Tuesday, August 31, 2010

Macroeconomic Theory vs. Microeconomic Reality--Guess which one fosters more Serious Medicine?

What should be the focus of our economic policy?  Should it be tangible things, or intangible things?  For too long, SMS believes, Washington policymakers have preferred to think about the gauzy big picture, where grubby realities are veiled behind abstractions; thus policymakers, enthroned in marble palaces, can contemplate numbers and theories, not human beings and reality.   And if this policy bias--an emphasis on grand financial flows, as opposed to mere working and making--just happens to serve the interests of the rentier class, well how 'bout that?  That is, if the bubblemakers and bailouteers prefer Alan Greenspan or Tim Geithner to some manufacturer or wholesaler, maybe that’s not such a coincidence that top officials have thought about finance, not about logistics.  

Yet now that we have seen the damage we have done by an over-reliance on the FIRE sector (Finance, Insurance, and Real Estate) we can conclude that what’s needed, instead, is a granular sense of how physical things get made--even if that means someone's fingernails might get dirty.  We need a more practical emphasis on fostering a climate where more physical things get made, and consumed, for the betterment of our economy, and of our health.

Richard A. Epstein, a professor at NYU and the University of Chicago, as well as a fellow at the Hoover Institution, also finds time to writes for Forbes, where today he delivered a sharp critique, "Our Macroeconomic Fetish," aimed straight at the the macroeconomic theorizing of Paul Krugman and Laura Tyson, who have argued, repeatedly, that the deficit should be larger, in the name, of course, of economic stimulus.  As Epstein puts it:

Unfortunately, both eminent economists keep their heads in the clouds when they ought to plant their feet on the ground. Start with their odd definition of success. The unemployment rate is higher now than it was when the stimulus program began. The secret of our success, evidently, is that the number of unemployed did not go higher still. By dumbing down the definition of success, it becomes impossible for any stimulus program to fail, so long as there is some scenario worse than the one we had, which there always is. By that generous definition, no market has ever failed no matter how dismal its results.

The situation is only worse because while our Keynesian disciplines preach the need for more stimulus now, they offer no explanation as to how much stimulus is too much. The law of diminishing returns applies to every known human activity, including government decisions to prime the pump. Yet both Tyson and Krugman give us no hint about when to quit or why.

After dismissing Krugman, Tyson & Co. Epstein moves to his own prescription, which includes familiar calls for tax cuts, and then an unfamiliar emphasis on microeconomics. As in, macroeconomic theorizing back and forth is important, although just as the left is prone to think that any spending is good, so the right is prone to think that any tax cut is good.    But what matters most to Americans is whether economic condition are such that an entrepreneur feels inspired to invest and create jobs--in the United States.    Not paper profits on Wall Street, not jobs in China, but jobs here in the US.   

Epstein cites three microeconomic projects--housing, the labor force, and medicine.  But as he writes, we should, 

Start with the pharmaceutical and medical device industries, which are beset by an aggressive Food and Drug Administration that thinks that the path to public safety is to raise as many obstacles to the introduction of new drugs and devices as it is humanly possible to design. Longer clinical trials are only the first stage. Silly conflict of interest rules that lead to bad risk assessments is yet a second.

These policies are in turn complemented by the Obama administration's endorsement of extensive tort liability for products that comply with all FDA-mandated warnings, and attacks on the patent protection currently offered existing and new molecular compounds. The pharmaceuticals industry today is consolidating and downsizing. Effect on growth and jobs: negative.

The impact on jobs is negative, and so is the impact on our health.   And as Will Durant said, "The health of a nation is more important than the wealth of a nation." 

Sunday, August 29, 2010

No news is bad news on Alzheimer's Disease--but that's no reason to give up.

The above headline, "Years Later, No Magic Bullet Against Alzheimer's Disease," doesn't quite do justice to the grim gist of Gina Kolata's report in The New York Times.   The truth is that we have barely any bullets at all against AD--and we're not even remotely sure if any those bullets can reach the target.

As Kolata makes clear, describing the work of a medical "jury" convened by NIH to consider the status of AD treatment:

“Currently,” the panel wrote, “no evidence of even moderate scientific quality exists to support the association of any modifiable factor (such as nutritional supplements, herbal preparations, dietary factors, prescription or nonprescription drugs, social or economic factors, medical conditions, toxins or environmental exposures) with reduced risk of Alzheimer’s disease.” 

“I was surprised and, at the same time, very sad” about the lack of evidence, said Dr. Martha L. Daviglus, the panel chairwoman and a professor of preventive medicine and medicine at the Feinberg School of Medicine at Northwestern University. “This is something that could happen to any of us, and yet we are at such a primitive state of research.”

To sum up: There's "no evidence" that anything we are doing to forestall or treat Alzheimer's is working.  And the chair of a panel analyzing the evidence calls the state of our effort "primitive." This chart, also in the Times story, sums it up:

This lack of any real good news on AD is a little disheartening, to be sure, but there's not reason to be permanently disheartened.  Science may be the closest thing we have to a free lunch, but it's still not free. And certainly never easy.

Remember the confident predictions of a half-century ago?   We were supposed to have established lunar colonies by now, and been to Mars and back.   We can still get to space in a big way--or achieve a hundred other worthy objectives--but we do have to try.

Thursday, August 26, 2010

Adam Keiper, editor of The New Atlantis and fellow at the Ethics and Public Policy Center, thoughtfully critiques my SMS blog post of yesterday, in which I raised the possibility that  Barack Obama could pull a "Harry Truman" on the opposition Republicans this summer and fall. This back-and-forthing comes  in the wake of Judge Royce Lamberth's decision, earlier this week, freezing federal funding for embryonic stem cell research.  (In his crisply written National Review Online article, Keiper also critiques Will Saletan's piece in Slate.com, but I will stick to my own defense here.) 

Keiper opposes embryonic stem cell research--that's the editorial thrust of Atlantis and also the general line at the EPPC--and yet I will not engage on the issue of the ethics of human embryonic stem cell (HESC) research.  This author will acknowledge that there are legitimate moral-ethical reasons to oppose HESC research, but at the same time, I will insist that there are solid moral-ethical reasons to support such research, starting with healing the sick.  Indeed, in keeping with the technoprogressive orientation of this blog, I will note that there's plenty of evidence to suggest that continued progress on hESC will soon eliminate the need for the "E" in stem cell research, because scientists will be able to routinely create new "pluripotent" stem cells from a variety of sources, not including embryos.  That's been a familiar pattern in the history of science, of course: The initial research is crude, or painful, or expensive, and only with the passage of time--the painful ascent up the learning curve--does the process get cheaper, better, and even more humane.

So rather than getting into a bioethics argument--if we were to have one, I am sure that at the end of it it, Keiper and I would still respectfully disagree--I will focus on the politics, where I think I have the better argument--even if Obama shows no likelihood for taking it.

In NRO, Keiper argues that the Truman-Obama parallel is not correct because while the country was basically with Truman in 1948, Americans are not with Obama in 2010.  And while Keiper is right about that--that's not what I said. I never argued that Obama has the majority with him--I said that he has the majority on this one issue.

