Saturday, October 31, 2009

The Internet and Serious Medicine

Tom Foremski, the always interesting editor of SiliconValleyWatcher, posts a "Happy Birthday, Internet" piece, noting the 40th anniversary fo the first e-mail, at UCLA, back in 1969.

Foremski, a Silicon Valley guy, makes a bold claim for the importance of the Net:

The Internet is the most significant collection of communications technologies ever created. It enables huge numbers of new types of businesses and services, many of them replacing pre-Internet businesses.

And yet that impact has been uneven. Foremski continues, distinguishing between those businesses protected by regulation and those not protected by regulation:

It helps if you are government regulated. The Telcos, for example are able to make use of VOIP and other advances in communications technologies to reduce their costs of doing business yet they are still able to raise the price of their services. Being a government regulated industry helps them keep competition away.

But on the other hand, there's everyone else:

But if you are in the music industry, movie industry, journalism, software services, cloud computing, if you are a software engineer, if you are a web designer, if you design logos -- if you do any kind of digital work you are exposed to a huge amount of competition, you are exposed to the lowest cost provider in your sector -- thanks to the Internet.

Foremski is right in everything he asserts. Absent regulation, if something can be digitalized, the price of that thing can and will plummet, thanks to technology and global competition.

And that reality applies to many healthcare costs, too. How long will it be before many if not most medical diagnoses are reduced to an iPhone app, or its equivalent, connected to a doctor in a low-wage country, or, even more likely, a computer somewhere? And how long before even the search for cures, and the production of medicines, is turned over to computer algorithms and robots? People will still be involved in medical research, of course, but they will be competing with machines. And so healthcare costs, some of them at least, will crash.

Now of course, not everything about healthcare can be digitalized, including bedside manner (although we see what happens with nursebots).

But the one thing that absolutely can't be digitalized--at least no time in the plausible future--is the human body itself. There's no Moore's Law of continuous improvement for us, sadly enough. So even as computers, and data, get better and better, our own physical bodies will inevitably age and decay, just like they always always. Medicine and vitamins and everything else can help, but they can only help so much.

Which is to say, there will always be a strong human demand for medical services. And if the price of everything digital goes down, for the reasons Foremski says, then the relative "value" of humans will rise, paradoxical as that may seem. Human beings, selfish genes and selfish beings that we are, will always be demanding medical treatments.

So by this reckoning, it will be a buyers' market for healthcare--we will be constant, but the price of technology will fall.

And from a Serious Medicine Strategy point of view, that's good news.

The Health Cloud

Coming soon, from Airstrip Technologies--a health-monitoring iPhone app (pictured above)

I saw a reference to this device, and to this iPhone app, described in MobiHealthNews from Johnson & Johnson, in a Farhad Manjoo article that appeared in last June. My apologies for being so slow!

But the point is that the humble iPhone has become a major hub for technology of all kinds, including healthcare technology. That was a point underscored in this piece for TechCrunch, in which Edo Segal argued that Apple and its iPhone are the emerging platform for just about everything.

The End of Liberalism: Popular Anger Strikes at the Legislative Equivalent of Insider Trading--Again

"A crisis in public authority...the atrophy of institutions of popular control." Those words do not appear in a well-argued editorial "A 1,990-Page Medical Monstrosity," appearing in Thursday's Investor's Business Daily. But those particular words--"crisis...atrophy"--would have fit right in to that IBD piece; as we shall see, the trainwreck of this latest legislation was foreseen by one astute political scientist, Theodore Lowi, four decades ago; Lowi saw that the ballooning complexity of social-welfare legislation would enable special interests to honeycomb the arcane legislative and legal language with special favors and secret codicils--thereby undermining public confidence in any legislation and any vision of truly representative government.

But in the meantime, the IBD editorial zeroes in some typical sneakiness in the new bill:

As the Hudson Institute's Hanns Kuttner noted on the National Review Web site, you would have to devour 221 pages a day to have read this life-changing legislation in its entirety before it comes to a vote, promised for before Veterans Day, Nov. 11.

Weeks after its unveiling, new tricks are still being discovered within the Senate health bill. Kaiser Health News' Julie Appleby reported Thursday that, despite claims the bill will limit what those in the lower and middle income groups will pay for health insurance, "The fine print shows that, over time, the premium costs could rise well beyond those caps."

And many other critics have made many other good criticisms of the House bill: about its cost, its overreach, its new provision to protect trial lawyers, and its general byzantine-ness.

Speaker Nancy Pelosi and her House Democrats argue, of course, that such length and complexity is necessary, to meet the health-insurance needs of more than 300 million Americans.

Maybe, but maybe not. Here at at Serious Medicine Strategy, we are reminded that the Social Security Act of 1935 was less than 16,000 words, while the new House bill is about 400,000 words.

Something has obviously happened--something bad--to our capacity to write and speak and legislate clearly. Is Kafka-esque too strong a word? No! After all, the real Franz Kafka worked for a time, a century ago, as a workman's compensation clerk--he knew about the alienating effects of bureaucratizing misfortune and misery. Of course, this alienation factor doesn't invalidate the idea of workers' comp, or of health insurance. Instead, the potentially dread combination of bad news and bureaucracy serves to remind those who operate such programs that they have a special duty to reassure ordinary people about the way those programs are being run. To reassure people who might wonder if there are any, say, death panels lurking within the forbidding walls of our castles of insurance. Making sure that unjustified paranoia continues to be unjustified is a principal reason why transparency and accountability are so important to any healthcare reform effort.

By contrast, today, healthcare advocates seem to revel in a kind of bland Kafkaism. They have absorbed the worst of spin-doctoring and the worst of litigious pettifogging. So the new bill is soothingly named the Affordable Health Care for Americans Act--and then it clocks in at an intimidating law-library length.

Which nobody can deny--because nobody can understand. That point, about the overall incomprehensibility of these bills, was memorably made by Sen. Tom Carper: “I don’t expect to actually read the legislative language because reading the legislative language is among the more confusing things I’ve ever read in my life,” the Delaware Democrat told on October 2. (I wrote about Carper's startlingly candid admission here.)

In addition, it seems clear--clear as mud--that one of the reasons for such legislative complexity is that the real goal of the complexifiers is obfuscation: hide the nasty needles in the biggest possible haystack. And so only a close reading of the new bill reveals that "death panels"--oops, make that death counseling provisions--are making a furtive comeback, burrowed within that two-foot-high-stack of paper.

Of course, such hideous complexity is not at all popular. As Peggy Noonan observed last summer, if people don't understand a piece of legislation, and they doubt the motives of the legislators, their instinct is to assume that the politicians are trying to pull a fast one--and so regular folks say "no," even "hell no." Hence the town hall protestors, and the tea partiers. And the polls, which show that most people support healthcare reform in theory, but think that anything Congress passes will make healthcare worse.

This populist suspicion about self-dealing by the process-controlling elites--we might call it the political equivalent of insider trading--was acutely foreseen, and ably described, back in 1969, by the well-known political scientist Theodore Lowi of Cornell University, in his book, The End of Liberalism. Lowi precisely described the policy crisis of the welfare state, which has so discredited liberalism over the past four decades.

I wrote a column for the LA Times about Lowi's brilliant book during the last big national healthcare debate, back on September 21, 1993. Here are some excerpts, from my discussion of Clintoncare, 16 years ago:

The biggest challenge [Bill Clinton] faces is the deep public skepticism that the government really is here to help us.

Theodore Lowi saw it coming. In 1969, he wrote The End of Liberalism, a far-reaching critique of the post-New Deal welfare state. Lowi, a former president of the American Political Science Association now at Cornell, is no conservative. He would describe himself as committed to real democracy, which he sees as threatened by the delegation of legitimate authority to the Iron Triangle of bureaucrats, lobbyists, and special interests.

