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Sunday, July 29, 2012

Not all bad outcomes need to be addressed with fundamental changes

Our lives are punctuated by dramatic episodes of, both dramatically positive and dramatically negative. The recent episode in Aurora, Colorado fit this description. The details are incomplete but the story follows a familiar thread. A young man, suffers a life set back and responds by killing or injuring many others in a public place. The fall out is predictable in that there is an immediate desire to assign blame and find a quick fix so as to make it impossible for this to happen again. In the lexicon og patient safety world, the should be a "never" event.

The problem is that in order to assign blame in any sort of functional way, one needs to understand actual causality and in order to understand causality, one needs to live in a world where one can predict events with some degree of accuracy. The world is not such a place. Granted, one can define a profile for who might commit such an act but there are tens of thousands if not hundreds of thousands (if not millions) of people who could be made to fit the profile. You can take about restricting access to the materials which are possibly dangerous and could be leveraged by such individuals. Again, such efforts can be undone by bright and perversely motivated human beings, of which there appears to be no shortage.

This reality then begs the question, "What to do when our lives are punctuated by spectacular events, either good or bad?" We don't think much of it when someone's life is randomly affected by some event is a positive way. Someone who has been living on life's edge who wins a $100 million lotto is lifted out of poverty. This is a random event but hardly should serve as an example to guide us on how to create incentive structures to help guide others out of such life circumstances? It would be wholly unwise to use this an a guiding principle to re-engineer law and society to improve overall welfare.

Similarly, when we observe spectacular bad outcomes, it may not be wise to respond based upon the assumption that the outcome is a result a something being fundamentally broken. The tragedy of such responses is that they often occur because our outrage as an immediate aftermath of the events creates the incentive to do something quickly, before we can possibly understand what happened. These responses are also predicated on the assumption that we must do something because we can't possibly make things worse or create new problems, an assumption which is often tragically wrong.

We witness natural disasters such as fires or floods. Prominent politicians showboat by doing dramatic fly-overs and legislators do what they do, passing new laws. The net effect is they create the illusion that the state can domesticate nature and insulate people from such events. Often the laws they pass and the regulations that follow actually make the situation worse. They create federal flood insurance that prompts people to build in flood plains. They create financial backstop rules that prompt people to take greater financial risks.

Risk is an inevitable element of human existence. Risk comes as a consequence of our inherent inability to predict the future. This is both a good and bad thing. The positive element of our inability to make predictions is that the future holds a promise of being better than the past. It also hold a promise of being worse. The range of possibilities from spectacularly good to spectacularly bad is driven by the actions of individuals, acting alone or in groups, following well tread paths or trying paths that are new, different, and possibly risky.

We have made such strides in the past two centuries regarding the improvement of human existence (although their deployments have been spotty) that we have developed a skewed view of the where we have come from and what expectations are possible. In the developed world, life expectancies have soared and yet, we act as though our world and life styles are vastly inferior to our ancestors who on average lived decades less than we do today.  The almost universal response to any new "crisis", which occur on an almost daily basis, is that we need more rules, more laws, and a greater role for the state in forcing people and non-state entities to do things is an increasingly constrained way. This path is driven by the assumption that the world is perfectible, if only enough rules made by smart people could be put into place. There will never be a shortage of bad events which happen which can serve as a constant  driver of this trend. It can and should be resisted. 

This thinking also makes its way into the practice of medicine. What we do and how we react is driven by spectacular anecdote more often than we are likely to admit. We talk about defensive medicine being driven the medico-legal environment but my perception is that the medico part came first and the legal response came later. We are taught from a very early stage in our careers that often vague clinical circumstances are to be viewed with great concern. These vague circumstances (e.g. -fever and rash, headache to name just a few) share certain characteristics. They are likely very common but their actual prevalence is unknown. The clinical characteristics of those with dangerous disease overlap almost entirely with those with banal disease. There is no way to consistently separate out the two groups with any reasonable precision.

