And I don’t think that most Democrats, surveying the 2010 political landscape, will agree with Jonathan Chait’s assertion in The New Republic, “The health care bill is the greatest social achievement of our time.” Or if they do agree with Chait, it will be with the grim ruefulness of old King Pyrrhus (pictured above). You know, as in, Pyrrhic victory--the kind of victory you’d rather not have.
From an electoral point of view, this bill will divide and demoralize the left; Keith Olbermann and Arianna Huffington, to name just two big-gun lefties, now seem liberated to trash this Democratic president. Every day. And in the meantime, the bill will raise taxes on many individuals and institutions in the middle, all to pay for benefits that will kick in years down the road.
And the secular decay of the healthcare system will continue. Not only will innovation be stifled, but the centrifugal forces in American life--including, but not limited to, political polarizing, conspiracy theorizing, trial lawyering, and computerized cherrypicking--will further spin the healthcare system into a million little pieces.
Obama, Pelosi, Reid & Co. can’t be blamed for that larger out-of-control trend, but, with this bill, they now take full and complete ownership of the issue.
Politico's "Arena" section asks if the Senate bill is sausage-making. My answer:
It’s not sausage-making, it’s three-card-monte-playing.
As Politico observes, just about every Democratic Senator is pointing to some special provision that he or she inserted into the Senate bill, to help the folks back home. Thus, for example, Ben Nelson claims perpetual Medicaid funding for Nebraska, Chris Dodd will soon be taking credit for a new hospital in Connecticut. But, we might observe, if every Senator claims a special deal, then they can’t all be good deals. Someone will eventually figure out the fiscal net, to and from each state, as a result of this bill, and by definition, a lot of states will be net losers.
I suspect, for example, that Minnesota will come out behind; Amy Klobuchar said on “Fox News Sunday” yesterday that she had secured a 50 percent cut in the new tax on medical equipment--a tax that would fall heavily on manufacturers in her state. So a $40 billion tax is now a $20 billion tax. So is that a $20 billion tax cut, or a $20 billion tax increase? It’s both. But $20 billion is still a lot of tax. Sorry, Gophers, and Hoosiers, and Bay Staters.
Moreover, as Kent Conrad also pointed out yesterday on “Fox News Sunday,” this Congress can’t bind future Congresses. And so, for example, when the federal government starts looking around for ways to reduce spending--to avoid, as President Obama warns us of, the “bankruptcy” of the federal government--those standout special spending items Senators are using now as a kind of “public finance” to their own re-election campaigns will be easy targets.
But the whole point of three-card-monte is not to build an enduring monument of some kind--the point is to get the money away from the rubes. Or, in this case, the votes away from the voters.
Is medicine a life-saving endeavor? Is it the art of healing, combined with the science of life? Or is it a statistical exercise--just an offshoot of utilitarian economics, the most dismal branch of the dismal science? If it’s the former, then medicine should be celebrated. If it’s the latter, then “healthcare,” a concept borrowed mostly from social science, should dethrone medicine and all is lore, and we should all die at the most economically opportune time. The choice is ours. Unless, of course, Washington-based bean-counters make the choice for us. As they fully intend to do: cue up the current debate over Obamacare.
And as we shall see, the power of these reigning social-science bean-counters--these “sophists, economists, and calculators,” to use Edmund Burke’s famous phrase--is so strong that even the most heroic of doctors feel defensive about their life-saving work. And that’s a sad state of affairs.
On December 14, The New York Times’ Denise Grady published a genuinely inspiring chronicle of the heroic effort to save the life of one Robert Collison, a 59-year-old Wisconsin man of no great importance--except to his wife and family, his friends, and to God. Which is to say, Collison is, in fact, important. As are all of us.
But since he was suffering from a rare form of seemingly inoperable cancer that had surrounded his liver and other internal organs, Collison faced quick death earlier this month. But Dr. Tomoaki Kato, a surgeon at New York-Presbyterian Hospital/Columbia University Medical Center, was willing and able to perform an ex vivo resection--Collison’s cancer-strangled organs were removed, the tumor sliced away, and the organs restored to his body.
Here’s how reporter Grady described some of Kato’s efforts: Surgery is a stunning blend of finesse and brute force. The incision was a huge, cross-shaped cut that ran from Mr. Collison’s breastbone to his pubic bone, then across his belly near the navel. Metal retractors needed to hold open the wound looked like tools from a hardware store, and it took three people to wrestle them into place. Electrocautery pens that did much of the cutting sparked, smoked and sent up a stench of burning flesh. Suction probes like bigger versions of the ones that dentists use gurgled as they vacuumed blood from the incisions.
The finesse is in the hands. Dr. Kato’s moved with confidence and grace that became all the more apparent when he worked across the operating table from someone less deft. An anesthesiologist said Dr. Kato had “soft hands,” reflected in the monitors tracking the patient’s pulse, breathing, electrocardiogram and blood pressure. When soft hands cut, stitched and moved organs around, the monitor readings held steady, but they spiked up and down when rough hands took over.
Surgeons tie knots in every single stitch. Dr. Kato said he made anywhere from 3 to 10 knots per stitch, depending on the type of suture material and the tissue being sewn. Nylon takes more knots than silk, arteries more than veins. Looking over his shoulder was like watching a magician: with a wave of his fingers, a knot would form, and it was possible to see the trick over and over without quite knowing how it was done. For Mr. Collison’s operation, he would ultimately tie 5,000 knots.
And they had to be tied just so. When a surgeon still in training pulled a knot too tight, Dr. Kato said, softly but insistent, “Don’t break the tissue, please.” At times, if helping hands fumbled, he would gently brush them away and say, “No, let me do it.”
When the liver finally came out, the tumor hanging from it was a dense, meaty-looking mass the size of a football. Embedded in the tumor were segments of Mr. Collison’s stomach, pancreas and intestines. Dr. Kato handed it to Dr. Jean C. Emond, the hospital’s director of transplantation, who cradled it in a purple towel like a grotesque baby. He estimated that the whole reddish-brown slab — tumor, liver and parts of other organs — weighed about 15 pounds. Ten of which were tumor.
Then Dr. Emond and Dr. Benjamin Samstein slid the grisly thing into a basin of icy salt water and went to work on it. The idea was to strip away the tumor, with minimal damage to the liver and its blood vessels and ducts, and then reimplant the liver.
And so Collison’s life was saved by Serious Medicine. Nobody knows for how long, but we know for sure that Collison would have had no chance were it not for Dr. Kato and his team.
But reporter Grady takes note of concerns that the New York City doctors harbor, even as they fulfill their Hippocratic duties:
A 43-hour operation inevitably raises questions about the best way to use medical resources. Dr. Emond, who eagerly hired Dr. Kato as a rising star who could push the envelope in transplant surgery, said that even he was somewhat conflicted about operations that he called “extravaganzas.”
“What does this mean for medicine, doing these incredibly complex procedures to save individual lives?” Dr. Emond asked. “It’s an important philosophical question.”
He referred to the Talmudic teaching, that whoever saves one life saves an entire world. But he added, “That’s not a very health-policy, quantitative way of looking at it.”
Another argument for the surgery is like the rationale for sending people to the Moon, Dr. Emond said: “Understanding things better or extending the limits of care in these extreme situations somehow moves the whole field of medicine forward.”
Both he and Dr. Kato likened ex vivo operations to the early days of liver transplants, which originally took twice as long as they do now and met with harsh criticism. Hopefully, we’ll get more efficient and make the surgery better,” Dr. Emond said. He noted that surgeons had a saying: “The great surgeon invents an operation that only he can do, and the truly great surgeon invents an operation that everyone can do.”
Thus we come to the ethical and political crux of the Times story: Was all this effort on behalf of Collison worth it? Was it a worthwhile expenditure compared to other possible priorities? Let’s take a second look at a key sentence from the passage above: [Dr. Emond] referred to the Talmudic teaching, that whoever saves one life saves an entire world. But he added, “That’s not a very health-policy, quantitative way of looking at it.”
