On a tip from Paul Krugman, I read Creative Destruction by Jon Cohn, which carefully considers the best case against universal healthcare, which is that when the government mandates universal coverage, there won’t be enough profit-motive for companies to innovate better therapies and drugs. Essentially, NIH (the government) is what advances medicine, not high prices for insurance or pharmaceuticals (corporations).
I urge you to read the whole thing. It’s long but worth your time.
Please share widely!
And here I went looking to press it.
the assumption that medical innovators are all in it for the money doesn’t square with my personal observations. i have a partner and numerous friends in biotech. while the ones working in industry get paid quite well, the paycheck is not what drives their desire to find cures to diseases. their drive comes from a combination of scientific curiosity, wanting to improve the human condition, and personal ambition. these are the actual scientists, mind you, not the all-too-frequent exec who is in it to swindle themselves a bundle (see: Eli Lilly takeover of Icos Corp, for one recent example).
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the observation that i can add to the article is that if you rely only on industry for medical advancement, you should expect very little in the future. the reason is because the biotech biggies are starting to shed their research departments. they’re doing this because it is financially risky. so, a lot of research is getting pushed down to start-ups or university labs. in other words, they’re letting the government take the risks. but they’ll do their patriotic duty and manufacture and market and make profits from anything promising coming out of the gov’t-sponsored research programs! just as Merck did with penicillin (although they had to be dragged into the deal kicking and screaming, since it didn’t look profitable to them at first!).
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Complete the sentence.
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Because the logic makes sense.
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Governments DO have incentive to create new cures for diseases, right, since they pay for treating them.
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So I’m waiting for Jon Cohn to complete the sentence with dozens of breakthru drugs that come from Britain, Japan, France.
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Jon Cohn completes the sentence with….
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Oh.
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The article is good, provocative, so thanks for the link, Joel.
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I’m definitely willing to buy the case AGAINST our pharma operation.
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But I also think it’s easy to kill baby with bathwater by eliminating profit motive.
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with at least one drug that changed human history: penicillin. it was developed in oxford england by scientists working for a government that was upset with all the soldiers dying from infection. for more on this drug’s discovery and development (and the oddball personalities that made it happen), read “the mold in dr. flory’s coat”.
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also you might consider the humble aspirin. many cultures in the northern hemisphere (at least) figured out the beneficial properties of plants containing salicylic acid (or something similar). but it was late 19th century european chemists who refined and formulated it into what we know as aspirin (acetylsalicylic acid).
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i’m sure there are many others, and more recent. these are just two biggie i know of because they are, well, biggies.
even cohn doesn’t dispute that USA creates lion’s share of all innovative new drugs in the world.
The translation is that the exception tests (“probat”) the rule.
i’ve seen the profit motive absolutely “kill the baby with the bath water”, as you put it. private industry, pharma included, can and has been tremendously wasteful. companies gobble each other up just to get hold of patents, then too frequently jettison the remainder. too often “the remainder” consists of promising new stuff in the pipe line, and the fabulous teams of scientists and engineers that created it. it all goes in the trash.
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preserving a profit motive won’t necessarily get you anything better than you could get without it. but it will certainly get you a few disgustingly wealthy ex-CEOs and too many productive companies smashed to smitherines.
AZT,the first drug to be effective against the HIV/AIDS virus, was developed with taxpayer funds at NIH. Due to lax regs the pharmaceutical giant BurroughsWelcome got an exclusive patent on AZT and began charging as high as “the market” would bear. That “market” price can go very very high in an wealthy country such as the U.S. when it is a life or death drug. In fact, AZT pricing was one of the early policy issues in the AIDS pandemic that led to the activism of the group ACT-UP…
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Thanks for the Cohn article link. I must say, we can debate the details ad infinitum (and ad nauseam) but substantive progress on healhthcare reform boils down to how we identify our fundamental social values on the healthcare issue.
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How do we collectively, first as individuals then as a state and eventually as a nation, answer this one very basic question:
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Do we want healthcare to be treated as a protected right – something that is viewed as essential to human life and dignity and that supports the maintenance of a robust civilized society – or do we want healthcare to continue to be treated as a market commodity?
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Poll after poll shows the majority of Americans are in the former group. The task is to neutralize the impact of big money enough to pass and enact reforms that will realize our shared values. Hopefully Edwards, Obama, or Clinton will be at the helm of this work.
…Irrespective of that, the use of AZT to treat HIV/AIDS is far more complex than you might want to believe. http://en.wikipedia…. (scroll down to “History”) It is doubtful that BW could have gotten a patent on AZT itself, but it is likely that it could have gotten a patent on its use as an HIV/AIDS drug.
governments help in drug discovery in indirect ways simply by producing competent scientists and engineers. these people either work on drug discovery problems directly, or create the needed basal knowledge upon which new drug investigations can be built. for example, if no one had bothered to develop biochemistry and genetics, we’d be no further along in drug discovery than that poor sops of the 19th-early 19th century.
