Friday, November 27, 2009

Social-Network Medicine and Scientific Progress--Building the "Infopolis" Of The Future

The BBC's Mark Ward reports on a new effort to harness the power of social-networking to the cause of good health. It's interesting to see the UK's National Health Service thinking ahead like this:

Social media could transform the NHS and other public services in the same way that file-sharing changed the music industry, a conference has heard.

Growing use of tools, such as Facebook and Twitter, offered an opportunity to reinvent services, delegates heard.

The MyPublicServices event debated ways to harness these conversations, many of which are critical, to make services better and more inclusive.

If this was not done, many services would be undermined, speakers said.

"It's happened to the music and travel industries and it's going to happen to public services," said Dr Paul Hodgkin, founder of the Patient Opinion site that organised the MyPublicServices conference.

Of course, there's another word for the effort to harness the rapid exchange of information--it's called science, which thrives on an abundance of data, and thrives even more when that data can be usefully analyzed and acted upon.

If everyone's medical history were transparent to science, science would benefit, as scientists would derive knowledge from ever-more-granular awareness of drug interactions--who gets helped, who gets hurt, who gets nothing. Similar data runs would provide great insight into questions of nutrition, fitness, surgical efficacy, and so on.

In a perfect world, medical scientists would have the benefit of knowing every possible data point, about every possible life history, about every possible medical record, and so on. That's the fuel of not only scientific progress, but also engineering and manufacturing progress.

Now of course, there are concerns as well. Most obviously, there are privacy concerns. Nobody has adequately explained how it might be possible to make medical data fully transparent to researchers and yet at the same time, keep that data appropriately opaque to governments, insurance companies, and snoops. Clearly, in a free society, personal information should stay personal, at the discretion of the individual.

On the other hand, as we know from observing social networks, such as Facebook and Twitter, many people can be extremely revealing, to the point of exhibitionism, on their sites. They are happy to part with their own personal information, in return for the most intangible of intangibles, e.g. membership in a group, or a widget for their site.

In addition, researchers are gaining access to other sorts of online sociological/anthropological information; earlier this year, it was revealed that Sony had shared with academic researchers 60 terabytes (1 terabyte = a trillion bytes) of data about players who played Everquest, Sony's massive multiplayer online role-playing game. One might think that somebody would have raised some privacy concerns about such a massive data divulging, but nobody seems to mind--we might suppose that anybody who logs on to such a game has no serious expectation of privacy. In any case, Sony's gift was a huge boon for social science, and perhaps also for science.

So it's possible to imagine similar hauls of information in the future, as researchers scour cyberspace for troves of data. And so the song of curiosity remains the same. For centuries, scientists and collectors have trolled the earth, looking for everything from gold to butterflies to ancient art . More recently, they have gone prospecting for more exotic types resources and also for medical information, in the form of research trials--for a nasty view of these efforts, see John LeCarre's book-turned movie, The Constant Gardener. And so in the future, info collectors could go trolling for something new--information. Obviously ethical guidelines for info-harvesting, like every other kind of harvesting, are needed.

And just as obviously, the cause of knowledge is best served by piling up information into usable formations, databases that are transparent and accessible to as many different users as is technically and ethically possible.

We can thus see that the amassing of information is going to a major political issue, as well as a major social, economic, and scientific project.

We don't need virtual pyramids of information, dead monuments just for show. Nor do we want Potemkin Villiges of phony information, as has been revealed by the data hack at the Climate Research Unit at the University of East Anglia. Nor do we want such knowledge to be housed in distant ivory towers, for the benefit only of an unaccountable elite.

Instead, we need virtual cities of information, in the here and now, where multitudes of people can work and discover. We need for these "infopolises" to be existing right before our eyes, so that we can all participate and assess.

That's one way how the world will become a better place.

Thursday, November 26, 2009

The Plasma Disinfectant Device: The Birth of A Win-Win-Win Industry. But For Which Country?

Could a new technology vastly improve our capacity to disinfect objects, as well as living tissue--or even cause injured tissue to heal faster? That's the claim reported by the BBC's Jason Palmer, detailing a new plasma device--the prototype sort of looks like a microwave oven--that can be used to kill microbes, including the deadly and dreadedly drug-resistant MRSA. Which is to say, if this device works, could it not only save lives, but could it also reduce healthcare costs--reducing them the right way, not by rationing, but by eliminating the problem?

And third, could such a device provide wealth and jobs for its inventors and makers? Create a whole new industry, perhaps? Let's hope so! Because we want people to develop the cures and treatments that will help us live better and longer lives. We should reward these medical trailblazers financially, as well as showering them whatever other honors and rewards a grateful nation--and civilization--can bestow.

That's the bright prospect, but unfortunately, current trends in political economy are going the other way. These days, as the U.S. Senate debates a healthcare bill that will almost certainly slow down innovation, we are left to wonder whether or not the benefits of this new technology will come to our shores any time soon. Sure, the rich in America--and a few rich hospitals--might be able to buy such a disinfectant device as an imported good in a few years, but the vast bulk of Americans will probably be left out, because their government is committed to a vision of insurance egalitarianism, a.k.a. low-tech austerity, in which all expenditures for healthcare, no matter how meritorious, are lumped into the category of "rising cost curves to be bent downward."

The BBC's Palmer, reporting on the work of Gregor Morfill, at the Max Planck Institute for Extraterrestrial Phyiscs in Munich writes:

Professor Morfill and his colleagues have worked out the precise details of the plasma production that effectively kills off such bugs without doing harm to skin, and demonstrated a number of prototype devices that do the job efficiently.

"To produce plasmas efficiently at low cost so you can really mass produce these things for hospitals, that's the big breakthrough of the last year," Professor Morfill said.

The team says that an exposure to the plasma of only about 12 seconds reduces the incidence of bacteria, viruses, and fungi on hands by a factor of a million - a number that stands in sharp contrast to the several minutes hospital staff can take to wash using traditional soap and water.

Professor Morfill said that the approach can be used to kill the bacteria that lead to everything from gum disease to body odour.

Now, of course, we'll have to study and see how this technology proves out. But on the operating assumption that Morfil has a workable idea here, it's possible to imagine that a whole new industry is about to be created. And that will be worth a lot to somebody, and to some country.

Indeed, there are actually two related devices in question. The Medical News adds this:

Two prototype devices have been developed: one for efficient disinfection of healthy skin (e.g. hands and feet) in hospitals and public spaces where bacteria can pose a lethal threat; and another to shoot bacteria-killing agents into infested chronic wounds and enable a quicker healing process.

A Serious Medicine Strategist, Aaron Jacobson, did some quick calculations on the value of this plasma technology, according to three variables: first, the number of lives that might be saved (the most important concern); second, the economic value of such life-saving; and third, the economic value of a future plasma disinfectant device industry. Here's what Aaron came up with, focusing on just the United States. These are, of course, extremely rough back-of-the-envelope figurings:

First, the number of lives saved:

In 2000 there were 103,000 deaths from infection in U.S. hospitals.  Let's imagine that 80% of those would have been prevented by this device.  That's 82,400 lives a year. 

That's good news for a lot of people.

Now, second, the economic value of lives saved. Here at SMS, we are always hesitant to express human life in dollar terms, but unfortunately, the data-driven language of today's public policy discourse demands it. Washington DC, after all, is a place where just about everything is reduced down to a Congressional Budget Office number (no matter how notional that number, derived through static analysis, can oftentimes be; in July, we wrote extensively about the limitations of such narrow-gauge static analysis). But, alas, when in Rome, do as the Romans do. So here goes with Aaron's estimate; SMS readers can see how he arrived at his numbers:

Now let's imagine that on average each of those people would have lived 10 more years.  (That's the most questionable estimate because it's really hard to say.  Some people might have lived 40 or 50 more years, while others might have lived just a few more months.  I'm assuming that many people dying of hospital-borne infections were already old and sick and may not have had a long time left to live.)  That brings us to a total of 824,000 life-years.

