Friday, June 11, 2010

"Talking Cures" -- The Case for a Serious Medicine Strategy, in National Review, June 21 issue

Talking Cures
To beat the Left, try beating cancer


Republicans are campaigning this year on a pledge to repeal Obamacare — and who can blame them? The Democrats are slathering another layer of bureaucracy onto the medical sector, an act that promises to both to lower the quality of our health care and raise the price we pay for it. Happily for conservatives, the country mostly agrees with their anti-Obamacare critique: A Gallup poll taken in March shows that 65 percent of Americans believe that the new program has given Uncle Sam too much control over the health-care system.

But the same poll finds that Americans are skeptical of purely private-sector solutions. Fifty-two percent think the bill that Pres. Barack Obama signed into law should have included a “public option” for health insurance, and 51 percent think that the bill doesn’t go far enough in regulating health care. If the GOP makes big gains in November, there is a danger that repeal-minded Republicans in the 112th Congress will be seen as simply wishing to overturn Obama’s signature legislation in order to hand him a stinging political defeat, peeling away a bureaucratic layer but doing nothing to address the fundamental flaws of our health-care system. This danger is compounded by the fact that just at the moment a new Republican congressional majority would be pushing to eviscerate Obamacare, many on the right would no doubt be arguing that Republicans must take the lead in cutting federal spending — including, inevitably, spending on Medicare. Unelected would-be budget-balancers, secure in their ivory towers, don’t have to worry about town halls or voters, but members of Congress do.

Health-care spending is a problem, but it is important to remember that spending is a secondary issue. The primary issue is health itself — how to achieve it, how to maintain it, and how to regain it in the case of sickness or injury. Health-care finance is hotly contested political ground, yet Washington has had precious little to say on the subject of health in recent years.

That is perplexing — and a huge missed opportunity. After all, people don’t go to the doctor because they have insurance plans or health-savings accounts. They go to the doctor to get well and to stay well. Americans’ eyes may glaze over at the wonky debates that are catnip to Washingtonians, but, beyond the Beltway, they can’t seem to get enough information about their bones, bladders, and blood pressure.

And they can’t get enough care for them, either. According to the Kaiser Family Foundation, 67 percent of Americans say that they are not getting the tests and treatments they need. By contrast, just 16 percent say that they have received unnecessary care. In other words, Americans more health-care services than they currently are consuming. This is the political chasm that separates average Americans from the elites who dominate the health-care policy debate: Reformers in both parties argue that Americans spend too much on health care, but most Americans believe we should be consuming more.

It goes without saying that the governing class sees no need to cut back on its own health care. In June 2009, President Obama was asked by ABC News whether he would be willing to see his family live by the cost strictures of his health-care bill. His answer was forthright in its limousine-liberal hypocrisy: “If it’s my family member, if it’s my wife, if it’s my children, if it’s my grandmother, I always want them to get the very best care.” In a Glenn Beck world, any American who is paying attention is wise to those double standards — and resents them.

Washington sees the health-care crisis as a possible opportunity to perform works of social justice, as well as a definite opportunity to save money, but doesn’t talk much about health itself. The American public is pushing in exactly the opposite direction: The regular folks care about their health, and they want access to more health-care services and products. If history and the polls are any guide, the folks will ultimately win that showdown.

A more intelligent approach would be to think of the public’s demand for health care as an opportunity rather than a liability. Our economy is driven by the harmonious convergence of entrepreneurial exuberance and insatiable consumer demand. Those are good things — so let’s have more of them.

People say they want more treatment. Great — but let’s make it a more effective treatment, which is to say, one that is less expensive in the long run. In most cases, it is cheaper to cure a chronic disease than to finance the long-term treatment of it. And prevention is cheaper still. It is expensive to develop cures and vaccines, but it is more expensive not to have them — and long-term extended care is truly expensive. If the policy elites want to offer something of value, they should find ways to support medical and scientific research rather than lecture us on our spending.