Indeed, a 43-hour operation to save a single life is “not a very health-policy, quantitative way of looking it.” For one thing, such an operation is qualitative, not quantitative. It’s about the quality of mercy, and that’s hard, if not impossible, to quantify.
And yet it’s interesting, and revealing that Dr. Emond, a distinguished doctor, feels defensive about his own profession and what he does to save lives--that he feels that he has to explain himself to social science.
Medicine, from at least the time of Hippocrates, is naturally focused on the patient. And because of that personal focus, the overall romance and mystique of medicine is inherently qualitative--save one life, goes the Hippocratic argument, and you save the world. Saving people, one by one.
And that's why civilization has so revered medicine through most of human history. Not only is there the life-saving aspect, not only the religious element--do God's merciful work here on earth--but there's also a romantic element. That’s “romantic” with a small “r,” as in, say, “Magnificent Obsession,” but also romantic with a capital “r”: dueling with death, battling fate, taking on long odds, stealing Promethean fire. So yes, there are many good and valid reasons why medicine has been mostly privileged over the millennia, seen as a higher calling that ledgering and bean-counting.
But medicine has not been so privileged lately, at least among the dominant policy classes. These days, “healthcare policy” in Washington DC is seen mostly as a battle between social scientists, financiers and pseudo-financiers, waged not by doctors, but by ideologues--the sophists, economists, and calculators that Burke derided in an earlier era. And yet ironically, that policy battle, bitter as it is, is actually more of a conflation, because both "left" and "right" seem to agree that non-medical ideology and belief is more important than medicine. Thus the two disputant sides have disappeared into a ball, an indistinguishable blur of quant-talk that does nothing for, say, Robert Collison.
Picking up on Dr. Emond's comment, not only is “health care policy” the antonym of medicine--and to the idea that there’s a value in so many people working so hard to save a single life--but “healthcare policy” was, in fact, intended to be the antonym, or at least the antidote, to the exaltation of medicine. Back in the 70s and 80s, the chattering policy classes decided that “medicine” was too cold and technological; and besides, “medicine” was too closely associated with the American Medical Association, a leading bete noire of the left in those days. And so “medicine” beame “healthcare policy.” (And the AMA has been dethroned, shrunken, and substantially proletarianized.)
Yet even so, real people, as they live their lives, are reflexively romantic and qualitative. They'll drop everything, for example, to try to save the life of a child who falls down a well. Yes, from a Kennedy School point of view, such strenuous effort might be deemed a poor investment. But there's a reason why nobody gets elected to public office from the Kennedy School--the folks out there see these life-and-death issues differently.
Because ranged against every wonk is a Wordsworth. Indeed, those who think in the mode of William Wordsworth, rejecting “bottom line” thinking in favor of romantic thinking, vastly outnumbering the nerds. As the great English poet lyricized back in 1807: Getting and spending, we lay waste our powers...We have given our hearts away, a sordid boon!
Not everyone can quote Wordsworth, of course, but almost everyone thinks that morality matters more than money--we all have, or like to think we have, that spark of that celestial fire within us. And such instinctive romanticism is an ongoing rebuke to those who would smother and freeze personal feeling and compassion under the ice of cost/benefit analysis.
But there is another reason why medicine is celebrated: In addition to the romantic element, there’s also the religious dimension, which has inspired so many, over the ages, to go into the healing arts.
Having been reminded, above, about the Talmud, we are also reminded of the story about Jesus in Bethany, the House of Suffering, as recorded in Matthew 26: 6 Now when Jesus was in Bethany, in the house of Simon the leper, 7 There came unto him a woman having an alabaster box of very precious ointment, and poured it on his head, as he sat at meat. 8 But when his disciples saw it, they had indignation, saying, To what purpose is this waste? 9 For this ointment might have been sold for much, and given to the poor. 10 When Jesus understood it, he said unto them, Why trouble ye the woman? for she hath wrought a good work upon me. 11 For ye have the poor always with you; but me ye have not always. 12 For in that she hath poured this ointment on my body, she did it for my burial. 13 Verily I say unto you, Wheresoever this gospel shall be preached in the whole world, there shall also this, that this woman hath done, be told for a memorial of her.
One lesson to take away from these verses is that the Moment, if that’s the right word, can be more important than the broader Context. A single highly specific Good Work matters more than larger, vaguer Good Works. From a Christian point of view, it was more important to illustrate, for all time, in a vivid story, the importance of devotion to Jesus. By anointing Him in anticipation of His death, Christians were subsequently reminded that some things are even more important than aiding the poor. A controversial position, perhaps, but so be it. Religion is always controversial.
And speaking of controversy, one might note the role that conservative religion has played in reshaping the healthcare debate in the last 35 years. Religious conservatives have been at the forefront of the battle against “modernism” in healthcare--modernism defined as Benthamite utilitarianism, using numbers to justify “hard choices” about who lives and who dies.
In the middle of the last century, experts deemed it inevitable, as well as desirable, that we should all be moving toward a more secular calculus about life and death--just as we saw in Western Europe, where assisted suicide and euthanasia seemed to be the confident wave of the future. (In such a “progressive” intellectual context, the Supreme Court’s 1973 Roe v. Wade decision was regarded as just another milestone in the long march to social rationalization.)
From a “numbers” point of view, it makes little or no sense to preserve the life of a 90-year-old in a coma. But history suggests that if we concede that it doesn't make sense to protect the lives of the senescent elderly, then we soon find ourselves slippery-sloping our way to the point where “experts” assert that it's not worth doing too much to save the life of a one-year-old, or a 30-year-old. Medicine and healthcare are, after all, expensive.
So the Right To Lifers, and those who argue for a “seamless garment,” and for “a consistent ethic of life,” have played an historic and decisive role in turning around greatest-good-for-the-greatest-number-type arguments.
Indeed, in 2009, the Republican Party, historically associated with efforts to cut entitlements, found itself playing the role of chief defender of Medicare. An uncomfortable feeling for many libertarians, but nonetheless a decisive triumph for religious (and romantic) sentiment-- a victory for feeling over budget-consciousness.
But can we afford such heroic medicine? That’s one argument of the utilitarians that can’t just be waved away. Heroic medicine, critics say, is expensive medicine, especially when it is expended on “futile care” for “vegetables.” President Barack Obama himself said, just this week, that unchecked medical expenses would “bankrupt” the federal government.
No responsible policymaker can ignore fiscal concerns, and neither religious nor romantic sentiment should blind people to other realities, including economic realities. As Martin Luther declared, our lives must be lit by the light of faith, and by the light of reason.
But as Dr. Emond said to the Times, in the long run, doctors will find a way to streamline even ex vivo surgical “extravaganzas.” And yet history tells us that such streamlining can only occur as the result of repetition--doing the same procedure over and over again, until better and more efficient techniques are identified and applied. Through such a process, streamlining leads to assembly-lining. And assembly-lining is the key to making things better and cheaper.
It’s somewhat paradoxical that we would have to spend more to ultimately spend less, but that’s an obvious lesson of the industrial revolution over the last three centuries. You have to bear the expense of building the factory, and all the costs associated with climbing up the learning curve, before you can get the benefit of mass production. (And the jobs, and the wealth.)
But when you do reach the level of mass production, the expensive boutique item becomes the inexpensive routine item--and also, a much better item. Today, the humblest and cheapest cell phone is a vastly superior machine than the bulky portable phones that presidents and generals were using just a few decades ago.
That’s how Serious Medicine becomes Routine Medicine. And so, for example, if we put our minds to it, not only will ex vivo surgery get cheaper--performed, laparoscopically, perhaps, by robots--but one fine day, tumors will be eliminated non-invasively, through some new and better technique.
