PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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SECTION TWO: Hidden Economics of Healthcare
Here are samplings of the reasons Healthcare Reform still isn't going anywhere.

The American Health Plan; Only in America is it Imaginable

Nobody told us to do it, but let no one suppose our scientific community was the only group who had the notion. Exceptionalism likely originates deep in our culture of conquering the wild frontier. There's also the Abe Flexner or Teddy Roosevelt progressivism theory, but sometime during the winning of World War II, we Americans strongly exaggerated the idea we could do anything, and carried that idea to surprising levels. Somewhere in the course of building the atom bomb, landing a man on the moon, defeating the whole world at war, defeating the Great Depression, and winning a whole lot of Nobel Prizes, we gave ourselves the idea we really could conquer all of disease. All it seemed to require was to spend tons of money, and to set our minds not to quit. It probably is well to remember that at the time of the Bretton Woods Conference in 1944 , we had two thirds of the gold in the world, locked up in Fort Knox. Foreign trade was paralyzed, because nobody else had any money.

Since 1900, average longevity has expanded from 47 years to 83. At least thirty major diseases have disappeared, fifty percent of drugs now in use were unknown just seven years ago, and so on. In 1950 we had 500,000 licensed beds for mental disorder, in 2010 only 40,000, although John Kennedy's impulsiveness probably overdid it a bit. Far from all those mental patients were transferred to jail, and far from all those jail inmates came from mental hospitals. There has been a remarkable acceleration of scientific discoveries, new drugs, new cures. And it would take more than money to do it. Why worry now about what medical care costs, when it is obvious if we cured all the diseases, even the poorest among us could easily afford to spend -- nothing at all on health care. Foreigners scoff at such childish belief, but then, they retire in their thirties and wonder why they don't accomplish anything. Nobody ever won a war without taking casualties. You aren't listening to Quakers, when you hear that last one; the feeling isn't universal, nor is it always valid.

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If we cured all the diseases, even the poorest could afford to spend nothing at all on health care. {bottom quote}
It does sound a little childish to go on like this, but there are signs it might actually be more or less the right path to take. We spent a billion dollars searching for cures in the genes of the entire human genome, and found very little. So we questioned the research and repeated it, spending another billion dollars. The result was unfortunately the same; apparently, that was the wrong place to look. But a man who lives in Philadelphia found thirty-seven more genes outside the cell nucleus, in the mitochondria, and spent his career finding out what they did. That sounds like a better way to go. There are scientific reasons to hope that among other things, these genes are responsible for the major diseases which make their first appearance during middle age. Four or five diseases of this sort, like cancer, diabetes, or Alzheimer's Disease, account for most of the medical costs we spend so much time worrying about. Obviously, no one is going to live forever, so there will continue to be substantial medical costs. At the very least, if we had no diseases, we would have the problem of outliving our income. Onward! Only a couple more decades to spend money, and then there will be plenty left over.

To make it last, maybe someone has to cut costs. The hospitals are the single largest source of medical spending, so somebody's unspoken plan is to let them put on fat for the coming winter, and then suddenly cut them off at the knees. After all, hotels seem to be considerably cheaper, and retirement communities run infirmaries at a fraction of the cost. We instinctively know state licensing agencies are somehow protecting some monopolies, which will disappear if we pass a few laws, although the Maricopa decision shows the weakness in acting on that hunch. All in favor, signify by saying aye, and it's as good as done. As somebody once said, nobody ever won a war without taking casualties.

It has been noticed by others we tend to make systematic prediction errors. If you predict what you will accomplish in a year, I'm sorry to say you can't get that much done in a year. But if you predict what will occur in twenty years, you always underestimate the enormous changes to take place in two decades. If you experiment between short-term extrapolation failures for what can change in a year, on the one hand, and imagination failures for what will take place in twenty, at the other extreme, it appears that predictions for about six years come out closest to what does actually happen. I think I got that from The Economist.

Will medical costs be substantially lower in six years? Probably not, but they will probably be somewhat lower, just from extending the scientific advances we have already made, to more or less everybody within our borders. Beyond that, much will depend on the scientists. Whether major discoveries will emerge, or how often, is beyond present prediction. But in five or six jumps, we can expect present accommodations to health costs, to become quite obsolete. Read the proposals to deal with them, which appear in a later section, in that light.

Although the language of exceptionalism really isn't my native language, right now the general sense it conveys, seems roughly correct. Although I'm not as reckless as some would be with research funding, I do believe the general sense of it is correct. With a little bit of luck, and considerable help from newly developed centers of foreign research, present trends do seem to be leading to a drop in both research costs and health delivery costs reasonably soon, let's say during the next generation. Improved transportation, tele-medicine and extended longevity seem to hold the promise of slimming most medical costs as we now know them. And it does seem to me reasonable to make most general hospitals into tertiary care centers, and then to shift the center of bread and butter medical care to the suburban and exurban retirement centers. Mostly, we need better transportation arrangements, to do so fairly soon.

What seems to be retaining the center of gravity in the present urban Medical Centers, seems to be: the location of research already present in those places, and the use of indigent populations for teaching purposes. When research (read: government funding) begins to dry up, it is my prediction the center of healthcare delivery will shift with the population centers, adjusted for their sickness content. My guidepost is the Hershey Medical Center, located on the most fertile farmland in the world, and only a few miles from where my ancestors lived for two hundred years. Each year I make a trip there, and every year there are more mini-mansions. A dear friend of mine advised Milton Hershey on how to build a medical school in the boonies, and frankly, all it takes is money. When present funding dries up, the center of Medicine will move to where the sickness is, unless government gets in the road of it. As far as I can predict things, it seems to mean medical care will move to retirement centers (CCRC). Some people prefer high-rise apartment buildings, but building vertically is invariably more expensive than building horizontally. Very likely, the migration of both healthcare and retirement will be dominated by making financial resources stretch further. Research? Well, research is a young person's game, so let them plan to retire earlier and become administrators later.

My ability to predict politics is poor, so I notice politicians can sometimes direct funding into wasteful directions. We might annex Canada, Mexico, and Cuba, and thereby jumble up the American economy in unrecognizable, unpredictable ways. Or we might annex Canada, Iceland, Ireland and England, for a different unpredictable future. Any of that would just be our Exceptionalism, carried out in another direction. But somebody else's exceptionalism might turn us all into a lump of molten ash, so this is a better choice. Using the same unconstrained reasoning, our leaders may decide the direction started by the careless Maricopa decision was ill-advised, and the people trained by the system Abraham Flexner set into motion are better qualified to run research systems, than the people elected on the second Tuesday in November. Governing this, however, will be the nature of the reaction when the taxpayers discover a few awkward things, like who benefits most when an employer gives health insurance to his employees as a tax-deductible gift.

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