"Health care is a losing issue for whichever party is in charge"

"Health care is a losing issue for whichever party is in charge"--those words were spoken to me by a shrewd and unsentimental former Member of Congress, still a close observer of the DC scene. His point was that the party in charge, the party that feels obligated to "do something" on health care, is likely to find itself on the wrong side of public opinion--the choices to be made are simply too unpopular. It doesn't have to be that way. We could be both healthier and richer, but it will take new thinking to get us out of this rut. In the meantime, that wise old legislator has it exactly right: Whoever wishes to "lead" on health care will have few followers.

One might think that after a while the parties would get smarter about strategy, but apparently not. Instead they simply repeat the same policy process, over and over, like the combatants in World War One, culminating in the British disaster at the Battle of the Somme in 1916, pictured above. Such unimaginative and maladaptive policy-battle plans don't work, of course, but they do seem satisfying nonetheless. Why? Because they meet the injunction of, "Don't just stand there--do something!" So when the whistle blows, it's once more over the top, boys. And if we are mowed down in No Man's Land? Well, at least we tried.

As John Maynard Keynes, who served in the British government during the bloody follies of the Great War, observed, for most people, most of the time, it's better to fail in a familiar way than it is to succeed in an unfamiliar way.

That's what is happening to the Democrats today. They are failing in a familiar way. Sample headline from The Washington Post: "GOP Focuses Effort to Kill Health Bills/ Republicans Seek to Link Issue With Obama's Handling of the Economy."

As Joe Biden says, Barack Obama has mishandled the economy, but even if the administration hadn't bailed out the wrong people, the Democrats would still be pushing health care plans that, for all their variety, are unpopular for two obvious reasons and one not-so-obvious reason. And what are those?

First, they will raise taxes on Americans who won't get better coverage.

Second, they will make health care worse for most Americans. As Newt Gingrich says, "There will be a bureaucrat between you and your doctor."

And third, more subtly--because you can't see an unseen, as Frederic Bastiat said way before Don Rumsfeld--every moment spent haggling over "access" and "equality" is a moment that could have been spent advancing Serious Medicine. That is, use Serious Medicine to make real deliverables for real people. That's a vote-getter.

What if the Democrats could say, "Vote for us and we'll cure Alzheimer's"? Would that be popular? Sure it would. Or, if not Alzheimer's pick another disease or illness and announce a plan to reach a cure, in the way that JFK said we would go to the moon in 1962, seven years before Apollo 11 touched down on Tranquility 1.

During the New Deal, Franklin Roosevelt chose not to push national health care, but starting in 1938, he did push The March of Dimes,to fight polio. That was popular to the point of being uncontroversial; it was simply a winner for FDR, because the tangible beats the intangible. Hey American people! Which should we focus on, advancing a policy abstraction, or helping crippled children?

What's needed, to tangibilize the intangible, to make medicine more helpful to folks, is the application of additional technology. (That's what the British did after the disaster of the Somme; after having failed more than enough--Herbert Asquith's government fell after the battle, and Asquith lost a son, too, in the fighting--prodded by Winston Churchill, got to thinking seriously about the tank as the solution to the stalemate of trench warfare. Which, indeed, it was.)

There's no technology, at least no medical technology, in what the Democrats are pushing--no blood, no guts, no life. So of course most people are detached and disaffected!

So Republicans are in pretty good shape, right? Well, yes, at least for now. Until they find themselves in the position of having to carry out their own version of "do something!" And while the GOP is at least 18 months away of being in charge of the Congress, and at least 36 months of being in charge of the White House, already, one can see distant early warnings of the trouble Republicans will have explaining their health care plan.

Speaking to the National Press Club in DC yesterday, Republican National Committee chairman Michael Steele was pounded in the press for not being able to answer a question about an "individual mandate" for health care. As he said, he is a politics guy, not a policy guy, but the truth is that the Republican Party as a whole could not answer that policy question--there is no GOP position. And maybe there shouldn't be.