That's the story of technology, and it has its own kind of romance to it. The evidence on this score is so overwhelming that those who choose to ignore that evidence--pushing instead policies of scarcity and rationing--qualify as a category of Romantic themselves. As Luddites, peddling an alleged realism that is really pessimism, or even nihilism.
Luddites are entitled to their opinions, however wrong they might be. But when confronted by Luddism in the political and policy sphere, the rest of us are required, for our own sake, to vote against them and to keep them away from our medicine our healthcare, and our loved ones.
The creation of health vs. the redistribution of health--which do you prefer?
The Washington Post, true to its classic media niche as the voice of politics and political power, continues its push for a political approach to healthcare, Politics isn't per se bad, of course--if politics follows an effective model.
Unfortunately, in the current climate, the dominant political model is an ineffective model--a model of scarcity and redistribution in healthcare. The latest expression of politicized scarcity, in what has become virtually a daily drumbeat, is Wednesday's column from Ruth Marcus, entitled "ISO a watchdog for health-care costs." (ISO, of course, is personals-ad shorthand for In Search Of.)
As Marcus puts it in her lede, the political healthcare hero she is looking for "Must be willing to take on drug companies, hospitals, doctors and other providers." We might immediately note that it's a warning sign for any political model when it's assumed that healthcare providers--drug companies, hospitals, doctors--are the opposition to be curbed. And we might further note that, for whatever reason, Marcus chose not to mention trial lawyers.
But in fact, healthcare providers aren't the foe, they are the friends. The friends who will provide the treatments and cures we need. If those providers aren't doing enough, they should be encouraged, however strenuously, to do more, but any solution to healthcare will involve healthcare providers doing more, not less.
Kitts is one of "tomorrow's people," a group whose missing or ruined body parts are being replaced by devices embedded in their nervous systems that respond to commands from their brains. The machines they use are called neural prostheses or—as scientists have become more comfortable with a term made popular by science fiction writers—bionics. Eric Schremp, who has been a quadriplegic since he shattered his neck during a swimming pool dive in 1992, now has an electronic device under his skin that lets him move his fingers to grip a fork. Jo Ann Lewis, a blind woman, can see the shapes of trees with the help of a tiny camera that communicates with her optic nerve. And Tammy Kenny can speak to her 18-month-old son, Aiden, and he can reply, because the boy, born deaf, has 22 electrodes inside his ear that change sounds picked up by a microphone into signals his auditory nerve can understand.
One expert gets us to the bottom line: "That's really what this work is about: restoration," says Joseph Pancrazio, program director for neural engineering at the National Institute of Neurological Disorders and Stroke. "When a person with a spinal-cord injury can be in a res taurant, feeding himself, and no one else notices, that is my definition of success."
"Restoration"--what a concept! How could we calculate the value of a new arm? From a strictly dollars-and-cents point of view, a new arm for Anita Kitts might be construed as a cost--all this research on robotics costs a lot of money. Millions. Billions. Would it be cheaper to just leave Kitts crippled? Maybe, in the crabbed and cramped reckoning of the Congressional Budget Office. But from a human point of view, the answer is completely the opposite. We might think, for example, of all the limbless veterans who are coming back from Iraq and Afghanistan.
Moreover, the creation of robotic prosthetics could be a huge industry. But we're less likely to get there with the current scarcity model of politicization.
In the meantime, Marcus seems to be in love with numerical projections. But as noted here at SMS many times, healthcare budget projections have little predictive value. Nonetheless, numbers offer a crutch to pundits; many seem to prefer illusory certainty to no certainty: A recent analysis of the Senate proposal by Richard Foster, the chief actuary for the Medicare program, offers a sobering demonstration of this reality. If the Senate measure were to become law, Foster concludes, overall health-care spending would increase by 0.7 percent, or $234 billion, over 10 years. The House measure, according to Foster's analysis, would drive up spending slightly more, by $289 billion.
The point here is not that spending control is a bad idea, but rather, we shouldn't live under the illusion that illusory spending control is the same thing as real spending control. And so might further take note of the pseudo-precision in the data that Marcus cites: It's possible to read the report in a more hopeful light. By 2019, Foster estimates, national health-care costs will be growing at an annual rate of 6.9 percent, compared with 7.2 percent in the absence of reform. A welcome degree of "curve" bending -- if it persists. That's a big if. The trend line for spending growth under health reform at the end of the decade is rising, and the gap between spending increases with and without health reform is narrowing.
But as Joseph Califanoobserved to Elizabeth Drew in The New York Review of Books recently:
It's preposterous to project ten-year costs. When we passed Medicare no one foresaw MRIs, CT scans, transplants, or the explosion of life expectancy. And now we're on the verge of a revolution in neurology and in genetics, stem cell research, and multiple transplants.
Here's the bottom line: If all the visionaries on healthcare--the folks who wish to change the nature of healthcare through technological transformation--get to do their thing, we will have a) better health care, b) better health, c) whole new industries, and d) lots of new jobs.
And by the way, from a strictly political point of view, creation, as opposed to redistribution, is a winning electoral value.
Two tough articles on spending in Monday's Washington Post require some thought--more thought than they are currently receiving. And that thought should include new approaches, because as we shall see, the old approaches, and the old solutions, aren't getting us anywhere.
Samuelson notes, with skepticism, claims from leading administration figures that there is so much waste and redundancy in the current system that spending restraint can be accomplished relatively easily:
The administration insists that it can insure most of the uninsured and tackle runaway health spending simultaneously. There's so much waste in today's health-care system that both goals can be pursued together, Peter Orszag, head of the Office of Management and Budget, has said.
But all this optimism is likely ill-founded, Samuelson concludes: The relentless advances reflect an open-ended insurance and delivery system that gives neither patients nor providers any reason to restrain spending. To attack costs first would be politically challenging. It would require admitting that all good things are not possible simultaneously and that the uninsured already receive much medical care. It would require genuine bipartisanship, not just a scramble for a few Republican votes. And it would require stronger measures to dismantle a fee-for-service delivery system that now rewards more, not better, care. That's a demanding and realistic approach; Obama's is wishful thinking.
Second, the Post's editorial page weighed in with an alarmist piece headlined, "The coming debt panic." Citing the work of the Peterson-Pew Commission on Budget Reform, the edit begins, "It is time to stop worrying about the deficit--and start panicking about the debt." Continuing in that vein, the edit continues: In the space of a single fiscal year, 2009, the debt soared from 41 percent of the gross domestic product to 53 percent. By way of comparison, the average for the past half-century has been 37 percent. This sum, which does not include what the government has borrowed from its own trust funds, is on track to rise to a crushing 85 percent of the economy by 2018. Getting the debt back down to a reasonable level will require extraordinary, almost unimaginable, fiscal discipline and political cooperation. Failing to do so will lower the national standard of living and ultimately threaten America's economic stability.
And so the Post endorses: Warnings about fiscal danger may sound familiar, but one reflection of the current circumstances comes in the composition of the group that signed on to this report and agreed that both tax increases and spending cuts would be required. They range from a liberal former chair of the House Budget Committee, William H. Gray III of Pennsylvania, to a conservative former chair, Jim Nussle of Iowa. The recommendations envision annual benchmarks, enforceable by a debt trigger that would impose spending cuts and a surtax if the specified reductions were not achieved. Once the debt is stabilized in 2018, the goal would be to set it on a glide path to further reduction, closer to the historical average of below 40 percent.
And the Post also lauds a bipartisan duo of Senators for their suggestions on budget restraint: "Last week Sens. Kent Conrad (D-N.D.) and Judd Gregg (R-N.H.) introduced a new version of their proposal to create a 'fiscal task force' to recommend a package of tax and spending changes." Marrying the notion of enforceable debt levels to a commission that could come up with ways to achieve these goals would be an interesting, and potentially productive, union. Both concepts are premised on the notion, sadly correct, that the fiscal picture is too daunting and too politically sensitive to be addressed under the regular order. As the Peterson-Pew report grimly underscores, time is running out to come to grips with that unpleasant fact.
