When you peel back a few rhetorical layers of the current health care debate, it is amazing how little has changed since 1993 (Clinton care), or 1965 (Medicare & Medicaid), or 1954 (ESIs tax exempt), or even 1912 when Teddy Roosevelt campaigned for national health insurance. (More on TR here.) In an imperfect world, empathy and good intentions naturally move us to seek solutions, and rational ignorance naturally moves us to favor vivid solutions with quick-fix promises backed by technocratic awe. On deeper consideration, or when later confronted with unintended consequences, we might appreciate the limitations of resting the outcomes for millions in the hands of the few, however smart and well-intentioned the latter may be. In turn, we might even consider subtler, more opaque, less obvious solutions, which might not even look like solutions at all but instead -- well, processes. Like the processes of innovation, or of developing best practices, or of discovering productive efficiencies, or of human competition in general. The division of labor, while an ancient concept (HT: Xenophon), isn't the first stop along the mind's route to choice (HT: Vernon Smith). Yet it underlies each and all of the processes that subtly and dynamically improve the human condition -- not to perfection, but certainly to betterment.

We live in an imperfect world -- a simple and obvious point that the current political climate simply and obviously ignores. So it is noteworthy when prominent voices urge our policies in the direction of processes that, while imperfect, will make us better off.

Last week Jeffrey S. Flier, who is the Dean of Harvard Medical School, published "Health Care Reform: Without a Correct Diagnosis, There is no Cure" Journal of Clinical Investigation, Sep 10, 2009. (HT: Jeffrey Flier). Dr. Flier argues that we ought to give policymakers some pause, and we should resist the temptation of falling for a major systemic overhaul that impossibly purports to fix all problems in one fell swoop. Rather, based on a sound (rather than political) understanding of the problems, we should: 1) neutralize the tax privilege of employer sponsored insurance; 2) eliminate barriers to entry in medical services and especially innovation; and 3) look seriously at Medicare and Medicaid (although he doesn't elaborate, he is noteworthy for even going near these third rails). Dr. Flier's paper is also discussed in today's WSJ editorial. Elsewhere, and earlier, Dr. Flier co-authored with Terry Flier a lengthier essay on the principles of freedom and beneficial consequences of exchange in health care markets. Greg Mankiw blogged about it favorably here.

Dr. Flier's colleagues at Harvard Medical School, Gerome Groopman and Pamela Hartzband, peel back the rhetoric offered in President Obama's summer health care stumps. Underneath, they shed light on the intersection of economics and medicine. The best section in Drs. Groopman and Hartzband's article shows us how best practices in medical treatment are discovered. Best treatments change quickly with new evidence, new drugs, new devices, and good judgment at the individual doctor-patient level. It cannot be centrally planned, even by good, smart people.

Even when experts examine the same data, they can come to different conclusions. For example, millions of Americans have elevated cholesterol levels and no heart disease. Guidelines developed in the U.S. about whom to treat with cholesterol-lowering drugs are much more aggressive than guidelines in the European Union or the United Kingdom, even though experts here and abroad are extrapolating from the same scientific studies. An illuminating publication from researchers in Munich, Germany, published in March 2003 in the Journal of General Internal Medicine showed that of 100 consecutive patients seen in their clinic with high cholesterol, 52% would be treated with a statin drug in the U.S. based on our guidelines while only 26% would be prescribed statins in Germany and 35% in the U.K. So, different experts define "best practice" differently. Many prominent American cardiologists and specialists in preventive medicine believe the U.S. guidelines lead to overtreatment and the Europeans are more sensible. After hearing of this controversy, some patients will still want to take the drug and some will not.

This is how doctors and patients make shared decisions—by considering expert guidelines, weighing why other experts may disagree with the guidelines, and then customizing the therapy to the individual. With respect to "best practices," prudent doctors think, not just follow, and informed patients consider and then choose, not just comply.

What would be a man of systems' preference for developing best practices? Quoting Groopman and Hartzband, "The president also said there should be financial incentives 'to allow doctors to do the right thing'."

I've never been, but I suspect you can learn more than good medicine at Harvard Medical School. These are refreshing and informative reads, well worth being absorbed in their entirety, both for understanding health reform and for learning good economics.