Indeed, I am fully aware that Obama is on the wrong side, public-opinion-wise, on the 10 most issues facing the country as Rasmussen Reports shows us (stem cell is not on the top 10, although healthcare is, showing Obama's deficit to be just eight points, one of his better showings--more on that in the future).  Indeed, according to Gallup, liberals are on the losing side of most public disputes--self-described conservatives outnumber self-described liberals by 42:20, better than 2:1.  That's why Obama can't reveal his true self, and can't rally the country to his larger agenda: The country doesn't agree with him.
But Americans--most of them--do agree with him on HESC.  For example, 52 percent of Americans think that there should be "fewer or no restrictions" on HESC, according to Gallup, compared to 41 percent who say that there should be the same restrictions or no funding at all.  That's not a huge spread, but it's a spread.   And as noted yesterday, 59 percent of Americans find HESC "morally acceptable,"according to Gallup--that's another good number, from Obama's point of view.  
If Obama wanted to, he could use the bully pulpit and move those numbers even higher, while energizing his own base.   

I should hasten to say that I did not vote for Obama in 2008.  But I am an advocate of medical research, and think it should be higher--much higher--on the national agenda.   Medical research and the search for cures--as distinct from healthcare financing--should be in the nation's top ten, top five, even.  Such elevation takes leadership--from someone.

As I wrote yesterday, I strongly doubt that Obama is the right leader, but that's not only his loss, it's our loss.   Because the followership is certainly there, waiting to be mobilized, among a public that wants medical advancement.   Six years ago, in California voters approved a $3 billion stem cell--including HESC--funding plan by a 59:41 percent margin; other states, too--including Connecticut, Delaware, Florida, Illinois, Maryland, Massachusetts, Missouri, New Jersey, and Ohio--have set up state-funded programs of one kind or another.  And I would wager that 90 percent or more of those who are engaged in medicine and medical research support HESC.  So if this were to become a larger issue, Obama and the pro-stem cell forces would have huge support from prominent opinion leaders.  

And that's why I argued that Obama could invoke a "Truman Strategy," rallying the voters to his side--on this one issue.   Would it work well enough to get Obama re-elected?  Probably not. But it might work well enough to advance some cures, and to save some lives.

PS:  I have always been intrigued by The New Atlantis.   The title, of course, refers back to the work, four centuries ago, of Francis Bacon, the father of modern scientific research.   As the "About" section of the TNA site explains:

The New Atlantis (1627) was the title Francis Bacon selected for his fable of a society living with the benefits and challenges of advanced science and technology. Bacon, a founder and champion of modern science, sought not only to highlight the potential of technology to improve human life, but also to foresee some of the social, moral, and political difficulties that confront a society shaped by the great scientific enterprise. His book offers no obvious answers; perhaps it seduces more than it warns. But the tale also hints at some of the dilemmas that arise with the ability to remake and reconfigure the natural world: governing science, so that it might flourish freely without destroying or dehumanizing us, and understanding the effect of technology on human life, human aspiration, and the human good. To a great extent, we live in the world Bacon imagined, and now we must find a way to live well with both its burdens and its blessings. This very challenge, which now confronts our own society most forcefully, is the focus of this journal.

Anytime such a great figure as Bacon gets worked into the public discourse, I am happy.  But frankly, the folks at TNA seem to be among the very, very few who think that Bacon was in any way ambivalent about the potential of science to improve the world.   Others agree:  Harvard's I. Bernard Cohen wrote in 1985 that Bacon's New Atlantis was "utopian," while MIT's Alan Lightman wrote in 2003 that Bacon had described a "utopian kingdom," a place where, as Lightman put it, "Air is treated for the preservation of health," where experts advance toward "the perfection of agriculture," and "the development of flowering plants for medicinal use."  Sounds good to me!

For what it's worth, I wrote about in the stem cell topic five years ago, in a column published in the June 7, 2005 edition of Newsday.  I think it holds up pretty well--and Bacon, of course, holds up very well:

The stem cell debate grows increasingly angry as the science behind it gains momentum.   Indeed, the science has a whole lot of momentum—four centuries’ worth.  

On May 24, the House of Representatives voted to lift federal limits on embryonic stem cell research.  But President Bush vows to veto any bill that reaches his desk—and if so, it would be the first veto of his presidency.    But the wind is at the back of the pro-stem cellers; a CBS poll shows 58 percent of Americans supporting embryonic stem cell research.  

Meanwhile, the states are rushing ahead.   Last year, California voted $3 billion for stem cell research.  This year, Connecticut and Massachusetts have enacted their own state programs.   

And now comes the big news from South Korea, where scientists have made a huge advance in cloning. In a nutshell, the enticing prospect—or, if one prefers, the evil nightmare—of “therapeutic cloning” is within reach.  

No wonder tempers are rising back in the US.   Michael Kinsley, editorial page editor of The Los Angeles Times, who suffers from Parkinson’s Disease, wrote:  “Imagine what it's like to open the newspaper . . . and read that scientists in faraway South Korea have made a huge breakthrough toward curing a disease that is slowly wrecking your life. But closer to home, your own government is trying to prevent that cure.” That’s powerful first-person stuff.      

Similarly, Jonathan Alter, columnist for Newsweek--and a self-described cancer survivor and beneficiary of adult stem cell therapy—argued that “only Bush bitter-enders and the pope are in the perverse position of valuing the life of an ailing human being less than that of a tiny clump of cells no bigger than the period at the end of this sentence.”

Those on the other side of the debate are intense, too.  Chuck Colson, leading Christian activist, declares that stem cell proponents have “decided to throw all moral caution to the wind.”  And Sen. Rick Santorum, Republican of Pennsylvania, denounces the prospect of “the wholesale destruction of human life, paid for by the federal government.” 

But government involvement in scientific research of just about every kind goes back a long way.  All the way back, in fact, to Sir Francis Bacon.  Four hundred years ago, in 1605, Bacon published The Advancement of Learning, which helped launch the scientific revolution.  Although most “scientists,” through the ages, had been alchemists and sorcerers—their quest was to rediscover the lost secrets of the past, which, of course, didn’t exist--Bacon was on to something new.  He looked to the future with confidence and, more to the point, a plan for state support.   

In a subsequent work, The New Atlantis, Bacon outlined a utopia, in which “pioneers” are subsidized as they “try new experiments, such as themselves think good.”  As historian Harvey Wheeler explained, Bacon intended his work to be “a practical handbook for bringing about a marriage between science and government.”  

That marriage first occurred in Bacon’s England, where the Royal Society of London for Improving Natural Knowledge was founded in 1660.   Since then, every advanced nation has developed its own scientific-industrial complex; these knowledge collectives inevitably suffuse their societies with their own techno-progressive ideology.   And so that’s where the momentum behind research, including stem cell research, has been coming from these past four centuries.  