This is all well and good. Here at Serious Medicine Strategy, we won't quibble with a single fact adduced by Samuelson. Nor will we argue with the data assembled by the Pew-Peterson folks. Indeed, we realize that healthcare costs--most notably, Medicare, are the biggest single driver of federal budget increases.
But it's the Pew-Peterson recommendations, seconded by the Post, that trip us up. Some, of course, will point to the virtually built-in tax increases built into the Conrad-Gregg proposal. Americans for Tax Reform, among other conservative/libertarian groups, has already condemned the Conrad-Gregg proposal, and would similarly denounce the Pew-Peterson recommendations. It is, indeed, hard to justify tax increases at a time such as this. And in any case, it will probably be suicidal, politically, for many of the lawmakers who might vote for such a proposal.
As as we have noted in the past, there's a right way and a wrong way to go about cutting healthcare--or more precisely, an effective way and an ineffective way. What's ineffective is to try to make cuts in healthcare, for example, by simply cutting back on healthcare. Such cuts inevitably mean real pain to real people, and history shows that such cutting is not popular--profoundly unpopular, in fact. The elites in DC and New York can provide all the arguments and justifications one could want, but the voters never seem to agree.
And so what's a politician to do? Is it too cynical to say that if the average politician were confronted with a choice--a) let spending continue and see the government go bankrupt, or b) vote to cut such spending and lose your seat--that the average pol would go with a)? That might be too harsh, or it might be a statement of risk-averse/welfare-maximizing people would do in an environment where somebody would be telling them that a) isn't really so bad.
So what's needed is a new kind of thinking, perhaps along the lines of Team B, an analytical group set up by then-CIA director George H.W. Bush in1976 to provide another line of thinking about the Soviet threat. Team B was and is controversial, but at a minimum, in times of crisis, it is a useful exercise to encourage speculative thinking and analysis, because one never knows for sure where it will lead.
And with fiscal crisis looming dead ahead, what's desperately needed right now is speculative thinking and analysis. If the goal is to cut healthcare spending, is there any way to do it without inflicting pain on patients? Without causing all incumbents who vote for spending restraint to lose their seats, to be replaced by new officeholders with a mandate for fiscal non-restraint??
And the answer: Sure there is. We could use our brains to come up with better answers, just as we have a hundred times in the past. If we really wanted to save money on healthcare, we could figure out how to keep people from getting sick, and/or we could figure out how to cure them. In the past, it was cheaper to prevent polio through the polio vaccine than it was to treat them after they were crippled by polio.
Today, if the Pap Test reduces the incidence of cervical cancer, that's a savings. If statins prevent heart attacks, that's a savings. If exercise prevents heart attacks, that's a savings, too. The list of preventive strategies, and cure strategies, is long indeed. So why aren't they fully incorporated into our thinking about healthcare spending?
And there's an additional element, too: If cures are developed, they can be sold, not only to Americans, but to the world. If a fully effective treatment for Alzheimer's were developed--a treatment that staved off the onset of the dreaded disease--it's safe to say that a lot of people would happily buy that drug for decades. Decades in which they could be, if they wished, economically productive. Not just in America, but around the world. And that's a revenue stream--for individuals, for corporations, for cash-strapped governments.
If the situation is urgent, and it is urgent, then we need every possible option in front of us. We need a Team B for healthcare spending, to consider out-of-the-box approaches to saving money. Yes, such thinking is difficult. But if there's no good alternative, then, we can say, there is no alternative.
Because otherwise, Pew-Peterson-type efforts are doomed, even with the Post on their side.
"What Cereal Should I Eat?" is a light-hearted flowchart done by a blog called Eating The Road.
And while this particular chart is strictly for laughs, there's a serious potential healthcare point lurking in these schematics: One of these days, there will be cool and easy to use programs--as user-friendly as iPhone apps--for many if not most healthcare concerns. To nudge you about what to eat, what not eat, to remind you about taking your medicine, and so on. There are plenty of these products already on the market, but they aren't yet as ubiquitous, or as cool, as what can be found on, say iTunes. It'll happen, and when it does, we will be healthier.
To be fully effective, healthcare IT can't just be for doctors and hospitals, it will have to be there for patients. That's the lesson of the Internet; it doesn't really work all that well until it becomes the operating standard.
This is the speech that President Barack Obama should have delivered when he accepted the 2009 Nobel Peace Prize:
Building A House of Mercy and Grace
Your Majesties, Your Royal Highnesses, honorable members of the Norwegian Nobel Committee, excellencies, ladies and gentlemen.
Thank you for this honor, which should not go just to me. I accept this Nobel Peace Prize on behalf of humanity--a humanity that wishes to live in peace, and that also wishes to live long, happy, and productive lives. And so there is much to be done, starting right now, starting tonight.
Please allow me to explain what I have in mind. I am here to announce a new concept--that is, a Serious Medicine Strategy--aimed at bringing all the nations and peoples of the world together, united into common cause. And that common cause is the accelerating of the search for medical cures. That’s a sure route--as sure as there can be--to world betterment.
Some might now ask: Am I here in Oslo to accept the wrong prize? No. I am neither a doctor nor a scientist, but in my reading of history, and in my public-service career, I have seen the power of collective action. And the time has come for constructive collective action, in an area where opportunities are ripe. That’s part of what many of us in America call servant-leadership--to humbly seek opportunities, and to maximize the benefit of those opportunities. And the big opportunity in front of us now is cures, medical cures.
Why? Let’s face it, the science of medicine is a lot further along than the science of peace.
War or conflict between nations is inevitable, and sometimes just. I believe that America and many other nations, today, are fighting a just war in Afghanistan. But suffering from many illnesses is not inevitable, and dying from preventable illnesses is not just. Nations can and will disagree about many things, but they can all agree and work towards eradicating illnesses and promoting health and longevity.
So we must be realistic. We must focus on what we can build and keep. And we can keep scientific knowledge, even if political understanding and cooperation fail us. Human nature is, alas, cyclical, while technology is, happily, linear. That is, we can reliably build on yesterday’s medical progress, building for today and tomorrow.
Don’t get me wrong: Peace is a great goal--and we must always work toward harmony and understanding--but peace is not always a realistic goal. Treaties and arms control agreements are valuable, but, in the minds of some, they are mere scraps of paper. And that is why we still need strong defenses--whole systems of defense, in fact. Tonight I will be talking about medical defenses.
If the last few million years of human evolution have taught us anything, it is that ending war is impossible so long as starting a war is so possible, so easy. Indeed, new technologies make war and violence easier than ever. War can come at the push of a button. Even before Pandora opened her allegorical box, it seems as if we have not been able to resist various temptations. We must realize that these deadly technologies are not going away, much as we might wish them gone.
So instead, we must turn those technologies on their head--from lethality to life-giving. As Abraham Lincoln once declared, we conquer our enemies by making them our friends. In a crowded world, full of destructive power, we have few alternatives, other than to carve out new zones of survivability and longevity. We must honeycomb the house of war with safe rooms, perhaps whole wings of survivability. Am I a pessimist? Or, perhaps worse, a cynic? No, not at all. I am supremely optimistic that we can make a better life for all the peoples of the earth--and that the people of my country can help point the way.
If we can’t end wars waged by humans against each other, we might be able to end much of the damage that wars do. And we can end, at least, some other kinds of evils--namely killer diseases that have killed in the millions, even billions.
What do I mean? We can go on the offensive ourselves. We wage war against the leading causes of illness, incapacitation, and death.
In undertaking these medical missions, in defending humanity against a common enemy, death, we can find common cause. As a child, I watched the old movie from 1951, “The Day The Earth Stood Still.” By the end of the film, the nations of the world discovered that they had more in common than they thought. Indeed, they had everything in common.
Because, after all, the desire to live, and to grow, trumps just about everything else. As Bruce Springsteen put it in a classic song, “It ain’t no sin to be glad you’re alive!”