In the same way that bad outcomes in the non-health care realm drive the adoption of new practices and rules, a similar set of events tend to play out in medicine. A single patient who develops a bad outcome after presenting with a non-specific complaint may result in wholesale changes in how patients are managed. This may result in huge changes in how scarce resources are allocated, which tests are done, and which treatments are deployed. Similar to the responses described above to natural and financial calamities, all of this is predicated on the assumption that more is always better and interventions, which may turn out to be useless, can be deployed at zero cost and without unintended consequences.

As people spend more and more money in the health care realm, we within the health care industry have a vested interest in promoting our crafts as being very powerful and impactful. It is very difficult to respond to the public when bad things happen with the message that events are beyond our control, even if that were the case and we were wiling to admit it. Such admissions may prompt the public to invest their resources in other realms where they perceive a better rate of return. That potentially would be unwise, unless in fact the public's investments in other things actually yielded better returns than an investment in health care. Perish the thought.

We share certain similarities with those within the political sphere in that we can leverage any bad outcomes to our advantage, preying upon the fears of the public and claiming that an investment in our industry is a useful approach to limiting the chances of similar bad outcomes  in the future. There is no question that we will have an almost unlimited set of opportunities to harness for our marketing advantage. However, should we reflect for at least a moment as to we should take advantage of the opportunities that the world will afford us? When we push to respond to spectacular anecdote, is the world better off? Does investment in health care result in the best return for the public or are there better places to put those resources?

Saturday, July 21, 2012

Distinguishing medical urgency from personal urgency

A constant thorn in my side is the constant drumbeat of our organization pushing us to get patients in to see our physicians with less and less delay. Don't get me wrong, I am an enthusiast for creating patient friendly and responsive environments. However, we live in a world of scarce resources and resources expended to get people in faster when they do not need to be seen faster has unintended consequences in terms of resources being available to serve patients who have real medical urgency.

 We confound medical urgency with personal urgency. If an Emergency department is filled with patients who have mild and self limited illnesses and this results in resources not being available for patients who have acute and life threatening injuries, everyone realizes this is an undesirable situation. EDs have triage protocols that allow them to prioritize patients.

However, in the remainder of the ambulatory world, triage tools which formalize how we separate medical urgency from personal urgency are rudimentary if they exist at all. Our triage tool is to respond to who calls first, or who screams the loudest, or who knows somebody. Our goal is for everyone to have immediate access whether they need it or not.

In the market driven world outside of health care, there is a premium which needs to be paid if urgent wants are to be fulfilled. Granted, urgent needs (and you have to define needs) should be given priority and I think giving them priority would be much easier if we were not constantly distracted trying to deal with the urgent personal wants of those who desire for immediate service comes at zero cost. Why not ask for more and immediately since there is no additional cost.

Where markets operate, people pay a premium for faster. Order a book from Amazon and you can chose the regular shipping or you can pay a premium to Fedex the package same day.  We are planning for the cremation of our ancient Labrador retriever (who at 16 years of age is living on borrowed time). If she dies at night at home, the pet crematorium will pick her up at home...for and extra $100, or I can wait and take her in the next day. If I have a toothache on a weekend, I can go to an emergency dental clinic and I will pay a premium for the convenience. Book an airline flight the same day and I will pay a premium. That would be foolish if I did not need to reach my destination urgently.

Can we define medical urgency? I am sure I can come up with definition but is it relevant who believe they have an urgent problem? What difference will it be if there is no mechanism for garnering resources to deal with urgency? If the public defines urgency and is not required to invest any of their resources to deal with their "urgent" problems, why not define all problems as urgent. I am afraid they will get no better than they are getting now. To borrow from the restaurant world, it is as thought they are expecting fast food prices and timeline at a 5-star restaurant. However, what they are likely get is 5-star restaurant prices, fast food restaurant quality, and consistently bad service.

