Wednesday, June 30, 2010

The Grand Compromise, Part Two: Raise the Retirement Age, Cure Alzheimer's.

As noted here yesterday, Rep. John Boehner said what many, maybe most, officials in Washington DC think: the retirement age for Social Security should go up.    But of course, here in Powertown, stating the obvious can get you in trouble.

And so Boehner's office dredged up a long list of nearly identical comments on Social Security from top Democrats, and passed them on to Hotline.   In the words of Hotline reporter Reid Wilson, summing up the state of play: 

Boehner's comments, made in the Pittsburgh Tribune-Review, have given Dems an easy target for today. But once upon a time, Dems thought raising the retirement age wasn't such a bad idea.  

And then Wilson cites a string of top Democrats and their quotes: 

Those senior Dems include VP Joe Biden, who told the AP in '07 he was open to discussions about raising the cap.
House Maj. Whip James Clyburn's official website says raising the age can keep Social Security solvent. "With minor changes to the program such as raising the salary cap and raising the retirement age by one month every year, the program could become solvent for the next 75 years," Clyburn's website says.

Just last week, House Maj. Leader Steny Hoyer told an audience at an event for Third Way, the centrist think tank, "we could and should consider a higher retirement age."

OK, so candor about entitlement policy seems to be bipartisan.  Good.  That's to the credit of both parties, even if both have been known to seek tactical political advantage on entitlement issues from time to time.    
But if both parties agree on the problem, then they might eventually agree on a solution.  As noted here yesterday, if the solution includes raising the retirement age, then the solution also ought to include doing something about Alzheimer's Disease (AD).  That's not only compassionate, it's also practical.   
As we wrote:
So here's a suggestion: Make a big offer to the American people: Couple the raising of the retirement age with a Manhattan Project-like quest for an AD cure.  
History tells us that we could either cure AD or put a big dent in it, IF we made a concentrated effort.   That is, bring the best experts together, sweep away the litigation and regulation that blocks progress, explore new financing mechanisms, such as "health bonds," and generally mobilize the country in the search for a cure, as Franklin D. Roosevelt did in the fight against polio, back in the 30s, when he established the March of Dimes.   It's worth recalling that the fight for a polio vaccine was initiated by a Democratic president, Roosevelt, then continued by another Democratic president, Harry S. Truman, and then completed by a Republican president, Dwight D. Eisenhower.   Which is to say, the fight against polio was a bipartisan success; great leaders of both parties joined together for the common good of the country. 
The logic here is as strong today as it was yesterday.

Correction and update: The Economist, cited in this space as the source for the assertion that cuts have been made in Alzheimer's spending, now says that it made a mistake--federal spending on AD did not fall, it has merely plateaued.   SMS regrets the error.

Tuesday, June 29, 2010

The Grand Compromise: Raise the Retirement Age, Cure Alzheimer's.

Rep. John Boehner (R-Ohio), the Republican Leader in the House, is quoted by The Pittsburgh Tribune Review today as saying that he thinks that the retirement age should be raised to 70, over the next 20 years, as part of any restructuring of Social Security.   Boehner's words were reasonable enough, and couched enough, that they should be taken as just a thoughtful politician musing over possibilities, and probabilities, in the decades ahead, and not as anything drastic about "the third rail of politics."   But as The Huffington Post headline, reproduced above, suggests, Boehner's political opponents will likely do their best to paint Boehner as an enemy of Social Security and, by extension, of senior citizens.   Cue up the direct mail from AARP and the National Committee to Protect Social Security and Medicare, as well as partisan foes.

Most observers, on both sides of the aisle, agree that something will have to be done about the future growth of entitlement programs.  But as with any problem, there are better solutions and worse solutions.  The better solution is to help Americans become healthier, so that they can be happier, live longer, and yes, be more economically productive.