Back in my home country, the American people are currently embroiled in a struggle of a different kind--a battle over healthcare policy, specifically, health insurance.
This struggle, in Washington DC, is not over yet, and I hope that the cause of “universal” coverage prevails, because I believe, as do most Americans, that everyone in a nation should be insured and have access to quality care.
But I can see that “healthcare policy” will always be a divisive issue. It’s extraordinarily difficult, if not impossible, to achieve consensus on such issues as abortion, assisted suicide, and any policy that could be construed as “rationing.” This stubborn reality has been a lesson to me. And if I am going to be true to my oath--to be president of all the people--then I must learn and reassess. We are all on this journey of discovery together. And that has led me to a new appreciation for the importance of cures, because even if people disagree on the details of policy, they all agree on the goal of good health and longevity.
I now see that healthcare policy is not an end in itself. The purpose of healthcare is not just to get everyone covered; the real purpose is to get everyone cured. We must be mindful of equity issues, and social-justice concerns, but we must always remember: You can’t redistribute health unless you have first created health.
All across American society, we have allowed our preoccupation with financial mechanisms to get the best of us, and to get the better of our judgment. And yet ironically, for all of our thinking about financial issues, we have done a bad job of thinking about our fiscal future. The current focus in Washington DC on the projected unsustainability of entitlement spending is needed and worthy, but we need to be smarter about our future strategy. Proposed cuts that can’t possibly occur are not particularly useful. There has to be a better way.
And there is. But we need a new and much different approach, which finds a new unity between the imperative to cut costs and the imperative to find cures. As another Nobel Laureate, Albert Einstein, once explained, “No problem can be solved on its own level.” That is, you can’t simply shuffle around the existing set of variables and expect to get something better. “Better” requires something different--some new input of imagination or inspiration. That’s what changes the equation.
We have before us the very real prospect of changing the equation.
What do I mean? I mean we should apply the basic lessons of a once dramatic historical event, the Industrial Revolution, to a new kind of revolution--a Medical Revolution. That is, we should start with heavy research and development, followed by mass production; thus we would reap the rewards of falling costs and rising quality--and by the way, enjoy a rising standard of living. Three centuries of history tell us that this is the way the world works.
That’s the game changer, if you will.
Through this time-tested method, we can cut the Gordian Knot of healthcare--because we don’t have time to slowly unravel the metaphorical bind that we find ourselves tangled in. We can attack the underlying source of the cost increases for healthcare. That’s how to “bend the curve.” Health is cheaper than either sickness or death. Cures bend the curve.
So in recent weeks, I have been thinking about a new strategy for American health, as well as for world health. That’s a true universalism--a universalism of the best possible health.
I have been consulting with Nobel Prize winners in medicine, and other experts in health and medicine, to talk about the breakthroughs we might achieve. And the humanitarian gains. And yes, also, the financial savings. We can’t repeal the basic realities of economic scarcity, but we can bend upward the curves of medical productivity, just as we have bent upward the curves for automobiles, computers, telephones, and medicine.
Additionally, in recent weeks, I have met with the heads of our leading health and public-health agencies and scientific institutes. I have met with foundation leaders and philanthropists, as well as with the chief executives of large corporations, some of which focus on health, but many of which don’t--although, of course, we are all connected to health concerns, in myriad ways. I am convinced that the latest advances in supercomputers and information technology can be harnessed to the task of improving health care, bringing the accelerating power of the microchip, --first foreseen by Intel’s Gordon Moore in the 60s, and now remembered as Moore’s Law--into closer harmony with our equally lofty goals for medical breakthroughs.
And I have met with leaders of Congress, in both parties. We have not agreed to put aside all our political and ideological differences, nor should we. But we have agreed that the delivery of cures has been a neglected area--neglected by both parties. Thus we will change. We will agree to agree on finding cures, and in so doing, we might well come to realize that our differences are shrinking as our common ground gets larger.
Once again, we can’t distribute--either by the market or by political action--that which doesn’t exist. Only after we create public goods, after they exist can we wrangle over the precise allocation of those goods. So let’s agree on the creation, and only then argue about the distribution. Let’s create an international medical entity, beyond the World Health Organization, to work with all the sovereign nations of the world, focusing on these great goals.
What unites all of us is the realization that the benefits of a new focus on cures are more than bipartisan; they are human. The impulses to health and life are more powerful than mere partisanship or ideology.
We call this coming together a Serious Medicine Strategy.
I say “Serious” because we are not talking here about the routine healthcare issues, as important as they are. Routine issues can be dealt with in different ways, by different people and cultures.
I say “Medicine,” as opposed to “health care,” because we are talking about those serious topics that require serious intervention. Serious illnesses require serious medicine.
And I say “Strategy,” because we need a comprehensive approach, not only for America, but for the world. The challenges to our health--the challenges to our lives--are too profound to be dealt with in piecemeal fashion.
I believe that only a Serious Medicine Strategy will help us out of the research & development rut in which we have found ourselves--a trough of rising prices, and disappointing productivity gains, as well as a bleak future of ruinous cost increases.
In democratic societies, we get the government that we deserve, that we want. As we think back on our own history in America, we see that when we really and truly want to get something done--when we have achieved an overwhelming consensus for action, backed up by real commitment and sacrifice--then that something gets done. That’s how we explored and filled up a continent. That’s how we freed the slaves. That’s how we built the railroads. That’s how we overcame the Depression. That’s how we won World War Two. That’s how we enacted civil rights. That’s how we built the Internet. That’s how we made great progress in cleaning the environment and putting the earth on a more sustainable course.
And the same is true for the world. From ending the slave trade and writing the Geneva Conventions in the 19th century, to outlawing gas warfare and establishing the United Nations in the 20th century, the world has come together to great things.
Some might say that the government--any government--is not competent to undertake this task. But I might remind those skeptics that we have been down the road of medical breakthroughs before--and government steered us there. Polio was mostly wiped out in the 50s. Smallpox was entirely wiped out in the 70s. We made great strides against HIV/AIDS in the 90s. And we could do more, much more, if we stuck with it, if we showed true and genuine political resolve.
Will we make mistakes? Of course.
But I am reminded of these lines from one of my presidential predecessors, Franklin D. Roosevelt, back in 1936: Governments can err, presidents do make mistakes, but the immortal Dante tells us that Divine justice weighs the sins of the cold-blooded and the sins of the warm-hearted on different scales. Better the occasional faults of a government that lives in a spirit of charity than the consistent omissions of a government frozen in the ice of its own indifference. There is a mysterious cycle in human events. To some generations much is given. Of other generations much is expected. This generation of Americans has a rendezvous with destiny.
“A rendezvous with destiny.” More than one of our great presidents have used that phrase, and it’s right and proper that leaders in both parties should remind us of history’s call, of our need to hearken to its sound.
Yet too often, as we have deliberated over our Serious Medicine Strategy, we have heard this response: “Yes, cures are wonderful, but we can’t afford them right now. There are greater immediate priorities.” This sincere but limited response has led us to an even deeper reconsideration of our current system--that is, the current structure within which medicine and healthcare are generated.
And so we came to see that our accounting system measures the wrong things. Our accounting accurately measures the cost of everything, but it never adequately considers the value of long life and happiness. Therefore, instead, we are establishing a new accounting regime, which sets the future in a 100-year time cycle, so that we can compute the value of good health, and weigh that value against the cost of sickness. We already know that healthy people are a greater asset than people rationed out of their wellbeing. Now we must reflect that reality with our numerical assessments.
John Maynard Keynes was right when he said that “animal spirits” were at the basis of economic growth. Life, energy, and even exuberance--joie de vivre--are at the basis of everything constructive that we do on this earth. Life is the ideology at the base of all other ideologies.