But what about morality?  What about the sanctity of life?  As Bush puts it, we must “balance ethics and science.”  True enough, but who does the balancing?  Answer: lots of people, in lots of countries, with lots of different perspectives.   As Santorum’s fellow Pennsylvania Republican Senator, Arlen Specter, observed, “The U.S. government can't control what goes on in South Korea, maybe not even California.”  The Baconian Grand Plan has gone worldwide.  

The historian Thomas Carlyle held that Bacon could “converse with this universe, first hand.”   That was true then, and it’s true of scientists now.   Bacon’s vision of inevitable scientific progress still holds us in its thrall, like it or not.   

The American Center for Cures: Hope for actual health, not just healthcare finance

Dr. Richard Boxer, co-founder, along with Lou Weisbach, of the American Center for Cures, lays out his argument in ASCO Post, a journal of hematology and oncology.  The American Center for Cures has been laboring in the Serious Medicine vineyard for years.  To read Dr. Boxer's piece is to be reminded that the ultimate point of medicine is not finance, but medicine--to be reminded that there is still such as thing hope in the medical field.

But Rick can say it much better himself:

American Center for Cures Could Ensure Health-care Reform Leads to Reform in Health

President Obama and the congressional leadership should call for the creation of a new public/private enterprise dedicated to the pursuit and protection of medical innovation in America. This enterprise-referred to as the American Center for Cures (ACC)-would be designed to achieve breakthroughs in cancer and other devastating illnesses that affect Americans, thereby improving health, health care, and the health of the economy.

The explosion of scientific knowledge in the past 50 years has been astounding, but cancer cases as a percentage of the population constitute the same proportion today as they did in 1950. It is appropriate and compelling to support not only improvements in health-care access, quality, and affordability, but also a new undertaking focused on achieving direct and dramatic improvements in the health of Americans.

Key Attributes

The ACC should be an applications and translational center with special emphasis on the discovery of early biomarkers to prevent, diagnose, or cure disease. A well-funded, focused ACC will bring to bear the genius and resources of America to eliminate the scourge of so many chronic debilitating diseases such as Alzheimer's, Parkinson's, diabetes, depression, schizophrenia, arthritis, cancer, heart disease, and others. The ACC would bridge the basic science-to-industrial production gap to safely, efficiently, and expeditiously bring discoveries to the bedside. It would be responsible for bringing together the pieces of the scientific puzzle produced by the world's basic scientists.

The ACC would be supported with public/private funding and directed by leadership from government, industry, academia, and nonprofit sectors. It would be mission-driven, accountable, and authorized to pursue high-risk/high-reward translational and clinical research opportunities. In addition, it would be multidisciplinary, including biologic and physical sciences. The organization would be charged with establishing collaborative centers of excellence in regulatory science defined by transparency, collaboration, and data sharing. Such centers of excellence would be designed to bring best practices from industry into academia and to train a new cadre of investigators skilled in moving products through the development pipeline from proof of concept in humans to commercialization.

The Center would be governed by a Board (Cures Council) appointed by the President, consisting of leaders in basic and clinical science, the physical sciences, patient advocacy, and entrepreneurs, with recommendations from the National Academy of Sciences. It would fall under the authority of the Secretary of Health and Human Services (HHS) with the power necessary to forge a new bridge across the HHS scientific infrastructure. Finally, it would be coordinated by a CEO charged with responsibility, accountability, and a sense of urgent mission to cure diseases targeted through cross-agency, multidisciplinary, global leadership.

Administrative Elements

The Director of the National Institutes of Health (NIH) would henceforth also be called the Director (or Secretary) of Cures (DOC). This position ideally will be elevated to a cabinet post to demonstrate the commitment of the nation. The ACC will be located within the Office of the DOC.

The new agency would be funded for success with new major appropriations and a bypass budget. The funding should be provided over 10 years for long-term commitment critical to scientific endeavors.

The Cures Council will determine what projects the ACC takes on, based on the intersection of diseases that have the greatest impact on Americans and those with the greatest likelihood of cure. Each disease cure effort will have a CEO accountable for cure within 5 to 7 years. Each unit will invest in researchers and research institutions around the world to get specific answers to specific questions needed for cures and prevention.

A Health Advanced Research Projects Agency (HARPA), modeled after the highly successful Defense Advanced Research Projects Agency (DARPA), will fund strategic high-risk/high-reward research and follow a "challenge model" to support innovative multidisciplinary research between NIH institutes, other federal agencies, grantees, and business partners, for projects with the potential for a significant impact on health. Funding for projects will be flexible and outcomes based.

An Office of Translational and Applications Research will coordinate all clinical research within the NIH and work closely with the FDA, Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Health Resources and Services Administration (HRSA), etc. The ACC will have a Center for Clinical Trials that will centralize and organize protocols and streamline the institutional review board complexities throughout the NIH to supply the public with new treatments more quickly, safely, efficiently, and economically.

Special emphasis through designated funding and coordination with other agencies (eg, the Small Business Administration) should focus on bridging the so-called "valley of death"-the often lengthy time between research/development and commercial availability-that has killed innovation.

Finally, an office would be established to coordinate efforts to reduce medical errors.

Justification for the ACC

A new mechanism is required to accelerate innovation and applications of basic research that will lead to cures in the diseases affecting Americans. This mechanism must have the authority to work across the Department of Health and Human Services (DHHS), to bridge the widening gaps between laboratory discoveries, early proof-of-concept applications in humans, and ultimate commercialization of lifesaving therapies. Such a mechanism should ultimately improve the health of individuals, health care, and the economy in the United States.

This new entity, the American Center for Cures, will have the authority and capacity to draw upon resources and scientific knowledge developed across DHHS, within health research (NIH, AHRQ), administrative (CMS), and regulatory (FDA) agencies, so that opportunities to leverage the collective strength and genius of the federal health enterprise are aligned and captured. For example, through new funding authorities the ACC may examine and support Centers of Excellence in Regulatory Science within academia, develop broad resource networks with biotechnology firms, create opportunities for federal partnerships with industries in the "precompetitive" space, and forge new models for public/private partnerships across academia, industry, government, and the nonprofit sectors.

The ACC will support America's leadership with global partners in research and therapeutic product development, bringing creative, multidisciplinary focus (ie, physical and biologic sciences) to bear upon diseases and conditions that may be ripe for high-risk/high-reward investments with the potential of driving toward cures. Ideally, the venture will be funded through a new innovative funding source, allowing it to be sufficiently endowed without requiring new taxes. Moreover, this endeavor can achieve the key measurable and ancillary outcomes of creating and protecting millions of jobs and maintaining our nation's global competitiveness in the life sciences.

Answering Great Challenges

America always answers great challenges, whether it is splitting the atom, preventing polio, or sending a man to the moon and returning him safely. It is time to meet the next great challenge and take on a cause greater than ourselves. Let it be said in 50 years that our children and grandchildren will not suffer from the same diseases that our generation and previous generations had because we took a stand in 2010 to do what we all know is needed-to bring the dream of the American Center for Cures to reality.