Lots of Americans would be happy to continue working till they are 70, or maybe even older, but they are unable to do so, due to various medical problems, perhaps the most serious of which is Alzheimer's Disease (AD).   AD is surging in the US; the incidence of AD is expected to triple in the next 40 years.  And early-onset AD may be on the rise, too.   Which is to say, given the current state of medicine, it might not be possible for a significant number of Americans to work longer.

And so AD poses a big problem for anyone who might wish to see the retirement age go up.

So here's a suggestion: Make a big offer to the American people: Couple the raising of the retirement age with a Manhattan Project-like quest for an AD cure.  

History tells us that we could either cure AD or put a big dent in it, IF we made a concentrated effort.   That is, bring the best experts together, sweep away the litigation and regulation that blocks progress, explore new financing mechanisms, such as "health bonds," and generally mobilize the country in the search for a cure, as Franklin D. Roosevelt did in the fight against polio, back in the 30s, when he established the March of Dimes.   It's worth recalling that the fight for a polio vaccine was initiated by a Democratic president, Roosevelt, then continued by another Democratic president, Harry S. Truman, and then completed by a Republican president, Dwight D. Eisenhower.   Which is to say, the fight against polio was a bipartisan success; great leaders of both parties joined together for the common good of the country.

In that spirit, Boehner might wish to have a chat with his fellow Midwesterner, Lou Weisbach, a Democratic businessman based in Chicago, who has been leading The American Center for Cures for the past decade.  Weisbach has been making Serious Medicine-ish arguments for all that time; he has assembled an impressive array of allies, in both parties.    Improvements in medicine are vastly more important to him--and to almost Americans--than mere partisan advantage.

So Weisbach and the American Center for Cures would be happy to help any leader wrestling with these issues, as part of an overall bipartisan approach to curing AD, among other serious diseases.   As Weisbach has said many times, in the long run, it's cheaper to cure a disease than it is to treat it.   His logic is impeccable, but as he himself has discovered, the politics are difficult, because too many politicians aren't very interested in long term solutions to problems, no matter how serious the problem.

But Boehner is thinking long term--about a very controversial topic.  So he would benefit from rallying together those who think creatively about the problem, those who are eyeing better solutions to the problem.

And, we might add, those who are eyeing, as well, the opportunity.  Because a cure for AD would not only be a boost to Social Security's solvency and a boon for America's aging population, but a cure for AD would immeasurably strengthen America's competitive position in the world.

Sunday, June 27, 2010

Sergey Brin confronts the need for Serious Medicine--and responds in a Googley way.

Sergey Brin, the co-founder of Google, is on the cover of the new issue of Wired magazine.   But the main focus of this piece is not computers, or the Internet, but rather a deadly and crippling disease.   The piece somberly notes that Brin seems to have a high genetic predisposition to Parkinson's Disease, which has afflicted everyone from Mao Zedong to Billy Graham to Janet Reno, plus, of course, Michael J. Fox.   approximately -- and kills about 100,000 people a year, worldwide.   The article's author, Thomas Goetz--who comes across as much more pro-technology than he did in this piece, critiqued here at SMS, just a few months ago--writes sympathetically, even enthusiastically, about Brin's efforts to mobilize computing power to the challenge of curing Parkinson's and other diseases.

Brin has donated some $50 million to Parkinson's research, but his real contribution could be a whole new way of thinking about scientific research:

[Brin's]  approach is notable for another reason. This isn’t just another variation on venture philanthropy—the voguish application of business school practices to scientific research. Brin is after a different kind of science altogether. Most Parkinson’s research, like much of medical research, relies on the classic scientific method: hypothesis, analysis, peer review, publication. Brin proposes a different approach, one driven by computational muscle and staggeringly large data sets. It’s a method that draws on his algorithmic sensibility—and Google’s storied faith in computing power—with the aim of accelerating the pace and increasing the potential of scientific research. “Generally the pace of medical research is glacial compared to what I’m used to in the Internet,” Brin says. “We could be looking lots of places and collecting lots of information. And if we see a pattern, that could lead somewhere.”