As government grows bigger and bigger, Lowi argued, representative government will inevitably give way to the undemocratic rule of insiders. Think about it: how many Members of Congress actually read the 1000-page legislative phone books they vote for? They can barely lift them, let alone comprehend them. So elected officials turn to un-elected officials to explain, interpret, and implement the law with thousands more pages of legalese. It's like the Marx Brothers movie, "A Day at the Races": you need a code book to interpret the code book.

Lowi coined the phrase "interest-group liberalism," to describe the bargaining and brokering among the Washington elites that has characterized American politics since the 30s. What we will get, Lowi prophesied, is "a crisis of public authority" leading to the "atrophy of institutions of popular control."

And I concluded that 1993 column with these words:

If popular sovereignty is to mean anything, then sovereign power has to be understandable to the populace. Lowi's book is a restatement of the truism: the devil is in the details. A quarter century ago, he warned us that the details were drowning us. Today, it looks as if democracy is about to take another dunking.

A sixth of a century after my column, and almost half a century after Lowi's book first appeared, nothing much has changed. The End of Liberalism is still in print, as it should be.

Reading, or re-reading, the book today is a sobering experience for anyone. But liberals, the people whom Lowi was mostly addressing back in 1969, ought to draw particular guidance. Lowi wasn't their enemy, back then; he was their constructive critic. But it would appear that today's liberals have chosen, yet again, not to heed Lowi's wise warning.

And now, at a time when 60s-style mistrust of authority seems to be afflicting just about every American institution, public and private, Pelosi and her liberal establishment have chosen to be part of the problem, not part of the solution.

Thursday, October 29, 2009

Waist Deep In The Big Muddy

Another look at recent poll data inspires me to ask: What does it remind you of when people see a bad outcome, see it dead ahead, and yet their leaders keep slogging closer and closer to that bad outcome? It reminds me of a famous Pete Seeger song, "Waist Deep In The Big Muddy."

These data from Gallup show clearly, that by a more than 2:1 margin, the American people think that their healthcare will get worse if "reform" passes.

And yet the big push continues.

A Healthcare App?

If we were really living in the world of leading-edge politics that many people thought they were getting with Barack Obama, he would have proposed an iPhone for health care-a flexible system for which all sorts of users could create or choose health-care apps that suited their needs. Over time, with trial and error, a better system would emerge.

No chance of that. Our outdated political software can't recognize trial and error. What ObamaCare is doing with health care-the "public option"-may be fine with the activist left, but I suspect it's starting to strike many younger Americans as at odds with their lives, as not somewhere they want to go.

A great point from Dan Henninger, in The Wall Street Journal.

If We Are Fighting a War Against Swine Flu--And We Are--Then We Should Look to Past Victories, For Both Inspiration and Guidance.

Barack Obama and his administration are getting slapped around pretty hard on swine flu. Last night, ABC's "World News" featured a story alleging that the US Government was relying on obsolete vaccine-making technology, while this morning, front-page stories in The Washington Post and The New York Times highlight administration vulnerabilities. As the Times puts it in its lede: "A vaccine shortage is threatening to undermine public confidence in government, creating a very public test of Mr. Obama’s competence."

Ouch! And those doubtful feelings will be reinforced as the public processes the admission of HHS Secretary Kathleen Sebelius, who told the Times that she had been "naive" in thinking that the vaccine would arrive in necessary quantities.

Conservative critics will ask, of course, what else the administration is "naive" about--including naivete about the ability of the government to make a complicated healthcare reform bill work. And conservative critics might further ask, "What if the same level of flu-SNAFU had occurred under George W. Bush, or any Republican president? Wouldn't the chorus of criticism be much louder?" Perhaps, but the blame-game is not the point of Serious Medicine Strategy.

What we are all looking for is better solutions. As argued here in the past, fatalism or nihilism toward public health is not an acceptable answer. As with any other kind of medicine, if the swine flu vaccine is not as good as it could be--not as available, not as effective, not as safe--the answer is to keep trying until it is as good and plentiful as it needs to be. We must be prepared to make changes, shift intellectual models, fire people--anything but give up the effort. Persistence. That's the only way anything gets done in this world.

And for inspiration on how to proceed--and for practical advice--we might recall how great national efforts of the past were carried through to a successful conclusion. One huge lesson is the need for a strong sense of prioritization, from the top down. And it is not at all clear that the Obama administration has done that. It's pretty clear that swine flu has been a lower priority than a half-dozen other issues, including "health insurance reform." Yet if there ever was a reminder that the delivery of health is more important than the delivery of health insurance, this is it. People are dying right now, and yet the Administration and much of Congress, locked into a particular politico-bureaucratic model of healthcare, is more focused on healthcare "reforms" that will come, if they come at all, in two or three or more years.

That's a serious lack of command focus. As Marc Rotterman, a veteran political observer, remarked to me recently about the long lines for the vaccine, "This wouldn't have happened with Eisenhower as President." Indeed. Dwight Eisenhower knew how to get things done, in the US Army, at NATO, and as Commander-in-Chief. Ike was neither a rigid ideologue nor a hand-wringer; he was an effective executive, committed to center-right goals, on both foreign and domestic policy. And he got most of them done, during two terms as president, by riding everyone involved until he or she produced.

And it's also clear that neither the Obama administration, nor the Congress, has set up an efficient decision-making/decision-implementing mechanism for dealing with swine flu. Once again, we can look to US history for successful models. One such model was the Joint Committee on the Conduct of the War, established on December 9, 1861, as the US government was reeling from early military failures in the Civil War. The Joint Committee had a grand total of eight--that's right, eight--members, four from the Senate, and four from the House. But in large part because it was manageably compact, the Committee helped organize and mobilize support for the war effort. And so it was a key to victory in that great conflict--a vital bit of streamlining, assuring competent, as well as constitutional, oversight from Congress.

There are, of course, other successful models. But all those models have a few things in common, including command focus and coordinated implementation. The Obama administration could profit from a little less hubris, and a little more humility.

(That's a screen grab of a committee report, above, from the University of Michigan archive.)

Tuesday, October 27, 2009

"The Stethoscope of the 21st Century" -- The Infosphere Bends The Cost Curve

Once again, the biggest and best news about healthcare comes from outside the Beltway--from technology.

If GE can make the Vscan a handheld MRI (that's GE CEO Jeff Immelt holding one at a San Francisco expo last week), then the cost of scanning is about to crash, as other players get into this soon-to-balloon sector of the market.

Which is to say, healthcare will get better without rationing. It's too bad that the Obamacare people can't process this sort of good news into their notional budget projections.

But the rest of us might reflect on how healthcare will change, when healthcare is fully integrated into the infosphere.

Too Bad President Obama Reserves That Sort of Visionary Thinking For Cap-and-Trade, As Opposed to Healthcare.

"I've often said that the creation of such an economy is gonna require nothing less than the sustained effort of an entire nation, an all-hands-on-deck approach similar to the mobilization that preceded World War II."

Barack Obama, at a solar power event Florida today. He continues to push a cap-and-trade plan that has no chance of working, when he could be better spending that energy on a Serious Medicine Strategy.

A comprehensive strategy did win World War II. And it could win the war against big killers in our time. But instead, Obama is pursuing a rationing strategy on healthcare--and on energy and the environment, too.

Monday, October 26, 2009

"Health Author Suzanne Somers Mostly Wrong About Science, Medicine"

But I guess other than that, her new book, Knockout: Interviews with Doctors Who Are Curing Cancer--And How to Prevent Getting It in the First Place, is probably OK.

But Newsweek's Patrice Wingert takes the book apart anyway.

The Morality of Medicine: The Traditional View of Hippocrates, and a Newer View From Arthur C. Brooks

Arthur C. Brooks, the president of the American Enterprise Institute in Washington DC, takes to the editorial page of The Wall Street Journal this morning to set forth his vision for healthcare, in a piece headlined, "Why Government Health Care Keeps Falling in the Polls/The health-care debate is part of a larger moral struggle over the free-enterprise system."