Never has the time for such a project been better or the need been greater. Never has a more substantial wealth of knowledge been available in the quest to relieve patient suffering. Never has there been a clearer vision of what must be done.

Hope for cures is a lot more compelling to people than healthcare finance.   If the Obama administration had led with this, they could have had cures, easy, and health insurance would have fallen to their laps, soon enough, once they convinced skeptical Americans that they weren't just about bureaucrats--or worse.  But instead of going the easy way, they went the hard way--with bureaucrats, leaving those skeptical Americans to imagine the worst.  

To sum up: Given a choice between downhill and uphill, the Democrats chose uphill. 

The question, upcoming is whether the Republicans--who are destined to have a lot more power in the next Congress--choose, also, to go the hard way--uphill, not downhill.  Repealing Obamacare will be harder, even, than enacting it--and probably impossible.  Yet that hard way will likely consume the Republicans for years to come.  

For reasons that you and I have discussed, everyone in DC seems to like doing it the hard way.  Not because they are naturally hard workers, but because the easy way has fallen off the mental roadmap that guides them--although Rick has laid out an excellent roadmap.  

Who runs American Healthcare? Answer: politicians, regulators, and financiers. Not an encouraging sign for Serious Medicine.

ModernHealthcare.com just released its 2010 list of the Hundred Most Powerful People in Healthcare.  But the headline atop Rebecca Vesely's piece was revealing: "Regulators extend their reign: Once again, administration officials and members of Congress top the 100 Most Powerful."  In other words, the long trend in health and medicine--the subordination of doctors and scientists, and the elevation of politicians, regulators, and financiers--continues unabated.  So Barack Obama is #1, Kathleen Sebelius is #2, Nancy Pelosi is #3, and so on.   The full list is here.  No wonder we have a stagnating medical system, in terms of cures. That's the bad news--and it is bad news for patients and future patients.  (And also for the medical-industrial complex, if we are to have one, creating good jobs at good wages making real things, real treatments and cures, not just reports and red tape.)   The "good news"--and it's actually not good news--is that the financial and paperwork side of the healthcare sector is booming.   Obviously we need some political, financial, and regulatory oversight and even income-transferring, but such politicking shouldn't come at the expense of treatments and cures.

As Serious Medicine Strategist
Jeremy Shane points out, "This is another list with virtually no researchers or clinicians.  . . .  the head of NIH - the #1 grant-giver in America is #82!"  That would be Dr. Francis Collins, who does, indeed, rank behind many hospital administrators, trade association executives, and even the Assistant Attorney General for Anti-Trust, Christine Varney, who, at #54 seems to way outrank Dr. Collins.

To paraphrase
Joe Biden, speaking in different context: Don't tell me what your values are. Show me your list of leaders, and I'll tell you what your values are.

And so here you have it: Our idea of healthcare is bureaucrats and financiers.

Wednesday, August 25, 2010

President Obama's Big Opportunity on Stem Cell Research--He Can Do What Harry Truman Did in 1948.

Amidst gathering gloom about a weak economy , and thus about Democratic political prospects this November, President Barack Obama has a big opportunity to regain some initiative--and maybe a lot of initiative.  How?  He could take up the stem cell issue, and demand that Congress take immediate action to void Judge Royce Lamberth's ruling, blocking federally funded embryonic stem cell research, in the only sure way--by immediately voiding the law that Lamberth upheld.  As in, do it this summer--right away.   Obama could give 'em some hell, just as Harry Truman did, 62 years ago.  Some hell, that is, on behalf of better health for all of us.

Congress act quickly?  That might seem like an oxymoron, but Congress can act quickly if it wants to. Back in 1941, Congress declared war on Japan the day after Pearl Harbor.   After 9-11, Congress passed the USA PATRIOT Act in less than six weeks--and that was an infinitely more complicated piece of legislation, written from scratch, than simply adjusting the stem cell limits in question--the Dickey-Wicker amendment from 1995.

But of course, it's almost easier to imagine Congress moving quickly than it is to imagine Obama becoming Truman-esque.

Still, if Obama were to do make such a call, summoning Congress back into session, he would have a lot of support in the major media, as we can see in this editorial in The New York Times, which called Lamberth's ruling "a serious blow to medical research," and concluded, "Congress should settle this issue once and for all—by passing legislation that ensures continued federal funding to support research on stem cells derived from human embryos."  But when should Congress do this?  Right away?  Or when Congress, operating at normal-government speed, gets around to it?  

And what about the public?   Would Americans back Obama if he called for immediate action to get stem cell research back online, moving forward?  Would the public react to pictures and stories such as this, seen in The Washington Post--about an American girl going to China to get treatment that she can't get here?   

Here's data from Gallup, which shows that by a 59:32 margin, Americans support embryonic stem-cell research:

One can argue these polls, of course, but Obama has long made his position clear--he is for such research.  Indeed, his Justice Department has already said that it will appeal Lamberth's ruling.  But who knows when a final ruling will come?  And who knows what legal judgment will ultimately be reached?   The courts are the courts--they can confound all sides.  

Moreover, Congress is the first branch of government--it says so right in the Constitution; the powers of Congress are enumerated in Article One, while the Executive Branch is Article Two, and the Judicial Branch is Article Three.   So Obama and the stem-cell cause would be better off if he went right to the source of national power--the Congress--demanding that Capitol Hill override this unfortunate decision by clarifying or changing the law.  It would all be on the legal and Constitutional up-and-up, it would just happen quickly.

And there's a grand precedent for this--an especially encouraging precedent for Democrats.  Obama could emulate the "Turnip Day" speech made by another embattled Democratic president, Truman, back in 1948.  Truman, it will be remembered, became President in 1945, after the death of Franklin D. Roosevelt.  Given the sad circumstances by which Truman came into the White House, he was somewhat resented by FDR loyalists, and underestimated by opposition Republicans.  Ill feelings toward Truman were deepened by the walloping that the Democrats suffered in the 1946 midterm elections, when they lost both houses of Congress for the first time since the early '30s.   Much of the Democrats' problem in '46 was that they had simply been in power too long--the GOP's national slogan that year, "Had Enough?" perfectly captured the public mood.   It was time for a change--at least some change.

Truman himself was seen as inadequate and wishy washy for the first three years of his presidency. (The greatness with which Truman is now endowed would come only later.)  One of the many jokes at Truman's expense in those years was, "To err is Truman."   And speaking of errors, the pollsters all predicted that Truman would lose, and lose badly, in the '48 presidential election to popular New York Governor Tom Dewey.

Yet as we all know, Truman came back from the political depths to win re-election in 1948, and not only that, swept the Democrats back into power in the House and the Senate.   How did he do it?  Truman and his consigliere, Clark Clifford, understood that the basic New Deal alignment was still in place--that is, the Republican victory in '46 was basically a spasm, a reaction to the accumulated ills of incumbency; yet even so, the country was still basically center-left--Democratic--that was the natural default for the electorate.  So the challenge then, to Democrats, was both simple and profound: rally Democratic voters back to the Democratic party.  And the way to do that was to loudly blow the trumpet for popular New Deal-ish programs; Truman called his agenda "The Fair Deal"--close enough.