In other words, Brin is proposing to bypass centuries of scientific epistemology in favor of a more Googley kind of science. He wants to collect data first, then hypothesize, and then find the patterns that lead to answers. And he has the money and the algorithms to do it.

As this chart from the Wired article shows, it appears that such "super-crunching" of data can make a huge difference, by dramatically accelerating--by 90 percent--the process of scientific discovery:

This is the so-called "Fourth Paradigm" of science, based on data-intensive computing.  In this reckoning, the first three paradigms, were empirical, analytical, and simulation.  But now, thanks to data-crunching, we have a “fourth paradigm.”  As described by a famous Microsoft scientist, the late Jim Gray, in this fourth paradigm we would see “A world of scholarly resources—text, databases, and any other associated materials—that were seamlessly navigable and interoperable.”

Microsoft's Craig Mundie sums it up in a book published by MSFT last year, available for free online:

As Jim Gray observed, the first, second, and third paradigms of science— empirical, analytical, and simulation—have successfully carried us to this point in history. Moreover, there is no doubt that if we rely on existing paradigms and tech- nologies, we will continue to make incremental progress. But if we are to achieve dramatic breakthroughs, new approaches will be required. We need to embrace the next, fourth paradigm of science.

Jim’s vision of this paradigm called for a new scientific methodology focused on the power of data-intensive science. Today, that vision is becoming reality. Com- puting technology, with its pervasive connectivity via the Internet, already under- pins almost all scientific study. We are amassing previously unimaginable amounts of data in digital form—data that will help bring about a profound transforma- tion of scientific research and insight. At the same time, computing is on the cusp of a wave of disruptive technological advances—such as multicore architecture, client-plus-cloud computing, natural user interfaces, and quantum computing— that promises to revolutionize scientific discovery.

Of course, a lot of this sounds more than a bit like the founding credo of Google, "to organize the world's information and make it universally accessible and useful."  Well, whoever's doing it, and whoever's getting the credit, we all have much to be thankful for.    Because of this approach works, we will all benefit.

Saturday, June 26, 2010

The win-win-win of Serious Medicine, Chicago-style

Sandra Guy, writing for The Chicago Sun-Times this morning, reports on new technological developments in the Windy City that could dramatically improve surgical outcomes everywhere:  

Dr. Pier Cristoforo Giulianotti, a pioneer in performing surgery with robots, envisions the day when he will see a patient's MRI and discuss surgery with experts worldwide on an interactive screen inside his operating room.

"The possibility of having high-quality imaging and interactive communication on the walls is a concept that's very close to our ideal," said Giulianotti, a professor of surgery and chief of the minimally invasive, general and robotic surgery division at the University of Illinois at Chicago.

"Imaging is of particular importance because images aren't just representations of reality, they contain all of the information one needs to perform an operation," said Giulianotti, who has worked in the field of surgical robotics since 1999 and who was recruited to UIC in 2007.

Dr. Giulianotti soon will be able to make his vision a reality with a 3-D, flat-paneled display system that provides so much resolution it achieves a human's 20/20 vision quality.

Dr. Giullanotti and his team are working to advance the Next Generation Automated Virtual Environment, which they abbreviate as NG-CAVE.   It's a breakthrough for medicine, and, of course, an economic shot in the arm for Chicago.

But wait!  There's more as reporter Guy relates: 

The NG-CAVE might even enable manufacturers to make better-quality 3-D TV sets, give astronomers a new look at the heavens and enable high-definition, life-size video of one's friends to jump to life on the wall when you want to talk with them.

So there's the win-win-win of NG-CAVE, and, by extension, all medical technology: A win for healthcare, a win for economic development, and a win for future technology spinoffs, into sectors unrelated to medicine.   In the short run, the bean-counters at the Congressional Budget Office might dread such technological innovation--Peter Orszag, a former director of CBO, now the director of the even more powerful Office of Management and Budget, has said that we need to slow the introduction of new technology in the name of budget savings*--but the truth is just the opposite. 