Growing up in a medically laissez faire household

I am at a stage in my life where I am well into reflecting upon where I am and how I have gotten here. For anyone who has read at least representative previous blogs, you will have almost certainly picked up a certain libertarian and laissez faire streak in the way I look at the world, including how I see the role of medical care. I am very much an advocate of aggressively dealing with symptomatic and impactful problems that affect patients and very skeptical of attempting to address problems that might happen to populations of well patients if it means doing things to people who are well at the time of the intervention.

In thinking back upon my exposure to the medical community while growing up, it was very limited. I was basically healthy and I went to the pediatrician perhaps once a year, at most. If I were injured or suffered some non-life-threatening situation (which is essentially all encompassing in my parent's perspective), we deployed something OTC and sent me to bed, assuming that it would be all better after a night's rest. I recall one particular episode when I was perhaps 15 years old when I was playing a pickup game of football (tackle) in the rocky school yard. We had recently moved to a new city and I was all excited about developing friends and "street cred". I fearlessly three myself into the activity until I suffered a profound blow to the head, the unfortunate consequence of friendly fire. My own teammate hit me with his knee to my temple when I was tackling the runner from the other team.

I was struck with such force that it knocked me unconscious briefly. When I came to within a few seconds, the world was blurred and I was wobbly kneed. Ultimately I ended up with two blacked  eyes. Later in medical school I realized I may have suffered a basilar skull fracture, as evidenced by the blackening of the eye on the collateral side from the blow. I got a ride home, still wobbly from the accident and explained the situation to my father who as far as I can recall was rather nonplussed. His solution to everything was the same; 222 tablets, purchased across the border in Canada. The consisted of acetaminophen, caffeine, and a modest dose of codeine. I took two, went to bed, and was up the next morning ready to go to school where I had immediate credibility based upon the dual badges of honor I wore. I could take a punch.

The assumption in my family was that episodes like this were not the province of the medical community. No specialists or specialized tests were required. No q 2 hour neuro checks were required that night. Everyone got a good night's sleep, me included. Was my family management of my sandlot football injury reckless?  Would my parents be reported to child protective services now if they did not take my current day equivalent to seek professional medical care?  I am sure there are well documented anecdotes where children in similar circumstances has less than desirable outcomes which might have been forestalled by timely interventions. The question in my mind is whether these examples warrant moving more and more of the management of these into the professional medical arena.

I wish I had actual data (I always do) but I suspect that we more heavily use professional medical services at a higher rate across all age groups and perhaps across economic tranches than we did 30 years ago and certainly more than we did when I was growing up more than 50 years ago (I give away my age...sort of). Are we better off from this?

Failure of our intuition

I colleague of mine sent me a link to a Medical Grand Rounds at Emory University dating back to 1971. I recorded a presentation made by a Dr. Lawrence Weed, who is credited with the conception of the problem oriented medical record. The presentation is well worth listening to. For those who do not want to listen to the hour long video (highly entertaining as it might be), he has written a follow up in the British Journal of Medicine almost 30 years later which eloquently states his case -

What I was struck with is how relevant his presentation is today. It is almost as though the concepts presented had been completely forgotten in the interval of time since 1971. I was trained ostensibly on the problem oriented medical record but it was never presented in the cogent way that Dr. Weed presents it in this 1971 video. It never quite sunk in, at least in medical school. I basically forgot any lessons that I may have been exposed to and it is only much later in life that I have begun to think about the purpose of the medical record. Thus, I have taken my own medical journey and oddly enough, I have ended up in place very similar to where Dr. Weed was encouraging his medical colleagues to travel back in 1971.  

Dr. Weed recognized early on that what was then the current practice of medicine was fundamentally flawed, not because its practitioners were any more flawed than people involved in other endeavors,  but because they were equally flawed. Progress in human systems is facilitated when success is not strictly dependent upon the activities of extraordinary people, but instead is made when systems are created which make things happen independent of the input of of such people. They work when ordinary flawed people are involved. 

