UPDATE: A nice post from a drug researcher stimulated by this post.
Megan McArdle has an interesting post about health care today so I thought I would add some comments. The Atlantic registration system has defeated me on several occasions so I didn’t even try to add a comment. The comments, however, are almost as interesting.
Here goes:
Basically, for me, it all boils down to public choice theory. Once we’ve got a comprehensive national health care plan, what are the government’s incentives? I think they’re bad, for the same reason the TSA is bad. I’m afraid that instead of Security Theater, we’ll get Health Care Theater, where the government goes to elaborate lengths to convince us that we’re getting the best possible health care, without actually providing it.
This is exactly what has happened in Canada where the politically motivated system has provided free primary care, filling GPs waiting rooms with “worried well” and severely rationing expensive care for the really ill.
That’s not just verbal theatrics. Agencies like Britain’s NICE are a case in point. As long as people don’t know that there are cancer treatments they’re not getting, they’re happy. Once they find out, satisfaction plunges. But the reason that people in Britain know about things like herceptin for early stage breast cancer is a robust private market in the US that experiments with this sort of thing.
The US provides a similar service for Canada which no longer produces enough heart surgeons or neurosurgeons to supply the needs of the population. Some provinces have been paying for residents to receive heart surgery in US hospitals. Waiting for less urgent surgery is the standard in Canada. Breast cancer in Canada is even seeing the appearance of private clinics in spite of the fact that doctors working in such clinics cannot also participate in the national health plan. This is similar to US doctors dropping out of government plans like Medicare.
So in the absence of a robust private US market, my assumption is that the government will focus on the apparent at the expense of the hard-to-measure. Innovation benefits future constituents who aren’t voting now. Producing it is very expensive. On the other hand, cutting costs pleases voters this instant. This is, fundamentally, what cries to “use the government’s negotiating power” with drug companies is about. Advocates of such a policy spend a lot of time arguing about whether pharmaceutical companies do, or do not, spend too much on marketing. This is besides the point. The government is not going to price to some unknowable socially optimal amount of pharma market power. It is going to price to what the voters want, which is to spend as little as possible right now.
It’s not that I think that private companies wouldn’t like to cut innovation. But in the presence of even rudimentary competition, they can’t. Monopolies are not innovative, whether they are public or private.
The government Human Genome Project is an example. It was rudely awakened when entrepreneur Craig Venter began a private genome project that quickly got the results that would have taken the government project decades to obtain. I have several posts on Venter and his work.
Advocates of this policy have a number of rejoinders to this, notably that NIH funding is responsible for a lot of innovation. This is true, but theoretical innovation is not the same thing as product innovation. We tend to think of innovation as a matter of a mad scientist somewhere making a Brilliant Discovery!!! but in fact, innovation is more often a matter of small steps towards perfection. Wal-Mart’s revolution in supply chain management has been one of the most powerful factors influencing American productivity in recent decades. Yes, it was enabled by the computer revolution–but computers, by themselves, did not give Wal-Mart the idea of treating trucks like mobile warehouses, much less the expertise to do it.
In the case of pharma, what an NIH or academic researcher does is very, very different from what a pharma researcher does. They are no more interchangeable than theoretical physicists and civil engineers. An academic identifies targets. A pharma researcher finds out whether those targets can be activated with a molecule. Then he finds out whether that molecule can be made to reach the target. Is it small enough to be orally dosed? (Unless the disease you’re after is fairly fatal, inability to orally dose is pretty much a drug-killer). Can it be made reliably? Can it be made cost-effectively? Can you scale production? It’s not a viable drug if it takes one guy three weeks with a bunsen burner to knock out 3 doses.
Once you’ve produced a drug, found out that it’s active on your targets, and produced more than a few milligrams of the stuff, you have to put it into animals, then people. Does your drug do anything in animal studies? Does it do too much, like, say, killing the patient? How about humans? Oral dosing is just the start. Does your drug actually get somewhere after it’s swallowed, or do the stomach/liver chew it up? Is there any way to wrap it in a protective package long enough to let it reach its target? Do clinical trials show efficacy compared to placebo, or other drugs? How big is the market (in other words, how many people want it, how badly, and how much of an improvement is your drug)?