After appropriately chopping up Obamacare, Brooks closes his piece with this peroration:

The health-care debate is part of a moral struggle currently being played out over the free enterprise system. It will be replayed in every major policy debate in the coming months, from financial regulatory reform to a cap-and-trade system for limiting carbon emissions. The choices will ultimately always come down to competing visions of America's future. Will we strengthen freedom, individual opportunity and enterprise? Or will we expand the role of the state and its power?

Brooks is thus saying that healthcare should be seen as a piece of the larger "moral struggle" over the free market, and economic freedom. Or to put it another way, he is saying that the the first principle should be freedom and free enterprise, and that other considerations, including medicine, should find their place within that principle. Principle first, to be followed by the application of that principle to other areas, including healthcare.

But actually, personal freedom doesn't come first in all areas. For example, I doubt that Brooks intends for "freedom, individual opportunity and enterprise" to prevail in the area of drugs, abortion, and the extremes of entertainment and scientific experimentation. Why? Because in some areas, morality trumps the market. We don't want a free market in child exploitation, for example.

Most libertarians/free marketeers/objectivists allow for the role of morality in some sectors of society--and they understand that the law enforcement needed to enforce the dictates of our collective conscience is also not to be left to the free market.

So the more precise question is whether or not healthcare should be part of this non-market "moral sector," or, instead, part of the market sector. And on that question, Brooks lays down his cards in favor of market pre-eminence. As he writes this morning, "The health-care debate is part of a moral struggle currently being played out over the free enterprise system."

But there is a different view, deriving from our roles as moral and charitable and spiritual beings, existing within some sort of universal order. Across the eons, across cultures, people have felt inspired to do good works, out of charity, compassion, love, and faith. This view is thus larger than the market, since it includes everything that human beings do--or should do, if they wish to do their best. Applied to medicine, these impulses were perhaps best distilled, 2500 years ago, by Hippocrates. His famous Hippocratic Oath is reproduced below. Note that it begins with an oath to the gods, not to any earthly institution:

I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

There's plenty here for people to disagree with, and plenty that some might wish to see changed. (And did I mention that Hippocrates was pro-life?)

But what's clear, here, is that the Hippocratic Oath is an oath to the divine, not to the free market: As the Greeks put it: "I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea." Of course, doctors today swear an oath only to the memory of the Greeks and to the rational and ethical traditions they fostered. Doctors today are more likely to feel a duty to God--that's a medieval rendition of the Hippocratic Oath, pictured above, written out in the shape of the cross--or else a duty to some other ideal, such as service of humanity, or to the pursuit of scientific knowledge. But all those goals are notable for having one thing in common: In their idealism, they transcend the free market.

And yes of course, some doctors will absolutely swear an oath to fortune, or to fame, or to their own ego. But I believe that such materialistic doctors are in the minority. Doctors might not be saints, but most of them have altruistic motives.

So should the free enterprise system have a place in health and medicine? Absolutely. Here at Serious Medicine Strategy, we have always argued that we need the full panoply of resources to the cause of better health and cures. We want incentives, the profit motive, and yes, greed, all harnessed to the cause of creating new treatments and improving well-being. That's all a part of an overall Serious Medicine Strategy.

But the free market is just one strand within this larger Strategy, other strands include compassion, idealism, pragmatism, national objectives, and international cooperation. And yes, the desire to do God's work here on this earth. Together, we can create a national effort that will enlist the talents and energies of everyone who wants to improve life--that's a much larger percentage of the population than just those who wish to celebrate the free market. And in politics, bigger numbers of people have a way of trumping smaller numbers.

The Serious Medicine Strategy has a place for the free market, but does not seek to maximize the free market. The SMS seeks to maximize the prospect of improving the health and well-being of the American people, and of all the people of the world. And to my reckoning, such an achievement would be a moral and ethical achievement of the highest order.

The Thing Speaks for Itself

From Gallup.

Sunday, October 25, 2009

Dancing With Death: The Real Reason That the Public Option is Back

So the public option is back. The headline atop Dan Balz’s story in The Washington Post this morning blares, “New life for the public option.”

But why? Why was the public option (TPO), as Balz puts it, “on life support” just a little while ago, and yet now TPO is up and walking around? Balz’s answer is two-fold; first, there was a backlash against the insurance companies, and second, TPO was rising in the polls, even as the pundits were saying TPO’s last rites. I won’t argue with Balz, a thoughtful and fair-minded reporter, but I think that we can look back and identify, with precision, a more specific “tipping point” in this latest phase of the healthcare debate. A tipping point that speaks volumes about the current political situation, and about larger cycles of popular passion.

That tipping point, in my reckoning, was Rep. Alan Grayson’s September 29 speech from the floor of the House, in which the Florida Democrat declared that the Republican healthcare plan could be summed up as “Don't get sick, and if you do get sick...die quickly.”

So, Grayson says, Republicans want to kill innocent people. Now that was a message that punched through. Because of those words, Grayson instantly rose from freshman obscurity, into (your choice) glory or ignominy. Grayson didn’t apologize, indeed, he used his newfound prominence to light a pro-TPO fire under senior Democrats; on October 14, he personally delivered a strongly worded pro-TPO petition to a fellow Democrat, Senate Majority Leader Harry Reid. “It’s so urgent that we move ahead,” Grayson told Politico. “The cost of delay is death.”

So there it is again, the “d-word”--death. Freud argued that all of life is an endless tug-of-war between eros and thanatos, between love and death. And so it follows that if you want to make a powerful argument, you tap into one or both of those two main cables of human thinking. Grayson chose death. And it worked. A killer argument, one might say.

So Grayson provided a vivid bookend to the other super-powerful utilization of the “d-word,” which had earlier been used by one of Grayson’s, uh, mortal enemies. And that enemy, of course, is former Alaska governor Sarah Palin, who launched the phrase “death panels” from her Facebook page on August 7. Palin’s use of the “d-word” was similarly electric last summer; within days of her posting, Democrats specifically kiboshed hitherto uncontroversial “end of life counseling” provisions in their healthcare bill.

And yet even so, support for the overall idea of Obamacare fell in the wake of Palin’s attack. Dark visions of death loomed larger in people’s minds than once-bright thoughts of “hope.” And as we have seen, when pro-TPO Democrats made their recent resurgence, it was powered by a death-vision of their own, courtesy of Grayson. Hope had nothing to do with it.

Thus dueling visions of death, Grayson’s and Palin’s, have hardened the two parties’ positions, further polarizing the healthcare debate--it's entirely possible that nothing can be enacted in this environment. So in a sense, this “death match” is of a piece with other polarizing forces in our politics and media.

And there’s also a larger politics lesson here, bubbling up from our collective ids. Wonky policy talk is the natural language of technocrats and experts who must communicate with each other, even across the partisan divide. Moreover, most of the wonks, on both sides of the aisle, are middle- and upper-middle-class strivers. They have been to the same schools, or at least read the same textbooks--whether or not they agreed with what was in them. They are, in the best sense of the word, professionals.

Yet to impassioned outsiders, such wonk-talk is brittle, even sterile, disconnected as it is from the wellsprings of faith and belief. To a Grayson or a Palin, to a Michelle Bachmann or a Dennis Kucinich, fluent professionalism often sounds like opportunism and cynicism, language that obscures more than it reveals. And so, outside the beltway, a new insurgency is always brewing, an attack of mistrustful outsider peripherals on the mistrusted insider core.

So one’s thoughts go back to the Enlightenment of the 18th century. Across the Western world, in the age of Johnson and Diderot, of Catherine the Great and Frederick the Great, elites and intellectuals agreed on a certain amount of secular and scientific progress--or thought they did. And then came Romanticism, in which poets and peoples rejected the baroque edifices of “the establishment” and embraced, instead, fervor and even mysticism. The result in the 19th century was, as someone put it, better art and worse politics.