What Dr. Weed posits (and I believe he is spot on),  is that contemporary medicine combines the use of global snap judgments by physicians with few mechanisms in place which feed back to inform them when they are wrong. He sees the fundamental problem as being an information problem. Information is not systematically collected, organized, or evaluated as part of decision making and assessment of success or failure. When medicine was dealing with hard outcomes which occurred rapidly after interventions, this was not an issue. Success was measured by patient living or dying in short order. 

Much of medicine is not blessed with such unambiguous outcomes now. Even short term measures of life and death may not be particularly relevant to the overall measurement of success or failure. Fulfilling human goals as a provider of health care is much more nuanced now and our tools to assess success or failure are not up to the task. To make matters worse, we are oblivious to how inadequate they are and the basic concepts of measurement and feedback are not at all embedded in how we think and what we value. Intuition is great as long as you have the tools in place to determine if your intuitions are deceiving you. 

Why has so little progress been made? I believe much of the blame can be assigned to the payment structure which over the past 60 years has become focused on doing discrete things to patients with timelines of success measured by getting paid and getting patients out of the hospital. It has had a bias toward action, whether effective or not, whether harmful or not. It is important to do something, preferably something for which you will get paid. Why bother with rigorous information collection and evaluation when its most likely effect will be to disrupt your revenue stream. 

There is widespread recognition that this model is broken and needs to be fixed. However, fixing this is no trivial undertaking and suffers from some of the same problems as the practice of medicine itself. How can we know what is working? It depends upon what you can measure and at this point the most measurable of element is money. Even that is not so easy. Is success measured by spending less or by cutting the rate of growth? From a microeconomics perspective,  systems which save money b doing less may find themselves in financial duress in the short term.  In the long term, there will undoubtedly be cuts but how can we determine whether cuts are too draconian when we are not so clear how to measure outcomes and whether our interventions actually add value to patients? 

We are at a cross roads and continuing on the present path is not a long term option unless you are content to bankrupt the nation. The insights needed to identify the best path forward will be created by information which guides us by defining what that we do that provides the most value at the least cost. Our intuition has failed us in this domain and it is time to get new tools.

Sunday, July 8, 2012

Unifying particles and concepts

Our understanding of physics took a substantial step forward with the announcement of the Higgs Boson, the so called "God particle" this past week. This discovery is a testament to human intellectual creativity, extremely large pieces of equipment, and large sums of money. While I do not really understand the specifics of the discovery, what I do understand is that decades of observations have pointed to its existence and the announcement this week implies that we have crossed a threshold in terms of our knowledge of the underlying structure of the universe.

The study of complex systems is not limited to using particle accelerators and particle physics. Physics may be viewed as the most basic of sciences with other fields of study contain less of the "basic" elements, whether that be chemistry, climate science, biochemistry, clinical investigations, or the social sciences such as psychology and economics.  All aspire to borrow the most basic tools they can use to further their studies and take on as much of the basic elements as possible.

I read a very interesting piece this morning is a blog, The Unbroken Window (author Michael Rizzo)( which was entitled "The problem with economics". This essay resonated with me, articulating the unifying concepts in almost Higgs Boson fashion. I believe sections warrant reprinting:

The Complacency of Modern Economics
Our students have spent the entire year reading the works of Hayek. A major theme in his work is a condemnation of the complacency of 19th century liberals (in the good sense of the word) which allowed utilitarian ideas, unanchored from natural law and dismissive of evolved institutions, to dominate – thereby setting the stage for what Neal Stephenson describes in his 1999 novel,Cryptonomicon:
“The twentieth century was one in which limits on state power were removed in order to let the intellectuals run with the ball, and they screwed everything up and turned the century into an abattoir. . . . We Americans are the only ones who didn’t get creamed at some point during all of this. We are free and prosperous because we have inherited political and value systems fabricated by a particular set of eighteenth-century intellectuals who happened to get it right. But we have lost touch with those intellectuals.”
I blame many economists for a similar complacency in the 20th century. In promoting policy tweaks to perceived problems with markets, they have been assuming that people would understand and respect Adam Smith’s, David Hume’s, Adam Ferguson’s, David Ricardo’s ideas irrespective of whether they were widely read or taught today. Modern economists falsely assume that the failure of hot-blooded socialism permanently taught us to be humble regarding central planning in the presence of complex social processes.
The problem I am describing actually derives from a good faith effort by 20th century economists to identify the difficulties with currently accepted classical economic theories, by identifying “market failures” and sets of conditions for which these might be mitigated by enlightened policymakers. This is admirable and noble, especially if your audience respects the intellectual foundations that economics was built upon. But many intellectuals, and many in the lay public, are hostile to these ideas, and have been unwittingly handed a fulcrum that would make Archimedes blush to justify virtually any intervention into our peaceful, private voluntary associations.
Allow me to illustrate:
In modern economics, the very starting point of our first course, the very premise it begins with, is wrong. Our greatest minds and books start by asking, “What are the causes of poverty?” Note that Adam Smith never committed this error. The natural state of man is poverty. If you do nothing, you remain poor. Nothingness requires no explanation. It makes as much sense to ask what causes poverty as to ask “what caused Rizzo to miss that penalty shot during the New York Rangers hockey game last night?”
Even our most market friendly books then say, “poverty happens when we don’t have markets.” And then lay out unrealistic, undesirable and never existing conditions for what a “perfectly competitive market” would look like for it to work. This permits an easy attack on the assumptions without forcing opponents to attack the chains of logic which are the foundations of economics, not the assumptions of simplifying models.
For thousands of years nearly every human being lived in excruciating poverty, and despite the existence of some people today who said we were freer back then, or happier or better, it was risky, dangerous, lonely and scary. Life expectancy at time of Jesus was less than 25 years old and stayed that way until the 19th century, and for millennia average income was about $800 per year – imagine having $800 today and then imagine not even being able to spend it on anything that exists only today. The most powerful and wealthy people in the world saw half their children die before adulthood, they themselves died from simple infections, could not enjoy a cool drink on a hot day, nor do any of the thousands of things that even the poorest Americans take for granted each and every day today.
In the world of particle physics, we can set up experiments where we know when they start and end and we can add energy to systems and look at the effects. The experiments are controlled and occur in a time frame where we can discern start and end, cause and effect. In the world of the economics, the experiments are not controlled and the time frames extend for many generations. We are not capable of consistently understanding where our ancestors started from or distinguishing stellar near complete success from abject failure. We use carefully selected examples of failure to indict markets which have brought more wealth, comfort, and a better life to humans on this planet than any other human innovation in the history of man. 

Contemporary medicine is perhaps the worst of offenders in this domain. No other set of endeavors perhaps has benefited more from the extraordinary wealth generated by markets than has modern medicine. Modern medicine required so many recent innovations created by our market economy; energy needed for clean and climate controlled environments, technology in the form of medicinal chemistry and machinery, information technology, transportation, supply chain and I could go on and on. I can state with complete certainty that without the deployment of markets, the benefits of modern medicine and public health would not yet have happened. 

However, within the intellectual leadership of medicine, there is a palpable hostility to markets (see "You'll shoot your eye out" blog - There are some notable exceptions but for the most part critical minds within academic medicine are not so critical when thinking about markets. Just look at the stream of editorials and commentaries published in the NEJM over the past five years. Market enthusiasts are the exceptions and look like voices in the wilderness. 

Living within this world, it is easy to see why. We have made huge investments in physical and human capital which are dependent upon some continuity of the present, non-market based system. Present decision makers have much to lose if the disruptive market based approaches gain traction and undermine the present business model. This would most certainly entail huge changes in regulatory and licensing arrangements and disruption of the present guild-like structures that create scarcity.  Combine this with a pre-existing hostility to market based approaches and it is not surprising to find so few market enthusiasts. It would not the first time that limited self interest and a short attention span and time line results in a non-Pareto optimum. 