There is precedent for this kind of approach. At one time, American leaders worked to eliminate diseases and their damaging effects. They worked on urban sanitation as a way of eradicating contagion, making our cities less pestilential and more habitable. In Chicago, for example, engineers reversed the flow of the Chicago River so that it drained sewage out of Lake Michigan. Those leaders were motivated by civic and humanitarian concerns, but also by strategic calculations. To use another example, Theodore Roosevelt knew from the failure of earlier French efforts that the Panama Canal could not be built if the malarial swamps surrounding it weren’t drained. So Americans pushed back the jungle and the canal was completed. The same thinking was then applied across the American South, eradicating a disease that had been a persistent killer.

Later in the 20th century, three presidents — Franklin D. Roosevelt, Harry Truman, and Dwight Eisenhower — oversaw the public-private partnership that developed the polio vaccine. Among its other benefits, the vaccine saved the government money: In 1950, Uncle Sam estimated that polio would cost the nation $100 billion by 2000 — about $1 trillion in current dollars. Instead, we have virtually eliminated polio, and polio spending has thus been virtually eliminated as well.

More recently, we went undertook a national campaign against AIDS. A disease completely unknown in 1981 became manageable, at least in the United States, by the early 1990s. AIDS in America is still a serious disease, but it is not a death sentence; its treatment is akin to that of diabetes. And along the way, our understanding of viruses and retroviruses has vastly improved, a great boon to our understanding of, among other things, cancer.

Polio-vaccine warriors Roosevelt, Truman, and Eisenhower

Thanks to these victories for medical progress, which are distinct from “health-care reform,” our lives are not only better, but longer. The life expectancy of the average American has soared from less than 50 years in 1900 to nearly 80 years today. And while it’s not hard to find cynically utilitarian economists who lament the long lives of Gramps and Granny, for most people longevity is good news. Woe betide the American politician who lets himself be associated with anything close to a death panel.

This pro-life approach to health care hasn’t cost us money at all; in fact, it has earned us money as people live and work longer and more productively than ever. While life expectancy has grown by 60 percent since 1900, the real per capita GDP of the country has risen by 800 percent. A healthier population is a wealthier population.

Given our experiences with malaria, polio, and AIDS, why aren’t we making similar national efforts on other diseases, such as cancer, heart disease, and diabetes? Is it too cynical to suggest that maybe the current federal government is less interested in medical research, which might extend people’s lives, than it is in public health insurance, which extends state power? A chronically ill senior, in poor health and anxious about his next dialysis session, is likely to be a diligent AARP dues-payer — and a Democratic voter.

Those on the right who have been fighting Obamacare have been loud and articulate in their criticism of its bureaucratic aspects, but they have had precious little to say about curing and preventing diseases. The opportunity now exists for Republicans to reassociate themselves with the creation of health. Let the Democrats own the redistribution of health-care dollars and the management of scarcity; Republicans have a chance to own the much more powerful issue of solving health problems.

Rather than running up a $1 trillion bill, as Obamacare will do, such a strategy promises actually to add to the national wealth. When the volume of value-added goods increases, the per-unit price falls — that’s the nature of mass production. Since the dawn of the Industrial Revolution, productivity increases have led to greater quantity, greater quality, and falling prices. This phenomenon can hold true in the health-care market, too. Already we have seen cost crashes in many health sectors: Treatment for heart attacks, for instance, was always expensive, as was open-heart surgery. Then came stents, statin drugs, and angioplasties. Now heart disease is cheaper to treat — but that treatment became cheaper only after lots of R&D investment was made in response to strong consumer demand. Which is to say, cardiac care became cheaper because we spent more on it, not less.

Along the way, health care has become a big business, giving profits and jobs to millions of Americans. In the United States today, health care provides 14.3 million jobs; ten of the 20 fastest-growing occupations are health-related. And the United States enjoys a major comparative advantage in health care: Already, we take in some $5 billion a year from medical tourism, as well-off foreigners visit us for access to the best medical care the world has to offer. Health care is what economists call a “superior good,” meaning that its consumption rises with income, or even faster than income. As new middle classes spring up in China and India, we have the opportunity to sell to the world ten times, or a hundred times, the $5 billion worth we already are selling.