The decisive moment in this rallying comeback campaign was Truman's "Turnip Day" speech, which he  delivered on July 15 at the 1948 Democratic National Convention in Philadelphia.  In that speech, Truman called Congress back into special session on July 26, which was Turnip Day in Missouri folklore.  Truman challenged the Republicans to come back and enact popular legislation concerning Social Security, civil rights, and, yes, national health insurance.   But the Republicans leading the 80th Congress reacted negatively to Truman's call.  In so doing, the GOP did not give Truman any legislative victories, but they did give Truman a political victory--the Democratic president could call the Republican-led Congress the "do nothing Congress," ignoring popular action items.  That label stuck.

In essence, Truman made a bet. He was betting that the liberal agenda was popular, and so that if Republicans staked out positions against that agenda, the voters would punish them at the polls in November.   For their part, Republicans, too, were making a bet--betting that the people were with them as they roadblocked Truman's ideas; moreover, many GOPers obviously hankered to repeal the New Deal in toto. (We'll never know what would have happened if the Republican leadership of that 80th Congress would have met Truman halfway; if they had, Truman might well have been defeated later that year, because the voters would have thought that they could get popular programs and get some fresh blood in Washington.)

But instead, the GOP stood firm against Truman in July--and was blown away in November.   Dewey, the House, the Senate, all defeated.

Sixty-two years later, is stem cell as big a cause to the voters as the overall New Deal?  The answer, of course, is "no."  Although here at Serious Medicine Strategy we believe that the cure-cause is a pretty big thing.   We would further argue that medicine should be a much bigger issue than it is, and that the voters would react positively to some strong medical leadership from Washington.  

But of course, there's little chance that Obama will do anything of the sort.  Populist invocations are just not his way.   Moreover, Democrats these days have staked out their position on healthcare--they are for health insurance, and that's about it.  Everything else is secondary, or tertiary.  Moreover, many Democrats cringe when they think of "healthcare" these days, for fear of enraging the Tea Partiers.   So even though stem cell, and Serious Medicine, is much different from "health insurance reform" and all the financialist wonkisms that we haven been marinated in for the last two years, stem cell/Serious Medicine and health insurance are close enough to each other that the Obamans, and the Pelosi-Reid Democrats, likely won't touch anything that could reopen the health issue in an unpredictable way.

And that's their loss, because the chance to redefine the healthcare issue away from ex post facto insurance that helps a relative few to the ex ante issue that helps the many would be a great opportunity for the President--or for any politician willing to take a pro-research stand.

We might add that stem cell is an issue-opportunity, too, for Republicans.   For those Republicans who support embryonic stem cell research--which is to say, they support medical progress, and scientific inquiry--here's their chance to speak up.  They could propose legislation to fix Dickey-Wicker.  Indeed, they could call for a special session of Congress themselves.  They wouldn't get it, of course, for all the reasons mentioned above, but as Truman demonstrated, more than six decades ago, in politics, you can win by losing.

H/T to Slate.com's Tim Noah.  This point came to me while I was chatting with him on  a forthcoming Bloggingheads.TV.

Update: Democrats seem to be stirring.

Dr. Francis Collins on the anti-stem cell decision: "Frankly, I was stunned."

Dr. Francis Collins, Director of the NIH, avowed Christian, speaking to The Washington Post's Rob Stein about  Judge Royce Lamberth's ruling  to halt federal funding of embryonic stem call research:

Frankly, I was stunned, as was virtually everyone else at the NIH yesterday, at the judicial decision. This decision has the potential to do serious harm to one of the most promising areas of biomedical research.

Dr. Francis Collins, Director of the NIH, avowed Christian, speaking to The Washington Post's Rob Stein about  Judge Royce Lamberth's ruling  to halt federal funding of embryonic stem call research:

Frankly, I was stunned, as was virtually everyone else at the NIH yesterday, at the judicial decision. This decision has the potential to do serious harm to one of the most promising areas of biomedical research.

Tuesday, August 24, 2010

Alzheimer's: "We have a tsunami coming at us, and we're sitting in a rowboat"

"We have a tsunami coming at us, and we're sitting in a rowboat," says neurologist Richard Mayeux of New York's Columbia University, speaking to The Washington Post's Aaron James about Alzheimer's Disease.

Researchers seem to be making progress toward identifying "biomarkers" for AD, which is helpful, but at the same time, scientists are a long way off from even beginning to find a cure: 

"Creating knowledge is a long way from making drugs," acknowledges [Howard] Fillit of the Alzheimer's Drug Discovery Foundation, which invests in start-up biotech firms, existing companies and academic research . . . The only way out of this conundrum is to find new drugs." . .  .

In a report last year, the Alzheimer's Study Group, a panel co-chaired by former House speaker Newt Gingrich and former senator Bob Kerrey, warned that the Alzheimer's epidemic will progress like the disease itself: slowly. But if we ignore it, the group said, it could have the same disastrous consequences as ignoring the levees in New Orleans or looking the other way as subprime loans subverted the financial system.

Tsunamis rushing, levees breaking, bubbles bursting.   Choose your analogy for the coming AD epidemic: They are all apt.   

Not Helpful

From Rob Stein and Spencer Hsu's story on the front page of The Washington Post today.

Thursday, August 19, 2010

"Lilly Stops Alzheimer's Drug Trials"

Depressing article in The New York Times.

The beginning of healthcare rationing.

A powerful editorial in The Wall Street Journal yesterday, describing the FDA's effort to withdraw approval of Avastin, an anti-breast cancer drug.   As the Journal notes, the Scarcitarian goal reaches beyond Avastin; the true goal seems to be to squelch all expensive medical R&D:

So here we have government-anointed medical patriarchs substituting their own subjective view of Avastin's risks and costs for the value that doctors and patients recognize. If Avastin is rescinded, thousands of dying women will lose more than proverbial false hope in the time they have left. They will lose a genuinely useful medicine.  . . . 

The Avastin mugging is really an attempt to undermine regulatory modernization like accelerated approval that offends the FDA's institutional culture of control and delay. It is also meant to discourage innovations like Avastin that the political and medical left has decided are too costly, with damaging implications for the next generation of cancer drugs.

Investigations at the frontiers of genomic science have only begun, and the learning curve for how subsets of patients respond to biologics, and how to target them, is steep. Yet the world's oncologists agree that the future of their science lies in patient-specific, biologic treatments. Cancer survival rates have improved gradually over the last several decades, thanks in part to improvements at the margin like Avastin.

After all, from the government's point of view, it's cheaper for people to die.   Of course, such a ruling is not only cruel, it is also short-sighted, because healthy and longer-lived people produce more for the overall economy.   And over time, drugs have a way of multiplying, and getting cheaper--that's the story of the whole industrial revolution over the last three centuries, and nothing about economies of scale will change in the industrial revolution's fourth century.  