However, I believe that any effective approach must incorporate market based tools which can undermine the strategies of the past 50 years, which have valued spending more over everything else. Only markets which include cadres of educated consumers using their own resources have the power to drive down costs and increase value simultaneously. Top down approaches, particularly state driven ones, have shown themselves to be terrible allocation schemes.  Those experiments have been done and the results are unambiguous, although remarkably they appear to have been quickly forgotten. In the last century, we did double blind controlled studies where we took defined populations, divided them, placed them under different economic systems for 50+ years, and then looked at the results; North and South Korea, East and West Germany, Eastern and Western Europe. These studies were unintentional but we could not have created such a better comparison if we set out to do so. These were extremely expensive experiments (in terms of both money and  human lives), even more expensive than creation of the particle collider on the Swiss and French border. While I do not anticipate the world forgetting the recent Higgs Boson results, we are rapidly amnesic regarding the what happened last century with what I view as just as an important (although inadvertent) experiment. 

There is no reason to believe that medicine and health care are any different than all other endeavors which require allocation of scarce resources and coordination of human efforts to fulfill human needs.  The continued predominance of market denial within health care leadership will lead us to statist (North Korean) results where South Korean outcomes are very possible. I may sound like a broken record in that I keep repeating this message. Markets work better at allocation of scarce resources than any of the alternatives we have yet devised and health care is not different from the rest of human activities. More market based approaches in health care will likely result in better outcomes. The default should be market based aproaches first.    

Thursday, July 5, 2012

Union busting - National style

While Scott Walker's antics in Wisconsin have attracted the lion's share of attention when it comes to union-busting, let us consider the prospects for a much more fundamental form of union busting. I want to pose the question as to whether events likely to unfold in the not too distant future may result in dissolution of a different union... The United States.

I see events unfolding which could trigger a serious threat of states threatening to leave the US. These events all relate to budget shortfalls, primarily on the state levels. It is hard to believe but 41 states have constitutional or statutory requirements for legislatures to approve balanced budgets. This includes both Illinois and California. This appears to provide little or no protection against running up debt and making promises which they cannot keep. Due to bookkeeping practices that would result in jail time for any individual doing the same practices in any private entity, unfunded liabilities are held off the books.

Due to unrealistic promises and profligate spending, there are certain politically influential states which face almost certain economic demise, following the Detroit model of economic undevelopment.  To add fire the mix, the Affordable Care Act now will offer "free money" as an inducement to expand state Medicaid programs. While you might imagine that no one could be so stupid as to believe that there is anything approximating free money. As it turns out there are plenty of people stupid enough to buy into this concept since it seems to provide good financial returns in the short term. Remember, as Keynes so astutely observed in the long term, we are all dead.

The financial logic of the Medicaid expansion program is untenable to anyone who spends slightly more than a nanosecond of thought. States will be initially spared the cost expansion which falls upon the Federal government, an entity which is presently either borrowing or printing fiat currency to cover one third of its budget. Sounds like a durable promise by a financially solvent entity to pick up the tab and one could NEVER imagine that the cost of this expansion will ultimately fall upon the states.

While some states may posture and pretend not to take the funds, all will step up because the money will come from their citizens. To not take the money is to play the role of the ultimate chump; the Feds take your money and ship to some other state because your take a principled stance against fiscal irresponsibility. . The Medicaid bribe is only the first of many games with the Federal treasury which will ultimately be used to bail out the most Greece-like of states. The states which run the most fiscally responsible path will be like the Germans, asked to indirectly fund the bankrupt states. Unlike the Germans they will have bargaining power unless they entertain leaving the union.

How could this play out? What if the Federal government declares that the pension obligations of selected union workers of non-right to work states are now the obligations of the Federal government? Not so unlikely since it already happened with the GM bankruptcy. Once states which have ignored their fiscal responsibilities and have accumulated huge debts find their way to print money using the Federal government, we are well into the Argentina model of fiscal decline.