Such techno-gains won't cost us money, they will make us money, as well as, of course, make us healthier.  

* From Orszag's testimony to Congress on January 31, 2008:  "Future increases in spending could be moderated if costly new medical services were adopted more selectively in the future than they have been in the past and if the diffusion of existing costly services was slowed. Although this approach would mean fewer medical services, evidence suggests that savings are possible without a substantial loss of clinical value." 

Friday, June 25, 2010

At the Extreme Edge of Medical Progress

Forbes magazine's Christopher Steiner offers a fascinating look at the AI future in a piece entitled, "At the Extreme Edge of Artificial Intelligence."

Two items of Serious Medicine interest.  First, "Second Opinions":

Medical imaging helps doctors diagnose everything from breast cancer to brain tumors. Now comes A.I. The University of Chicago's Department of Radiology is testing a method, called Computer Aided Diagnosis (CAD), where a computer corroborates or challenges a radiologist's initial diagnosis. The computer combs images for suspicious regions and lesions while estimating the probability of each spot's malignancy. "Image interpretation by humans can be limited by incomplete visual search patterns, the potential for fatigue and distractions and the presence of structure noise in the image," says Chicago's Dr. Maryellen L. Giger.

And this, "Virtual Nursing": 

Timothy Bickmore, a computer science professor at Northeastern University, has created a virtual nurse named Louise who talks patients through the discharge process and can tell if they are correctly absorbing medical instructions. Louise is the work of Bickmore, MIT and the Boston Medical Center. Her skill in reading faces for clues is a huge breakthrough, says Dr. Brian Jack of the Boston Medical Center. Jack says that 20% of discharged patients show back up at the hospital within a month because they misunderstood the directions.

Monday, June 21, 2010

A New Novel About Penicillin in World War Two

Lauren Belfer has just published a new novel, A Fierce Radiance, about the development of penicillin during the early days of World War Two, when development of the drug was a vital national security issue, as well as a matter of compassion and humanitarian relief.

And of course, today, seven decades later, nothing has changed.  Our ability to win wars, for example, is directly challenged by out completely understandable squeamishness about death, injury, and disfigurement.   And while we are spending billions on military medicine, we should be spending more, and doing more.  If we did, we would not only see greater progress on behalf of our warriors, but we would see the development of new industries on the homefront.  That was the story of plastic surgery, which emerged in Britain during World War One--and has been both a a help, and a profit center, ever since.

But today, we just seem less interested in that sort of profound medicine.  As a society, we have drifted into the strange position of wanting to pay for the disease after the fact, not prevent it or cure it.

The New York Times gave A Fierce Radiance a nice review on Sunday, saying in part:

Lauren Belfer’s death-haunted medical thriller begins in December 1941, just three days after the Japanese assault on Pearl Harbor. Claire Shipley, a photojournalist working for the phenomenally successful Life magazine, has come to the Rockefeller Institute in New York to record one of the earliest trials of a new medication called penicillin. Highly effective in experiments involving bacterial infections in mice, this substance is about to be tried on a human. Will the drug work? Or will it have serious, potentially lethal, side effects? For the patient and the doctors, there’s no real choice: this experiment is a desperate last chance for a 37-year-old man who had been robustly healthy until a seemingly harmless scratch, acquired during a game of tennis, rapidly developed into a life-threatening infection.
Claire’s assignment introduces her to the world of medical research — and to Jamie Stanton, the dedicated physician who will administer the penicillin, along with his younger sister, Tia, a mycologist who serves as his chief assistant. These highly attractive, hard-working siblings are motivated by a personal tragedy: their parents perished in the great influenza epidemic that swept the country just after World War I.
Claire Shipley has suffered deep losses too, but hers are of more recent vintage. Seven and a half years earlier, her 3-year-old daughter died of a blood infection after an apparently minor accident, a circumstance not unlike that of the patient she has just photographed. In the aftermath of her daughter’s death, Claire’s marriage collapsed, leaving her the sole custodian of her surviving child, an 8-year-old son. Claire’s stepfather and mother have also died. For her, the last 10 years have been a “decade of death.”
The day after Claire’s initial photo shoot, she returns to find the critically ill patient looking fully recovered. He’s awake and alert, freshly bathed and shaved, and reading the newspaper. But, as Tia Stanton explains, this miracle may be short-lived. If a relapse occurs, there will be no way to save the patient because there is no more medication. Penicillin grows agonizingly slowly, harvested from small droplets that leak from a kind of green mold. The hospital’s supply is being cultivated in makeshift rows of sideways-turned milk bottles, even in bedpans, but the patient has received all the available supply. Sure enough, within hours he begins to fail, and by the end of the day he is dead.
Belfer uses the urgency of the Stantons’ mission — finding a means of quickly mass-producing penicillin — to add drama to the romantic attraction that develops between Claire and Jamie. America has just become a country at war, with soldiers soon to be dying from infected battlefield wounds. The novel’s tension increases as Jamie is called away by the government to oversee and coordinate penicillin projects in laboratories throughout the nation. Back in New York, Tia continues her own research, which may put her in personal danger. And as the race for lucrative pharmaceutical patents on penicillin’s so-called cousins heats up, Claire’s father, a wealthy tycoon, begins to play a significant role in the ever widening narrative.

Saturday, June 19, 2010

Penny Wise and Pound Foolish: As Alzheimer's Increases, Government Funding to Combat Alzheimer's Decreases

The June 17th issue of The Economist features an important article on the penny-wise-pound-foolish nature of America's health expenditures on Alzheimer's Disease (AD.)

As the magazine notes, AD costs the US some $170 billion a year.   And the number of Americans suffering from AD is projected to triple by 2050.

Yet the NIH is cutting back on anti-AD research, thus condeming us all to a terrible public-health and fiscal fate.  As the magazine explains:

Yet Alzheimer’s research, on which the NIH spent $643m in 2006, is to receive only $480m in 2011. It has not been singled out for these cuts. They are part of a general belt-tightening at the agency. But in this as in everything, you get what you pay for. And that might, in the future, be an awful lot of witless, wandering elderly.

It might not be so bad that the government is cutting back if the private sector were making up the difference.  But there's plenty of evidence that Pharma companies have hit a wall.   As The Economist notes, Pfizer just abandoned its effort on the anti-AD drug Dimebon, after having spent $725 million.

Making drugs is hard--harder, even than plugging oil spills.   So absent suitable incentivizing and/or prodding, it’s possible that the drug companies will work on something else.

So clearly, leadership is needed.  But from where is it going to come?  The White House? The Congress?  The private sector?  Philanthropy?   And it's not just money that's needed,
 of course: To cure AD, we will need to reform the FDA, clear away the trial lawyers, and probably revisit intellectual property rules.   

And by the way, there's political advantage to be had here.   The elderly vote in disproportionate numbers; if one politician, or one party, emerges as a clear champion of effective AD research--that is, genuine victory, as opposed to just propping up the status quo--it's a safe bet that that politician/party will reap a substantial political reward at the polls.   

The alternative to effective leadership is a continuation of the current system, which is to say, fiscal disaster: A big chunk of our population comes down with AD, and we pay the bills for their futile care over the course of decades    That's a grey dawn, indeed.  

It would be a lot cheaper, as well as more humane, if we could figure out a cure for AD, focusing on it as we did with polio and AIDS.    And who knows--if we could figure out a cure, here in the US, we would have a new precious export. 

Saturday, June 12, 2010

A $20 billion industry growing within the healthcare sector -- does anyone in Washington DC care? Or should we let China take the lead?