But if so, don't expect the Republicans to do any better than the Democrats at putting forward on a health care plan a few years from now, when the GOP is back in power. Indeed, at the rate things are going, intellectually, the GOP has a political Somme of its own in the future.

In the meantime, Democrats, realizing that they are exposed and overextended, having outrun their supply line of support, are hoping that the Republicans will rush up to join them on the political equivalent of Gallipoli, to borrow another grim WW 1 analogy. Here's some more from that front page Post article cited above:

"Instead of doing nothing and using insurance industry talking points to defend the broken health-care system we currently have, Republicans should work with us or at least put forward some new ideas," said Doug Thornell, a spokesman for Rep. Chris Van Hollen (Md.), a Democratic leader in the House.

Sure. Of course. The Democrats had better hope that they can talk Republicans into joining them in the health care killzone. And if Dems can talk Republicans into joining them inside the Kesselschlacht, then Doug Thornell, for example, quoted above, will have earned a promotion.

But neither party, even if they work together in good bipartisan fashion, will get very far without new inputs that are qualitatively different, not just quantitatively greater. Whoever wants to break out of this policy stalemate will need the medical equivalent of the tank.

That is, the history-changing firepower of Serious Medicine.

"The proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients."

"The proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients. In fact, it will do the opposite." That's a quote from the Mayo Clinic, an icon of Serious Medicine. Here's the Mayo statement in full:

Although there are some positive provisions in the current House Tri-Committee bill – including insurance for all and payment reform demonstration projects – the proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients. In fact, it will do the opposite.

In general, the proposals under discussion are not patient focused or results oriented. Lawmakers have failed to use a fundamental lever – a change in Medicare payment policy – to help drive necessary improvements in American health care. Unless legislators create payment systems that pay for good patient results at reasonable costs, the promise of transformation in American health care will wither. The real losers will be the citizens of the United States.

Not only is Mayo an icon, it's also a great brand. So in the meantime, unless and until Uncle Sam puts a stop to it, Mayo continues to expand; it is entering into that citadel of commercialism, The Mall of America.

The "R Word"--Rationing--Spills Into the Health Care Debate

Barack Obama is hitting rough water--maybe shattering rocks--in his quest for health care "reform." Sample headline in The Washington Post: "Poll Shows Obama Slipping on Key Issues/Approval Rating on Health Care Falls Below 50 Percent." That was today's front page, above the fold. Ouch! And then along comes a Rasmussen Poll today, showing Obama and Mitt Romney in a dead heat for 2012, 45-45.

What's going on, of course, is that voters are starting to realize what's happening to them. They are starting to see that the Obama administration made a priority of bailing out Wall Street, and that bail-out-for-billionaires plan took precedence over help for Main Street. Oh, and a "stimulus" package that was mostly a sop to local governments. So now, after all that bad blood--and red ink--has been spilled, Obama is pushing lefty ideas for health care to a scared public and a wary Congress.

Meanwhile, the real intellectual roots of health care "reform" are starting to show--and they don't look good. Peter Singer, the eugenics-minded "bioethicist" at Princeton, probably didn't help the liberal cause when he wrote a piece for The New York Times Magazine entitled, "Why We Must Ration Health Care." Singer is a smart fellow, but his writings on so many topics are so extreme that his "endorsement" of rationed health care is a kiss of death. And so you have to wonder: Why did Singer go public? Perhaps he likes being in the opposition, being a critic, and so he is doing his sly bit to make sure that nothing he might like ever gets done.

The thoughtful blogger Bob Wachter, adds his own liberal take on the rationing controversy, in a post for The Health Care Blog entitled, "A Brief History of the R Word." He agrees with Singer and Uwe Reinhardt that some sort of rationing is inevitable, as a pure function of economics--somebody, somehow, has to allocate resources.

But that puts a pretty huge premium on the "who" doesn't it? That is, do we trust the neo-Platonic Guardians to make these decisions for us? A majority of Americans voted Democratic in the 2006 and 2008 federal elections, so that gives the Dems some claim to leadership. But not even a minority of Americans had ever of John Holdren, whom Obama named as his White House science adviser earlier this year--and whom the US Senate confirmed, obviously because few Senators bothered to read what he had written. But anyone interested in the fate of future US scientific policy--and medicine, after all, is partially a subset of science--should take great interest in what Holdren has written. And here's one detailed look.