And two more great economists, Kenneth Arrow and Robert Fogel, both Nobel Laureates in Economics, have argued that we shouldn’t worry about rising medical costs--provided that we make sure we are creating medical benefits that exceed those costs. As an investor would say, we need a “hard ROI,” a hard return on investment--that is, a specific and verifiable return on investment to justify the expenditure. If we can discipline ourselves on this matter, always focusing on a positive ROI, there is no limit to what we can accomplish. That’s the nature of increasing returns, as opposed to diminishing returns.
But we also have some housekeeping work, back home in America. We must address our legal policy toward malpractice and medical mistakes of all kinds. While we will never tolerate bad behavior or victimization of populations, we also understand the need for a protective armor--a conscious strategy for protecting risk-takers--is needed for the advancement of medical science. And that means appropriate legal shield and regulatory shields, even spearheads, for the strategic health and medical goals we wish to achieve. That’s what sovereign powers do; they use their sovereignty to good ends.
In addition, in America, we will be working with Congressional leaders to review our policies on anti-trust, even as we strengthen protections for intellectual property, so that the time horizons of inventers and investors can be lengthened. And we will be encouraging other countries to enact the same policies, again, with an eye toward persuading inventors and investors that we want them to cluster in the health and medical sector, so that we and all future generations can benefit from a “permanent revolution” of scientific and entrepreneurial endeavors. Yet our goal is not to make corporations and investors richer. Instead, our goal is to produce more high quality medicine, and then to make sure that such medicines are distributed at fair prices to all who need them, in America and around the world.
That’s what the late Jack Kemp, a Republican leader whom I always greatly admired, called “The Good Shepherd” approach. Let’s use our compassion, as well as our wisdom. Let’s create win-win-win outcomes: better health, lower costs, and greater economic activity--more and better jobs--as the icing on the cake.
I share all this with you, not because everyone around the world is fascinated by American politics, but because I am convinced that what we have achieved in the United States will prove to be a microcosmic snapshot for the future of a healthier world. Every nation will be different, but in the final analysis, scientific truth is scientific truth, everywhere and anywhere. And the desire for good health, too, is universal.
And the right answer is to work on cures. The right answer is to undercut the superstructure of costs, to go right to the root of the problem, which is expensive care for chronic diseases.
OK, but one big question: How to pay for all this ambition? How can we pay for our Serious Medicine Strategy, and avoid increasing the tax burden, and adding to deficits?
Here’s how. We will seek out new sources of capital. Starting in the United States, we will be adjusting our tax laws to see about new ways of funneling funds into worthy projects. We will be selling “Health Savings Bonds” to the public to finance our effort, and working with Wall Street and other financial capitals to see what new financing mechanisms might be created, bringing money in from around the world in the most efficient possible manner.
And we will be seeking out still more sources of revenue. We are prepared to announce a special plan to repatriate the wealth of overseas tax shelters, estimated to be as much as $6 trillion, by offering tax and legal amnesty to most tax scofflaws, in return for half of the money being turned over to the Serious Medicine Strategy Fund.
And there is still more to this Serious Medicine Strategy.
I have met and spoken with leaders from around the world. Presidents and kings, prime ministers and emperors, all told me that they and their their countries will help.
In recent weeks, labor leaders, social leaders, and opinion leaders have also told me that they see the potential, here, to provide a great good to all of humanity. Religious leaders, conscious of the importance of moral and ethical frameworks, have given this project their blessing. We are grateful for this support, although we have much more to do.
That’s why we are so confident that the world will share our vision for realizing this Serious Medicine Strategy. Parents everywhere want their children to grow up strong and healthy. Nations wish to be fruitful and multiply. Good leaders wish the best for their citizens.
There is still more to our Serious Medicine Strategy. Mindful, as we must be, of new power relationships, I have also met with financial leaders, the fiduciaries of pension funds, and the of overseers sovereign wealth funds. They are fully committeed to this project. Thus we will have not only a wide variety of stakeholders, but we will have, for lack of a better word, shareholders.
I can also tell you about an exciting new joint venture we have worked out with the Secretary General of the United Nations. Under U.N. auspices, we are going to begin medical research projects within troubled zones around the globe--in the Palestinian territories, in Kashmir, Sri Lanka, Nigeria, the Philippines, Mexico. These “Medical Enterprise Zones,” or MEZ, will focus on regional health issues, while seizing on regional medical resources, such as medicinal herbs and plants. These efforts will not take the place of negotiations and peacekeeping efforts, but we can hope these efforts will take the place of at least some fighting, by providing disputants with hopefully one thing that they can all agree on--better health and cures.
These MEZ will be staffed by diverse groups of volunteers, reflecting the ethnic and religious balances of the particular region. We realize that this is a risky venture, but the volunteers who will go to these MEZ have committed their lives to this process. And we will protect these medical volunteers to the fullest extent of our ability, invoking the moral weight of the highest of humanitarian efforts. Moreover, other new inventions will “harden” these medical-research sites, in order to maximize safety. And thanks to the Internet, it will be possible, in real time, for anyone to log on and watch exactly what is happening in these places. We believe that this total transparency is not only a confidence-builder for the project, but will help keep MEZ safer and more secure.
And scientific progress, of course, is one of the great validators of human cooperation. When men and women come together in common purpose--scientific research for the betterment of humanity--well, that’s a confidence-builder.
So I am also announcing a new data-sharing project, a world medical consortium, called “Mednet,” in the spirit of the Internet.
The Mednet will aggregate, on a voluntary basis, human medical information. As computer visionaries are wont to say, everything, in the end, comes down to information: ones and zeros. This is, after all, the Information Age. And so, too, with health information: every bit and byte of data has a value to the scientific enterprise, in terms of studying health and medical outcomes. Value, that is, if it can be accurately and ethically collected, and if it can be used in a rational and moral way. And so that’s what we will do. Soon, everyone in the world will be able to contribute to our Serious Medicine Strategy.
And in return, people everywhere will get the benefit of the Mednet, if they want it--advice for themselves, monitoring of their health information, and so on. As with the Internet, the Mednet will be structured and refereed by international authorities, but it will be open to contributions from all. In the world today, there are more cell phones, and more computers, than there are people. We will harness those machines to the cause of our own well-being. Out of all those devices, we will create a new web of health, a new platform for cooperation.
The core of the Mednet will be both helpful and interactive. The Mednet will be with you, always, helping and coaching you, if you want, through life.
In the course of these wide-ranging discussions about the future health of the planet, leaders have shared, too, other ideas.
Specifically, ideas on how to do more than just bend curves; we have seen a way to break curves. We will break curves by finding cures.
We have decided to focus on cures for three diseases in particular: cancer, Alzheimer’s, and malaria, building on the wonderful work of the Bill and Melinda Gates Foundation. These are three great killers, afflicting people all over the world. We will add others, but we will make our start with those three.
Sometimes the best way to get something done is through a profound mobilization of resources on a natioal and international scale. That’s “the moral equivalent of war,” as William James put it a century ago, the moment when a civilization, or a planet, comes together in profound agreement: This we will do.
In thinking about this Serious Medicine Strategy, I have thought about the twinned nature of destruction and creation--two horns on the same beast, some might say. Mindful of both, we must focus on one.
The great Alfred Nobel, as we all know, took destructive power and turned it into a creative power. When Mr. Nobel, the inventor of dynamite, who grew rich from the mass production of explosives, signed his last will and testament in 1895, he set in motion a process whereby the best of human thinking--in the sciences, in economics, in literature, and, of course, in peace--has been celebrated and rewarded.
It is Alfred Nobel’s work, and the work of all great visionaries and peacemakers, which we wish not only to recognize, but also to build upon.
offers a clear guide for thinking about strategic mobilization, the sort of William James-inspired pulling together for collective purpose that can apply to the moral equivalent of war, just as much as to war itself.
That’s why, together, we have forged this Serious Medicine Strategy--a systematic connectings of ways and means, something for the world to unite around.