Brendon Nafziger, writing for, reported recently on a new study from Scientia Advisers, suggesting that Regenerative Medicine (RM) could grow into a $15-20 billion industry in the next decade-and-a-half.   While the idea of RM might lend itself to all manner of sci-fi scenarios, the bulk of RM is likely to be in such comparatively humdrum feels as spinal regeneration--such regeneration, of course, is not humdrum to the patient.

As Lauren Lentini, writing for Fierce Biotech, emphasized in her story on the same report, the biggest RM growth is likely to be in China.

Here at Serious Medicine Strategy, we believe that a rising tide of science can raise all boats, and so it's good to see this research flourishing anywhere, but it would be most optimum for the US if it most flourished here.  And so the question: What are American leaders doing to make RM a boom industry in the 21st century, as most Americans--if they fully understood the stakes--would be undoubtedly agree.

And so once again, we come to the perversity of our current healthcare accounting.  Is that the US share of that future $15-20 billion judged by DC bean counters to be a "cost," or an "assset"?   That is, should those billions spent on healthcare be seen as part of our "excessive" healthcare sector, or should those same billions be seen as a source of jobs and profits and tax revenues, to say nothing of compassionate medical relief?

Obviously the answer is the latter--a robust RM industry is a plus, not a minus.  But does our government see it that way?   My hunch is that the federal government doesn't bother with such medical issues, because the feds, as we know, are focused on "controlling healthcare expenditures." And compared to, say, cutting Medicare, it's easy to say that we are going to shrink down on speculative medical treatment, such as RM.  It's much easier to snuff out a future hypothetical than it is to kibosh a present-day tangible,

But if I am wrong in my gloomy assessment, then I might ask: What is Uncle Sam doing to help this industry, and by extension, all the rest of us?

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.

Tuesday, June 8, 2010

Regulating the Elderly--The (re)creation of a two-tier healthcare system. Or is it a three-tier system?

The Houston Chronicle headline from May 17 tells a tale: "Texas doctors opting out of Medicare at alarming rate."   As reporter Todd Ackerman explains:

Texas doctors are opting out of Medicare at alarming rates, frustrated by reimbursement cuts they say make participation in government-funded care of seniors unaffordable.

Two years after a survey found nearly half of Texas doctors weren't taking some new Medicare patients, new data shows 100 to 200 a year are now ending all involvement with the program. Before 2007, the number of doctors opting out averaged less than a handful a year.

"This new data shows the Medicare system is beginning to implode," said Dr. Susan Bailey, president of the Texas Medical Association. "If Congress doesn't fix Medicare soon, there'll be more and more doctors dropping out and Congress' promise to provide medical care to seniors will be broken."

More than 300 doctors have dropped the program in the last two years, including 50 in the first three months of 2010, according to data compiled by the Houston Chronicle. Texas Medical Association officials, who conducted the 2008 survey, said the numbers far exceeded their assumptions.

The largest number of doctors opting out comes from primary care, a field already short of practitioners nationally and especially in Texas. Psychiatrists also make up a large share of the pie, causing one Texas leader to say, "God forbid that a senior has dementia."

There it is, the Big A--Alzheimer's.   As noted here many times at SMS, it doesn't really matter what sort of health insurance system we have, if we all, or many of us, end up with Alzheimer's Disease (AD).   We personally will come to a grim end, and so, too, will our economy, burdened down by runaway entitlement spending.    

But the issue is larger, even, than AD.  The Chronicle's Ackerman concludes:

The growth in Texas Medicare opt-outs began in earnest in 2007, when 70 doctors notified Trailblazer Health Enterprises, the state's Medicare carrier, they would no longer participate, up from seven in 2006. The numbers jumped to 151 in 2008, fell back to 135 in 2009 and are on pace for 200 in 2010. From 1998 to 2002, by contrast, no more than three a year opted out.  

Now, according to a Texas Medical Association new poll, more than four in 10 doctors are considering the move.

