things we’ve learned from the past half century’s experience in education reform is that neither input regulation nor incentives/accountability focused on outcomes are, on their own, sufficient to get results in many of the biggest problems facing our education system. We need something more complex that combines both better incentives (as Gawande notes the agricultural improvements of the early 1900s also required) and new strategies that actually help and persuade practitioners to change their behavior in ways that produce greater results. Secretary Duncan has talked about creating a more collaborative partnership between the feds and state and local school districts to improve achievement–the history of the agricultural extension service may offer some useful models here.
Second, it’s worth noting that the dramatic improvements in agricultural productivity in the early 1900s did not come without a significant degree of displacement and pain for some producers. People in education tend to want to be nice and look for solutions that don’t require anyone to suffer–but getting to a much better system is going to require changes that do threaten the interests, privileges and prerogatives of some current participants in the system.
Third, I think it’s important to recognize that there’s actually tremendous similarity between some of the challenges facing health care right now, and those facing education. Both the health and education sectors face shared challenges of reigning in costs and persuading practitioners to change behavior and implement effective practices. In both sectors, change cannot be imposed by fiat but requires using rather oblique policy levers to shift the behavior of thousands of local providers. And both sectors deliver complex services to people–students and patients–who ultimately need to participate themselves in producing desirable health and education outcomes. There are interesting things going on in both the education and health sectors that the other sector could learn from, but policy wonks and practitioners in both sectors are often unaware of what’s going on in the other. Health and education policymaking, in particular, would benefit from much more robust and deep exchange of ideas, lessons, and best practices across the two sectors.
Finally, I think the notion that certain types of challenges are never solved, but managed in ways that generate ongoing improvement, is particularly important to keep in mind in thinking about education reform.
Of late, some folks in the education policy space have been grappling with the question of “what next”–what will be the driving ideas and focuses in education policy in a post-NCLB world. To date, I haven’t heard a lot of compelling answers there. But I think the ideas in Gawande’s article provide a useful starting point for thinking about some of what the “what next” should look like.
–by Sara Mead