Tuesday, August 17, 2010

Engineering our way to Serious Aviation Safety--lessons for Serious Medicine Strategy

How many of the 131 aboard this airplane survived this crash on a Caribbean island yesterday morning?   Amazingly, everyone survived, even as the plane broke into three pieces.  (One man did die of a heart attack shortly after impact.)   “It was a miracle and we have to give thanks to God,” said San Andres Gov. Pedro Gallardo.  That's a perfectly good answer, of course, but here on this earth, there were other factors, too.  Such as better planning and engineering.

And that point is full of implications for improving healthcare and for saving money.  But let's start with transportation safety.

"ABC World News" took up the topic of the air crash last night.  The segment headline featured the chyron, “A Miracle?”   Then reporter Sharyn Alfonsi intro'd her piece, noting that this crash-miracle was “the latest in a series of unbelievable crashes, with unbelievable results,” citing two recent airliner crashes, in Denver and Jamaica, in which everyone survived.

Next up, anchor George Stephanopoulos, spoke with ABC's aviation consultant John Nance.

Stephanopoulos:  John, you see those pictures, you wonder how anyone could survive.  Yet as Sharon points out, these other dramatic survivor stories.  Is this a significant pattern, or just coincidence?

Nance: George, I think it is significant.  I think it’s 20 or 30 years of very hard work in the aviation manufacturing arena, and safety.  In looking at what’s happened in the past and saying, how do we keep seats from collapsing on people, how do we put fireblocking materials in.  I think we’re seeing the fruits of all those labors.

Exactly.  It's a lot safer to fly on an airplane these, days, thanks to better engineering--and yes, maybe some mandates.  And the same holds true for autos: seatbelts, padded dashboards, and airbags, better highway design and signage, among other innovations--all have made driving safer.  Ninety-five percent safer, in fact, over the last nine decades.

The group Advocates for Highway and Auto Safety has computed the death rate per million vehicular miles traveled, going all the way back to 1921, and found something interesting: the death rate has gone steadily downward.  In 1921, the first year for which Advocates tabulated statistics, the US suffered 13,253 motor vehicle fatalities; that was a rate of 24 per hundred million miles traveled.  Interestingly, that death rate fell steadily for most of the following decades, exactly four decades later, in 1961--before anyone had ever heard of Ralph Nader--the death rate had fallen by almost 80 percent, to 4.9 fatalities per hundred million miles.   Which is to say, the general trend of systems is to improve efficiency--and safety is a function of efficiency.   And since the early 60s, thanks in part to Nader’s efforts, the death rate has fallen drastically yet again, by roughly three-quarters, down to a minuscule 1.27 in 2008.  That is, the total drop in fatalities per vehicle mile is 95 percent.

Did such efforts cost money?   Sure.  But we were worth it.  And there's a larger savings to the economy if people aren't getting killed as much--a 95 percent drop in fatalities can be calculated as an increase in GDP; just as those 130 survivors of the San Andres Island aircrash will go on to live productive lives.

The commonality between aviation safety and auto safety is this: Accidents will happen.   The challenge, therefore, is to see the problem whole and clear in advance, and to take appropriate action, in advance.   To get on the left side of the experience curve.

Thus the parallel to a Serious Medicine Strategy.   Aviation safety, and auto safety, can be thought of as a pre-emptive cure for accidents.  Accidents will happen.  The issue is how bad they are.   And so we should think ahead, realizing that a certain percentage of us will suffer an accident every year.   We should realize that it's cheaper to pay for accident-mitigation in advance--cheaper than paying the costs of people in the hospital, or suffering the opportunity cost of people in the morgue.  Such anticipatory cost-accounting might seem like a chilly way of thinking about safety issues, but the results--people living longer and better--are plenty warm.

And so the same lesson applies to the inevitable health-occurrences in our lives.  As we grow older, starting from birth, we will get the common cold, the flu, cancer, Alzheimer's--or a thousand other diseases.   It's completely predictable that we will get at least one killer disease, and many of them will cut us down in the midst of our productive lives.  In the past, in our wisdom, we chose to eliminate some of those inevitable diseases through a vaccine, notably measles and polio.  And we have fought the good fight against other diseases, including TB, smallpox, and AIDS.   Unfortunately, we seem to have lost interest in such anticipatory health-creation in recent decades.    These days, in Washington, all the discussion seems to be about health insurance, as distinct from medicine.

Our pre-emptive health efforts can be considered the medical equivalent of pre-emptive efforts to promote aviation and auto safety.    Thus the question: Should we have more such pre-emptive health efforts, or should we content ourselves with picking up the damage--and, of course, paying for the damage?

As Nance might have said, aviation safety is not a vaccine, but it edging closer to a cure.   The aviation equivalent of a vaccine, we might observe, would be some sort of mechanism that prevents planes from crashing; who doubts that we could develop such a mechanism if we wanted to.  Once again: Are we worth it?

And if we are worthy of a Serious Aviation Strategy, then we are also worthy of a Serious Medicine Strategy.

Monday, August 16, 2010

The Open-Source Revolution Comes to Serious Medicine

On Friday, The New York Times' intrepid health-beat reporter, Gina Kolata, took note of a new and promising trend in healthcare research: open-source collaboration, involving some of the biggest names in medical research and medical philanthropy--and, of course, involving all of us.  As Kolata put it:

In 2003, a group of scientists and executives from the National Institutes of Health, the Food and Drug Administration, the drug and medical-imaging industries, universities and nonprofit groups joined in a project that experts say had no precedent: a collaborative effort to find the biological markers that show the progression ofAlzheimer’s disease in the human brain.

Now, the effort is bearing fruit with a wealth of recent scientific papers on the early diagnosis of Alzheimer’s using methods like PET scans and tests of spinal fluid. More than 100 studies are under way to test drugs that might slow or stop the disease.

And the collaboration is already serving as a model for similar efforts against Parkinson’s disease. A $40 million project to look for biomarkers for Parkinson’s, sponsored by the Michael J. Fox Foundation, plans to enroll 600 study subjects in the United States and Europe.

The work on Alzheimer’s “is the precedent,” said Holly Barkhymer, a spokeswoman for the foundation. “We’re really excited.”

The key to the Alzheimer’s project was an agreement as ambitious as its goal: not just to raise money, not just to do research on a vast scale, but also to share all the data, making every single finding public immediately, available to anyone with a computer anywhere in the world.

No one would own the data. No one could submit patent applications, though private companies would ultimately profit from any drugs or imaging tests developed as a result of the effort.

Today, Dana Blankenhorn, writing for ZDNet.com, further translates this new collaboration into geekspeak, which is good, because it's computer types who will have to be at the spearhead of this effort, right alongside medical researchers:

We think of open source as being a process for developing software. It’s also a process for developing cures. . . . Open source developed in software as an outgrowth of the Internet, as people realized that collaboration could be done cheaply and could create projects no one company could fund on its own. That same idea has now come to medicine, it’s being proven to work, and I predict it will soon sweep the sciences.  Open source is not just for software any more.