And of course, the same basic story could be written everywhere across the country: Doctors are fleeing Medicare. 

So we have come to an interesting historical fork in the road: For decades we were told, by advocates of national health insurance--now known as Obamacare--that "Healthcare is a right, not a privilege."  The liberal-left dream was equality and solidarity, that we would all be in one big egalitarian system.  Conservatives and libertarians fought back against that idea for just as long, but they lost, finally, in 2010.  So now, are we all in "one big system"?  Of course not--no more than Beverly Hills is the same as South LA.   We always knew that there would be exceptions and loopholes in healthcare, too, by which the rich would buy their way out of any system, and its strictures. As Barack Obama himself said on ABC News last summer, he would never let any healthcare system restrict the choices that he made for himself or his family. 

But what about the healthcare of the ordinary American?  What happens to him or her, especially as they grow old?   Well, if what's happening in Texas is any indication, senior citizens will face an increasingly spartan healthcare future.  Could it be that this is what the government has had in mind all along?   Is that too cynical an interpretation of the ultimate course of government programs--regimentation and restriction?

By this reckoning, government "compassion" comes at a price--the price being the limit on what's possible.   You get a floor, but you also get a ceiling.  If you want the Post Office to deliver your mail, fine.  Just accept that your mail will be delivered as the Post Office sees fit.   And now the same with healthcare.    You wanted healthcare?  You got it!  You have a card that says "healthcare card"!  Now leave us alone, the government seems to be saying.   Now that we're done with healthcare, our leaders seem to be saying, the feds can get back to bailing out banks, fighting foreign wars, and whatever else the governing class chooses to truly worry about.

There's something a bit familiar in this scenario.

Back in college, I had to read Frances Fox Piven and Richard A. Cloward's Regulating the Poor, a book that has had enormous influence on public policy over the last 40 years--first published in 1971, it's still in print.   Piven and Cloward wrote from a left-wing perspective, cheering on groups such as the National Welfare Rights Organization, which demanded welfare payments, no questions asked, and got a sympathetic hearing from the likes of then-New York City Mayor John Lindsay.   The result was that  Piven and Cloward provided intellectual "air cover" for the vast--and disastrous--expansion of welfare in the 70s and 80s, and the growth of a whole new kind of underclass poverty and dysfunction.   Which is to say, it's easy, and proper, now to dismiss the Piven/Cloward argument that welfare is a good thing because it liberates people from government control.   We soon learned what happens when you give people money for doing nothing--proletarian class consciousness is not among the results.  But there's a grain of truth to the argument that governments across history have seen social spending as an opportunity to put people in their place--and keep them there.

Consider what the Obama administration is doing now, three months after the enactment of the bill.  Confronted with weak poll numbers, the White House has summoned into being a $125 million ad campaign, according to Politico, to spin Obamacare.   Indeed, just today, Obama himself was out spinning it.   Is Obamacare a good program?  Does Obama have the executive skills to effectively run national healthcare??  Those are not permissible questions.

But in addition, trying to stay on the right side of the Zeitgeistial wind, the Administration is now talking up spending cuts.    Nobody thinks that Obama is actually going to reduce spending, or anything close, but he'll have to reduce something, or at least its rate of growth.  And so now we can see where the future heads--toward a bare-bones approach to healthcare.  Yes, of course, you are covered, but don't get much for your coverage, because the country can't afford it.   (And of course, if Uncle Sam gets careless, or chooses to stomp out existing niche categories of private healthcare coverage, well, that's just a cost of the government doing business, its way.)   And yet the big enchilada, spending-wise, is Medicare, so expect more of the sorts of doctor-dearth stories that the Houston Chronicle reported on, above.

