Michele Bachmann, Right About Health Care
Ricochet friend Jim Pinkerton has been saying for years, especially on his excellent (though slightly wonky) blog Serious Medicine Strategy, that we need to be thinking a lot bigger about health care than we are.
Right now, the sad, small-timers in the Obama administration are concentrating on allocating -- read: rationing -- resources.
Pinkerton has been arguing that we need to be focusing on curing diseases, not treating them. And he's apparently convinced Michele Bachmann, the hugely misunderestimated congresswoman and potential presidential candidate. From the Daily Caller:
There are essentially three ways to lower the cost of health care — two of which get all the attention. The first option, supported by many liberals, is bureaucratic rationing of care. The second option, supported by many conservatives, involves cuts in overall spending, plus the use of market forces, to control costs. The first two options are perpetually in conflict, and so far, at least, the two options seem to be fighting to a stalemate. But there is a third option for conservatives, which builds on the free-market/limited government model — and which offers the hope for a political breakthrough.
And that third option — currently being championed by Rep. Michele Bachmann — is to actually cure diseases.
Bachmann’s argument, which she first sounded on “Fox News Sunday” on May 1, is that [Paul] Ryan-type fiscal rigor needs to be linked to pro-medical science vigor. As she told Fox’s Chris Wallace, “We should focus on…cures — cures for things like Alzheimer’s, cures for things like diabetes. It’s very expensive to just cover the care for sickness. I’d prefer to see money that we have at the federal level go for cures.”
It is an interesting, albeit seemingly obvious, point — a cure is cheaper than care. But actually, it’s not so obvious. The idea of curing diseases as a health care strategy — as opposed to financing the care for those diseases — seems to have faded from the political discourse in recent years. Whether it’s Ryancare or Obamacare, both parties have chosen to focus on the mechanisms of health care finance, as opposed to health itself. The immediate question comes back: Are cures even possible?
And Bachmann has an answer to that, too, pointing back to past successes for a can-do America; as she told Wallace: “Probably one of the best examples is polio. If you look in the 1950s, polio was a huge issue. And government was forecasting at that point that we might be looking at $100 billion in costs. Today, polio costs us really virtually nothing. Why? A private charity, March of Dimes, put money in to finding a cure. We all have the little vaccines that Jonas Salk came up with. Thank God. I would like to see that with Alzheimer’s and diabetes and others.”
I love it when a conservative politician speaks eloquently and passionately and especially optimistically about health care. We shouldn't fall into the Obama Gloom trap. We're Americans. We solve problems. There's nothing intrinsic about health care to suggest that it's any different from any other technical or industrial problem. I like the way Bachmann is reframing the debate, and I hope she does more of it.
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Comments:
Mar '11
Re: Michele Bachmann, Right About Health Care
As a biomedical researcher working on infectious diseases, I must say that most of the previous comments are absolutely spot on, and I have witnessed many of these observations first-hand. This plan from Bachmann is flawed in so many ways, I don't even know where to begin.
The only place I see a potentially sensible role for government support of research into "cures" is when it comes to low probability/high risk events, such as preparation for/prevention of infectious disease epidemics like pandemic flu (purely coincendentally, the field I work in).
Just as in finance, the biomedical private sector is bad at predicting very rare events with very "fat" tails (like viral pandemics), and vaccine development has such low margins that most pharmaceutical majors avoid it like the plague. In this situation, government support of vaccine research/preparation, though inefficient, might save society a great deal of money (and suffering) if the big one hits.
Apr '11
Re: Michele Bachmann, Right About Health Care
BThompson Do you not grasp that there is a way to shore up medicare in the short term (30-40 years) and wind it down for the long term, in a more gradual, equitable way than telling people in their 40s that they're the ones who have to bear the lion's share of the burden for fixing the mess? · Jun 6 at 8:34am
Edited on Jun 06 at 08:35 am
There is no way to shore up a ponzi scheme. Whether that scheme is labeled Medicare or Social Security. Just ask Bernie Madoff. The largest generation in our history is beginning to retire. By the time they all retire (1930) it will take roughly 97% of your income to pay for those two plans alone. I can't live on 3% of my income. I can, however, take care of myself, pay my medical bills and invest for my retirement. It would be much easier to do so if the government wasn't taking such a big chunk.