This is the stuff academic pharma doesn’t do, and as you can see, without it, you don’t have a drug; you have a theory. What the NIH does is supremely valuable. But so is all that “useless” effort at the pharmas.
Now, maybe government institutions could be made to produce innovations; I certainly think it’s worth trying Dean Baker’s suggestion that we should let the government try to set up an alternate scheme for drug discovery. Prizes also seem promising. But I want to see them work first, not after we’ve permanently broken the system. The one industry where the government is the sole buyer, defense, does not have an encouraging record of cost-effective, innovative procurement.
The prospect of Hitler getting the atomic bomb was probably the only reason why the Manhattan Project succeeded.
At this juncture in the conversation, someone almost always breaks in and says, “Why don’t you tell that to an uninsured person?” I have. Specifically, I told it to me. I was uninsured for more than two years after grad school, with an autoimmune disease and asthma. I was, if anything, even more militant than I am now about government takeover of insurance.
But you can also turn this around: why don’t you tell some person who has a terminal condition that sorry, we can’t afford to find a cure for their disease? There are no particularly happy choices here. The way I look at it, one hundred percent of the population is going to die of something that we can’t currently cure, but might in the future . . . plus the population of the rest of the world, plus every future generation. If you worry about global warming, you should worry at least as hard about medical innovation.
The other major reason that I am against national health care is the increasing license it gives elites to wrap their claws around every aspect of everyone’s life. Look at the uptick in stories on obesity in the context of health care reform. Fat people are a problem! They’re killing themselves, and our budget! We must stop them! And what if people won’t do it voluntarily? Because let’s face it, so far, they won’t. Making information, or fresh vegetables, available, hasn’t worked–every intervention you can imagine on the voluntary front, and several involuntary ones, has already been tried either in supermarkets or public schools. Americans are getting fat because they’re eating fattening foods, and not exercising. How far are we willing to go beyond calorie labelling on menus to get people to slim down?
It might help to be a bit more honest about the ethnic factors in the obesity epidemic. We are the only society in the history of the world in which obesity was a major problem for the poor.
These aren’t just a way to save on health care; they’re a way to extend and expand the cultural hegemony of wealthy white elites. No, seriously. Living a fit, active life is correlated with being healthier. But then, as an economist recently pointed out to me, so is being religious, being married, and living in a small town; how come we don’t have any programs to promote these “healthy lifestyles”? When you listen to obesity experts, or health wonks, talk, their assertions boil down to the idea that overweight people are either too stupid to understand why they get fat, or have not yet been made sufficiently aware of society’s disgust for their condition. Yet this does not describe any of the overweight people I have ever known, including the construction workers and office clerks at Ground Zero. All were very well aware that the burgers and fries they ate made them fat, and hitting the salad bar instead would probably help them lose weight. They either didn’t care, or felt powerless to control their hunger. They were also very well aware that society thought they were disgusting, and many of them had internalized this message to the point of open despair. What does another public campaign about overeating have to offer them, other than oozing condescension?
Of course, the obese aren’t the only troublesome bunch. The elderly are also wasting a lot of our hard earned money with their stupid “last six months” end-of-life care. Eliminating this waste is almost entirely the concern of men under 45 or 50, and women under 25. On the other hand, that describes a lot of the healthcare bureaucracy, especially in public health.
Once the government gets into the business of providing our health care, the government gets into the business of deciding whose life matters, and how much. It gets into the business of deciding what we “really” want, where what we really want can never be a second chocolate eclair that might make us a size fourteen and raise the cost of treating us.