It's safe to say that 90 percent or more of Americans would strongly disagree with Holdren's writings on forced abortions, mass sterilizations, and mandatory family-size management. Admittedly, he advocated those policies in the 70s, but he didn't retract them until those words until critics discovered them in the last few weeks. So it's reasonable to ask, and perhaps even accurate to surmise, that Holdren's recantation is less than sincere. (Note to Republicans in the Senate, who had a chance to vote on Holdren's appointment, and to at least raise concerns, even if they couldn't block him: Take the advise and consent function more seriously--use interns, if you have to, to pore through all the writings of these people; no doubt Holdren is not the only extremist that Obama has nominated.)

Thus the big question: Do we want Holdren anywhere near our health policy? And in addition, do we want the people who hired Holdren, and who think of him as a colleague, anywhere near our health policy?

Yes, some kind of system is needed: Hopefully it will be a system that encourages Serious Medicine. But if we are unlucky, then we will get a rationed system in which innovation is stifled, and so not only is health worsened, but the path to lower costs is blocked by short-term stinginess.

As an aside, blogger Wachter makes a good point: Why are so hung up on the "17 percent of GDP for health care" meme? What should the percentage be? Should we spend less on health care so we can spend on... Let's have a national conversation on how best the country should spend the other 83 percent of the economy. Much of it is private property, of course, and it should stay that way, but even conservatives and libertarians want good health care. If someone figures out what we really need, there could be lots of innovative ways to finance such an expansion. In addition, Wachter makes casual reference to ways that countries with Socialized Medicine, as opposed to Serious Medicine, deal with their hard medical cases:

As Singer notes, every society that rations provides a safety valve for the wealthy disaffected. In the UK, you can buy private insurance that allows you to jump the queue for your hip replacement. Canada’s safety valve is called the Cleveland Clinic. We don’t talk about the percent of our GNP we are spending on Starbucks lattes, or on iPods, or on vacations. People pay for these things out of pocket, and receive no tax advantages when doing so. Given the American ethos of self-determination and consumerism, any rationing plan will need to allow people who can afford care that isn’t covered by standard insurance to buy it with their own money (with absolutely no tax advantage). Two-tiered medicine, sure, but I see little problem with this as long as we are using the money in the communal pool to provide a reasonable set of benefits to the entire population.

What's the Big Issue in Health Care? Is it Health? Or is it Cost?

What's the Big Issue in health care? Is it health? Or is it cost? Those dueling questions were brought to mind watching "Meet the Press" this morning, as David Gregory interviewed, first HHS Secretary Kathleen Sebelius, and then second, Senate Minority Leader Mitch McConnell. The topic, of course, was Obamacare.

Along the way, they helped clarify the choices that the American people face on health care: Do we focus on the quality of medicine, or do we focus on the policy of health-care distribution?

In arguing for the administration's agenda, Sebelius said that "Thirty percent of tests don't make people any healthier." One's immediate reaction is, "Maybe, but how does she know which 30 percent of tests are ineffective?" One is reminded of the famous quip about advertising effectiveness, attributed to 19th-century department-store pioneer John Wanamaker: "They say that half of all advertising doesn't work. But nobody knows which half!"

Indeed. Who should we trust to tell us that one-third of medical tests aren't worth doing? Has the federal government earned our trust?

Sebelius went on to criticize "money that's misdirected." Well, again, who do we trust to make those decisions? Who do we trust to do the re-directing?

Advocates of Serious Medicine understand that priorities must be established, but if so, let's get a closer look at the prioritizers, and what their proposed priorities might be. Then, and only then, will we feel better about putting them in charge of anything. And the right priority--the prime directive of Serious Medicine--is heavy research on critical diseases and problems, with an eye toward victory over those diseases and problems. We might not be able to defeat death, but we sure as heck can defeat, say, liver disease. How can I be so confident? Because, as Steve Jobs reminded us earlier this year, you can always get a new liver. Cost, of course, is an issue, but that's argument for economies of scale, as opposed to rationing. Or I should say, the popular argument is on behalf of driving the cost down through mass production. Unfortunately, the dominant argument is rationing.