Now back to the present day. Like every other aspect of human nature, politics is ultimately driven by visionaries, by those who lead by revelation, from the heart, not the head. As George Bernard Shaw observed, “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.” Unfortunately, it is not known if Shaw also said, “All regress, too, depends on the unreasonable man--and woman.”

There will come a day when passions cool, when men and women can come together and reason together. When consensus can be reached and compromise can be forged. But it is obviously not to be this day--or any day soon.

Saturday, October 24, 2009

The Need for Serious Medicine--And A Serious Medicine Strategy

David Axelrod, the White House adviser, and his wife, Susan Axelrod, tell the moving story of their daughter, Lauren Axelrod, who has suffered from epilepsy all her life. The Axelrods will be featured on "Sixty Minutes" Sunday night.

That The Huffington Post gives the story such prominence--on its front page, as of Saturday night--is a useful reminder of the importance that medicine plays in our lives, with little or no regard for ideology. Good health, and the tools we need to keep our good health, are not only decisive on matters of life and death, but health and medicine also determine how we are able to live our lives.

Serious Medicine Strategists say that we should be organizing our society toward maximizing good health and the search for Serious Medicine. If we do, not only will people live longer and better, but we will have more prosperity, as we live better and more productive lives, and as we export our knowhow to the rest of the world. SMS is a win-win.

Let's hope that the Obamacare healthcare plan, if and when it finally emerges, will do everything possible to accelerate the search for cures for epilepsy, and for all other diseases. I will admit that I am not confident on that score, and if, in fact, we miss this chance to effect real cures, that would be a tragedy of monumental proportions.

Powering Through Swine Flu

More than 1000 Americans have died from swine flu, and worldwide, swine flu deaths near 5000. Meanwhile, the headline in yesterday's New York Times painted a somewhat disconcerting picture: "Shortages and Confusion in Flu Fight." But of course, skeptics abound, from Bill Maher on the left (sort of) to Glenn Beck on the right (sort of). So in the midst of this muddle, what's the right public-health strategy?

One answer, as we shall see, comes from the history of technology, which can eventually be made to work. With enough patience and persistence, even the greatest national endeavors can succeed.

But first, we should pause over the good news about swine flu, starting with the fact that we have the vaccine at all. Thanks to improved science, including the decrypting of the human genome, we have dramatically accelerated the vaccine-making process, getting done in weeks that which used to take months--and, of course, couldn't have been done at all just a few decades ago.

But of course, that doesn't explain away all the SNAFUs. And some have leapt to make their case that governmental incompetence is endemic, even about epidemics. "Life Under Obamacare?"--that was the acerbic headline of a pungent editorial in yesterday's The New York Post:

Many say that's what Americans will face if the government runs the nation's health-care system, as Democrats in Washington propose. And that suggestion is certainly gaining credibility, based on the way Washington is handling today's flu-vaccine program. ...

If federal bureaucrats can't handle this program -- despite having warned about it since last spring -- how on earth will they manage a trillion-dollar comprehensive health-care system, if Congress enacts ObamaCare?

Here at Serious Medicine Strategy, we won't defend everything that the Obama administration has done on the swine flu issue; on "Fox News Watch" today, I noted that the White House seems more interested in attacking its enemies than attacking public health problems. It would, in fact, be nice to see the President spending as much time on the health of Americans as he is spending on Afghanistan, or cap-and-trade, or other issues with considerably less impact on American lives. Yes, it was nice that the President last night declared swine flu to be a national emergency, bu we might review the first nine months of his presidency and fairly ask of the President: Swine flu ranks exactly where on your list of priorities?

Still, here at SMS caution against the tempting conflation between public health efforts (almost all of which carried out by professionals, whether or not the commander-in-chief shows any interest) and the push for national health insurance (almost all of which is being carried out by politicians, pundits, and ideologues). Despite the bad name that "national health" is giving to "public health," we tend to think that the government, working with private industry, and all the various stakeholders, should be doing more, not less. We should seek to power through the problem, as part of our overall Serious Medicine Strategy.

Those thoughts were underscored for me as I was reading Antony Beevor's new book, D-Day: The Battle For Normandy, specifically, the chapter on the American assault on Omaha Beach, memorialized so harrowingly and dramatically in the 1998 movie, "Saving Private Ryan." Those portions from Beevor's excellent book remind us that every technology is usually in a process of improvement--much needed improvement. A case in point is aerial bombing.

As Beevor describes it in his book, 329 American heavy bombers flew over Omaha beach in advance of the amphibious assault, dropping 13,000 bombs. And what was the damage done to the German targets? Zero. That's right, none of the bombs hit the beach defenses. As one observer said of the failed bombardment of the Germans, "That's a fat lot of use--all it's done is wake them up."

Beevor summarizes: "The US Army Air Corps had made wildly optimistic claims about their 'precision bombing.'" Gens. Bernard Montgomery and Omar Bradley "seemed oblivious to the fact that the heavy bombing formations remained incapable of dropping the majority of their load within a five-mile radius of their target."

The Normandy campaign abounded with such tragic mistakes--hundreds, if not thousands, of Allied soldiers were killed in "friendly fire" incidents, including Gen. George Patton's right-hand man, Lt. Gen. Lesley McNair. And much of the air power in the whole war was wasted, on one bad plan or another. But that's the nature of war: Like anything else, it takes experimentation to figure out what works and what doesn't work. And that experimentation, bloody as it might be, is the only way to do it--you can do a lot in a laboratory, but for those inventions to do their job, they have to be introduced into the battlefield.

And of course, air power was probably the single most effective and decisive weapon in World War Two, especially if one includes the B-29-dropped atomic bomb as part of air power. But still, the fact remains that airpower over-promised and under-delivered on so many occasions during World War Two--and in just about every war in the last 90 years. Most notoriously, the perceived failure of air power to change the course of the Vietnam War haunts American policymakers to this day. (There is a substantial school of thought that holds that the US could have won in Vietnam by dropping more bombs, on top targets, as we did in the "Christmas Bombing" of 1972, but of course, we'll never know.)

But by now, after decades of relentless efforts at improvement, and billions or even trillions of expenditure, we have gotten to the fact that we can drop a bomb--or a cruise missile--onto just about any target anywhere, with precision accuracy that is really precise. As we have discovered, such precision doesn't guarantee that we can kill, say, Osama Bin Laden, because he's a moving target, but if we knew exactly where he was, we could blow him up within minutes. And that's quite an achievement--a reminder that if we try hard enough, we can solve these problems.

And so back to public health. If we can precision-strike military targets, we can also precision-strike medical targets. And most Americans would probably be glad to see us try just as hard on medical targets as we do on military targets.

Thursday, October 22, 2009

"Six Diseases You Never Knew You Could Catch" An Article In The New Scientist Challenges Orthodoxy

Priya Shetty, writing for The New Scientist, sums up an emerging body of research, which argues that many diseases--including diabetes, schizophrenia, and some kinds of cancer--that were previously seen as caused by environmental, lifestyle, or genetic variables are, in fact, contagious. That's right, contagious.

Science is nothing if not counter-intuitive!

One such hugely counter-intuitive finding, now accepted as true, was that ulcers come from bacteria--that finding, of course, upset centuries of intuition and research. Yet that discovery won the Nobel Prize for Medicine in 2005 for Barry J. Marshall and J. Robin Warren, and should serve as a reminder that there are huge rewards for finding better answers.

The implications of these additional findings about contagion, now kicking around science magazines, are huge.

Why? Because for decades now, entire orthodoxies of thought, as well as costly policy, have been built up around alternative explanations for disease--and alternative solutions and treatments.

Consider the diagnostic-prescriptive "if-thens" of our current explanatory paradigms: If disease comes from environmental factors, then we need to clean up the environment. If disease comes from lifestyle, then we need to change our ways and live healthier. And if disease comes from our own genes, then we must reflect upon, in a way that John Calvin would recognize, our own innate flaws.