Jan '11
Re: Michele Bachmann, Right About Health Care
If you leave it as is. No one is proposing that. Let's just cut to the chase. Do you support Ryan's plan or not? And if you think everyone above the age of 35 is just going to write off their contributions altogether to support the idea that 20 somethings will start building smart retirement plans (which they won't do, by the way) I think you're deluding yourself. Ponzi schemes aren't sustainable, but they can be wound down in responsible ways so that a tiny minority doesn't have to bear the majority of the pain. You are proposing false choices.
Edited on June 6, 2011 at 6:00pmMar '11
Re: Michele Bachmann, Right About Health Care
Boots on the Table
Governments role should be in the licensing of medical professionals and in their punishment if they act fraudulently or maliciously. Their role should have nothing to do with money. The government shouldn't be paying for healthcare nor should they be funding r & d. Private parties will fund r & d along with corporations who will see a profitability in the products developed. · Jun 6 at 8:21am
I agree with everything you write, Boots. What I was trying to get at was to see if we could identify specific things an enlightened government could do to get out of the way of those private parties most likely to promote progress. For example, what should the FDA do to assure that safe new drugs make it to market without undue delay? Should it abandon its efficacy requirements as long as it’s reasonably safe? How safe should a drug have to be if there are no alternatives but death? Should government continue to discourage off-label use of approved drugs? Does the current patent law reward developers of successful new drugs enough?
Apr '11
Re: Michele Bachmann, Right About Health Care
The biggest problem I see with the FDA is that they are designed in such a manner as to delay or reject approval. The system punishes them by showing how many are harmed or die from drugs they approve, yet, does not either punish them for not approving a life saving drug, nor reward them for speeding up approval of a drug that will save numerous lives.
continued next post.......
Apr '11
Re: Michele Bachmann, Right About Health Care
Also, by capitulating to low prices mandated by state run medical programs (e.g. Canada) the cost of prescription medication is both increased in the U.S. and reduces the incentive for r & d required for future drugs. Off-label use is a consumer choice. The Government should not be reducing choices. However, I do believe the patent law should be adjusted as to the duration of time a company has to make back it's investment. An adjustment tied to the date of approval rather than it's date of manufacture should be appropriate.
Mar '11
Re: Michele Bachmann, Right About Health Care
To return to the original post (government-sponsered "cure hunting"), one problem with this logic is that many "cures" to diseases are already in our hands, we simply don't know it yet.
One good is example is HIV/AIDS. Over the years, the number of new antiviral drugs has expanded slowly, yet tremendous progress has been made toward reducing the number of AIDS deaths (in America, very few people die of AIDS anymore). How did this happen? Because many doctors all over the world experimented with different doses, schedules, etc. of the existing drugs, until they found combinations which worked much better than the sums of the individual drugs.
By reducing restrictions on approval, off-label use, etc, decentralized networks of doctors can often find "cures" much more quickly than large-scale centrally-planned research. Unplanned, incremental progress doesn't leave us with the same good feeling as a moon landing, but has a much higher success rate in science.
Re: Michele Bachmann, Right About Health Care
SD Spicer: Rob,
On a past podcast you mentioned being severely under the weather and purchased at little cost to yourself a strong, and I'm sure expensive, antibiotic. I too purchased one myself at the cost of a small co-pay.
I believe you stated then Rob, and I believe I agree now, is that we are spoiled by the fact we don't see the true cost of our care. Until we do then the incentive is for the healthcare industry to keep giving us care and for the government, insurers and ourselves to go on acting like it is fine.
I believe the incentive in finding a polio cure was because the cost would have been direct to the one who is sick or their family. Not so anymore we will drive the incentive for a cure when the cost for our care becomes overwhelming. · Jun 6 at 7:36am
Agree. Of course, back then, everyone was afraid of polio. They even closed the public swimming pools. So giving to the March of Dimes was in everyone's interest.