“the kinds of innovations that yield long-term, diffuse benefits–such as the creation of a better information infrastructure that would help both doctors and consumers judge what treatments are necessary when.”
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At that point he’s in the middle of pointing out how corporate insurance, which emphasizes this quarter’s bottomline at the expense of longterm benefits to patient & company.
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Cohn’s not arguing for the removal of profit-motive. He’s arguing profit-motives don’t advance some important therapies/practices. He’s willing to concede that a universal health insurance might decrease overall innovation, but Cohn’s convincingly argued that opponents are off-base if they say it will decrease innovation. And on the off-chance that it does decrease innovation, Clinton, Obama and Edwards all have plans for the government to find and fund therapies that could better improve public health.
cohn starts with: would we get same amount of breakthrough drugs, surgeries, and medical devices?
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then he shifts: his suggestion that we’ll get other innovation in medical record keeping and such.
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that’s my quibble. his one example from other nations doesn’t line up with his main argument.
reduces the risk of physician caused error (which I believe is on the top ten list of illnesses in the USA), that’s an improvement in public health.
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I understand what you are saying about Cohn not providing some sort of foreign breakthru on par with GE’s development of CT.
..CT was not invented by GE It was invented in Britain.
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BTW, I was using the equivalent of MRI in my graduate work in 1970-71. It was on solid hydrogen, but it was MRI nonetheless. This stuff isn’t new.
instead of “invention.”
…regarding your first paragraph, I do believe that you are on point. But it depends on how the medical information is used–or abused.
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From what we have been led to understand, Lahey Clinic is, with its patients’ permission, willing to put the medical records on line. I tend to consider that a plus, particularly when we’re in Germany (yes, most German doctors understand English quite well). Unless, of course, there is a problem acquiring health insurance coverage in the US.
i’m a big fan of improvement in medical record keeping. i’m not saying it’s worthless.
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my wife has oft told me of the diff between treating her patients at Boston Area Hospital A (which has electronic records) and Boston Area Hospital B (which does not).
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just saying the straightforward question raised by cohn is whether PHARMA innovation will rise or fall under universal health care, and then he kinda shifted to other (useful but not equivalent) health innovation.
…but not really much of one.
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Apothecaries, even in the US are often interlinked. Trained pharmacists will not only fill prescriptions, but also check their links to determine whether the customer’s prescription might conflict with other previously issued prescriptions, and, if so, at a minimum, issue a warning, and may also inform the physician.
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We’ve noticed that here in the US. We’ve also noticed that at our little Apotheke in our Munich ‘burb. A couple of years ago, we wanted to purchase some cold medicine, and the pharmacist took forever to sell us the product. She was checking the database to determine what drug interactions there might be. And those were not even prescription drugs.
[quote] So I’m waiting for Jon Cohn to complete the sentence with dozens of breakthru drugs that come from Britain, Japan, France. [/quote]
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—>With Bush’s hamstringing of stem cell research driving leading edge research out of the country, I wouldn’t be suprised to see big things coming from just those countries. Well, maybe not France.
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—>With Bush’s hamstringing of stem cell research driving leading edge research out of the country, I wouldn’t be suprised to see big things coming from just those countries.
this is an interesting radio story on today’s The World. it describes how finland drastically reduced it’s very high rate of cardiovascular disease by the gov’t getting heavily involved in what foods were available, in intensive school programs, and through farm programs that redirected production towards more healthy food items.
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imo, this is as good as if not better than developing a drug. this is figuring out a way to avoid the need for a slew of drugs, procedures and hospitalizations (and funerals).
of what can be accomplished when a country actually has a health care system. A system implies planned, integrated and coordinated parts that function together as a whole toward agreed upon goals (uh, that’s pretty much the exact opposite of what we currently have in the U.S.).
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Interested readers might like to see Health as a National Asset: Can this perspective from Finland help us to rebuild our health sector? [ by Freeman, P. & Robbins, A., October 2001.(8500 words and 153 references).
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I distributed copies of that publication after making a comment about the valuable example it might offer us here in MA and the U.S., way back at a “Health reform and the business community” forum held at the Park Plaza hotel back in about 2002 or ’03 I think it was. I’m almost sure that Richard Lord from AIM got one of my precious 10 copies, as did Alan McDonald from the MA Business Round Table, Peter Meade from Blue Cross Blue Shield, and a few state legislators… Lotta good that did. I wonder if any of them even read the thing.
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Thanks for the heads up about The World piece.
Does any of that really matter when 45 million Americans don’t even have health care? Or when insurance prices are rising 10% per year, so fast that soon tens of millions more will be priced right out of their insurance policies. Furthermore, I highly doubt most HMOs would cover the DBS treatment example, or that people in most states could afford an HMO that would cover them. All reasons that make Cohn’s argument very, very flawed.
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But let’s ignore all that. What about systems like France, that clearly have health coverage far better than minimum standards? We can create a system of insurance that would cover procedures like that. Single-payer, after all, is a system in which doctors and medical professionals are still independent of the government, it’s just the gov’t that pays the checks. Presumably, the people will pressure the government to make sure that cutting edge procedures are covered by universal medicare. They’ll also pressure the government to keep funding our nation’s colleges and universities to stay cutting edge.