Here at SMS, we observed this same techno-trend back in June, taking note of Google co-founder Sergei Brin's efforts to use open-source methods to cure Parkinson's.

What's so interesting about this story, and these developments, is that politicians seem so little interested. Plenty of government officials are closely involved in this effort, most notably at the National Institute on Aging--which put in $41 million--but there are no elected officials seem to be involved.  Strictly speaking, it's not necessary for politicians be so involved--if the system is working, let it work--but as a general rule, politicians like to be associated with good things, including ribbon-cuttings, awards ceremonies, and the announcement of breakthroughs.  And in the long run, that's healthy, because some of the value that politicians bring to the process is the sense of public stakeholdership.

And of course, there's also the issue of shining a public spotlight--"a grateful nation"--on meritorious behavior.  As John Locke observed in 1678:

The principle spring from which the actions of men take their rise, the rule they conduct them by, and the end to which they direct them, seems to be credit and reputation, and that which at any rate they avoid is in the greatest part shame and disgrace.

After citing examples, Locke concluded:

He, therefore, that would govern the world well had need consider rather what fashions he makes than what laws, and to bring anything into use, he need only give it reputation.

So it's in the orchestration of credit and reputation that politicians can play their greatest role--a role for the ages.  

So why aren't contemporary politicians interested?  I think Democrats are shying away they fear that mentioning the words "healthcare" or "medicine" in any way will provoke a reaction among voters.  And Republicans might fear, in this tea-partying time, that being associated with anything that the government does could be trouble for them.   So both sides stay away.  That's their loss, but also ours.

Saturday, August 14, 2010

Dr. Thomas C. Peebles, father of the measles vaccine, RIP

All Dr. Thomas Peebles, MD did during the course of his long life was try to improve the lives of others.  He helped develop the measles vaccine, figured out how to add fluoride to vitamins to fight tooth decay, and improved tetanus protection.

In other words, a good life.  And he did it all in the name of health and science, not partisanship.  Revealingly, he died, at age 89, back on July 8, but our  divisive political and media culture didn't notice till today.

Wednesday, August 11, 2010

A cure for Alzheimer's? "Absolutely." The question is, when?

A cure for Alzheimer's Disease (AD) is coming--but when?   Will the Obama administration seize the opportunity to accelerate efforts to improve the health and wealth of Americans--or are the Obamans too stuck inside their own model of shortsighted austerity to take advantage of scientific progress?  

A new study out today suggests that a reliable test for AD may be available soon.   A team of 13 doctors and scientists, spread across three countries--Belgium, Sweden, and the US--teamed up to write “Diagnosis-Independent Alzheimer Disease Biomarker Signature in Cognitively Normal Elderly People,” appearing in the Archives of Neurology.  The study suggests that a test of spinal fluid will yield up indicators as to whether someone is suffering from the beginnings of the disease.

This would seem to be a big breakthrough in AD research.   After all, you can’t cure a disease if you don’t know exactly what it is--including its biomarkers.

Yet interestingly, at least one prominent doctor didn’t seem very impressed with these new findings.   On his CNN blog today,  Dr. Sanjay Gupta wrote: “I would be remiss if I didn’t point out that nowadays, there aren’t great options for prevention or treatment of Alzheimer’s disease.”  And then he added another downbeat observation:

Even if the spinal tap becomes a proven, effective screening test for AD – would you really want to know, if there isn’t much you can do about it?

A bit defeatist, wouldn't one say?  Don't go looking for bad news, Dr. Gupta is saying--because you might find it, and then you will feel even more defeated.   The counter view, of course, is that knowledge is power--the beginning of power to achieve a cure.   And without knowledge of AD, surely there's no hope.

Perhaps we know why Dr. Gupta was recruited by the Obama administration for the post of Surgeon General of the United States in early 2009.  He shares their “scarcitarian” mindset, the idea that medical advance means medical expense.  But in fact, medical advance means, over the long run, medical savings--enormous medical savings.  That was the story of all cures--in addition to the humanitarian imperative, being healthy is cheaper than being sick.  And living people are more economically productive than dead people.   Moreover, if the new cure could be made in the US, that new production would be a source of jobs and wealth.     But as we know, the Obamans seem interested in bailouts and “stimulus”; by contrast, the nuts and bolts of actual production have little appeal--and they seem to look askance at any new economic activity beyond issuing and signing checks--gotta watch that “carbon footprint.”

On “ABC World News” last night, another medical journalist, Dr. Richard Besser,  (picture above) was much more upbeat: The new research he said on the broadcast, will lead “one day” to “a cure for the five million Americans suffering from Alzheimer's.”  Dr. Besser also spoke, on air, to Dr. Paul Aisen,  a neurologist at the University of California at San Diego, who offered viewers real hope:

We now have a tool that allows us to identify the disease, years before dementia starts.  And that's the stage of the disease at which intervention should be effective.  if   treating the Alzheimer's Disease process before there's irreversible damage to the brain.   I think that's the key to bringing this epidemic of Alzheimer's under control.

“Bringing this epidemic of Alzheimer's under control”--now that’s hope, that’s change we can believe in.  

OK, but when do we get AD under control?  As Dr. Besser recounted his conversation with Dr. Aisen to guest-anchor George Stephanopoulos, Dr. Besser recalled, “I asked him if there would be a cure or an effective treatment  in our lifetime.  And the answer I got, George,  'absolutely.'"  Stephanopolous agreed that was cheerful news, but failed to pin down Besser as to a more specific timeline--”our lifetime,” after all, is a bit unspecific.  For the record, Dr. Besser and Stephanopoulos are both in their early 50s, so we can all do some mathematical guesstimating.

So an AD cure is in sight--the issue is whether or not we should speed up the cure by mobilizing public and private resources to conquer AD before AD conquers all of us.

Once upon a time, spurring the progress of an ambitious undertaking would have been a no-brainer for a Democratic president.  John F. Kennedy, for example, relished the space race as an opportunity to show off America’s greatness.  As JFK said at Rice University in 1962, “We choose to go to the moon.”  Not only that, he continued, this feat would be accomplished in the cming decade, because setting such a goal “will serve to organize and measure the best of our energies and skills.”   It's easy to imagine that a different president would have said "we'll get around to getting to the moon," in which case, of course, the Apollo 13 landing never would have happened.  Not in the 60s, not never.

Kennedy, indeed, had the "right stuff"--and that’s what we need today: the organization and measuring of “the best of our energies and skills.”  Everybody responds better to a challenge--and Kennedy challenged us, so profoundly, that even after his tragic death, we fought the good fight to get to the moon.  And indeed, that’s how big things get done--through inspiration and mobilization, getting our energies and skills in gear.

Unfortunately, the incumbent Democratic administration doesn’t seem interested in any great undertaking to cure AD.  In fact, it has allowed federal funding for AD research to level off.  To the Obamans, the only issues in healthcae seem to be covering everyone, while at the same time “bending the cost curve” so that healthcare gets cheaper, according to Office of Management and Budget/Congressional Budget Office rote calculations.   That’s a terrible way to run a government--letting OMB/CBO determine policy.