Much of the strength of the environmental and consumer-protection movement, for example, comes from fear--fear that chemicals in the environment and in additives are carcinogenic. Some journalist-activists have built whole careers advancing this argument. Devra Davis, for example, in The Secret History of the War on Cancer, argued that most, if not all, cancers were environmentally caused; she further declared that Richard Nixon's "war on cancer," begun in 1971, was thus a diversionary fraud, aimed at taking pressure off tobacco companies, asbestos manufacturers, and other corporate polluters. Indeed, the backlash against the scandal-plagued Nixon and "the war on cancer" has been so strong that the "big science" approach to curing disease has been out of political fashion for most of the last four decades.

This is not an argument in favor of laissez-faire on pollution. But it is an argument for a relentless focus on the actual causes of disease, as opposed to trying to harness medical imperatives into the service of other social and political objectives.

With the notable exception of the battle against HIV/AIDS, the political and popular culture has chosen to focus on the aforementioned trinity of environment, lifestyle, and genetics. The larger culture told us that cancer, for example, was "our fault," because we had polluted our environment, or because we did unhealthy things, or because, in a deep neo-Calvinist way, we had simply harbored cancer within us, predestined in our genes. And if any of these variables--environmental or lifestyle or genetic--were seen as decisive, the political pressure to seek cures in a laboratory was thus lessened.

Obviously many chemicals are harmful, and one assume that the cigarettes-cause-lung-cancer linkage is secure for all time, but who knows about many other cancers? And about many other diseases? And the same goes for obesity and genetic propensity.

Here at Serious Medicine Strategy, we take no daring stands on scientific truth or falsehood. The SMS view is that the needed answers--the needed cures--will emerge from a Kuhnian processs of scientific revolution, followed by yet more scientific revolutions.

The SMS mission is merely to make sure that those revolutions are fully debated, fully analyzed, fully disclosed--and yes, fully funded. It's the ever-flowing process of paradigm-shifting that ultimately showed us, for example, that ulcers come from a bacteria.

And of course, if we really want to "bend the curve" on healthcare costs, it helps to actually cure the disease. In the scheme of things, cures are cheap. By contrast, simply treating a disease is expensive, to say nothing of the cost of treating a disease following the wrong diagnostic paradigm.

So to that end, SMS offers this challenge to both the Obama administration and to Congress: Which leader will be the first to hold a public hearing on this contagion question--either within the executive branch, e.g. NIH, or on Capitol Hill? Obviously there's lots of scientific discussion going on among experts, but which government official or politician will air these topics for the benefit of the larger public? Don't the people have a right to know how their government resources are being used, and to be assured that the powers-that-be are constantly revising their priorities in light of new information? That's the Serious Medicine Strategy in action.

The fear we have here at SMS is that the notion of pursuing actual cures is "an inconvenient truth" to those who are committed to ideological positions on other topics, such as health insurance financing. Health insurance and healthcare financing are great, but ask yourself: In the end, isn't health more important than health insurance? You don't go to the doctor because you can, thanks to a government-insurance card, or even a health savings account. You go to the doctor to get better.

That's the purpose of medical science, and that's what the Serious Medicine Strategy is all about.

Here's the lead of Shetty's piece:

TWENTIETH century medicine was phenomenally successful at developing vaccines and antibiotics to fight infectious diseases, taming ancient scourges such as smallpox, tuberculosis and typhoid. In the 1960s and 70s, the prevailing view was that all diseases caused by microorganisms would soon be conquered, leaving only those caused by genetics, unhealthy lifestyles or ageing.

That idea now seems naive, not least because of the rise in antibiotic resistance. And there's another reason that no one even considered back then. A growing number of diseases that were thought to be down to genetics or lifestyle turn out to have an infectious origin.

Take stomach ulcers. Long thought to be triggered by stress, it emerged in the 1980s that many cases are caused by a bacterium called Helicobacter pylori. Now a short course of antibiotics is all that's needed to cure the condition, and in the west stomach ulcers are on the decline.

Since then, researchers have unearthed the unexpected infectious origins of several other diseases. In some the explanation is unique, but in others common mechanisms are at work. For example, several autoimmune diseases arise because infection with a microbe triggers an immune attack, which cross-reacts with similar molecules from the host, causing the immune system to attack human tissues. And several cancers may be caused by viruses, sometimes because they insert themselves into our DNA and disrupt the genes that usually stop cells multiplying out of control.

The idea that lifelong conditions such as type 1 diabetes and obesity could be caught as easily as a cold is spine-chilling. Yet it raises the tantalising possibility that they could be treated with antibiotics or antiviral drugs, or possibly even prevented with a vaccine. So which of the following illnesses will be next to go the way of stomach ulcers?

1. Obesity
2. Diabetes
3. Schizophrenia
4. Breast cancer
5. Obsessive-compulsive disorder
6. Prostate cancer

And the rest is here.

Wednesday, October 21, 2009

The Government Needs A New Language to Convey Health Risk

Fox News Channel, where I am a contributor, is devoting more and more energy to healthcare coverage. And while Serious Medicine Strategy makes no attempt to cover all of health news overall, we reserve the right to pick out particularly important items, including at FNC. A case in point is something that Dr. Marc Siegel said this morning about swine flu, the H1N1 virus, on the eve of hearings at the Senate Homeland Security Committee. I didn't get a chance to record exactly what Dr. Siegel was saying, but the gist of it was, The government needs a new language to convey health risk. It needs a new way to communicate with people about what's safe and not safe.

I am not doing justice to Dr. Siegel's words, but the point he was making squares with a constant theme here at SMS, which I wrote about at some length just a few days ago: We need a strategy for thinking about healthcare and medicine. And the information age should be our friend in this effort, helping to surround us in a veritable aura of information, about what's possible, and about what's going right, or wrong, in our own bodies.

Standing Up to the Paralysis of Care for the Paralytic Diseases of the Digestive Tract

Gastroparesis is a disease that doesn't get much attention--except of course, from those who suffer from it, and from their family and friends. Which is to say, it is one of a thousand diseases that would benefit from a Serious Medicine Strategy, in which the political class took medical security as it did economic security or national security.

This is part two part two of a guest piece from Michael Smith, a lawyer in New York City and a board member of G-PACT, the Gastroparesis Patient Association for Cures and Treatment. Part one of Mike's piece, published on September 23, is here.

The issues Mike raises here are long and complicated, and yet the issues are vital, not only for gastroparesis, but for serious illness overall. Those who suffer from every other kind of serious illness, and who take the time to study the issues in detail, will quickly see common elements in their struggle, too. We all have an interest in a Serious Medicine Strategy.

Standing Up to the Paralysis of Care for the Paralytic Diseases of the Digestive Tract

by Michael Smith

In Part I, we discussed the key issue for patients suffering from paralysis of the digestive tract; namely, not the inability of medical science to offer treatments, but the inability of the bureaucracy responsible for approving and maintaining the effectiveness of treatment to use and decipher the best information available to make appropriate choices. The following is a series of solutions, both short-term and long-term meant to reform the current drug approval bureaucracy in a manner that both responds to what should be the central goal of this bureaucracy, namely getting patients better with the fewest side effects possible, while also properly respecting the scientific process that drugs must and should go through to get approved in the United States.

1) Appropriate and Speedy Appeal of Drug Withdrawal: When Zelnorm was initially removed from the US market on March 30, 2007, the FDA promised in a press release the following:

“FDA has also indicated to Novartis the possibility of considering limited re-introduction of Zelnorm at a later date if a population of patients can be identified in which the benefits of the drug outweigh the risks. Any such proposal would be the subject of a public advisory committee meeting before an FDA decision.” (Source:

Unfortunately, the promise of the public advisory committee has never been fulfilled by the FDA; what instead has been gained is a nebulous and ever-changing emergency directive process which lacks the transparency that Jim Pinkerton has alluded to in other pieces.