At present, the United States spends 17 percent of its GDP on health care, while the rest of the world devotes a mere 6 percent. The would-be reformers insist that our health-care spending should go down; the rest of the world’s is more likely to go up. Instead of trying to bring Americans’ health-care consumption down to the world average, we should be asking ourselves: Where will the world’s new rich go for their health care? Will the medical meccas of the future be in the United States, or will they be in Singapore and Switzerland? Medical technology, as Segway inventor Dean Kamen observes, is “one of the few industries where the U.S. still exports to the world, and we still have leadership.” Do we build on that technological advantage, or do we choke it off in the name of fictitious deficit reduction?

In truth, we don’t have much choice other than to push ahead into a better health future — because a go-slow approach to health is an invitation to financial disaster. Today, some 39 million Americans are over the age of 65, and by 2050 that number will rise to 89 million. Many of those seniors will develop Alzheimer’s disease. And whether we pay for their care with public or private money, we will still face a crushing fiscal burden. So why not make it easier on ourselves? Why not try to cure or prevent Alzheimer’s? We don’t know for sure that we can succeed, but history suggests that with a concentrated effort — as we saw, most recently, with AIDS — we could make a major difference.

Such a national effort would surely necessitate, among other reforms, overhauling intellectual-property laws and reining in the trial lawyers. We might offer a variation on the Ansari X Prize, the $10 million reward that helped inspire inventors and entrepreneurs to reach space in private vehicles. In the past, we used all manner of public and private tools to build the railroads, to win our wars, and to reach the moon. If we set a great national goal — a goal that inspires our best and our brightest — we may be pleasantly surprised by the outcome. At a minimum, we could push back the onset of the disease. This wouldn’t take a tax increase. It would take a coordinated and catalytic effort here in the United States, pulling in the best scientists, along with corporations, medical schools, philanthropists, and maybe even a sovereign-wealth fund or two. Alzheimer’s is a worldwide problem, and it would be better to profit by curing it than to go broke managing it. That’s just one example of the kind of creative thinking that is needed in — but currently absent from — the health-care debate.

Republicans would do well to occupy this strategic terrain — presenting a vision of America as the world’s medicine chest. Democrats seem instead to be enraptured by the siren songs of scarcity and rationing, part of a chorus of green no-growthism. The danger for conservatives is that they will be so eager to charge against the particular objectionable features of Obamacare that they lose sight of even better, bolder objectives.

Hot pursuit of a partisan foe does not amount to a sound strategy for the betterment of the medical commonweal. We need a strategy for cures. That’s the route to both medical and political victory — because Obamacare is not the only thing that ails Americans.


  1. People want “free” treatment when they think they need it. I have “free” coverage; yes, it is that good; however, I don’t always go to the Dr. when they want me to because it’s a pain in the neck! I’m tired of visiting rooms! I don’t abuse my insurance privileges. Sometimes you have to be your own doctor. You have to recognize "lawyering" medicine.

    What we need is management of the medical industries cost effectiveness & the lowering of this cost: i.e.;
    * Federally License all medical personnel & institutions.
    * Cap Malpractice awards, say at $600K
    * Take malpractice out of the courts & put it with regional arbitration panels empowered to make awards & discipline-discharge, medical personnel (quacks).
    * Have doctors send their insurance premiums to a government corp. like an FDIC type that would have over cite of arbitration boards & their expenses + awards.
    * Make Losers Pay court fees if any + winners’ expenses! This is not a frivolous idea.
    * Let Health Insurers compete in all states for business.
    * Let people buy drugs from the cheapest countries. Hello Canada.

    Regarding Alzheimer’s: eat foods with Curry seasoning like the Indians do; take fish oil since the Japanese eat a lot of fish. Hey, it works for them! Why not introduce these spices into a school’s lunch room meals. Mold their palates and they’ll continue to eat this way when they grow up. Yes?