Medicare payments functionally value a life-year at $50,000.  Multiply that by 824,000 lives and you get $41.2 billion.  And that's per year.

Third, on a cheerier note, Aaron provided some initial thoughts on the possible size of the market for these plasma machines:

There are 7600 hospitals in the United States, employing 5.1 million people.  The former device (the one for disinfecting hands) would probably be a standard feature in hospitals, like sinks and hand sanitizer are now.  Let's say 1 for every 50 employees (remember that only about a third of employees are on shift at a time).  That's 102,000 devices.

The latter device (the one for disinfecting wounds) would probably be rarer.  There are about 965,000 hospital beds in the United States, with an average occupancy of about 75%, which means about 723,000 patients at any given time.  Let's say 1 of these devices for every 500 patients.  That gives us 1446 devices.

Estimates of the prices are even more conjectural.  I imagine that a plasma device that would "disrupt" traditional sinks and sanitizer would have to be affordable, let's say $200.  (This seems plausible if we remember how cheap the cheapest plasma TVs have become.)  The other device, on the other hand, might be significantly more expensive--although still nowhere near the scale of some hospital equipment.  Let's say $2400 apiece.

That gives us a total market of $23,870,400.  Based on current employment in manufacturing and manufacturing as a percentage of the GDP, we can estimate that manufacturing these devices would provide jobs for about 6500 people.

It's important to realize, of course, that these estimates are completely rough.  The new technology could have dozens of unforeseen applications--if it turns out to be truly efficient it could replace traditional sinks and sanitizers in public restrooms and restaurants (the latter market being much larger than the hospital market).  On the other hand, it might never be feasible to make the devices that cheap, and then the technology would just flop.  There's no way to know.

OK, let's sum up Aaron's estimates: This plasma device could save 82,400 lives a year, saving us $41 billion a year, by staving off the economic losses that come from premature death. And the industry that would be created would generate almost $24 billion in revenue, creating 6500 jobs, before the U.S. market was saturated. Although, of course, there would undoubtedly be a large home- and office-use market as well. And as the market got bigger and bigger, per-unit costs would fall and quality would rise. There would even be mini- and handheld versions of these disinfectant devices.

In other words, plasma disinfectant devices would go through the same virtuous cycle as has happened with every other consumer electronic device. Today, 80 percent of Americans have cell phones--and why shouldn't they? They are cheap, they are useful, and sometimes, as we know, they can be lifesavers. If even a quarter of Americans decided that they wanted an inexpensive device that would disinfect anything, including themselves, it's easy to see this hypothetical industry being a future peer to the home entertainment industry.

But of course, beyond the 300 million people in the US are another 6 billion or so people around the world. And those folks account for economic product approximately triple that of the U.S. Not all of those billions could afford these devices--but many of them could, especially as prices fell. So that's a lot of devices to be made and sold, and then, out of the enormous surpluses generated, it would be right and proper to give some of them away to the truly needy.

But in any case, a new industry could be created, as line-extensions beget spinoffs, begetting uses that we can't even imagine right now. So on top of the value of the initial sales of the device, what would be the market capitalization of such a new industry? How much wealth would that add to the economy? How much momentum for future breakthroughs?

That looks like a win-win-win to us: A win for saving lives, a win for saving money on healthcare, and a win for economic development.

It might seem strange that such a discussion of techno-entrepreneurial possibilities is completely absent from the current healthcare debate in Washington--yes, that it strange, And a huge lost opportunity for our health, and for our wealth.

If DC continues to let itself be dominated by CBO numbers--numbers totted up by well-meaning beancounters, who are deliberately oblivious to the transformational potential of technology--then of course Washington policymakers will be blind to the sort of scientific potential outlined by Morfill, and to the economic potential outlined by Jacobson.

So the question: Which company, and which country, will jump on this technology? For the sake of the hard-hit American economy, let's hope that the U.S. gets ahead of the pack, but for the sake of humanity, let's hope that somebody does it, even if we don't.

Thanks to another Serious Medicine Strategist, Peter McBrien, for first tipping us off to this item.

Tuesday, November 24, 2009

Now THIS Is Serious Medicine

WBCBS in New York City has the whole story.

But consider this nugget, from reporter Chris Wragge's account, concerning the new life-saving technology that saved the life of 56-year-old Joe Tiralosi:

A specific procedure helped save Tiralosi's life. Special cooling pads, not available in all emergency rooms, lowered his body temperature to 91 degrees, essential in preventing long-term neurological damage and preserving brain function. Placed in a medically induced coma, incredibly, he began to wake up three days later -- without brain damage.

Now we might ask ourselves: will every ER have this technology? And if not, why not?

Here at SMS, we are reminded of a medical-equipment controversy surrounding the death of Michael Jackson in June: As we noted at the time, some argued that a $1300 device, an Automatic External Defibrillator, might have saved Jackson's life, if one of those machines had been available in his house when he died.

How many such devices are there, waiting to be placed everywhere they are needed? And how many more such devices are out there, waiting to be invented?

And we might further ask: How will the procedure that saved the life of Joe Tiralosi be accounted for? Will it be counted as a cost, part of the bulging expenditures for healthcare in the US? Or will be counted as a savings, because Tiralosi, who seems to have suffered no ill effects from his dramatic encounter with death, is now free to continue being productive?

The Medical Good Shepherd: Structuring "Invisible Hand Values" to the Supply Side of Healthcare and Medicine

In The New York Times this morning,David Brooks sums up the conventional wisdom on healthcare, arguing that we face a choice between "vitality" and "security." Brooks' dichotomy, which echoes Virginia Postrel's distinction between "dynamism" and "stasis,"is the familiar way of thinking about healthcare. Do we want raw-boned capitalism, and inequality, or do we want the snug, albeit somewhat smothering, cradle-to-grave welfare state?

That's familiar analysis, and it's also static analysis, taking it as a given that if somebody gets more, somebody else will have to get less. As we shall see, there is a third, dynamic, way of thinking about the problem, which Brooks neglects. That dynamic alternative is to use medical technology as a sort of "good shepherd," improving everyone's life, from the richest to the poorest, while lowering costs and improving outcomes for all. Sadly, that Good Shepherd alternative is not only absent from Brooks' column, it is almost entirely absent from the current debate.

Here's Brooks, in his own words, offering us a choice between "decency" and "vibrancy":

The bottom line is that we face a brutal choice.

Reform would make us a more decent society, but also a less vibrant one. It would ease the anxiety of millions at the cost of future growth. It would heal a wound in the social fabric while piling another expensive and untouchable promise on top of the many such promises we’ve already made. America would be a less youthful, ragged and unforgiving nation, and a more middle-aged, civilized and sedate one.

We all have to decide what we want at this moment in history, vitality or security. We can debate this or that provision, but where we come down will depend on that moral preference. Don’t get stupefied by technical details. This debate is about values.

Where to begin? Let's start by noting that for opinion-mongers, it's always comfortable to divide choices into two: we can do A or we can do B, and the pundit, of course, has ready phrases and formulations to describe both A and B. But what makes life easy for the pundit is not often the same thing as what makes life better for Americans. If the choices, "brutal" or not, are familiar, then the odds are that those choices aren't the best choices, because in a dynamic world, the best choice is often the newest choice. But new choices tend not to fit into the comfortable repositories of conventional wisdom. Binary is easy, multiple choice that is really a multiple is hard, because the choices need to be updated with the speed of Schumpeterianism.

We might further illustrate the defects in this sort of binary thinking by asking the question: What if this same kind of static discussion had been about information technology, circa 1970? The punditical worthies of that bygone day might well have said, "Computers are ruinously expensive. Only the rich and powerful can afford them, and besides, they don't really work that well. Moreover, for most people, they are cold and alienating, with all those punchcards and tape reels. So let's think through whether we really need more of them in America, with an eye toward cutting back, because, as we all know, 'Small is Beautiful.' And if we do need more--big if--let's focus on making sure that everyone has fair access to computational power. Because, after all, the computer discussion should not about 'technical details,' it should be about 'values.'"