The one foundation that FDA must be built on prior to any other is a constitutional foundation. When FDA pulls an approved drug from the US market, it is not just pulling a simple economic good from the US market; it is a pulling both an economic right of patients, in essence their license to be able to take a prescription drug which has been granted through both the doctor-patient relationship, when a doctor determines that a drug is best suited for a patient’s well-being, as well as in some case a right to life and liberty by the denial of right to medicine that in some cases will simply allow patients to maintain quantity of life and in others will allow patients to maintain quantity of life.

A solution to this problem should be that when FDA pulls any drug from the US market that a right to a public advisory committee meeting or hearing should automatically be granted upon a drug’s withdrawal from the US market. The taking of a property right must from a procedural due process standpoint be granted when government revokes a right that cannot be easily substituted. To those who would argue that FDA has a larger public health and safety consideration to deal with in making such decisions, I would argue that the right to a hearing is different from the right to the medication itself; the hearing represents an open forum is which all interested stakeholders should have the right to properly present valid scientific information which may not have been available to the FDA at the time of its original decision. To those who would argue that patients are either overly emotional or overly vested in a single drug, I would contend that most patients managing serious chronic illnesses have been managing them for several years, have had to work out difficult treatment plans themselves which require the recognition of medical knowledge that perhaps only doctors themselves or forced to convey and that we harbor no particular loyalty to any single drug company whose support for a given condition may last only as long as a given drug remains on patent.

2) Standard of Review for FDA’s Decision Making Process: In situations where it appears such a hearing process as I allude to here has either been denied or improperly administered, we must give careful look at the credence given to FDA’s review and drug approval or rejection process and standard under which such decisions are reviewed in a courtroom or by Congress. Generally, FDA is perhaps given the fullest credence of any administrative agency in the land when decisions are provided with regard to the approval or rejection of drugs. As seen in the recent Abigail Alliance case, or in other FDA-related drug litigation or alternatively in the setting of legislatively-induced FDA reform, courts or Congress contend since most judges and legislators are not scientists or doctors, they are not in the position to review the merits of a decision made by FDA under any circumstances. In the world of corporate law, we call this situation, a “futile demand” meaning that there is really no one we can properly appeal to with regard to merits of a decision since no arbiter feels that they have the standing to listen. I would contend that there must be a standard below that of absolute discretion granted to the FDA. Such a standard should ensure that no decisions made by the FDA stand on the ground of being “arbitrary and capricious”; in other words, these should not be decisions which are solely based upon past FDA practice, lacking in scientific validity or lacking insight after careful examination of the fullest information base available. Patients, doctors and other stakeholders can have faith in a system that even when it makes a decision that goes against their interests is a system that works in a manner where transparency is not simply a watchword and that such stakeholders are viewed not as hysterics with no standing, but as human beings with a right to stand on their two feet.

3) A More Compassionate Clearance Process: Currently, all compassionate use indications for medications under clinical trial or clearance to proceed with individual directives are cleared through the FDA. Many patients caught in this process will tell you that it takes months or years until applications for such use are cleared by the FDA. This often is insufficient for patients whose need for medication is based upon imminently emergent medical conditions where the need to treat is predicated upon the speed in which treatment can be administered. Those who claim understanding of FDA’s difficulty in moving through with the process have often contended that FDA is burdened with the constraints of a budget equal to that of the Montgomery County school district. Unfortunately, as we have seen in the private sector bailouts of the last two years, there are moments where improvements upon decision making processes can and will prevail over large sums of money deployed to correct given situations. I would contend that potentially ceding FDA authority over such compassionate clearance protocols over to the NIH which controls a series of hospital-based Institutional review boards or to an independent agency fully resourced and geared to making such decisions might be more appropriate. When looking at the structure of FDA, one is struck by the fact that no matter that size of their budget, FDA is tasked with making “en mass” decisions regarding the effect of medications on substantially populations of individuals; the difficulty of reshifting bureaucratic thought and focus for the good of one may not be a fair request of the limited resources and manpower that FDA purports to have.

Even more essential than what I noted above, there needs to be a shift in the focus of the general public. Members of the public, regardless of whether they have been touched by chronic illness or not need to be more properly engaged in this debate. The decisions made by the FDA on a daily basis more greatly affect any decision made by the President on health reform; regardless of how pays for your health insurance, if a treatment is not available for your condition, the payment system is immaterial. Additionally, if the FDA does not hear your voice and Congress does not your voice, the few trees in the forest who are rustling make no difference. Myself and other members of my organization do not feel that FDA harbors bad intent in any way; these are good people who have families and often join up with FDA because their families face similar problems to ours. But a discussion needs to be had where FDA does not assume that they are working in the patient’s best interest, but where the FDA can know that they are working in the patient’s best interest.

And it needs to start now.

Research Means Hope

That's the title of a promising new group, advocating Serious Medicine.

Tuesday, October 20, 2009

As part of a piece on the positive socializing impact of TV around the world--definitely a contrarian take--development economist Charles Kenny, writing in Foreign Policy magazine, mentions this nugget:

“Today, the world's most popular TV show is the medical drama ‘House,’ which according to media consulting firm Eurodata TV Worldwide was watched by 82 million people last year in 66 countries, edging ‘CSI’ and ‘Desperate Housewives.’"

"House" is a terrific show. But these data are a reminder that people are fascinated by medicine, all over the world. And for the reasons Kenny details, TV is probably increasing that fascination.

Sunday, October 18, 2009

The Continuing Debate Over "Romneycare"

As everyone following healthcare issues knows, Massachusetts enacted a health insurance plan in 2006, under the leadership of then-governor Mitt Romney. Today, 96 percent of Bay Staters are covered.

But that’s not the end of the story. As Los Angeles Times writers James Oliphant and Kim Geiger related on October 17, the fate of “Commonwealth Care” is tied to even larger issues, most obviously the current healthcare debate in Washington DC--and also the ideological contours of the 2012 election.

As the Times reports from Boston:

The state's system, like the proposals moving toward votes in the House and Senate, focused on three goals: making medical insurance almost universal, fostering competition through a regulated insurance exchange, and helping low-income workers pay for coverage.

OK, so is that proto-national plan working out in Massachusetts? Oliphant and Geiger do not paint a positive picture of Commonwealth Care in action these past three years:

But insurance premiums for most residents are going up, not down. Many middle-class people who had insurance before the overhaul see little change -- except that they're spending more. They're seeing little or no difference in the quality of their care

The Times adds this killer quote from a Democrat in the state legislature:

"What we did was health insurance reform, not healthcare reform," said Massachusetts state Sen. James Eldridge, a Democrat who regrets having voted for the bill.

For what it’s worth, the distinction between “health insurance reform” and “healthcare reform” is a favorite distinction here at SMS. We think that healthcare should be “reformed” by accelerating the search for cures; by contrast, fiddling with the financing, important as that is, should be secondary to the march of Serious Medicine.

OK, that’s the report from Massachusetts--more people covered, prices up, care about the same. But what are the future implications for the country? Oliphant and Geiger quote one observer, assessing the Senate Finance Committee bill:

Robert Laszewski, a healthcare policy analyst and former insurance company executive, calls the finance panel's bill "Massachusetts all over again."

So does that mean higher costs for Americans if the SFC bill becomes law? Yikes! And these harsh words are found in the LA Times, a member in good standing of the MSM. As I have said repeatedly on, Congressional Democrats might say that they are strongly in favor of Obamacare, but, fearful of a backlash in coming elections, they are petrified of actually enacting it.

Meanwhile, over on the political right, there’s been massive pushback against the Massachusetts plan. Just last week, The Wall Street Journal ran an opinion piece attacking Commonwealth Care, headlined, “Paying the Health Tax in Massachusetts.” Let author Wendy Williams tell her story:

My husband retired from IBM about a decade ago, and as we aren't old enough for Medicare we still buy our health insurance through the company. But IBM, with its typical courtesy, informed us recently that we will be fined by the state.