Mar '11
Re: Michele Bachmann, Right About Health Care
Unplanned, incremental progress is better than unplanned excremental progress any day!
Re: Michele Bachmann, Right About Health Care
How was it government sponsored? Bachmann was talking about private initiative. The March of Dimes was a private charity.
Re: Michele Bachmann, Right About Health Care
Michael Tee: In all seriousness, what do you think GSK, Pfizer, Merck, et al. have been doing all these years? Do you think NIH money for chemistry is aimed at what, exactly, besides advancing the careers of well-connected scientists?
This line of argumentation offered by Pinkerton is worse than arguing beside the point. It's fiddling while Rome burns.
Those imaginary drugs will cost money. As Richard Muller says about global climate change, nothing substantial will happen unless someone can make a profit. · Jun 6 at 6:58am
Isn't that the problem? I'm not clear what you're arguing. Bachmann seems to be saying that private initiatives and a low-regulatory environment will do more to materially benefit the heath of all citizens than a government boondoggle which just wants to treat patients. What she's saying is that only the private sector can think big.
Big Pharma complains about this all the time. They've even admitted they're no longer trying to cure AIDS. They regulatory and patent and insurance environment makes this unattractive. They'd rather come up with another Lipitor.
Bachmann, at least, is identifying the problem: Big Government stifles innovation.
Mar '11
Re: Michele Bachmann, Right About Health Care
Profit (or the lack thereof) may be the problem when it comes to diseases which are life-threatening, but affect relatively few people or in developing vaccines for low-probability pandemics, but can it be that it’s the problem for medical research overall? If it’s more profitable to find a treatment than a cure, then there may be a role for government to play in getting the incentives right.
Nov '10
Re: Michele Bachmann, Right About Health Care
There is a fundamental problem with the way we fund research. Research, whether medical, in the physical or social sciences, or in basic science (my domain -- my work is in pure mathematics), is unpredictable. You can't simply choose which problems you wish to solve and throw money at them until they are solved. There are a few types of projects that can be solved this way. Most cannot -- and this is particularly the case in medical and basic science: those problems that can be solved by "deciding to solve them" have been done long ago.
Not to say that I disagree with Bachmann's take. I think it is essentially correct. Cures can be and are found by funded science. But we need smarter use of research funds; today's overnment-funded research too closely parallels crony capitalism in which nonexperts with a lot of power pick winners and losers based on "what's sexy", their own interests or that of lobbying groups. Government-funded "peer reviewed", is often merely "pal reviewed". Some conservative scientists in Canada are proposing a better model ... maybe I'll post or have a friend post here about it sometime.
Re: Michele Bachmann, Right About Health Care
No, we cannot cure more diseases simply by wishing it so. Whatever your views about the origin of humanity, we can all agree that we didn't specify our own design. Progress in advancing absolute therapeutic capability is necessarily slow.
However, we could do a whole lot more with the the therapeutic capability we already have. Here I'm referring to what we in the medical biz call the "efficacy-effectiveness gap." Very few people take full advantage of the "cures"--usually management strategies--that we already have. This is unsurprising since medical companies make components rather than products.
If you had to build your car one piece at a time, it would cost a fortune and not work half the time. Right now doctors build medical products for doctors to use in a regulated, reimbursed market that presumes labor-intensivity and patient passivity.
Compare this trajectory to the computer industry. Where's the medical iPhone/iTunes system for chronic disease management?
What health care needs is business model innovation: Consumer-oriented treatment systems that leverage the wireless Internet to dramatically change what a drug is, and with it the cost-benefit equation in health care service delivery.
Aug '10
Re: Michele Bachmann, Right About Health Care
George Savage wrote: Very few people take full advantage of the "cures"--usually management strategies--that we already have.
There's also the more fundamental issue that lots of people simply don't want to comply with treatment regimes and lifestyle changes, even if it's made easy for them to do so. Although it's framed as a problem of "access," Gawande's piece for the NYer a few months ago is really about how diabetes patients have to be dragged kicking and screaming into complying with doctor's orders. There might be technological and/organizational fixes to mitigate this problem, but there's probably an irreducible extent to which a large number of people simply don't want to comply with treatment or improve their health behaviors --- they'd rather wait until it gets critical then expect it to be fixed at the ER.
