"A Sunrise Industry: Life Sciences and the Genomics Wave"

A cure for Alzheimer's? How much is that worth in lives saved, humanitarian karma gained--and dollars made?

"A Sunrise Industry: Life Sciences and the Genomics Wave"--that's the title of an important article in The Huffington Post by Fred Hassan, former chairman and CEO of Schering-Plough and current senior advisor with Warburg Pincus.

As Hassan explains, genomics hold out the hope of transforming healthcare altogether, through the greatest medical tool of all--actual cures. "For example, just imagine the costs we will save if we can prevent Alzheimer's, and keep millions of older Americans out of nursing homes. Good health will be good economics." That is, not "bending the cost curve" by rationing or anything that might be construed as a "death panel," but bending it by curing disease. Good health is ultimately cheaper than bad health.

And also, potentially, good health, and the preservation of good health, is a money-maker--a big moneymaker. If a company (say Schering-Plough) could actually develop an Alzheimer's cure, and could bring it to market, well, that would be a big market, here and around the world. Which would be jobs and growth and capital gains for the New Jersey-based company, and for all Americans, and for all the people of the world.

But whatever company takes the lead on this--that would be a stock to go long on.

Or, of course, we can have a medical recession, or worse, in the form of a bad healthcare bill that seeks to slow down medical progress in the name of slowing down the rate of medical costs. In which case, we won't actually save any money, except on some notional piece of paper conjured up by the Congressional Budget Office, but we will have slowed down, for real, medical progress.

Hassan's whole article is a must-read, but here's the best stuff:

Until recently, we have seen disease as a homogenous condition that affects everyone who has the disease in the same way. Now we know that afflictions like cancer are not one disease, but are rather constellations of many diseases that affect different people differently. Likewise, until now most medicines have been one-size-fits-all, even though we knew that they worked great in some people, and less so, or not at all, in others.

All that will be changing -- in large part through genomics. We are entering the era of personalized health care. Our health will be improved, and disease prevented, according to what we need and what we know about ourselves. It's the same kind of individualized steps that might go with personal financial planning or choosing a family vacation -- except with more certainty of success than most of us achieve through financial or vacation planning!

This is enormously exciting. It is why life sciences will be our country's most important sunrise industry over the next several decades. Because of this sunrise, the tens of millions of baby boomers can expect to live longer and live better. And because of this sunrise, we will also have the power to avoid billions of dollars in new health care spending. For example, just imagine the costs we will save if we can prevent Alzheimer's, and keep millions of older Americans out of nursing homes. Good health will be good economics.

That last point is worth repeating: "Good health will be good economics."

Is Healthcare IT a White Elephant? Or Are Semi-Luddites on the Loose?

A curious article in Computerworld, headlined, as you can see above, "Harvard study: Computers don't save hospitals money/Hospital computer systems are often built for administrators, not doctors."

In the piece, reporter Lucas Mearian interviews Dr. David Himmelstein, who healthcare observers know to be one of the leading advocates for single-payer health coverage, a.k.a. British-style socialized medicine. Here at SMS, we are always reluctant to assess people's motives from afar, but a critic might wonder whether Dr. Himmelstein is throwing mud at a healthcare status quo that he doesn't like, for ideological reasons that transcend concerns about the practicality of a certain technology. Or it could be concluded, for reasons that we shall see, that Himmelstein just doesn't like technology very much.

But, we report, you decide. Here's the nut of the Computerworld story:

The problem "is mainly that computer systems are built for the accountants and managers and not built to help doctors, nurses and patients," the report's lead author, Dr. David Himmelstein, said in an interview with Computerworld.

Himmelstein, an associate professor at Harvard Medical School, said that in its current state, hospital computing might modestly improve the quality of health care processes, but it does not reduce overall administrative costs. "First, you spend $25 million dollars on the system itself and hire anywhere from a couple-dozen to a thousand people to run the system," he said. "And for doctors, generally, it increases time they spend [inputting data]."

Himmelstein said that only a handful of hospitals and clinics realized even modest savings and increased efficiency -- and those hospitals custom-built their systems after computer system architects conducted months of research.

The issues of healthcare IT, are, indeed, huge: there's $19 billion in the stimulus package for health IT, just for openers. But how well that money will be spent is subject to debate. This summer, my colleague at the New America Foundation, Phil Longman, wrote a thoughtful piece for The Washington Monthly about the software challenges confronted by the Department of Veterans Affairs. In a nutshell, none of this is easy. And so to the extent that Himmelstein wishes to be a part of the solution--achieving better healthcare outcomes for people--more power to him, even if we don't agree with him on single-payer.

But Himmelstein, who speaks from the authority of Harvard, as well as the medical profession, might wish to try harder to communicate a positive problem-solving tone--lest he be mistaken for a Luddite. A true optimist--and all doctors should be optimists, shouldn't they--would say that these problems can be solved.

But in fact, Himmelstein seems to have a second agenda, in addition to single-payer. He seems to be dubious about the value of health IT:

"For 45 years or so, people have been claiming computers are going to save vast amounts of money and that the payoff was just around the corner," he said. "So the first thing we need to do is stop claiming things there's no evidence for. It's based on vaporware and [hasn't been] shown to exist or shown to be true."

That seems to be Himmelstein's bottom line: This IT stuff is unlikely to work, or work well, so don't spend too much time on it. In this sense, Himmelstein is clearly part of a movement within medicine--a movement fitting snugly within the larger Green worldview--that argues that social and political concerns should trump technological advance. That's an opinion, but it is not an opinion supported by the weight of technological history, including med-tech history. And, fwiw, it's certainly a loser, politically, with the American people.

As Americans have always said, "If at first you don't succeed, try, try, again."

And that's the point here: When confronted with a hard challenge to an important goal, the way to solve it is keep pushing forward against challenges. That's the only way to overcome the difficulty. Remember what telephones were once like? And if you remember back to the days of heavy Princess phones, then maybe you're not old enough to remember rotary phones. And few today are old enough to remember the phones that came before rotaries, the "candlestick" phones of yore. It was hard work, every step of the way, to get from there to where we are now. And along the way, there were plenty of critics. But there were many more eager consumers, and so now we all have not just phones, but smartphones.

Here at SMS, we can see many ways to push ahead with healthcare IT, but would say that the challenges of healthcare IT are much more likely to be solved by our mixed economy, by a pluralist and competitive economy that accepts general goals articulated by society and then uses invention and entrepreneurship to find the best way forward. And that the best healthcare outcomes are likely to come from a similar approach on healthcare policy--sorry Dr. Himmelstein.

But every step of the way, in any field of scientific inquiry and engineering improvement, we have seen trial and error, followed by trial and success. Here at SMS, we have made this point many times, most recently concerning swine flu. It's easy to criticize the way that the federal government has handled H1N1, and we should never hesitate to speak truth to power (especially incompetent power), but the greatest laurels should go to those who can solve the problem.

And that's the mission of the Serious Medicine Strategy: To help develop a framework through which we can achieve the best possible medical and healthcare outcomes, for all Americans, and for the peoples of the world.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

First, the number of lives saved:

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

That's good news for a lot of people.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now THIS Is Serious Medicine

WBCBS in New York City has the whole story.

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

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

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

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

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

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

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

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

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

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

The bottom line is that we face a brutal choice.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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