Here at Serious Medicine Strategy, we remind the reader that "values" are always good turf for pundits, who are rarely equipped, in any case, to talk about technical details. But its technical details, technology, that drives the future.

Our little parable about computers in the Disco Age is a prefiguring of the rationing discussion that we are hearing in our own time, the iPhone Age. Policy discussions, then and now, are inflected with the anti-technological ethos that suffuses the Brooksian right, as well as the post-New Deal left.

But let's continue to draw the parallel between computers then and healthcare now. The conventional-wisdom-dispensing pundit of 1970 would add, "Now there are some who say that we should try to figure out how to equip every small business and other small users, with greater access to an IBM 360. But that's just too much--such an expansion of the computer market would drive the share of our national GDP devoted to computers to an absurd new high, and it would increase the gap between the computer 'haves' and the computer 'have nots.' So let's slow down the development of computers, even as we seek to figure out how to help small businesses with greater access to computer timeshares."

If that had actually happened--if the same politicizing forces that are seeking today to grab control of our healthcare had grabbed control of computers back then--it's a safe bet that today we would all be waiting in line somewhere, punchcards in hand, queued up to do a little computing. (If that is, we knew how to do it, and where to go.) Or, as another alternative, Japan would today be the world's computer superpower, leading the world with computers about a quarter of what we actually have now; those of us who wanted to advance in computer science would thus have to learn Japanese.

Happily, none of that happened. The government had a huge role in fostering the development of computers, and the Internet, but then it mostly got out of the way. And here we are, choosing apps for smart phones, most of which are free.

Now back to healthcare. Currently costs are rising rapidly in healthcare, mostly because of inefficiently delivered routine care, and inefficiently delivered futile care. The conventional wisdom says that these costs are unsustainable. And the c.w. is correct, as far as it goes. But the conventional wisdomeers need to understand that cutting back on healthcare costs by simply ordering cuts in healthcare is like cutting back on the cost of IBM 360s in 1970. Yes, you could have said, back then, that we needed to reduce the rate of growth on computer spending, perhaps even impose price controls, but computers wouldn't have gotten better under such an edict, they would almost certainly have gotten worse.

So what's the answer? The answer, for computers, was to move forward, piling on more capital, and more R&D, and more freedom for geeks in garages--and the result, of course, was a stupendous explosion of computing power, far beyond anyone's imagination. And yet at the same time, computing got cheaper, to the point of ubiquity. Just about everyone in America today has access to more computing power, in his or her hand, than whole buildings of computers possessed just a few decades ago. That's success.

But does such success count as a "value"? Such success might be called an example of "invisible hand values." As Adam Smith wrote in The Wealth of Nations, 234 years ago:

It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest. We address ourselves, not to their humanity but to their self–love, and never talk to them of our own necessities but of their advantages.

Such talk of self-interest, shrewd as it is, offends many. And in fact, self-interest is not the highest human emotion. Adam Smith didn't write to get rich, he was, at heart, a moral philosopher, who wrote because he had distinct opinions on how to help England in particular, and humanity overall. Smith understood that self-interest is merely the most effective human emotion, a proven mechanism for unleashing (among other things) the world-transforming power of economics, productivity, and discovery. Those emotions, he argued, could and should be harnessed for the greater good of the whole.

The highest human emotions, most people would agree, are love and charity and a sense of duty. And these emotions should oversee the provision of ethical medical care.

Hence the idea of "The Good Shepherd," which I freely admit that I am borrowing from the late Jack Kemp, the apostle of both supply-side economics and also "bleeding heart conservatism." Kemp's argument, back in the stagflationary 70s, was that both the left and right had it wrong when it came to economic issues. The right, in those days, said that we were spending too much, and that we had to cut back--only then could we think about cutting taxes. The left said that we had to spend more, and that thus we needed to increase taxes.

Kemp's "supply side" argument went right down the middle, or, more precisely, the center-right: If we cut tax rates, we would increase economic activity, and thus increase tax revenues. The Laffer Curve-driven result woud be more for everyone: both the private sector and the public sector could get bigger. Thus Kemp's argument didn't sit well with those who were more interested in inflicting pain on their enemies: conservatives who wanted to abolish the welfare state, and liberals who wanted to soak the rich and build socialism.

But to Ronald Reagan, the argument made sense; the Gipper embraced "supply side economics" in the late 70s, on his way to the 1980 presidential election. And the American people, too, came to embrace the argument during the great boom of the '80s. Of course, it can be argued that for some things, such as welfare for non-work, we should cut spending, not only for the sake of principle, but for the absolute betterment of the people in question. And that's undoubtedly correct; unfortunately, Kemp had something of a blindspot when it came to controlling spending. But it's also the case that in a complicated society, there will be plenty of things to spend public money on. And such spending will will be popular--and thus inevitable. Thus the challenge is to make sure that the money is spent wisely, generating the greatest possible individual and social return.

And so, once again, back to healthcare. A libertarian purist might say that we shouldn't spend public money on healthcare, even if we had the money--because the money, after all, was taxed away from someone else. And a left-wing purist would say that we should have absolute equality of healthcare, administered by the state, aka, single payer. Both of these positions have been thumpingly rejected by the American people, over and over again, but of course, ideologues never did worry about elections. What's left is the mostly non-ideological but somewhat center-right remainder of the country. Those are the folks who liked Kemp's message in his time, at least what they knew of it, and those are the folks whom the Serious Medicine Strategy is targeted at today.

The Serious Medicine Strategy is not per se about tax rates, but it is about providing more--providing abundance. Not just more care, or an abundance of money, but more cures, and an abundance of good health outcomes for people, so that they can live longer and healthier lives. (And if they live longer, they'll produce more and spend more--once again, a win-win fusion of good health and good economics.)

And we'll get to that Abundance Point if we make sure that there is plenty of demand for healthcare, by empowering people to make their own choices (which usually tend toward "more"), and by empowering both the private sector and the government to further increase supply. In this sense, Serious Medicine Strategy, like supply-side economics, also owes something of a debt to Keynesianism, because spending more isn't bad, so long as you are getting something for it, so that the size of the pie is ultimately increased, thus rendering the debt more manageable in a relative sense.

If you spend money and get the TVA and Hoover Dam and LaGuardia Airport, as the New Dealers did back in the 30s--well, that's worth a lot. By contrast, if you spend money and you get nothing but padded payrolls and environmental impact statements--well, that's not worth much at all. Thus the difference between Franklin D. Roosevelt and Barack Obama.

Similarly, if we spend more on healthcare and medicine and we get real cures, we will not only make our own people happier and healthier, but we also be establishing the industries that can sell medicines and medical technology to the world. That's the sort of supply-side increase that we're looking for. Of course, to achieve those supply-side breakthroughs, we need not only lots of demand, both domestic and foreign, but also a lean, clean regulatory and legal environment. The New Dealers were pro-growth and pro-technology--they wouldn't have allowed growth to be crippled by trial lawyers. The supply-siders were the same in the 80s; the challenge now, in the 21st century, is to reclaim that producerist ethos.

But in the end, it's not about supply, or the invisible hand, or lawyers, or any of that stuff. It's about the Good Shepherd, as Jack Kemp explained. Kemp's fundamental impulse was Christian--or, as he was always at pains to say, Judeo-Christian. Kemp thought in terms of individual entrepreneurship, but as an old quarterback, he thought of teams, and team play. And as an American, he thought of his country, and everyone in it.

And because he cared about America, he was willing to think hard--think outside the box--about how to make America a better place. And so Kemp spoke frequently of the Good Shepherd, who uses his wisdom to care for even the least among his flock--even as that same wisdom increases the overall size and well-being of the flock. That's a gentle sort of conservatism, focused on bringing everyone up, while not hurting the prospects of the best or most fortunate.