    Nice article Jim. All your points should be digested by the DC Hill People and WH. But they haven’t and wont; and that’s why they will have their first date with destiny this November :-)

  2. Peter has some good ideas (special malpractice courts, loser pays, interstate insurance sales, and international drug sales) but I don't see what could possibly be accomplished by federal licensing or federal control over insurance premiums and arbitration. Of what value could this be relative to the alternatives?

    What is it that makes people think that federal officials have any knowledge of or interest in something like medicine (or petroleum engineering or Internet architecture for that matter)? If they were interested in any of these things why didn't they go to med school, engineering school, go work on oil rigs for a couple of decades? The answer is that they are generally completely ignorant of these things and uninterested in them. What they are interested in is power and fame and perhaps raking in some money. Why should we who are interested in medicine (or engineering or oil) want their "help"?

    What makes anyone think that they are less likely to be corrupt or uninterested in spending resources effectively? Operating as they do outside of any chance that they will ever meet any of the people whose lives they are controlling, why should they be expected to know or care what happens to us? I'd rather have city-based groups handling these things. That way there's some chance that they might occasionally know the reputation of a doctor accused of wrongdoing, or know who the town hypochondriac is. If they are crooked in some way, there's at least a chance that something other than a national revolution might be able to kick them out of their comfortable positions.

    Believe it or not, passing into the District of Columbia does not confer any specialized knowledge on the people who reside there, nor does it make them more moral. If anything the transformation is just the opposite.

    One thing that you neglected to mention about malpractice reform would be to actually remove from the profession doctors who commit actual malpractice. I'm not talking about getting an 11% failure rate on operations that other docs get a 10% failure rate on, I'm talking about the guys who operate while drunk or treat cancer with snake oil. Malpractice insurance not only is expensive, but it also protects the careers of this latter group of docs who should be drummed out of the profession.

    As for putting curry in school menus, I like curry as much as the next guy, probably more, but I think that what goes onto the plates of students should be determined by their parents, or at least the lunch lady in the cafeteria, not self-appointed social planners in Washington. They know nothing about diet, schools, or what kids like to eat and they should have no say in setting up the menu at my local school. Where did the Constitution ever grant them such a power?


  3. Brian, my thought re federal licensing is that at the moment Drs., RNs etc. require state licenses. If a doctor is a screw-up, the state takes his license. The doctor then moves to another state and continues his recklessness, much like when my bishops moved my troubled priests to another diocese. The canceling of their federal license by a regional arbitration board composed of citizens, medical and judicial people would stop them from practicing medicine in our country.

    Instead of my son giving $46K & his wife $127K yearly, (he is MP & she OB/GYN). They would send their malpractice insurance payments to a quasi governmental agency, maybe an AMA type who would run all the regional Arbitration and Licensing boards.?
    These payments would fund malpractice award arbitration which would be now capped. These new procedures should stop the medical profession from practicing lawyer medicine. The new procedures would drive costs down, both billing (fewer tests) and malpractice insurance premiums.
    My Heart Dr & I joke that I have never seen a Doctor with the ‘acorns’ to take a patient off of a med. What they have been doing is adding another log (a new med) on the fire because some lousy attorney would say: “see he practiced bad medicine, he took Peter off of this drug ... etc.”
    Federal licensing would enable “Cooping the Kooks”. Capping awards would get doctors back to practicing regular non lawyer medicine and what ever agency would do this wouldn’t have any profit to make. The doctors’ insurance payments would cover all costs and all associated overheads. If the doctors premiums are more than the annual O&M budget; then next years premiums would be lower.
    I hope I have made myself clearer. Sorry, I am not always best with my pen. I meant exactly what you said, “the lunch lady in the cafeteria” determines the curry and if the kids don’t like it there are always PTA meetings for menu adjustments :-)

  4. Sometimes someone stumbles into a discovery that will change everything in one particular area of life. Currently a double blind clinical trial of 2,000 mothers-2-B is being run that, if 1,450 healthy births out of 1,500 was significant, will reduce premature births dramatically. Cost: $.05 per day per mom. At type in the author's name: John B. Irwin. Four hundred mothers are in the trial so far, and the children start arriving in August.