Then Gregory asked Sebelius about the swine-flu vaccine. And suddenly, the Health Secretary was all about Serious Medicine. Sounding fully briefed on the status of the pandemic around the world, she said that scientists were working hard on a vaccine, and hoped that it would be ready by October. Well, that's great. But how much will all this cost? A lot, I am sure--but all worth it. And that's the point. Serious Medicine costs money. But it's cheaper than dying.

Next up: McConnell, who said of Sebelius-types, "They don't seem to grant that we have the finest health care system in the world." He's right. But of course, to the bean-counters, the overriding issue is cost. All these Euro-influenced left-liberals share a style of thinking, a style of critiquing. And in their critique is a heavy element of anti-technological romanticism, if not Luddism. That is, sewn into this style of thinking is the sense that enough is enough, that we lose our soul if we rely too much on technology.

This anti-technological argument--masquerading as a health-care-cost-control argument--reminds me of the defense-reforming "neoliberal" Democrats of the 80s, such as Gary Hart and Pat Schroeder, who accused the Pentagon of building "gold-plated weapons." Well, they were sort of gold-plated, cost-wise, but that's the thing about technology--it's expensive, at least at first. Only after awhile does it tend to get cheap on a per-unit basis. But cheap upfront is not necessarily good. I can remember one discussion, from the mid-80s, when the topic was building lighter (i.e. less "gold-plated") tanks for the Army. To which one pro-technology defense expert said, "They expect us to fight in orchards." That is, to fight in places that weren't too rough, that wouldn't require too much horsepower to get around, against enemies who weren't too dangerous. You know, sort of like suburbia, as opposed to Kursk. Well, history shows that the big battles, the Kursks, are the ones that determine the fate of nations and empires. If you come to a battle overprepared, as in too much armor and technology, fine. But if you come to a battle undeprepared, not so fine. Less is more might work for aesthetics, but it does not work for technics.

And the same is true for medicine: Technology is a necessary, albeit not always sufficient condition for good health. The treatments have to work, of course, but the treatments have to exist, first. And somebody has to pay for it. McConnell recalled a recent visit to the M.D. Anderson Treatment and Cancer Center in Houston, where he said that people from 90 countries around the world come to Anderson. And why do they come? For the results, obviously. And so who decides which procedure to do, and which test to run? We can assume that it's the doctors and other clinicians making those decisions. The moment that docs at Anderson have to ask permission from some rationer in Washington DC is the moment that people from 90 countries will stop coming to Anderson. And such a rationing scheme would not only be a loss to the cause of fighting cancer, it would also be a loss to the Houston economy, and, by extension the economy of Texas and the USA overall.

As McConnell said, "We have a cost problem. We have an access problem. We do not have a quality problem." And as we have seen, quality is the key to the economy--you have to make something better than anyone else makes, be it a good or a service. Anderson is obviously a world-class medical facility. So do we want to restrict it--or expand it?

Interestingly, Sebelius tried to make the case that Obamacare would be good for the economy, but she expressed herself in terminology that skipped right past McConnell's argument. Speaking in the "Meet the Press" segment before McConnell, Sebelius said that "reform" of health care "may be the single most important issue to get our economy on track." Well, put me down as doubtful. I think that the fate of the economy, up or down, will be driven by taxes and spending and "cap and trade." But to the extent that health care and medicine are economic drivers, their potential is seen in M.D. Anderson, which competes with the world--and wins--not some plan to recreate the UK's National Health Service here in the US.

That's the economic component of Serious Medicine, which can be summed up in Gompers-meets-Bauhaus precision: "More is more."