In return, the American people cared about Kemp, and listened to him. As Fred Barnes observed at the time of his death earlier this year, Kemp was without a doubt the most influential American of his era who did not become president.

So then why is that Kemp-like thinking seems to have died with him? Why are so few today carrying on his intellectual legacy, seeking to use new ideas to establish win-wins across the board? Serious Medicine Strategy put this question to Peter Ferrara, a veteran of the Reagan White House domestic policy office, a longtime associate of Kemp, and a creative and hard-charging thinker in his own right. Peter's answer was that Kemp-like thinking does, indeed, seem scarce today, because there is something permanently counter-intuitive about the idea that you can get more out of less.

Taking a bleaker tone, SMS volunteered that perhaps because the chattering classes have reverted back to "root canal" thinking, taking a quiet pseudo-tough-guy glee in "brutal choices," because such thinking provides the pleasure of seeming stern, even harsh, toward friends as well as opponents. Being hard, after all, is a "value."

And yet, Peter observed, Kemp-like thinking is needed now more than ever--as America faces looming crunches over not only healthcare, but also other forms of spending, to say nothing of the prospect of a renewed bout of 70s-style stagflation. In all of those areas, Peter asserted, we need a revival of Kemp-Reagan thinking.

We've come along way, in this post, from David Brooks' static-analysis column. But although he is wrong to pose the choice as merely a static choice between "vitality" and "security," perhaps he was right, after all, in thinking that in the end it's about values. As we have seen, there are many values.

Here at SMS, we believe that the right value is to help people, to provide them with the tools to enjoy the best possible life. But an equal value is the willingness to think anew, and act anew, in pursuit of the greatest good, realizing that the answer, when it comes, will be shocking and startling to comfortable power relationships--as the mainframe makers discovered in the 80s and 90s. The willingness to be stunned by the power of the counter-intuitive is thus another valuable value.

That was Jack Kemp's great insight, and it's a positive and hopeful vision that animates Ferrara, and all of us here at SMS.

Monday, November 23, 2009

"The latest polls are an unmitigated disaster for Democratic efforts to get their health care bills passed."

"The latest polls are an unmitigated disaster for Democratic efforts to get their health care bills passed." Those are the words of Robert Laszewski, no conservative he, writing for The Health Care Blog.

Laszewski is thinking about the Rasmussen poll, showing support for the bill down to 38 percent, with 56 percent opposing. But as he notes:

It is not just Rasmussen that is measuring a dramatic slip in approval ratings for the Democrats on health care. Here are the last five consecutive polls released in the last week:

Fox - Favor 35% Oppose 51%
Quinnipiac - Favor 35% Oppose 51%
CBS News - Favor 40% Oppose 45%
CNN Favor - 46% Oppose 49%
PPP Favor - 40% Oppose 52%

Sunday, November 22, 2009

Serious Medicine in Action

A premature baby in an incubator, also from the Wellcome Trust. A reminder of why we fight. Note the teddy bear.

Serious Medicine

The Wellcome Trust, a UK foundation, sponsored this exhibit of Serious Medicine images. This is an electron micrograph of the drug prednisolone, used to treat inflammatory bowel disease. The orange spheres are the drug itself, encased in a blue polymer that enables it to travel through the stomach to reach the bowel.

None of this is easy. None of this is cheap. But it is worth it.

The Death Panels Live!

Sen. John Barrasso, Republican of Wyoming, was just on "Fox & Friends" this morning, making the point that the Democratic healthcare bill, now moving forward in the US Senate, would have the effect of codifying the power of advisory commissions into policy and fiscal reality. A reality that will kill people.

As Barrasso explained, if a seemingly innocuous panel, such as the U.S. Preventive Services Task Force, recommends that women should have fewer mammograms, that's not just ivory tower academics talking--that's a recommendation with real legal force.

Barrasso volunteered that his wife was diagnosed with breast cancer in her 40s, and that she has needed three operations to deal with her illness. The point being, if you don't catch it early, breast cancer is serious--deadly serious.

And now federal policy is going to come down hard on the side of fewer checkups. Some will claim that such decisionmaking bodies are not literally, "death panels," but whatever they are, they are certainly not long-life panels.

J. Taylor Rushing of The Hill caught this exchange between Barrasso and his fellow Republican, John McCain of Arizona; the subject is death panels, or something close:

In a scripted exchange with Wyoming Sen. John Barrasso (Wyo.), McCain assailed a recent recommendation by a U.S. Department of Health and Human Services panel that women receive regular mammograms once they reach 50 years of age, instead of the traditional 40. McCain used that to revive a criticism of the Democratic-written healthcare bill that Palin raised over the summer, that advisory boards could create polices that would make them become "death panels."

"Isn't that the kind of advisory board that this legislation could put into law, that those kinds of mandates could come down which could literally jeopardize the health and lives of Americans?" McCain asked Barrasso.

Barrasso's wife is a breast cancer survivor, a fact he referenced.

"This type of legislation would have cost my wife her life," Barrasso said. "She is a breast cancer survivor, diagnosed by a routine screening mammogram. And she was in her 40s when that mammogram was performed... It was a screening mammogram that saved her life."

A grinning McCain then asked, "You would not describe that as a death panel?"

Barrasso replied, "Some people might."

Above is a Photoshop rework of a 1983 Michael Douglas movie, "The Star Chamber," about vigilante justice; the title is a play on the very real Star Chambers of mid-millennium England.

Here at SMS, we don't approve of vigilantism, but we can observe that whenever the elites botch the job of doing something important, the masses will find their own way of doing--or at least trying to do--that important thing. In so doing, the masses might well do a bad job, because they aren't experts, aren't trained, and so on, but at least they are willing to try. Ergo, vigilantism. We note that the popular vigilantism--seen in movies of the 70s and 80s, such as "Dirty Harry," "Death Wish," and "Star Chamber"--mostly faded away when the law enforcement/justice elites started taking seriously the issue of crime and crime control. Which is to say, the elites usually have it within their power to squelch populist upsurges, through the simple expedient of solving the problem.

And now the same with healthcare: If the elites aren't to be trusted--if the elites have decided that the peasants are getting too much attention and should get less--then the masses will step forward with their own ideas, their own theories of explanation, which will all too often be labeled "paranoid," or "McCarthyite."

Thus if Sarah Palin chooses to dub the likes of the US Preventive Services Task Force as a "death panel," well, that's the people speaking. And if the elites don't like what the people say, or how they say it, they should look first to themselves. The elites should ask themselves: "What are we doing wrong that has caused the populace to lose confidence in us?" After all, since the elites have the power and the expertise, they should be able to fix whatever is wrong--at least they should get the first whack.

It's not all that often that the elites possess that sort of introspection, of course. Most of the time, the elites simply dismiss popular concerns, and so the populist rebellion continues to grow.

Like now.

Saturday, November 21, 2009

"The Henry Ford of Heart Surgery"

The Wall Street Journal's Geeta Anand published a fascinating article on Dr. Devi Shetty, dubbed "The Henry Ford of Heart Surgery." That is, Dr. Shetty has created a veritable factory for surgical procedures. And in good factory fashion--a pattern as old as the industrial revolution--the price has plummeted. Whereas the typical US hospital charges between $20,000 and $100,000 for an open-heart procedure, Shetty charges $2000. Now that's bending the curve!

There is a catch: Shetty's hospital is in Bangalore, India. Prices for everything tend to be lower in India, so it's not quite fair to compare his facility, Narayana Hrudayalaya Hospital, to an American hospital. And of course, we must always be mindful of quality and safety.

But the larger lesson is clear enough: Mass production is the only way to make things both cheaper and better, be it autos, or cell phones, or medical procedures. Yes, there will always be an art to medicine, but there's always going to be a science, to, as well as engineering. And if the science and engineering get cheaper and better, then the art, too, will be better.