In that vein, one has to wonder whether federal beancounters would have let the Manhattan Project, for example, go forward, on the ground that atomic technology was too expensive and speculative.  Fortunately, another Democratic president, Franklin D. Roosevelt, wasn’t interested in green-eyeshade objections.  As assistant secretary of the Navy during World War One, FDR had seen the reality of trench warfare; so in World War Two, he wanted to use technology to minimize that sort of carnage.  And so he gambled on the wisdom of Albert Einstein, Edward Teller, and Robert Oppenheimer.   The gamble paid off; Hiroshima and Nagasaki saved millions of lives by bringing World War Two to a quick end.  And yes, the atom bomb, and then atomic power, saved money, too.

Instead, the Obama administration is patting itself on the back for Medicare reductions that will never come to pass.   Real science is ignored, while fake politics is extolled.  Only in Washington DC would such foolishness seem normal, even savvy.

Monday, August 9, 2010

"A gap in trust" on Medicare. And the return of the "R" Word--Rationing

Two new perspectives are out today, taking a close look at the Obama administration’s claims about future Medicare financing.  Who's telling the truth about Medicare?   What’s the future of the program?    Some say that we are seeing a return of the “r” word--rationing.    

But first, some background.  On Thursday, the Treasury issued a new report hailing the deficit-reduction powers of Obamacare.  As Treasury Secretary Geithner put it: 

The Affordable Care Act has dramatically improved projected Medicare finances.  Medicare's Hospital Insurance (HI) Trust Fund is now expected to remain solvent until 2029, 12 years longer than was projected last year, which is a record increase from one report to the next.  In addition, the 75-year financial shortfall for HI has been reduced to 0.66 percent of taxable payroll from 3.88 percent of taxable payroll in last year's report, and the projected costs for the Medicare Supplementary Medical Insurance (SMI) program over the next 75 years, expressed as a share of GDP, are down 23 percent relative to the projections in the 2009 report  Nearly all of these improvements in projected Medicare finances are due to the Affordable Care Act President Obama signed into law in March. 

That all sounds pretty good, but Chicago Sun-Times columnist Terry Savage noticed that Geithner’s claims were at odds with the assertions of Medicare Chief Actuary, Richard Foster.     Here's how Savage explained it: 

There's a huge gap in Medicare, and it can't be covered by a supplement. It's not just a gap in coverage, it's a huge gap in the solvency of the Medicare program itself. And now, it's a gap in trust.

On the one hand, the government is promising senior citizens that Medicare recipients won't feel any cuts. And on the other hand, they're promising the program will be more solvent, essentially because of huge cuts that are planned for the program. It's the worst, most dangerous kind of double-talk. And it will impact all of us.

The trustees' report, usually out early in the year, was delayed for six months to "factor in the impact of the new healthcare reform law." When it was made public last week, the man in charge of crunching the real numbers, the chief actuary for Medicare, called the rosy predictions "unreasonable" and "implausible." Instead he wrote his own report, contradicting those projections -- and urged everyone to read it. So let's see who's right.

The preface to that much-delayed trustees' report released Thursday starts with a cheery greeting from Treasury Secretary Tim Geithner.

Geithner proclaims: "The outlook for Medicare has improved substantially because of program changes made in the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010." He goes on to predict that "the Medicare Fund will now remain solvent for an additional 12 years, until 2029."

But the Alternative Report posted by the Medicare chief actuary, Richard Foster, on the same day included this statement in the opening paragraph:

"The trustees report is necessarily based on current law; as a result of questions regarding the operations of certain Medicare provisions, however, the projections shown in the report do not represent the 'best estimate' of actual future Medicare expenditures." Foster says his report is designed to "help illustrate and quantify the potential magnitude of the cost understatement under current law."

So whom do you believe -- the guy with the numbers or the guy with the politics?

As Savage explains, the result could be mandated shortfalls, as costs are crimped and doctors and hospitals exit the field: 

So what will happen when all those facilities close because of low reimbursements? You'll find yourself standing in a long line for medical services. That's known as "rationing health care."

So there it is--the “r” word--rationing.   Rationing, of course, is fine with the current cadre of Washington bean counters.  Indeed, it’s the desired policy outcome.   

Another look at the same split, between Geithner and Foster, appears in a Wall Street Journal editorial this morning; the headline reads, “Richard Foster for President.” As the Journal notes, Geithner’s optimism is put first in the report--and then, at the end of the report, Foster, the actuary, repudiates it:  

But then comes the report's final appendix, where Mr. Foster disowns the previous 280-odd pages. Mr. Foster has been Medicare's chief actuary for 15 years, and as such he is required to evaluate the law as written. But as he notes in his appendix, the law as written bears little if any relation to the real world—and thus, he says, the trustee estimates "do not represent a reasonable expectation for actual program operations in either the short range . . . or the long range." In an unprecedented move, he directs readers to a separate "alternative scenario" that his office drew up using more realistic assumptions.

Mr. Foster shows that the Medicare "cuts" that Democrats wrote into ObamaCare exist only on paper and were written so they could pretend to reduce the deficit and perform the miracles the trustees dutifully outlined. With the exception of cuts in Medicare Advantage, those reductions will never happen in practice. 

One of the fictions Mr. Foster highlights is the 30% cut in physician payments over the next three years that Democrats have already promised to disallow. Republicans would do the same, we hasten to add.

Another chunk of ObamaCare "savings" are due to cranking down Medicare's price controls for hospitals and other providers that Mr. Foster says are also "extremely unlikely to occur." In the absence of "substantial and transformational changes in health-care practices"—in other words, a productivity revolution in medicine that has never happened—costs will simply rise for private patients, or hospitals will refuse to treat seniors insured by Medicare. Congress will never allow that to happen either.

In other words, under ObamaCare the "cost curve" will not be bent as the White House has advertised.

It seems apparent that one of two things will happen over the years and decades to come:   

The first possibility is that the Obama administration, and future presidential administrations, will find a way to tamp down Medicare spending, through rationing and whatever other scheme the feds can cobble together.   In which case, we will see a two-tier system of healthcare emerge.   

The second possibility is that these cost-controlling efforts will fail, as politicians yield to popular pressure.  In which case, Medicare spending will continue to climb faster than GDP.    

Based on past history, one would have to bet on possibility #2.  But it could be, of course, that we are living in new times, as fear of “Greece-ization” takes hold--in which case, possibility #1 becomes more likely.   And so we could see a two-tierization of US healthcare--a chintzy system of rationing and planned scarcity for ordinary seniors, and a limousine system for the rich.   That two-tiering might sound fine from the perspective of Greenwich or Beverly Hills, but it’s unlikely to prove political sustainable, without major changes in our political system.    

Curbing costs is obviously desirable, but as noted here at SMS many times, there’s a right way to do it and a right wrong way to do it.   The right way is cures, the wrong way is cuts.    And of course, everybody knows that Washington officialdom is firmly committed to cuts.