I realize that to most people, these are airy-fairy considerations that should be overridden by the many “practical” considerations of the awesomenes of central health care. Well, I’m actually pretty underwhelmed by that awesomeness, for reasons I’ll happily elaborate elsewhere. But not here, because fundamentally, to me, the effect on the tax code and the relative efficiency of various sorts of bureaucracy are mostly beside the point. The real issue is the effect on future lives, and future freedom. And in my opinion, they way in overwhelmingly on the side of stopping further government encroachments into health care provision.
The comments on her blog are also very interesting.
excellent reflections on the mess you call “Health Care Theater”. And you’re right (shudder) it will be every bit as effective as the nightmare of TSA.
I don’t like our current system but what they propose to replace it with is “allocated care”. Did you see Ezekiel Rahm’s essay in the Lancet? Creepy…the new system will be dedicated mainly to those betweeen the ages of 15 and 40, because they are the ones most likely to be in good health and to have what Rahm deems sufficient “qualilty of life years” left so that they are worth treating.
People who rely heavily on health care — the handicapped, the aged, children with chronic diseases — will have to justify their treatments periodically by going before a panel of providers who will decide for them if they qualify.
Rahm is being echoed by that “moral” “ethicist” , Singer.
People need to understand that this is about allocation of care. It has nothing to do with the “uninsured”; they are merely the cover for a central government aggrandizement.
I fail to understand why it is not enough to have accomplished the fascistic takeover of GM and the banks, plus the HUGE tax encroachment via the invasive Cap and Trade monstrosity. What is “enough” for these people?
When this massive legislative blitzkrieg is done, the vulnerable will be even poorer and sicker than they are now. Abortion could well become a top-down decision, though that won’t happen immediately.
BTW, have you read about the UK’s mares’ nest of a national computerized medical system? Or is that part of NICE? At any rate, it follows the same template as any other government project, e.g., the Big Dig in Boston. It’s corrupt, incompetent, has huge cost over-runs and it still doesn’t work. Was supposed to have been on line by now and fully functional. It may be another decade before they reach that goal. If they do.
American cancer care leaves much to be desired, too. In fact, medical break-throughs all too often fall into a kind of Bermuda Triangle only to be “discovered” by a later generation. As an example, cancer cells feed on sugar, the only energy they can garner from the human body is via carbohydrates. The best treatment is therefore to prevent growth of a tumor by an all-protein diet. Yes, the body goes into ketosis, but this is not nearly as hard on the kidneys and liver as chemotherapy.
Notice it doesn’t cost much and besides monitoring progress, there is not much valiant effort necessary on the part of oncologists and Big Pharma. So three guesses how much of this research will ever be broadcast by those who control the information portal?
The data is out there, as is the information that prima gravida abortions performed on teenagers raise the risk for aggressive breast cancer twenty years down the line. The risk rises exponentially if the girl has first degree relatives with the BRCA gene.
The mechanism seems to lie in immature mammary glands. These glands are only matured by carrying a fetus to term and delivering it. Spontanseous abortions (miscarriages) don’t hold the same risk — i.e., the body prepares itself to abort and the process is more gradual.
A few years ago two teenagers who had abortion “counseling” in two clinics in Washington state found out later about the connection between this procedure and the risk for breast cancer. They both had first degree relatives with the BRCA gene. They sued the clinics but it was quickly and quietly settled out of court and never made the news. I suppose they have the comfort of knowing they have enough money for the bilateral mastectomies they will have to have, since that seems to be the only preventive measure to date. But they need to do them *early* before any of the glands turn cancerous.
There doesn’t seem to be a way to break the stranglehold that the Breast Cancer-Abortion industry has on public information. I am hoping it is the insurance companies (the “market forces”) who make this known by refusing to pay for mastectomies on women who’ve had prima gravida abortions and carry the BRCA gene. It would be hell on the women who were subject to this, but at least it would open the portal and permit younger women coming behind them to know the risks of elective abortions and thus be spared the horror.
Unfortunately, this isn’t conspiracy thinking. I wish it were. But anyone publicizing it becomes a pariah, a meanie trying to limit women’s freedom over their own bodies. What a farce…as if anyone has that kind of freedom.