For fun, the Journal adds a black and white slideshow. In one of the slides, screengrabbed above, we see a plaque with words that could have easily been on the desk of any American inventor/visionary: "Most of the things worth doing in the world had been declared impossible before they were done."

And so as we watch the healthcare debate unfold, we might keep asking ourselves: One way or another, are the political changes that we are seeing in Washington going to make it easier, or harder, for an American Dr. Shetty to bring the same blessings of mass production back to the US?

Who Will Win The Healthcare Vote?

For Politico's "Arena" section:

And the winner of the healthcare vote tonight is going to be … politics. In my view, that’s a good thing. Or, more precisely, it’s a good start. In America, the people should rule--and the American people want more healthcare, not less; 67 percent of Americans don’t think they are getting the treatment they need, and only 16 percent think they are getting too much treatment, according to the Kaiser Family Foundation. Powered by lopsided numbers such as those, the voters will eventually win this fight. Indeed, they already are winning it.

So what we have seen, and what we will continue to see, is the gradual peeling back of all the rationing and rationing-esque “reforms” dreamed up by the national policy elites. Those elites are plenty smart, but the grad-school group is committed to an intellectual model that the American people reject. Think of it as the healthcare equivalent of cap-and-trade--that is, a too-clever-by-half scheme that works well on a Cambridge chalkboard, and nowhere else. Those politicians who are overly impressed by eggheads and foundation-money glitz might buy into avant-garde claptrap for a while, but eventually, the more survival-oriented politicos will read the unmistakable smoke signals wafting up from the flyover folks: “Knock it off!”

A healthcare case in point is the thundering repudiation of breast-cancer-screening guidelines this week. It’s hard to think of a purer example of the gap between policy and politics: The policy experts, conclaved in some ivory tower, and seeking to do their part to advance the rationing agenda, issued guidelines that were immediately cut down by opposition fire, like British Tommies at the Somme. The guidelines were machine-gunned by politicians of both parties, reflecting not only public opinion, but also much media opinion. Hats off, in particular, to ABC’s Robin Roberts (herself a breast cancer survivor).

Meanwhile, as context, President Obama, like President Clinton before him, is still plodding forward, with General Haig-like determination, despite bleeding heavily in the polls. Obama, a clever fellow but not much of an historian, seems serenely happy following a doomed downer of a plan.

But as noted, the political class is wising up: If the American people want more healthcare, then the risk-averse-est course is to give them what they want. And that’s why all the cuts are fake, destined to be overturned by this Congress, or any and all future Congresses. It’s the triumph of politics, as a long-ago budget cutter, David Stockman, once ruefully described it.

Some day, maybe, the policy class will figure out how to turn fiscal lemons into economic lemonade. That is, if people want to live longer and healthier lives--not only in the US, but around the world--then that’s a good thing, not a bad thing. Whole new industries could be created, providing jobs and growth, as well as better medicine. The American people can’t quite articulate that bright future, because that’s not their duty; it’s the duty of the thinking classes. But as we have seen, the thinking classes are on their own ideological jaunt, quagmiring down in the deadest of political dead ends.

So in the meantime, the American people will watch--that’s all they can do. They will vote “no” on rationing foolishness, and so will their elected representatives. And if someone puts a better medical model in front of them, they will happily vote for that.

That day will come, and it can’t come soon enough.

Thursday, November 19, 2009

The Senate Bill, The "R"-word, and the "M"-word

Politico asks, "Is this the healthcare 'holy war'?"

Holy war? Probably. Word war? You betcha. The folks at Americans For Tax Reform have helpfully counted up the number of times that the word "tax" appears in the Reid bill--183 times. Other buzzkillwords: "taxable" (164), "taxes" (17), "fee" (152), and "penalty" (115).

But the real killer word is the "r"-word--"rationing." The fiasco over those breast-screening guidelines, which the White House rescinded after just the days of withering criticism, is a harbinger of things to come. As Rep. Marsha Blackburn said this morning in the WaPo, "This is how rationing begins...This is when you start getting a bureaucrat between you and your physician."

And so we come to the "m"-word--"more." As Samuel Gompers could have explained, the American people want more healthcare, not less.

Monday, November 16, 2009

Carly Fiorina On the Paradox of Cost vs. Quality--In Healthcare, and Everything Else

Carly Fiorina, the former CEO of Hewlett-Packard, now running for the US Senate seat held by Barbara Boxer, was in Washington DC today, talking about, among other topics, healthcare.

Fiorina is a Republican who played a prominent role in John McCain's presidential campaign last year, and her answers, heard at a small gathering, mostly reflected Republican healthcare orthodoxy: patient empowerment, choice, and competition, including in insurance. And interestingly, she also put in a plug for community clinics, the expansion of which was a significant, if generally unheralded, achievement of the Bush 43 presidency.

But what makes Fiorina stand out is her obvious orientation toward problem-solving, based on her three decades in corporate America, during which she rose to lead a Fortune 50 company. Asked to sort through the issue of whether government is too big or too small, she left no doubt about her own conservative inclination toward limited government, drawing a further distinction: between government that is effective and government that is ineffective.

And it was on this question, of effectiveness, that her organizational experience became apparent: “If you focus on quality," she said, "you drive costs down. But if you focus on costs, you get unintended consequences.” That might seem a bit counter-intuitive to some, but not to SMS readers; as argued here many times, powering through on technology is the key not only to improving the quality of technology--making it work better--but also to making it cheaper. Think computers, or cell phones, or just about anything else: Innovation times productivity equals lower costs. You make it cheaper by making it better.

But let Fiorina tell her own story. Asked to elaborate on her answer, she recalled that when she took over at HP, “There were 87 separate divisions, each with its own president, or CFO, each its own little empire...a very expensive cost structure...hard for customers to navigate."

It would have been simple, Fiorina said, to give each division its own “10 percent haircut"--just a rote budget paring. But the better way, she continued, was to ask a new and potent question: “How do we improve the quality of service for the customer?” That is, rather than directly confronting the budgets of those 87 divisions--each one turf-conscious, each eager to defend its own little silo--Fiorina sought a more indirect approach; she changed the equation by which the entire company operated.

Was Fiorina successful? As her website puts it:

Carly served as the Chairman and Chief Executive Officer of Hewlett-Packard Company (HP) from 1999 to 2005, leading the reinvention of the legendary company, successfully steering it through the dot-com bust and the worst technology recession in 25 years. During her tenure, HP's revenues doubled, from $44 billion to $88 billion, with improved profitability in every product category. Today, HP is the largest technology company in the world.

She proved her leadership in tough times. Her pursuit of the controversial merger with Compaq Computer is now acknowledged to be the most successful merger in high-tech history and positioned HP to become the first $100 billion information technology company, creating market leadership positions for the company in every one of its product lines.

And while not everyone is a fan of her performance at HP, she demonstrably has a lot more valuable real-world experience than Boxer, who is perhaps the leading left-wing ideologue in the Senate, and a staunch supporter of paleoliberal policies.

Listening to Fiorina's answer about costs vs. quality, we were reminded of the famous quote from Albert Einstein: "No problem can be solved on its own level." That is, when confronted with a seemingly insoluble conundrum, new intellectual inputs are needed to get out of mental stasis, even stalemate.

So how to apply such wisdom to healthcare? The answer, she said, was "integrated care," as well as the aforementioned empowerment, choice, and competition.

Here at SMS, of course, we would have wished that Fiorina had put more of an emphasis on cures--because cures are the real purpose of healthcare and medicine.

But Fiorina herself was recently treated for breast cancer, and while her doctors, she said, have given her a clean bill of health, she still has the short hair to prove that she has recently gone through chemotherapy. So she knows about Serious Medicine--and what it can do. And no doubt she has plenty more ideas on how to make medicine and healthcare work better.