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Furthermore, by having a national health care system, it would free up money for people to get supplementative insurance that concievably covers procedures like that and many more. There’s no one system of universal health care we need in this country; we can pick and choose the best aspects of all the options across the world. There’s no reason why we can’t spend the time to create a new health care policy that will set an example for the rest of the world to follow, we just need to develope the political courage and will to do it.
We HAVE universal health CARE – via emergency rooms and clinics, in addition to HMO’s, PPO’s, Fee-for-Pay, etc.
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We do NOT have universal health INSURANCE.
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There IS a difference.
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Carry on with your exposition.
you know what i mean =p
PP’s point wasn’t semantics. You probably ought to re-read. Alternatively, take a look at this essay on those 45 million uninsured. Alternatively.:
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… we forgot to take into account all that enormous health-care that the uninsured have not been denied access too.
It’s a tragedy when there aren’t enough resources for everyone to receive unlimited coverage, and the example you’ve referenced (i.e. the guy in Lousiana who apparently couldn’t get chemotherapy after insurers left LA) is a sad example.
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Could such possibly happen with Government run Universal Coverage?
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Access to immediate trauma care is not the same as healthcare. There are many many people who emerge from the emergency room with simply a diagnosis for which they are prevented from treatment by lack of health insurance. A persistent cough might be the flu, in which case the ER will get you some antibiotics and get you on your way… or it might be lung cancer, for which you will be given a slip of paper and instructions to ‘follow up’ with a primary care physician. The uninsured are often not able to do this…
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When they are able to follow up, it’s on the government’s dime: to wit, medicaid. And they are often the most expensive patients because they didn’t deal with their situation until it became absolutely unavoidable.
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Absence of health insurance can translate, very easily, into absence of health care. At the very least it translates into costlier health care…
One, regarding the Cohn article, it really isn’t surprising. The issue is that physicianing isn’t a science, it’s an art. A physician sees a symptom, has been told that this compound may ameliorate the symptom, tries it; if it works, ok. If it doesn’t work, we’ll try something else; if that works, we’ll write a paper about it.
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Two, and more important …governments help in drug discovery in indirect ways simply by producing competent scientists and engineers (from Laurel). Maybe, but not exactly. Most of the “wonder” drug discoveries in the last couple of centuries have come from observation. I’ll avoid the litany, but aspirin and penicillan (the two most important drugs), digitalis (foxglove plant), erythromycin (from a soil in the Philippines), Viagra(!) (originally designed for but rejected to address angina). People observed that the condition was ameliorated by ingesting these substances, and then the Pharma companies isolated and dosed the respective chemical. That isn’t to suggest that the isolation and dosage wasn’t useful, but the Pharma companies did not invent the effective chemical.
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Well, maybe they did with lifestyle drugs like Viagra. (I’ll avoid the joke about the 4 hour erection.)
i used the term “drug discovery”. it was for a reason. lots of important advances were came from serrendipitous observations. if the observer isn’t bright enough to understand how what they’re seeing can be of use, itll be a wasted opportunity. so, well-trained people do matter a great deal. penicillin is a great example of that. several scientists before flemming had noticed some sort of anti-microbial action of this mold, but didn’t put 2 and 2 together in terms of a systemic therapeutic. (and btw, it does not fall in the category of “big pharma noticed that people ate it and so just isolated the active compound”. sure, that’s true for many things, like my aspirin example. but that is not at all how it happened with penicillin.
…one might also use the term “active ingredient identification” instead of “drug discovery.”
i think you do a useful job of describing last century of drug discovery.
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but this century will be less about observation of natural substances and more lab-created stuff, made possible in part by decoding of genome.
…most of the pharmaceuticals that we are referring to are from the last century.
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BTW, as far as I can tell (and I do not purport to be a biologist) regarding the genome is interesting, but a bit over-rated. Don’t forget, nuclear DNA (the genome) is not the only DNA in the cell.
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I’ll gladly acknowlege that computer simulations will likely be quite useful in helping to synthesize pharmaceuticals. But that will be a task for this century, not the last.
Can we agree on “Long Term” instead? If the genome were a book, right now we’ve got the letter-by-letter text, and now we’ve got to figure out the punctuation, capitalization, paragraph breaks and footnotes.
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A huge part of that discovery is happening right here in MA.
…mitochondrial DNA, which comes solely from the bio-mother’s egg, is at least as important as nuclear DNA.
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The only research I do on the subject of DNA is through SciAm, but it appears that it will be some time before we have figured out how DNA really encodes so much in so little.
So your assertion is that the 37 genes in the very highly conserved mtDNA (essentially the same ~16kb hundreds to thousands of times per cell) is “at least as important” as the ~30,000 genes in the 3 billion bases of the genomic DNA?
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Not to discount the importance of the noble mitochodrion, but I’ll have to disagree.