To live in Washington DC, as I have for the last few years, is to be surrounded by war memorials and monuments to soldiers, sailors and heroes of all kinds. They all earned their place in our national pantheon, but they aren’t the only great Americans. We will have more heroes in the future, and we will, of course, honor them, too. To my fellow Americans, I might ask: Where are the monuments to the heroes of health and medicine? Because Milton Friedman was right: The more we reward, the more we will get. So if increasing the honors for medical visionaries means more medical vision, we will increase those honors.
And that’s why part of our strategy is to endow new prizes not only for medical research, but also for the development of medications and cures, nationally and internationally. We believe in the profit motive, but we also know that men and women are motivated by many goals, other than money.
I am confident that the rest of the world will join us in this peaceful effort. Thus we could have a new kind of benign competition--not an arms race, but rather a medical race. I recall with reverence the words of Robert F. Kennedy, who reminded us that we shouldn’t just think of things as they are and ask “Why?” We should dream of things and ask, “Why not?” We understand, of course, that not everyone shares the idealism of the late RFK, and that’s why we seek to knit the world together in a web of relationships, based on medical research and cures. Because if and when idealism attenuates, we will still have the glue of self-interest to keep the structure together. That glue is the most profound self-interest of all--the desire to live.
There are some, of course, who are impatient with the world as it is. They look forward to not just better life, but also to much longer life, or even to life elsewhere in the solar system, or in space. To these people--who include some of our richest and smartest and most talented--I say this: You can’t get to where you want to go without the rest of us. But if you help us, we will help you. Whatever it is you wish to accomplish, on this planet or somewhere else, a strengthened understanding of how the human body flourishes is absolutely necessary as a platform for future advancement. It is simply not currently possible to imagine long space flights, for example, if our bodies are the way they are now. Before we can get into spaceships, we first must survive better on spaceship earth. So we see that Serious Medicine is connected to Serious Research, and Serious Space Exploration. If we all do our part, perhaps a century from now, these awards ceremonies will be heard on more than planet. That would be cool.
But today, for all of this planet, our Serious Medicine Strategy will not be an effort just of the elites. This will be a broad-based effort, across the whole of humanity, from the richest to the poorest. For those who join us--by, for example, joining our World Health Data Project--we will offer a pin, like the one I am wearing on my lapel now. It bears the letters, “SMS,” for Serious Medicine Strategy. People who join with us are entitled to wear this pin, or to put it on their websites, or anywhere else they wish--if they have earned it with their resolve and commitment, by joining, for example, the World Health Data Project. Everyone can be a part of the Serious Medicine Strategy.
My kids tell me that “SMS” stands for “short message service,” and I like that--right to the point. And so with apologies to all those texters out there, here’s something new for you to text: SMS = Hope + Life.
In America, most of us are inspired by the Bible to act justly and to be merciful. But all the great works of religion, and all the great religious leaders, everywhere in the world, have taught the same thing: be just and be merciful. So we will build, all of us, a house of grace and mercy. A house of life. And ultimately, a House of Peace.
Writing on the op-ed page of The Washington Post yesterday morning, Obamacare supporter Ezra Klein tries out a new line of advocacy: He advises workers to line up behind the Obamacare bill because it will raise their wages. As Klein explains, "health-care coverage is not a benefit. It's a wage deduction."
Any more questions? If one ever needed more proof that the healthcare policy establishment sees healthcare as a zero-sum game, Klein's column provides it. Which is not to say that Klein's piece is wrong, in any of its factual particulars.
But the point is that healthcare is, among other things, an economic good--and not only that, it is a transformative economic good. People will happily pay for better health--turn on a TV, and there you see ads for Boniva, or Restasis, or Aricept. Those are desirable goods. If Medicare pays for those drugs, fine, but if Medicare doesn't pay, lots of people would still want them. And of course, the sky would be the limit for drugs and treatment that would truly bend the curve on illness--a cure for Alzheimer's, for example, or even a drug that would significantly slow down its onset.
Cures. That's healthcare at its truest and most profound. The kind of healthcare that makes you better. It was success in the search for cures that turned medical scientists, from Edward Jenner to Louis Pasteur to Paul Ehrlich (the German discoverer of syphilis treatment, and the man who coined the word "chemotherapy," not to be confused with Paul R. Ehrlich, the American Malthusian) into heroes.
But Klein lives in his own new world, in which healthcare advances are to be feared, because they will raise costs, as noted here at SMS in September. In fairness to Klein, he is in good company inside and outside of the Beltway; much of the healthcare establishment has come to see healthcare through a prism of skepticism and negativity, in which awareness of the upside of healthcare is outweighed by appreciation of the downside. It's an intellectual style, a fad among wonks, but for the time being, it's all pervasive. Here's the Klein quote in its original context: But health-care coverage is not a benefit. It's a wage deduction. When premium costs go up, wages go down. When premium costs go down, wages go up. Yet workers don't know that. In fact, the information is hidden from them. That means that cost control seems like all pain and no gain, which makes it virtually impossible for Congress to pass. It's like asking someone to diet when they don't realize it will help them lose weight.
Klein offers a contrarian defense of managed care, and then makes a good argument for transparency in healthcare costs: One of the best reforms that could be made this year would be to give workers that information. So far, however, efforts have been unsuccessful. During the Senate Finance Committee's negotiations, Ron Wyden (D-Ore.) offered to give employees the option to reject their employer's offerings in return for a voucher that would help them choose their own insurance on exchanges, which meant they would save money if they chose cheaper plans. Much more modestly, Chuck Grassley (R-Iowa) floated an idea to simply require employers to report their health-care spending on workers' W-2 forms. Both were stymied by an odd-bedfellows alliance of employers and unions.
It's not too late, though. Perhaps the easiest way to dramatize the issue for workers would be to attach health-care costs to each paycheck. If employers listed the cost of health care alongside the bite taken by payroll taxes, it would be much clearer to workers that health-care coverage was coming out of their wages, not out of their employer's largess. That, at least, could help them see the costs of the system more clearly, which is, unfortunately, something that all the congressional debate isn't helping anyone do.
Yes, transparency is good. And yes, higher wages are good. But good health is better.
From the journal Cancer, via CNN: New cancer cases and mortality rates linked to the disease have fallen significantly in recent years for almost all gender and ethnic groups in the United States, researchers said Monday.
Cancer diagnosis rates decreased by an average of 1 percent per year from 1999 to 2006, the last year data are available, according to an annual report in the journal Cancer.
Mortality rates declined between 2001 and 2006, according to the report. The decline was bigger among men, at 2 percent per year. For women, it was 1.5 percent per year in the same period.
"Death rates for all cancers combined from 2002 through 2006 were highest for black men and women and lowest for Asian/Pacific Islander men and women," the report said.
The declines in mortality rates were a result of a drop in death rates from common cancers: lung, prostate and colorectal in men; and breast and colorectal cancers in women. These are the leading types of cancer in men and women, respectively, the report said.
Despite an increase in the late 1990s, rates of breast cancer in women decreased by an average of 1.2 percent per year between 1997 and 2006, the report said.
Also decreasing were the rates of lung and bronchus oral cavity cancers among men and uterine and ovarian cancer among women, it said.
Serious Medicine works! The positive results are a result of better health behavior, but also better screening, and better treatment. (And of course, the behavioral changes, routine as they might seem, are in fact the result of serious research in decades past. That's the goal: Turn Serious Medicine into Routine Medicine.)
One would think that the political class would be more eager to take credit for these successes. But instead, it would appear that they are too busy rumbling over health insurance financing.
Pic is of colo-rectal cancer cells, from the Wellcome Trust.
Robert Samuelson, the veteran writer for The Washington Post, makes it clear, in his column this morning, that he thinks "health-care nation" is a bad thing. That is, the idea that we have committed 17 percent of our GDP to healthcare, with the prospect of spending a lot more than that.