Why? Because Massachusetts requires every resident to have health insurance, and this year, without informing us directly, the state had changed the rules in a way that made our bare-bones policy no longer acceptable. Unless we ponied up for a pricier policy we neither need nor want-or enrolled in a government-sponsored insurance plan-we would have to pay $1,000 each year to the state.

My husband's response was muted; I was shaking mad. We hadn't imposed our health-care costs on anyone else, yet we were being fined ("taxed" was the word the letter used).

“Taxed.” A tax increase. Them’s fightin’ words to Journal readers.

Of course, we might note that Mr. and Mrs. Williams seem to have chosen to live on Cape Cod after they retired. It’s a beautiful area, but the peninsula is, of course, part of what has long been known as “Taxachusetts.” That is, Mr. and Mrs. Williams knew what they were getting themselves into--and went there anyway. If we believe in federalism, we have to make allowance, to be sure, for different states to have different tax policies. Yet one result of such political diversity, seen in 2005 Census data, is a wide variety of per-capita taxation levels among the 50 states--from a high of $3600 per person per year in Vermont, to a low of $1430 in South Dakota. Massachusetts ranks seventh from the top, with a per-capita tax burden of $2818.

We might also note that Williams’ statement, above--“We hadn't imposed our health-care costs on anyone else, yet we were being fined”--is more than a little arguable. Specifically, we can argue with her statement that “we hadn’t imposed” healthcare costs on anyone else. Such non-imposition of healthcare costs is true for everyone before they incur healthcare expenditures. But everyone does incur such expenditures, and oftentimes the rest of us end up paying.

We don’t know the particulars of the Williams family insurance plan, but we do know that many Americans get sick well beyond their ability to pay, or the limits of their insurance coverage. These things happen, and, almost by definition, they are neither planned nor intentional. But they are inevitable. Accidents and serious illness happen, oftentimes imposing huge burdens on the taxpayers.

Yet not only do Americans tend to be compassionate in the distribution of healthcare, well beyond individuals’ capacity to pay, but there are also laws that force the delivery of expensive care. One such law is the Emergency Medical Treatment and Active Labor Act, passed in 1986, requiring virtually all U.S. hospitals to provide emergency care, regardless of the patient’s ability to pay. Interestingly enough, there is no corresponding federal responsibility to reimburse hospitals for these costs, although there exists a federal subsidy program. Still, one study found that the total cost to hospitals of uncompensated care totaled more than $34 billion in 2005; other estimates go much higher. But whatever the cost of uncompensated care, it is not small--and we all pick up the tab.

In addition to the policy issues raised by Williams’ piece, there are political issues, too.

Williams quotes former governor Romney as saying, back in 2006, “We insist that everybody who drives a car has insurance, and cars are a lot less expensive than people.” And yet obviously she doesn’t buy that argument for the “Romneycare” mandate. Nor do others who write opinion for the right-tilting Journal editorial page. For example, on September 18, David B. Rivkin Jr. and Lee A. Casey published a fighting piece in the Journal headlined, “Mandatory Insurance Is Unconstitutional.” Take that, Mitt!

In Romney’s defense, the health-insurance “tax” that Williams and her husband are now paying was imposed by a different Massachusetts government, after Romney left office. But let’s not minimize the damage being done to Romney’s future inside the Republican Party. Romney’s gubernatorial support for a health-insurance mandate--thus opening the door to future increases in mandated coverage, and mandated cost, as seems to have hit Mr. and Mrs. Williams--will be a big vulnerability for him if he seeks the Republican nomination again in 2012.

So is that the final word? Is a Massachusetts-type health-insurance mandate a bad idea, and/or a Republican Party loser?

Not necessarily, according to Jim Woodhill, a Houston-based businessman. Woodhill, a fixture in conservative-libertarian circles, does not defend Romneycare per se, but nonetheless, he has shown a distinct willingness to challenge conservative-libertarian orthodoxy. He is the original Serious Medicine Strategist. And so here at SMS we were delighted to receive Jim’s detailed response to the Williams piece. It appears in bold below, with bits of the Williams piece included again, in both bold and italics. The bracketing asterisks in the text are Jim’s way of emphasizing a word or a point:

I must tell you that I am a hard-core believer that carrying sufficient insurance so that one does not risk imposing one's medical costs on one's fellows is a fundamental *duty* of citizenship and so I favor an individual mandate strong enough to achieve the goal of taking the amount of "uncompensated care" delivered in the United States of America down to *zero*.  (It's only at zero that we can let all the financial services people working in hospitals and doctors offices go.)

The root cause of the problem below is a failure of imagination on the part of insurance companies and also the regulators.  Under America's current health care (non-)system, medical providers are unwitting and unwilling parties to insurance contracts the terms of which they had no say in and which they did not sign.  Part of The Woodhill Plan is that health insurers could cut any deal they wanted with the insured (e.g., any size deductible, co-pays, and co-insurance), but the *insurer would take the risk that the insured might not have those sums*, not the provider.  That is, the medical providers would experience all patients as being fully insured with "first-dollar" coverage and would be paid 100 cents on the dollar for services rendered at whatever rate was pre-negotiated with the patient's PPO network.  It would be the insurance company that would dun the insured for the amounts not covered by the specific insurance in force.  Under such a system, the state would not care whether the deductible was $1, $2,000, or $20,000, just that its health insurance companies were solvent.  There would be no uncollectible medical debt, and therefore no public purpose for a mandate of a "reasonable" deductible. 

  Ten years ago, we had excellent coverage through a
     more gold-plated plan. But we found that it was no
     longer worth paying the premiums and scaled back to
     a more modest policy. Today, we pay about $300 a month
     for catastrophic care. If we went with the next step up in
     plans offered to us by IBM, our monthly premium would
     increase to $800.

Then IBM needs to work with its insurer to tweak their current plan, at least for Massachusetts!

     We simply don't need to pay that
     kind of money for the amount of health care we
     actually consume.

This statement is reflective of the editorial page of The Wall Street Journal needing to consult a *dictionary*.  "Insurance" is not something that one pays for because of the health care expenses one *has* had in the past (which is what this health-blessed couple is *assuming* they will continue to enjoy in the future).  It's what one pays for the health care expenses one *might* have in the future!   This fundamental misunderstanding leads the Journal to denounce the notion that the "young and healthy" should end up paying for the care of the "old and sick."  Alas, I have news for them.  As long as the "sick" get care, it will be the "healthy" who pay for it.  The problem is that what I call Serious Medicine either costs nothing or some big multiple of the median financial net worth of an American family.  All there is to be done is replace super-high-"friction" mechanisms such as cost-shifting with low-friction mechanisms such as universal *adequate* insurance.

Woodhill is making an important argument here: We have a duty to be covered. If we aren’t covered, we will still get treated, but others will end up paying for our treatment. If libertarians and limited-government advocates mean what they say--that people should be free, so long as they aren’t doing harm to others--then they need to consider the harm that the uninsured are inflicting on others by their lack of insurance.

Yes, there are other ways to address this problem--using, for example, insurance pools for emergency and catastrophic care--but Woodhill argues that those alternatives are less satisfactory than the mandatory insurance plan he favors.

Woodhill’s position is controversial in Republican circles, but he is looking way ahead, past even the 2012 elections. The resurgent right may ambush Romney over his past support for Commonwealth Care, thereby derailing his bid for the presidency, but one of these years, a Republican is going to win back the White House. At which point, he or she will have to figure out a healthcare plan that will really work for the country, even if that plan doesn’t please the ideological avant-garde.

Indeed, as I have pointed out here at SMS, the actual policies--defined by money spent, laws written, and, yes, taxes collected--that have been put in place by elected Republicans, such as Romney, or Louisiana Governor Bobby Jindal, are a lot different from the policy proposals dominating opinion pages.