I have to wonder whether before all states go all in on this bad bet, there will be one or a handful which entertain simply leaving the Union. Perhaps Alaska; it is isolated, rich, and filled with independent cusses. What if they simply told the Feds to take a hike. What if they played a bit more passive aggressive and simply refused to enforce certain Federal statutes relating to drilling for oil? Can the Federal government really mess with Texas? What if Texas and /or Arizona created its own military to deal with border issues that the Federal government can or is not willing to deal with. None of this is likely as long as the Feds creates sufficient financial incentives to persuade states that this is a bad idea.

The money will run out and then what.  I don't know but given the regional differences, I suspect that certain regions which have resources will want to go it alone. Nothing lasts forever.

Wednesday, July 4, 2012

No Clear Path

I have waited to weigh in the the implications of the Supreme Court ruling on the Affordable Care act. Talk about surprise endings!  I have read lots of commentaries and reflected upon what this decision might mean. I have come to the conclusion that I simply do not know and neither does anyone else, despite what they claim to know. 

Justice Roberts accomplished extricating the Supreme Court from the immediate political fights associated with the Affordable Care Act. In an odd stroke of judicial activism (rewriting the legislation) he has succeeded in dodging a situation whereby virtually any other Court actions could be interpreted as being activist. The ACA is now unambiguously back in the political sphere and those running for President and legislative offices will need to address this in their upcoming campaigns. It is off the SCOTUS docket. Justice  Roberts effectively kept his powder dry, and may be a force in the future.

I must say that I am saddened by the continued transition of the Constitution from a document which was viewed as the law of the land to a document which is merely a suggestion. How we have transitioned from a document which defines clear limits on the power of the Federal Government to one which Congress, the courts, and the legal profession can pick and choose as to what can be ignored has a timeline extending far enough in the past to allow for selective amnesia. We are like the frog in the pot with the water slowly heating up and we are destined to be oblivious to the fact that we will inevitably be boiled.

The Constitution is like our DNA and stable as DNA might be, all organisms suffer from gradual accumulations of mutations which will ultimately affect the ability of the DNA to code for the genes required for effective functioning. Private property protections have eroded to the point to where they are unrecognizable, being replaced by protection of privacy. Unfortunately, protection of privacy will never be effective unless it is backed by real property protections.  The rule of law is becoming the rule of men and the rule of expediency, driven by an inexorable expansion of state power, particularly Federal power.

How this will all play out and how the health care economy will evolve is impossible to discern. The potential brake on the expansion of Federal power will be financial. After 2030 the Federal government has basically promised its entirety of all future tax collections for entitlements. Granted I am a skeptic when it comes to making projections that far into the future but there is a reason to believe that my projections are in fact much too optimistic. Projections of entitlement program growth have always UNDERESTIMATED the rates of growth.

Whether the individual mandate of the ACA was held constitutional or not is likely irrelevant in the long term regarding health care finances. What is pretty clear to me is that government at all levels will not have the money to maintain our historic growth rate of spending for health care. What we are seeing in Europe, California, and Illinois is the preview for what we face as well. Our growth economy has put off the day of reckoning but it will not hold it off indefinitely, unless there are profound changes in the cost structure of health care.

Here is where I believe the ACA has simply got it totally wrong, mandate or no mandate. Certain elements of the ACA serve as anchors for its remaining popularity, those being no exclusions for pre-existing conditions and the provision which allows adult children to remain on their parents insurance. Without these elements, the ACA would be toast. No politicians want to come out against these provisions and these provisions will accentuate growth in spending will only accentuate the financial quandary we are facing. The provisions within the law to address growth of costs provide limited confidence that can succeed since they do not really fundamentally change the underlying drivers of health care inflation and consumption of services.

I don't believe we will need to wait until 2030 for the effects of the financial squeeze. After the election this fall, we will face the "fiscal cliff" which may make discussions regarding the individual mandate and its constitutionality look like an odd distraction. Those left in office in January will need to figure out how all the promises they made can be kept. Perhaps they can consult Bernie Madoff from his prison cell.