Indeed, we are sure that she will have more fresh ideas to bring to the healthcare debate in the months and years to come, which is more than Barbara Boxer can say.

Sunday, November 15, 2009

The Left Rethinks Single-Payer Healthcare

Maggie Mahar, a well-known health analyst at the Century Foundation, published an interesting opinion piece in the Washington Post this morning, entitled, "If conservatives ran health care..."

In the piece, Mahar makes the case for choice and pluralism--that is, against healthcare universalism--as well as any conservative or libertarian. Indeed, Mahar makes her case so well that one must conclude that thinkers in both ideological camps, left and right, recognize that they have a huge stake in choice, and yes, dare I say it, competition. Because within choice and competition, we all, liberal and conservative alike, find freedom. Mahar begins:

If you're a progressive like me, and you're upset by the Stupak amendment, which bars federally subsidized insurance from covering abortions, consider this: What if we had a single-payer health-care system and someone like Jeb Bush or Sarah Palin were running the country?

Yes, that is a good question. Mahar continues, "A single-payer system would have put us at the mercy of whomever happened to take control of Washington." Exactly. And according to Gallup, conservatives account for 40 percent of the population, moderates for 36 percent, and liberals for just 20 percent. So because of that conservative preponderance, everything else being equal, those who take control of Washington are more likely to be on the right, or at least center-right, than on the left.

There is no one-size-fits-all that fits everyone comfortably. And if one size is made to fit all, as in a single-payer system for healthcare, then that one size is likely to lean right, not left--at least in a small "d" democratic country. Once again, Gallup tells the tale: for the first time in the history of Gallup asking the question, a majority of Americans count themselves as pro-life. Which is to say, a universalized single-payer system would probably be pro-life--majority rules. And such a pro-life stance would be popular with many Democrats, as well as Republicans--Bart Stupak, mentioned by Mahar above, is a Democratic Congressman from Michigan.

And of course, the recent elections have put the left on notice that America is very much a two-party system; yes, the Republicans took a severe drubbing in 2006 and 2008, but those results were mostly a repudiation of George W. Bush, John McCain, and various scandal-plagued Republicans in Congress, not proof of an enduring Democratic majority, to say nothing of an enduring liberal-left hegemony.

Thus Mahar quite reasonably calls for pluralism in healthcare:

So I want to hedge my bets. I want alternative insurance options, especially from nonprofits such as Kaiser Permanente. And I don't want to find myself locked into an insurance plan run by conservatives -- or Democrats -- who feel they have a right to impose their religious beliefs on my access to care.

Universal systems, if they contain even the slightest bit of coercion toward others, are only appealing if you are sure that your side will win--and you are absolutely confident that your side should win. Every time. We can aim to be universal and absolutist on a few things, such as the rights and dignity of the individual, although even that's not always easy.

But as a rule, it's hard to spread universalism to very many areas of human activity. And of course, if you are not sure that your side will win the fight, then the last thing you want is universalism.

In addition, if you are are willing to concede that the opposition might have a good point or two, or at least should have the right to be wrong, then you will logically also be against a universal system. Indeed, even if you simply think that checks and balances are a good idea--the constitutional equivalent of compartmentalization--then you should oppose universal systems.

We learned this lesson in the 20th century, as we successfully opposed coercive universalisms, aka, totalitarianism. And in the 21st century, it's gratifying to see that the lessons of choice and freedom are deeply imbued on both sides of the aisle.

This does not mean that Mahar is a conservative: As she makes clear in the piece, she supports "the public option"--which most on the right see as a Trojan horse aimed at achieving a single-payer system. So the battle over healthcare visions is hardly over.

But as Mahar also makes clear in her Post piece, she supports the existence of private-sector alternatives, such as Kaiser Permanente, and would not want to see them done away with. If healthcare disputants can agree that the ultimate solution for healthcare should be a public-private mix, then we have made at least some progress.

Saturday, November 14, 2009

Growing the Economy by Growing Healthcare: Serious Medicine Strategy as an Economic Strategy

Mike "Mish" Shedlock, an investment analyst, projects that US unemployment could stay above 10 percent through 2015, and stay above 8 percent for a decade.

We aren't economic experts here at SMS, so we report, you decide. But whatever the unemployment numbers prove to be over the next decade, under current conditions, they don't seem destined to be very good.

For all the discussion of economic stimulus, as Serious Medicine Strategist Jim Woodhill says, "The world economic situation can be summed up as, 'desperately seeking demand.' And healthcare is perhaps the most voracious source of demand there is." Indeed.

According to the Labor Department's Bureau of Labor Statistics, seven of the 20 fastest-growing occupations in the US are healthcare related. The BLS further notes that healthcare is adding jobs, even during the recession.

Those on the left often think of "stimulus," as building roads, but the problem with that strategy, as the Japanese have discovered, is that contemporary road-building is not very labor intensive. In the 30s, to build a road, hundreds of men might be swinging picks. But today, roadbuilding requires relatively few workers and lot of machinery. We're all for higher productivity--not many people particularly enjoy doing manual labor outdoors--but America still faces the issue of getting people into jobs. How to do that?

Of course, not everyone is a fan of "stimulus" packages. But conservatives and libertarians--especially if the GOP regains power in 2010 or 2012--must grapple with unemployment, and what to do about it. So they, too, will need a strategy for generating more real jobs here in the US.

And so we come back to healthcare, which is hard to outsource or offshore. The opportunity for growing the economy by growing healthcare has been a steady theme here at SMS. bbbAs we wrote back in August, taking note of ideas from Segway inventor Dean Kamen, Serious Medicine has great potential to be an economic driver, because medical equipment is one of our remaining competitive industries, worldwide.

And we also quoted Nobel Laureate Robert Fogel in September, making many of the same points, reminding us that healthcare can pull along many other industries, including construction, finance, and manufacturing.

Serious Medicine Strategy is good for health, and it's also good for the economy. A win-win!

Wednesday, November 11, 2009

"The Absolutely Worst Bill Ever"

Never one to mince words, Peter Ferrara, a veteran of the Reagan White House, now at both the Institute for Policy Innovation and the American Civil Rights Union, takes apart the House Obamacare bill in the pages of American Spectator, labeling it, "The Absolutely Worst Bill Ever":

The bill is a serious threat not only to your freedom and prosperity, but to your very life as well.

That is because at the heart of this bill is a cruel perversion. The bill labors mightily (though it actually fails) to expand insurance coverage to everyone (taking the most expensive route possible). But then it is devoted to taking away the very health care that you may need to save your life, or the life of a loved one.

Ferrara, long a leading thinker on entitlement issues, including Medicare and Medicaid, always presents his arguments in a lawyerly style, but one of his points, in particular, stuck with me:

The left-wing extremists currently in complete control of Washington ... are wedded, emotionally and religiously, to outdated ideological crusades of 100 years ago.

That squares with our sense, here at SMS. The left is pushing a bill that celebrates a certain kind of politics, over everything--a politics of redistribution, not production. One can argue that there's a role for redistribution, but production must come first. You can't redistribute what doesn't exist.

Tuesday, November 10, 2009

A Bodyguard of Life

Harvard’s Dr. Will Shrank recently tipped us off to an important study of medication usage--that is, who takes his or her prescribed medication, and who doesn’t. This study comes out of the burgeoning field of pharmacoepidemiology and pharmacoeconomics--18 syllables of tongue-twisting, to be sure.

But the subject, polysyllabic as it might be, is no laughing matter, because it’s a matter not only of life and death, but also of economic health. Sponsored by
CVS Caremark,
the study seeks to address a puzzling phenomenon:

Non-adherence to essential chronic medications has been widely recognized as a major public health problem, according to prior research cited in numerous medical journals. One quarter of original prescriptions for essential medications are never filled, and patients with important chronic diseases such as diabetes and coronary artery disease adhere to their medication only about half of the time. Non-adherence to essential medications is a frequent cause of preventable hospitalizations and patient illness, with costs to the U.S. health care system estimated at over $200 billion annually. A better understanding of the predictors of non-adherence and strategies to improve medication use has the potential to meaningfully impact the public health.