Scott Atlas, writing for the National Center for Policy Analysis, unloads some valuable information about health care in the US vs. health care in Europe and Canada:

Medical care in the United States is derided as miserable compared to health care systems in the rest of the developed world. Economists, government officials, insurers and academics alike are beating the drum for a far larger government rôle in health care. Much of the public assumes their arguments are sound because the calls for change are so ubiquitous and the topic so complex. However, before turning to government as the solution, some unheralded facts about America's health care system should be considered.

Fact No. 1: Americans have better survival rates than Europeans for common cancers. Breast cancer mortality is 52 percent higher in Germany than in the United States, and 88 percent higher in the United Kingdom. Prostate cancer mortality is 604 percent higher in the U.K. and 457 percent higher in Norway. The mortality rate for colorectal cancer among British men and women is about 40 percent higher.

Fact No. 2: Americans have lower cancer mortality rates than Canadians. Breast cancer mortality is 9 percent higher, prostate cancer is 184 percent higher and colon cancer mortality among men is about 10 percent higher than in the United States.

Fact No. 3: Americans have better access to treatment for chronic diseases than patients in other developed countries. Some 56 percent of Americans who could benefit are taking statins, which reduce cholesterol and protect against heart disease. By comparison, of those patients who could benefit from these drugs, only 36 percent of the Dutch, 29 percent of the Swiss, 26 percent of Germans, 23 percent of Britons and 17 percent of Italians receive them.

Fact No. 4: Americans have better access to preventive cancer screening than Canadians. Take the proportion of the appropriate-age population groups who have received recommended tests for breast, cervical, prostate and colon cancer:

* Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).
* Nearly all American women (96 percent) have had a pap smear, compared to less than 90 percent of Canadians.
* More than half of American men (54 percent) have had a PSA test, compared to less than 1 in 6 Canadians (16 percent).
* Nearly one-third of Americans (30 percent) have had a colonoscopy, compared with less than 1 in 20 Canadians (5 percent).

Fact No. 5: Lower income Americans are in better health than comparable Canadians. Twice as many American seniors with below-median incomes self-report "excellent" health compared to Canadian seniors (11.7 percent versus 5.8 percent). Conversely, white Canadian young adults with below-median incomes are 20 percent more likely than lower income Americans to describe their health as "fair or poor."

Fact No. 6: Americans spend less time waiting for care than patients in Canada and the U.K. Canadian and British patients wait about twice as long - sometimes more than a year - to see a specialist, to have elective surgery like hip replacements or to get radiation treatment for cancer. All told, 827,429 people are waiting for some type of procedure in Canada. In England, nearly 1.8 million people are waiting for a hospital admission or outpatient treatment.

The Hospital of the Future?

Why not? Why couldn't hospitals be like cities? Or even pleasure domes, with apologies to Samuel Taylor Coleridge?

After all, health care is the ultimate consumer good. Ask yourself: Which would most people prefer? To make more money, or to live longer?

Serious Medicine in Action

Innovation is good, and economic growth is good--so if it seems expensive, well, let's just be glad we have the money to pay for it. As noted here at Serious Medicine, health care is a superior good. When you have the money to spend on it--you do!

A third example of U.S. leadership is that many important medical innovations in the past 30 years arguably originated in the United States. This evidence is based on a survey designed to determine the relative importance of a variety of medical innovations developed over approximately the last 30 years. Starting with a review of the medical literature, researchers compiled a list of 30 major medical innovations and then surveyed over 300 leading general internists in the United States concerning the relative importance to their patients of the innovations. Based on the survey, researchers ranked the innovations in order of importance. The first and second columns of Table 10-1 reflect the results for the top ten innovations. -- From the 2004 Economic Report of the President, page, 192.





















Research suggests that between 50 and 75 percent of the growth rate in health expenditures in the United States is attributable to technological progress in health care goods and services. Potential sources of the remaining 25 to 50 percent of the growth rate include: higher demand for health care due to increasing incomes and the aging of the U.S. population; the increased practice of “defensive medicine” (that is, medical procedures with limited therapeutic value that are performed by physicians to avoidlawsuits); and increased use of health insurance plans as a payment mechanism for health care. -- From the 2004 Economic Report of the President, page, 194.