But is health-care nation really so bad? Is it such a bad idea that Americans are focused on their health? And if the people do focus on their health, is it not possible to see whole new industries developing to better serve the rest of the world, as other peoples focus increasingly on their health? That's billions of potential customers, benefiting, among others, our own American healthcare industry.
But for Samuelson, "health-care nation" is clearly intended as a dig, in the vein of Fast Food Nation,the muckraking 2001 book by Eric Schlosser, which attacked our burger-and-fries culture.
The shared presumption of both "health-care nation" and Fast Food Nation is the idea that Americans don't know what's good for them, and that haute cultural critics, such as Samuelson and Schlosser, will guide hoi polloi toward better decisions about food and health.
Here's what Samuelson said this morning about healthcare spending: All this is transforming politics and society. The most obvious characteristic of health spending is that government can't control it. The reason is public opinion. We all want the best health care for ourselves and loved ones; that's natural and seems morally compelling. Unfortunately, what we all want as individuals may harm us as a nation.
That last sentence is worth dwelling upon, because it goes right to the heart of the Establishment worldview on healthcare. So let's repeat it: Unfortunately, what we all want as individuals may harm us as a nation.
In other words, Samuelson is saying, we can't all get we want. Oh sure, the rich and powerful will get what they want, and we shouldn't worry about that too much, but if the masses, too, start getting what they want, well, that's trouble. Let's see: Where have we heard this kind of argument before? Can you say, "Louis XIV"?
Why is it a priori bad that people spend more on healthcare? Of all the possible things to consume--from "mcmansions" to machine guns, from fine art to Facebook, why is healthcare spending to be so vilified?
Is 17 percent of GDP really too much for us to spend on healthcare? As Louis Woodhill observes, if we were spending 17 percent of GDP on software, nobody would complain. Heck, nobody would complain if we were devoting 25 percent of GDP to software, or more, even, than that. Why? Because people think software is cool. It's an expenditure that passes aesthetic muster with the elites.
In a free country, expenditures per se should not be a great source of concern. In a free country, the presumption is that if people want it, they should be able to have it. In free country, the aggregation and satisfaction of personal wants is known as a "market," and is also known as "prosperity."
Yet expenditures are a source of concern to some, because some people just can't resist expressing an opinion, usually critical, as to how other people live their lives, and how they spend their money. And yet in a dynamic economy, choices and preferences are going to be changing constantly. So we just have to learn to roll with it, that's all.
Over the last century, expenditures for food, for example, have plummeted as a share of overall income, while expenditures for leisure have risen. In neutral economic terms, these changes are the result of rising productivity and prosperity. Food has become cheaper, leaving people with more money for leisure--and the leisure industry, from amusement parks to radio to movies to TV to videogames, has grown enormously. (Obviously some expenditures bring with them costly "externalities," and so we quite rightly restrict weapons of mass destruction and pollution--even if you personally can afford an A-bomb, society still doesn't want you to have one!)
But healthcare has positive externalities. If people are healthier, they are more productive and they live longer. And living longer, contrary to what many say, is a good thing, not a bad thing. Not only do people naturally enjoy a long life--and reward the politicians who help them live into their golden years--but a longer life means a longer working life, and that means more economic output. Life expectancy in the U.S. c. 1800 was around 35. In 1900, it was up to 47, according to Answers.com. How much work and output do you get out of people who die so young? What's the financial and social cost of families being deprived of breadwinners and caregivers?
Today, life expectancy in the US is pushing 80, and we are the richest country in the world. And all the other rich countries, too, have long life expectancies.
Of course, there is always room for improvement. Americans could eat healthier, and exercise more, and smoke less. And over time, improvements can be made. No doubt, for example, Schlosser's book has had an impact on eating patterns.
Furthermore, it can be argued that we are spending too much money on "futile care," as in, changing bedpans for the comatose and those stricken with Alzheimer's. Of course, to label someone as "comatose" is to skip over other possible names for that individual, such as "mother," or "father," or "loved one" or "dear friend." That's why nobody in electoral politics is too quick to try to pull the plug on anyone--if for no other reason than, as we have seen, the small "d" democratic system will put a stop to such efforts. (See "death panels.") Which, of course, drives the elites crazy, as they think about red ink in the future--or the peasants getting too much.
But if the elites were as smart as they like to think they are, they would be looking to use our healthcare expenditures as an asset to be leveraged, not as a liability to be squelched. Ask yourself: In the short run, with unemployment at 10 percent, is this really the time to cut back on labor-intensive healthcare spending?
And over the long run, the elites might figure out that, in fact, there are cures to be found in the thicket of millions of sick people, and trillion-dollar health expenditures. That is, lots of demand. And it's through cures, and only through cures, that we can bend the cost curve.
Cures bend the curve.
Use research and development and mass production to make people healthier--that's a win-win.
Unfortunately, the elites don't seem interested in solutions, only criticism.
An important new book, The Fatal Strain: On the Trail of Avian Flu and the Coming Pandemic, by Alan Sipress, reviewed in The Washington Post this morning.
H1N1, a.k.a. the swine flu, has proved to be serious public health issue, but not a massive pandemic. But it could be different next time, warns Sipress, who covered South Asia for the Post; he asserts that the pandemic killer will not be H1N1, but rather H5N1, an avian influenza that has killed millions of birds throughout East Asia since the 1990s. And so Sipress concludes, we are “closer to a global pandemic than...in a generation.”
And how will we deal with this threat? Will we have a strategy? We know that we did not have a strategy for swine flu.
A cure for Alzheimer's? How much is that worth in lives saved, humanitarian karma gained--and dollars made?
"A Sunrise Industry: Life Sciences and the Genomics Wave"--that's the title of an important article in The Huffington Post by Fred Hassan, former chairman and CEO of Schering-Plough and current senior advisor with Warburg Pincus.
As Hassan explains, genomics hold out the hope of transforming healthcare altogether, through the greatest medical tool of all--actual cures. "For example, just imagine the costs we will save if we can prevent Alzheimer's, and keep millions of older Americans out of nursing homes. Good health will be good economics." That is, not "bending the cost curve" by rationing or anything that might be construed as a "death panel," but bending it by curing disease. Good health is ultimately cheaper than bad health.
And also, potentially, good health, and the preservation of good health, is a money-maker--a big moneymaker. If a company (say Schering-Plough) could actually develop an Alzheimer's cure, and could bring it to market, well, that would be a big market, here and around the world. Which would be jobs and growth and capital gains for the New Jersey-based company, and for all Americans, and for all the people of the world.
But whatever company takes the lead on this--that would be a stock to go long on.
Or, of course, we can have a medical recession, or worse, in the form of a bad healthcare bill that seeks to slow down medical progress in the name of slowing down the rate of medical costs. In which case, we won't actually save any money, except on some notional piece of paper conjured up by the Congressional Budget Office, but we will have slowed down, for real, medical progress.
Hassan's whole article is a must-read, but here's the best stuff: Until recently, we have seen disease as a homogenous condition that affects everyone who has the disease in the same way. Now we know that afflictions like cancer are not one disease, but are rather constellations of many diseases that affect different people differently. Likewise, until now most medicines have been one-size-fits-all, even though we knew that they worked great in some people, and less so, or not at all, in others.
All that will be changing -- in large part through genomics. We are entering the era of personalized health care. Our health will be improved, and disease prevented, according to what we need and what we know about ourselves. It's the same kind of individualized steps that might go with personal financial planning or choosing a family vacation -- except with more certainty of success than most of us achieve through financial or vacation planning!
This is enormously exciting. It is why life sciences will be our country's most important sunrise industry over the next several decades. Because of this sunrise, the tens of millions of baby boomers can expect to live longer and live better. And because of this sunrise, we will also have the power to avoid billions of dollars in new health care spending. For example, just imagine the costs we will save if we can prevent Alzheimer's, and keep millions of older Americans out of nursing homes. Good health will be good economics.
That last point is worth repeating: "Good health will be good economics."