Such findings--one quarter of prescriptions never filled, patients failing to keep their regimen half the time, at a cost to America of $200 billion--pose a serious challenge to many prevailing orthodoxies in the policy world. For free-marketers, the challenge is obvious: What is to be done when people exercise their freedom in perverse ways, by not taking needed medication? How valuable is “empowerment” when people can’t handle their power? A libertarian purist might dispute these non-med-taking findings, or shrug them off as a cost of freedom, but, either way, we all pay when people get sick. We pay for Medicare and Medicaid and other government programs, and we also pay in terms of lost economic output and productivity.

So the challenge is to figure out how to help people make better use of their own volitional power--how to get them to take their meds. The Obama administration and top Democrats would say, of course, that they have the answer, that Obamacare provides for such assistance through more efforts at developing holistic care. But here’s the rub: Not everyone trusts the government. In fact, not too many people.

So what to do? The answer is to improve on the various hybrid systems--which go by many names, including managed care, integrated care, and medical home--that encourage people to do the right thing. It’s a tricky field, because it takes us right into the murky realms of psychology, sociology, and behavioral psychology, where “unintended consequences” sometimes seem to be the norm.

And to realize, further, that the information age can be our greatest ally, if we think through how to make it work. Google, for example, has created an online flu shot finder.

Another encouraging straw in the wind was seen on ABC News Tuesday night; it seems that "World News" ran a story in Juneon a certain DNA-specific lung cancer treatment. One man, suffering from terminal lung cancer, saw the story, got ahold of the treatment, and is now cured. Which is to say, it's hard/impossible to know what message will click with what patient. So the answer is probably to try all possible messages, in hopes that one message or another clicks. (And on "World News" last night, we saw ads for Aricept, Vesical, and Medicare--a further reminder that medical information gets out to people in all different ways.)

Here at Serious Medicine Strategy, we have nothing but praise and admiration for those--including Shrank & CVS Caremark, ABC, and Google--who are working through pieces of this overall puzzle. And while we are inclined to wish that there’s an iPhone app to solve every problem--and they're getting there, as the iPhone becomes more and more tricorder like--I realize that life is not anywhere near that simple. New technology is surely a big part of the solution, but tech must be integrated into a larger system--that’s where the strategy aspect comes into play.

That’s why, here at SMS, we have invoked, here and here, the work of Carl von Clausewitz, the 19th century thinker who systematized thinking in the field of military strategy. We need the same for medical strategy in the 21st century. How do we create a system whereby all elements of our society and culture are harmonized and mobilized to achieve agreed-upon goals? There hasn't been much harmonization and mobilization in recent decades, which is why we've had a hard time getting things done.

And as often argued here at SMS, when we are confronted by a serious problem, we should do more, not less. We should push harder for a solution. We should power through.

So we might ask: What could we do to strengthen the incentive system for people to “get with the program,” without tumbling into coercion? As we were thinking about these questions, we Googled the phrase “bodyguard of lies” and got 106,000 hits.

Those words, “bodyguard of lies,” are attributed to Winston Churchill, who supposedly told Stalin in 1943, “Truth is so precious that she should always be attended by a bodyguard of lies.” The phrase became the title of a 1975 best-seller by Anthony Cave Brown, Bodyguard of Lies: The Extraordinary True Story Behind D-Day.

But here’s something interesting. We Googled “bodyguard of life” and got just six hits.

Now what does that tell us? It tells us that we have put more focus on one kind of bodyguard than the other kind. I am glad that we cloaked D-Day, for example, in a bodyguard of lies, thus taking the Nazis by surprise. And we must never lose the capacity to cloak our military operations in stealth. But if we know a lot about cloaking our miliary actions, it would appear that we are not as far along when it comes to cloaking our medical actions in a positive way--reinforcing good-health behavior.

We have much work to do. Fortunately, some of that important work is being done by Will Shrank and the phighting pharmacoepidemiologists and pharmacoeconomists up in Massachusetts.

Bodyguards of life. It would be cool if there were a best-selling book by that title, trumpeting some enormous health success, on a par with D-Day.

The Stupak Amendment Lays Bare Split Among Obamacare Advocates

The Stupak Amendment lays bare a basic split in thinking over healthcare policy--actually two splits.  

First split: Is national healthcare about health, or is it about politics?  "Progressives" deny any distinction between health and politics; to them, healthcare is politics, and politics is healthcare.   And so if abortion is "progressive," then by golly, abortion has to be in everything, because to a good leftist, politics should permeate everything.  

But the United States Council of Catholic Bishops doesn't agree, and that laid bare a second split over healthcare, between the mostly secular view of progressives, and the more faith-based view, which draws its inspiration from Matthew 25:40, in which Jesus says, “Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.”  

Secular leftists were happy, of course, to have the Bishops' support on national health insurance--Catholic support for the idea goes back to the 19th century--but when the Bishops peeled away on abortion, as they always do, those same leftists were just as happy to lambaste the Bishops. Thus the co-chair of the Congressional Progressive Caucus, the Honorable Lynn Woolsey, threatening the tax-exempt status of the USCCB.

But before leftists go too far down this vengeful road, they should Google Kulturkampf, a word that emerged from an earlier period of state-church relations, in 19th century Germany. If the Catholics could beat back Otto Von Bismarck, the Iron Chancellor, they can probably beat back Ms. Woolsey.

Monday, November 9, 2009

Dead Parrot On The Senate Floor

OK, so the healthcare bill passed the House on Saturday night. For all the talk of Nancy Pelosi as the woman of the hour, I am pretty sure that the House bill is dead on arrival in the Senate. It's the political equivalent of a dead parrot, and as with that famous Monty Python sketch, attempts to talk the parrot back into life are good only for humor.

As Jim Lucier was the first to point out, the vote on healthcare (220-215), was similar to the vote on cap-and-trade (219-212), and "cap-and-tax" seems to be not only DOA, but dead, period. Another dead parrot.

So if one had to bet, one would bet on "something" getting through, eventually, but nothing much. And in the meantime, the issue of research and cures continues to recede. You don't hear the Republicans talking much about it, either.

Thursday, November 5, 2009

Thomas Sowell on heathcare costs in RealClearPolitics this morning:

Although it is cheaper to buy a pint of milk than to buy a quart of milk, nobody considers that to be lowering the price of milk. Although it is cheaper to buy a lower quality of all sorts of goods than to buy a higher quality, nobody thinks of that as lowering the price of either lower or higher quality goods.

Yet, when it comes to medical care, there seems to be remarkably little attention paid to questions of both quantity and quality, in the rush to "bring down the cost of medical care."

In other words, reductions in healthcare costs are just that, reductions, if the only goal is to spend less, without regard to quality.

My friend Andrew Langer, of Institute For Liberty, put it well awhile back: There are three kinds of "costs" in healthcare. There's the healthcare costs that you pay, out of pocket, there's the cost someone else--e.g. an insurance company, or the government--pays, and then, out there somewhere, is the "actual cost." That actual cost is hard to figure of course, since the whole healthcare economy is a big welter of cross-subsidies, but the truth is out there, somewhere. It's just that nobody is very interested in figuring out what it is.

John Cassidy in The New Yorker Describes Obamacare as a Trojan Horse--Which He Applauds

The U.S. government is making a costly and open-ended commitment to help provide health coverage for the vast majority of its citizens. I support this commitment, and I think the federal government’s spending priorities should be altered to make it happen. But let’s not pretend that it isn’t a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won’t.

John Cassidy in The New Yorker.

"HHS Admits overstating flu-vaccine availability"

Ann Geracimos, writing in The Washington Times this morning, boils it down:

The government's initial plan was to have 160 million doses available in October; the actual production at month's end was barely 15 percent of that -- 24.8 million doses.