So we see an illustration of the old saying, "the more things change, the more they stay the same."   That is, we had a two-tier system before, some people covered, some not.    Now, after the passage of Obamacare, we still have a two-tier system, but the tiers have changed: the first tier is those who have good-quality care, which they pay for out of their own pocket, or out of the pocket of plush private plans.   And the second tier is those who rely on the government for their care, including Medicaid recipients, and also, of course, senior citizens who rely on Medicare.    The plan--not written down, but obvious nonetheless--is to spend what it takes on the first tier, and then scrimp down on the second tier.

So yes, Obamacare is expensive.  But if you believe, as I do, that relative status, i.e. power, is a more important factor to most people--certainly most people in politics--than absolute well-being, then what really matters is the perpetuation of the tiers.   And Obamacare has delivered on that objective.  Those in the upper tier know that they are special, and they can feel good about themselves, if they choose to, for having done a good deed for the poor--they can check off another box on the "social justice" column of their moral resume.   And know that if they need to--say, around re-election time--they can always throw some more money down on the folks in the second tier.  (Maybe a lot of money, if the second-tier gets organized--if, for example, AARP wakes up.)

But actually, there aren't two tiers, there are three.  The third tier is illegals, not covered, at least not officially, by the Obamacare bill.

As it happens, Houston has an energetic civic and business community, and the hub of that civic/business spirit is the Greater Houston Partnership, (GHP) which produced a major report on healthcare in the 10-county Greater Houston area in February.   The report noted, for example, that at present, as much as a third of the 5.7 million people who live in those 10 counties do not have health insurance.   Therefore, the report continued, if the Obamacare bill excludes illegals--the legislation was signed into a law a month after the report was issued--then between 13-15 percent of the population of Greater Houston would not be covered.  Those folks, numbering three-quarter-of-a-million, will still have health needs, of course, and so they would end up in emergency rooms, and wherever else they can  get care.    As Houstonian Jim Woodhill observes, "We have universal care, we just don't have universal coverage."   The working poor might not have insurance, but they still get treatment, one way or another.   It's a lousy system, of course, rife with ripoffs and other unintended consequences of uncompensated care, but it's not going away.

The result, though, is that "the safety net will fail," as the GHP report explains:

The lack of access to care, stemming from the uninsured problem, results in a poor health status for Texas and the Houston region’s residents.  . . . If the situation is left at status quo and the Houston region’s hospitals and community health care organizations are stretched to meet future demand at current capacity, the safety net will fail. This failure will not only affect the people who will be left untreated, but will also diminish the competitive advantages the Houston region holds over other metropolitan areas – a good business climate, low taxes, and a large, low-wage labor force – ultimately weakening the quality of life for Houston area residents.

Yes, the current system will collapse if present trends continue.  Hospital ERs will be overwhelmed, doctors will turn away Medicare (and Medicaid) patients.  And, of course, if there's a major public-health emergency of some kind, well, watch out.

Eventually, there will be some sort of resolution of this three-tier system.  Most likely, we will close the border with a fence and with Arizona-type legal action, and then, once acute concerns about the border and homeland security are resolved, the chronic reality that there are 12 million or so Americans living illegally inside this country will demand some sort of resolution.   Most likely, the third-tier people will slide, one way or another, into the second tier.

And the business community will be supportive:  It's a businesslike trade: Everyone gets coverage, and so that "social justice" issue is put to rest.  But of course, we won't spend that much on the tier two class, especially when times are tough.   As the GHP puts it:

Any effective federal health reform must address lowering costs, improving quality and increasing access to appropriate health services for uninsured and underinsured individuals through innovative, cost-effective approaches to purchase health insurance.

One can't criticize the GHP for its position.   No city, or metro region, can solve a national crisis.

But at the same time, Houston, blessed with abundant medical and research facilities, could spearhead the solution.  One fine day, we will see that curing diseases, starting with AD, is a better medical plan than treating those diseases. Baumol's Law guarantees that chronic care will be expensive, but a cure, well, that's cheap--everybody can afford it.  Oops.  Maybe I shouldn't have said that, because maybe the point, all along, has been to preserve a tiered system, under one name or another.