parkerMy friend Josh Freeman and I have had an ongoing discussion over the last 15 years regarding the (un)design of our health system and the fact that every system is designed to get the results it achieves. Based on our results, the current design “bites the wax tadpole” as the Chinese say. Josh has calls for the complete redesign of the system. I tend to agree with Johnathan Cohn in “The New Republic” that one of the things that killed the last effort at serious reform was the fear of the overwhelming that threatening to retool one sixth of the economy all at once invariably brings. I tend to look at HR 3200 as being a little over half a loaf. as does the National Rural Health Association. It is not perfect. It does not going to go far enough to correct payment  inequities that lead to students to select training to become “partialists” rather than primary care specialists. What it does include is increased money to assist with training of generalist physicians and important fixes to the system of paying for this training and increased money for the National Health Service Corps. It also includes some (but still not enough) money to establish the “Medical Home” as a method of care delivery. It could include more on mental health and rural trauma as well but all in all, not a bad start. Now lets see what happens as the sausage gets packed in the skin.