A government projection off by 85 percent: The healthcare equivalent of "We will, in fact, be greeted as liberators."

And these are the people doing national health insurance?

Tuesday, November 3, 2009

Where Does This Legislative Complexity Come From? Could There Be A Machine That Spews All This Stuff Out?

Jim Hubbell, a friend from Whitesboro, Texas, reacted to my "End of Healthcare Liberalism" post from Saturday. As I wrote then, the proliferating complexity of legislation threatens to undermine democracy and popular sovereignty.

To which Jim adds:

One has to wonder just who wrote all these multi-thousand word pieces of proposed legislation going around both houses of congress lately. What with three-day work weeks and long lunches, it doesn't seem possible that the honorable members have the time to pen these obviously wordy proposed laws, designed to take over the medical industry by the Obama regime. They have already made it clear that they have neither the time nor the inclination to read any of the lengthy bills before they vote on them. Perhaps the actual writing has been done by organizations that benefit from the contents of the bills.

Jim continues:

I can visualize a database on a computer in a K Street office, containing bits and pieces of proposed legislation that can be kludged together and packaged into one massive document. If it isn’t this way, then how is it?

And so he did visualize such a "kludge machine"--see above.

Swine Flu: Obama's Public Health Katrina?

As deaths from swine flu continue to increase, and as the vaccine continues to be scarce when and where it is needed most, criticism of the Obama administration is increasing, too--including from some unlikely places, such as Obama's lefty base.

For example, Barbara Ehrenreich, an early Barack Obama supporter, is not happy with her man at all. She has let Obama have it over the swine flu fiasco, even going so far as to drop the "i" word, impeachment. Here at SMS, we don't find ourselves agreeing with Ehrenreich all that often, and we don't agree on impeachment; but we will certainly agree that she is a smart, as well as prolific, port-side observer.

And given that something has clearly gone wrong with the swine flu vaccine program, we read this post of hers, from today, "Why Your Child May Not Get a Swine Flu Shot Soon," with considerable interest. Ehrenreich is the author of a provocative new book, Brightsided: How the Relentless Promotion of Positive Thinking Has Undermined America, critiquing the "positive mental attitude" movement. And so her new piece on swine flu, published by The Nation Institute, is laced with snarky references to "positive thinking."

But whether one agrees or disagrees with Ehrenreich's somewhat dyspeptic leftism, her slicing of the Obama administration's over-optimism on the vaccine is, indeed, cutting:

If you can't find any swine flu vaccine for your kids, it won't be for a lack of positive thinking. In fact, the whole flu snafu is being blamed on "undue optimism" on the part of both the Obama administration and Big Pharma.

Optimism is supposed to be good for our health. According to the academic "positive psychologists," as well as legions of unlicensed life coaches and inspirational speakers, optimism wards off common illnesses, contributes to recovery from cancer, and extends longevity. To its promoters, optimism is practically a miracle vaccine, so essential that we need to start inoculating Americans with it in the public schools -- in the form of "optimism training."

But optimism turns out to be less than salubrious when it comes to public health. In July, the federal government promised to have 160 million doses of H1N1 vaccine ready for distribution by the end of October. Instead, only 28 million doses are now ready to go, and optimism is the obvious culprit.

Of course, when she is not dumping on positive mental attitude, Ehrenreich is an advocate for socialism--and also, interestingly, she raises the issue of impeachment:

Are we ready to abandon faith-based medicine of both the individual and public health variety? Faith in private enterprise and the market has now left us open to a swine flu epidemic; faith alone -- in the form of optimism or hope -- does not kill viruses or cancer cells. On the public health front, we need to socialize vaccine manufacture as well as its distribution. Then, if the supply falls short, we can always impeach the president. On the individual front, there's always soap and water.

Impeachment? Really? I will assume that Ehrenreich is kidding.

But in the meantime, back to swine flu. Whatever it was that the Obamans have been doing these past 10 months, we now that they weren't strategizing over Serious Medicine. Or if they were strategizing, they didn't do a very good job.

Indeed, amidst all their delays, and, yes, dithering, their public-health effort is looking increasingly Katrina-ish. That's not grounds for impeachment, but it is the basis for a harsh verdict from the voters.

Sunday, November 1, 2009

"Medicare Fraud: $60 Billion; Profits of Top Ten Insurance Companies: $8 billion" -- The Search for the Political Equivalent of Dark Matter

"Annual Medicare Fraud: $60 Billion; Annual Profits of Top Ten Insurance Companies: $8 billion"--that's the headline atop Jeffrey H. Anderson's Saturday blog posting in The Weekly Standard.

Anderson's apt juxtaposition of two different numbers from two very different sources makes me think of dark matter, which we know exists, even if we can't see it. As Wikipedia explains:

In astronomy and cosmology, dark matter is hypothetical matter that is undetectable by its emitted radiation, but whose presence can be inferred from gravitational effects on visible matter. According to present observations of structures larger than galaxies, as well as Big Bang cosmology, dark matter and dark energy could account for the vast majority of the mass in the observable universe.

In other words, most of us look up at night sky, or think about the universe, and we think of stars and planets suspended in nothingness. But in fact, space is not nothing, it is full of material--dark matter. We can't see it, but we still know that it's there.

Indeed, as the graphic above illustrates, "dark matter" accounts for about 23 percent of the universe, whereas mere stars and planets account for about .4 percent. And on top of the dark-matter category, there's "dark energy," which accounts for 73 percent of the universe. All of which serves as yet another reminder to us--to be humble about our own powers of intuitive perception, as opposed to the tools that are needed to truly apprehend the situation. Or, to put it another way, back here on earth, one can rely on politics to simplify and shorthand things, to the point where their true solid proportion threatens to melt into the air, like so much dark matter.

In other words, the insurance companies declare their legal profits, paying taxes on them, and all those numbers go into the maw of OMB, CBO, the media, think tanks, etc. Meanwhile, the illegal profits simply go into the pockets of criminals, who presumably pay little tax on their ill-gotten gains. But the Beltway hue and cry is over insurance company profits.

It's the difference between the observed and the unobserved. We all know the joke about the man who loses the dollar bill on Fourth Street but looks for it on Third Street--because the light's better on Third Street.

The natural pattern for human beings is criticize, even excoriate, what you can observe, while you mostly ignore what you can't observe. To be sure, Democrats who run the show in DC would all say that they are against Medicare fraud, and also Medicaid fraud, but ask yourself: When's the last time you heard anyone in charge of anything on Capitol Hill complaining about Medicare or Medicaid fraud?

Here's Anderson's brief post:

As 60 Minutes reported last week, Medicare fraud is rampant and has now replaced the cocaine (ahem) business as the major criminal activity in South Florida. Both 60 Minutes and the Washington Post report that Medicare fraud now costs American taxpayers roughly $60 billion a year. That may sound like a lot of money, but surely it pales next to the extraordinary profits of private insurance companies, right?
Well, let's see.... Last year, the profits of the ten largest insurance companies in America were just over $8 billion -- combined. No single insurance company made even five percent of what Medicare reportedly loses in fraud.

While we're making comparisons, in its real first ten years (2014-23), the Senate Finance Committee bill would cost $1.7 trillion. At the rate of last year's profits, the combined ten-year profits of America's ten largest insurance companies would be $83 billion -- five percent of the costs of the Senate Finance Committee bill. Eighty-three billion dollars may not buy you much in comparison with BaucusCare, but -- on the bright side -- that ten-year tally is somewhat more than what Medicare loses each year in fraud.

So, the next time someone alleges that government-run health care is cheaper because of "lower administrative costs" -- a truly preposterous claim on its surface -- these numbers would be good ones to have at the ready: $60 billion in annual Medicare fraud, $8 billion in combined annual profits for America's ten largest insurance companies.

H/T: Newsalert blog