And yet the outlines of future healthcare policies--hopefully representing a constructive synthesis of best practices and best ideas--need to be blueprinted now. That’s work that Jim Woodhill, among many others, has been willing to do. And I have no doubt that in the future Jim’s innovative ideas, challenging as they might be to comfortable orthodoxies, will gain respectful hearing in the corridors of actual power.

Friday, October 16, 2009

Swine Flu In The Information Age

"Swine Flu Characteristics Becoming More Evident/Links to Pneumonia, Rapid Effects on Young Noted"--that's the scary headline in The Washington Post this morning. "It's very difficult to get this double-barreled message out that: 'Yes, most cases are mild, but in a small percentage of cases these cases are disastrous,' " Vanderbilt University's William Schaffner told the Post's Rob Stein. "But the message is: Don't underestimate H1N1."

People are dying of swine flu, in increasing numbers, but many are resisting getting the vaccine. And so we come to an important crossroad of public policy, at the intersection of public health, scientific research and the search for cures, "health insurance reform," the disseminating of information in modern governance, and, indeed, the structure of authority in our society.

In September, a survey by the University of Michigan’s C.S. Mott Children's Hospital survey found that a plurality of Americans said they would not get the H1N1 flu shot. No doubt some Americans have memories of the 1976 swine flu vaccine fiasco when 25 people died, apparently from the vaccine.

But as Christopher Beam observed in Slate, significant chunks of both the left and the right have staked out positions against the swine flu vaccine. On the other hand, most of the religious leaders surveyed by The Washington Post said that they saw a moral duty to get vaccinated.

Meanwhile, people are dying, especially the young. AFP, the French news agency, reported on Friday afternoon:

US health officials warned Friday that deliveries of swine flu vaccine are likely to be delayed even as influenza deaths climb, with children hit particularly hard.

Eleven more children were reported to have died of flu in a single week, 10 of them from swine flu, bringing the number of pediatric deaths from H1N1 flu since April to 86, Anne Schuchat, a senior official at the Centers for Disease Control and Prevention (CDC) told reporters.

In the worst of the past three flu seasons in the United States, which usually run from August to March, 88 children died.

As of mid-week, 11.4 million doses of H1N1 vaccine were available and around eight million had been ordered by the states.

Inoculation clinics got under way in several US states last week, targeting children, health care workers, people who work with infants, and young, healthy adults.

Long lines have been reported outside the clinics, as parents rushed to get their children -- one of the most at-risk groups -- inoculated against swine flu.

Let's sum up with five points:

First, vaccines are a great idea--a signature of scientific achievement. They are a true lifesaver; and saving lives is the best bender of the cost curve. But what about the argument that thimerosal, a preservative in some vaccines, causes autism? Most scientists, and most courts,have reject the imputed linkage between thimerosal and autism, but there's no need to get into that fight here. Suffice it to say that there is always room to improve medicine, including vaccines. But the opportunity for improvement does not obviate the immediate necessity, sometimes, of getting vaccinated.

Second, vaccines for the flu are not on a par with, say, the vaccine against polio. (Although the polio vaccine did not arrive in perfect form back in 1955; as this WaPo obituary of legendary health expert Ruth L. Kirschstein reminds us, deadly mistakes occurred during the evolution of that vaccine. That's the nature of science--you learn from mistakes, even tragic mistakes.) The various flu vaccines don't have the track record that the polio vaccine has now, but that's because we worked at it.

Third, even though recent flu outbreaks have been relatively benign, we never know when the flu is going to turn for the worse, as the WaPo reminds us. And we never know when or if it might turn into something as bad as the Spanish Flu, which killed 50 million or more worldwide in 1918-1919.

Fourth, in today's culturally libertarian age--everyone is empowered with information, everyone has rights, everyone has an opinion and a way to give voice to it--it's hard for government to get anything done, just as it's hard for people to trust the government. And let's face it: Much of the time, such mistrust is justified. And when, for example, 83 percent of Americans think that legislation should be put online before Congress votes on it, and the government simply ignores that overwhelming sentiment, well, that further degrades public confidence.

Fifth, vaccines, or anything else medical, won't get better unless they’re tested and tried, first on test subjects, then on larger and larger populations. So all of us interested in better medicine, and cures, have an interest in encouraging people to participate in these efforts.

OK, so where does that leave us? Here's the SMS view: We should encourage people to get the vaccine, maybe even incentivize them to get the vaccine. With money? Maybe. Or maybe we should launch some other sort of persuasion campaign; I still remember President Gerald Ford getting the swine flu vaccine, on camera, back in 1976; and while that particular public-health exercise didn't work out so well--either medically for the country or politically for Ford--one of the many reasons that we should admire the 38th President was that he was physically courageous. Whether it was heroism in World War Two, or getting that swine flu shot, Ford was always willing to lead by example, putting himself at risk, if need be.

So now to the present: Who will step forward, today, to lead by example? Will President Obama, for example, get a swine flu shot? He has said that he will get the shot, but that he will wait his turn in line. That's an admirable position--and let's be honest, he would have suffered heavy criticism had he received the shot ahead of others--but perhaps he should cut to the head of the line. Not for his sake, but for ours.

Why push this vaccine effort? For this reason: If flu vaccines today are not as good as they could be, we should always bear in mind that the only way to make them better is to keep pushing forward.

But in the meantime, we clearly need a better information effort, as part of our Serious Medicine Strategy. We need to convince and persuade people to support vaccinations--for themselves, and as part of a needed collective effort. But at the same time, we need thorough scrutiny, even muckraking, on these and all other health issue. (But probably not, except for the grossest cases, trial-lawyer buccaneering.)

And vaccines, of course, are just a small, albeit important, part of a Serious Medicine Strategy. As the WaPo story on swine flu this morning reminds us, sometimes doctors take extraordinary measures to save lives. Let reporter Rob Stein tell the tale:

And some of those who develop serious illness deteriorate soon after starting to feel ill. They require oxygen masks, ventilator machines to pump oxygen into their lungs to keep them alive, and drastic, often rarely used measures to try to save them within days of the first fever, ache or cough.

"The rapidity of it is striking," said Andrew R. Davies, deputy director of intensive care at Alfred Hospital in Melbourne, Australia.

Some of the cases in Australia and New Zealand were so severe that doctors resorted to a much more aggressive, less commonly used treatment known as extracorporeal membrane oxygenation (ECMO). It involves siphoning patients' blood into a machine to remove carbon dioxide and then infuse it with oxygen before returning it to their bodies.

"It's quite an extreme form of treatment," said Steve Webb, a clinical associate professor at the Royal Perth Hospital in Australia.

Other doctors have tried administering nitric oxide and putting patients in a bed that turns them upside down to help their lungs work better. "Our back was against the wall," Murphy said, adding that after the deaths of patients such as Hays his hospital is working to make ECMO available.

Now that's Serious Medicine. I am glad that they can do that lifesaving procedure in Australia, and I am glad that it can be done here. And I hope, of course, that nothing in the Obamacare legislation will crimp such heroic technology, or slow down the future introduction of even better technology.

What we really need is a public debate over a vision for a healthier future--a vision that renews our commitment to cures, a vision that builds on a public consensus on fighting a real war against illness, incapacitation, and premature death. I think that such a Serious Medicine Strategy would be a huge winner with the American people, but we need a solid and yet transparent process for getting there.

We have all these great tools available, from TV, to the Internet, to Twitter, to Google Wave and to the wave after that. Are we using them for good purposes--to save lives? Unfortunately, it would seem that the incumbent political class is so hung up on building a bigger bureaucracy that it has lost sight of the real goal of healthcare and medicine, which is to make people healthier.

So once again, we need a better strategy--a Serious Medicine Strategy. And once we get that strategy in place, the communications tactics needed to implement that strategy should become readily apparent.