Wednesday, December 16, 2009

The Creation of Health vs. The Redistribution of Health

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.

Meanwhile, out beyond the Beltway, the world is bursting with innovation and invention, offering the promise of genuine transformation. A case in point is the cover story, "Bionics," appearing in the January 2010 issue of National Geographic, in which writer Josh Fischman profiles, for example, Anita Kitts, who lost an arm in a car accident. As Fischman puts it:

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 Califano observed 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.


  1. I think that there are three primary battlegrounds on which one can fight this power grab. Practical, moral, and legal.

    When it comes to practicality you make good points. Of course politicians can't heal anyone. Of course they will get in the way of the people who can. Of course they will make stupid decisions based on their need to grab and hold onto power. Of course one size fits all policies are going to provide care that is too costly for some and too stingy for others and therefore simultaneously impoverish some and kill others. Of course this will put millions of people into an early grave. But none of this will stop them from wanting to take over the system because they are professional power grabbers, not professional healers.

    They will also get a lot of mileage out of the idea that what they are doing is moral because it is altruistic and that "others" will benefit from the sacrifice of the few who oppose the power grab and that anyone who opposes the benefit of others is selfish and therefore immoral. Changing this moral idea is tough (though well worth chipping away at for a century or two until it isn't an issue anymore) but it's a tough sell and people don't change their moral ideas easily. When it comes to short term goals like stopping this bill this month we are probably better off looking elsewhere for solutions to the problem.

    What we need to do in the short run is to limit their power and the best tool we have to accomplish this is the US Constitution which very obviously does not grant them the power to do any of this. Where are the lawsuits? Where is the Supreme Court? Why are we even talking about whether their actions will help or hurt us? Even if the government violating our rights would bring about wonderful results they still have no legitimate power to do so in a free country.

    I worry that in our zeal to demonstrate how awful it would be if they took over medical care we are changing the subject from the far more clearcut issue which is that they have no legitimate power to do so in the first place regardless of how good or bad it would be if they did.

    The statists in Washington have no answer to that charge and they refuse to even have that conversation with various people who challenge them on it. That's because they know if they have that conversation they will lose the argument, so let's make it impossible for them to avoid the question! Every time they poke their noses outside of their offices they should be challenged by someone demanding to know what article of the Constitution empowers them to do this. There isn't one. This whole effort of theirs is not only truly impractical as you have ably pointed out but it is also immoral and illegal as well.


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