Edited on June 6, 2011 at 9:47pmMay '10
Re: Michele Bachmann, Right About Health Care
I will take the challenge and outline a set of solutions in a Memberpost that isn't limited to 200 words. Clearly, returning health care to a retail market, returning "insurance" to actual Insurance, and research are important. The two most important other issues, however, are tort reform and significant changes in medical licensing. The practice of medicine will look very different in the future.
Regarding research, you need to have a bounded problem, unlike "cancer" which is hundreds of diseases, each of which behaves differently, and one that isn't a fundamental flaw in the germ line such as cystic fibrosis, where we've know the cause for 20 years but can't change the victim's DNA to fix it. The Alzheimers challenge is a far more sensible goal than most, and would pay off in spades- if all you did was reduce long term care by 25 or 50%, you would save billions in government costs (sorry, Michael, the horse has already left the barn, Medicare won't be eliminated).
Re: Michele Bachmann, Right About Health Care
Anon, it's the same issue. People don't comply because people aren't machines and don't like being treated as such.
Medical research focuses exclusively on biological possibility and design-for-physician rather than making products relevant for patients. In the acute care setting, this approach to product design is the right one.
But it is wholly inadequate to chronic, long-term disease management.
Very few patients are sufficiently sociopathic not to want to get well. Most patients find it impossible to "comply" because the product doesn't fit their mental model of disease. Maintaining motivation is a related problem. And why is this a surprise? That scrip for metformin and instructions to exercise make no sense at all to the typical patient.
Facebook and Zynga have certainly shown how sustained behavior change can work in practice, at nearly zero cost. We need to bring this thinking into our regulatory and reimbursement systems so that we change the value equation in healthcare delivery
May '10
Re: Michele Bachmann, Right About Health Care
Many diseases are caused by problems with proteins, if you can figure out which ones (of the more than 100,000 to 300,000 in your body, most of which we don't understand very well).
Alzheimers is tied to beta tau which is linked to plaques in the brain, and the first generation of drugs that tried to control beta tau have largely failed as treatments because the errant assumption was that plaques were a cause of the disease rather than what it appears to be, a defense mechanism to protect the neurons from the inflammation caused by other means.
This illustrates why basic research cannot be left only to the pharmas- they must look for early, single-cause therapies. AIDS is largely controlled because the government harnessed multiple pharmas, cutting through the IP thicket for the complicated combination treatments that can't be achieved by Merck or Pfizer acting alone.
The current work with beta star is moving in new directions, and this is the kind of challenge that could respond to a concentrated and accelerated program because the brain is isolated enough by the blood-brain barrier that you can better identify the proteins involved.
Aug '10
Re: Michele Bachmann, Right About Health Care
George Savage
Anon, it's the same issue. People don't comply because people aren't machines and don't like being treated as such.
Thanks for the detailed reply. I totally agree that it's possible to improve compliance with better technology and I think such efforts are laudable. (Certainly this is better than Pinkerton's completely backwards suggestion that the "war on cancer" approach will yield cost savings). I'm just thinking that there will always be a big noncompliance problem, even as I agree with you that it is possible and desirable to mitigate the problem through organizational and technological solutions that do their best to realistically accommodate human nature and human cognition.
Mar '11
Re: Michele Bachmann, Right About Health Care
Rob Long
How was it government sponsored? Bachmann was talking about private initiative. The March of Dimes was a private charity. · Jun 6 at 11:05am
According to the Daily Caller article:
"One can imagine a Bachmann presidency might likely pursue some sort of “Moon shot” summoning of Americans to accept the challenge to cure Alzheimer’s.
A hypothetical President Bachmann... might consider elevating someone...to equal status with the national security adviser."
1) The projects being mentioned here (Alzheimers, etc) require significantly more money than has ever been donated by charitable organizations. Without government (or other external) funding the hope of finding a cure is low.
2) Even without government money, having a "cure czar" lead a new "moon shot" certainly sounds like centrally-planned Big Government research.
Edited on June 6, 2011 at 10:51pm