The Human Condition:

Thoughts on Public Health Care (II) – November 25, 2012

Last week I discussed my personal thoughts about the question of publicly providing for health care. That discourse examined three issues: (1) the parallel situation with public education in America, (2) the lack of choice available in all publicly provided systems, and (3) the unsuitability of insurance as a business model in an environment of rapidly improving medical knowledge and practice. Insurance is an inappropriate way to pay for routine health maintenance and a really bad way to take care inevitable processes, like dying.

4. Health Care Will Become More Effective—and More Complex

Of course, “inevitable” is just a state of mind. If you think medicine has advanced since the 19th century, you ain’t seen nothing yet!

The sequencing of the human genome in 2000 was originally intended to find “genes,” the A-C-G-T combinations that code for proteins, the building blocks of cells. This effort assumed that all three billion base-pairs in the genome were just the parts list. What we learned in the process was that protein-coding occupies only about 10% of the genome. The far larger and more complex story is that the other 90%—rather than being the leftover “junk” of evolution, as we first thought—is actually the internal mechanism for timing the expression of those proteins, controlling the differentiation of cells in the body, directing its development from a fertilized egg to an adult human being, and coordinating the daily operation and maintenance in all the different cell types. The larger part of the genome is an assembly and instruction manual riding along with the parts list.

Life scientists at universities all over the world are now working eagerly and productively on two fronts. First, they are linking proteins and their coding to various cellular functions and diseases. Second, they are figuring out the assembly manual so that we can understand how humans develop and grow. When we know the latter, we will be able to program the body’s repair kit—the various stem cells associated with each tissue type—to grow new tissues and replacement organs.1 And then we will quickly advance from simply growing replacement parts, to fixing any genetic defects that may have damaged the original organ, to adding genetic enhancements so that the new organ functions better than before.2

People who worry about medical privacy and the possibility that insurance companies will deny a person coverage because of his or her inherent genetic propensities are simply not seeing the bigger picture. Genetic defects will be eradicated or compensated as a matter of routine practice, probably in the womb if not before conception. Accidents and diseases that now cause disfigurement and disability will no longer be life-changing events but mere temporary inconveniences. Aging will become optional, and its debilitating effects will be corrected as they occur. Medicine might not be able to repair a case of sudden accidental death—or not right away—or eliminate death’s ultimate arrival, but we’ll all go into old age as healthier, happier, and stronger individuals.

What do I mean by “all”? Surely, this new medicine will just be a perk for the super-rich, won’t it? In the meantime, the rest of us proles will struggle along with perfunctory care and shoddy medicine, won’t we?

Well, no. Once we have perfected the techniques for chemically manipulating stem cells and growing them on armatures that are mass-produced from proteins or other inert materials—and true, these techniques will first be tried out on the rich—the rest is just a matter of grunt work. Medical technicians will sample your tissues, isolate the stem cells, apply the appropriate reagents, take a prefabricated armature off the shelf, and put the whole works into an incubator. The most complex part of the medicine, requiring real hands-on expertise, judgment, and timing, will be the surgery that cuts out your old heart, kidney, spleen, or whatever and installs the new one. Getting a new heart will be about as complicated as getting a new titanium hip or knee replacement today.

In this environment, medicine becomes less expensive. It’s only “personalized” because it starts with a person’s own copy of the genome as coded in his or her stem cells. But as we know more about the body and its processes, about how each person’s genome guides his or her susceptibilities and propensities according to universally recognized patterns, medicine becomes less an art of diagnosis and discovery and more a science of observation and application.3 The mystery and the chance—and the heartbreak—go away, because we understand human bodies the way a mechanic these days understands your car. The processes become routine, simple, and inexpensive.4

What will we do with all these superannuated citizens? Since they’re stronger and healthier—we’ll put them to work. The problem in developed societies today is not over-population but under-reproduction. Smart, educated, busy people have less time for children and, with the Pill and other means of contraception, children become a decision for the future rather than an unexpected consequence of conjugal relations. In this environment, life becomes more precious, not less. We will cherish each new child and work to make its health and education complete. We will value the knowledge and experience of older people at the peak of their productivity and try to prolong their best years. Quality, not quantity, will become the human mantra.

In this environment, medical care advances far beyond being a response to an insurable catastrophe. Health maintenance, physical repair, and improvement of the body become a necessity of living, like education to improve and prepare the mind.

5. The Affordable Care Act Pushes Insurance Over the Cliff

If insurance is the wrong business model to pay for the new medicine, the Affordable Care Act is the perfect antidote. When it was first proposed, the insurance companies supported the legislation because it mandated that all citizens buy health insurance, whether they expected to need it or not. That way, healthy young people would pay premiums that covered the costs of caring for sick and old people. The insurance companies saw a bonanza of new premiums and came aboard.

But the act also does two things that insurance companies don’t like and wouldn’t support under the normal business model. The first poison pill is treatment of pre-existing conditions. Even if you’re sick or have a bad prognosis through a history of obesity, smoking, or lousy genetics, the insurance company has to take you on and then pay out for your treatments—which are now a matter of certainty rather than actuarial chance. The second pill is community rating. No matter how sick you become or how high the costs of your care, the insurance company can only charge you the same premium as everyone else. These are gifts to the patient at the expense of the insurance business model.

Add to these pills the fact that the legislation lets the government define the menu of benefits that an insurance policy must offer. As we’ve seen in implementation, these mandates now include routine maintenance practices like contraception and chemical abortion. Pretty soon, at the whim of government regulation, the business model becomes broken no matter how many healthy young people are paying premiums for catastrophic services they don’t expect to need for years.

No one can force the insurance companies to stay in business if they are losing money. So, for the uninsured, unemployed, or self-employed people whose insurance company happens to leave the industry, the legislation offers a state insurance pool, similar to Medicare and Medicaid, with funding shared between the federal government and the states. The bet, in the view of those who desire an end-result of single-payer medicine, is that insurance companies will eventually give up or go broke, and then the federal government and the states will have to step up and fund the entire system of providing medical care.5

It would probably not be legal, or even workable, for the government simply to close down the insurance companies one night and start funding health care through taxes the next morning. But the Patient Protection and Affordable Care Act sets up circumstances that accomplish this slowly, over time, with a maximum of apparent personal and corporate choice and a minimum of fuss. You’d call that pretty sneaky, if it wasn’t all out there in plain sight.

There are probably other potential systems for funding health care that would work better at a state, county, or community level—which is the way we handle education in this country. However, with the results of the national election, those won’t be proposed or tried now. And that probably makes no difference in the long run.

One way or another, health care as a societal obligation is no longer a matter of personal luck and a strong constitution. Advances in the life sciences are already taking medicine out of the realm of insurance and into the sphere of everyday expectations and necessities. Staying healthy and growing old while maintaining your strength and abilities will be like obtaining an education and ongoing training through state-funded schools, colleges, and training programs. Claiming the bonanza of scientifically boosted medicine will be like tapping into any of the other national infrastructures that are dominated by science and technology: the energy grid, transportation systems, food supply chains, the internet, and communications systems.

All of these complex networks are designed to provide good service and a rich lifestyle at low cost. They’re what’s keeping this continent-wide whirligig we call the United States functioning smoothly. Health care as a right of citizenship will be no different.

1. The concept of organ “transplants”—which involve taking a fully grown organ from one person and donating it to another, with the requirement of suppressing the recipient’s natural immune system so that he or she will not reject the foreign tissue—becomes a rapidly passing phase of our current medicine, rather like leech craft. Instead, it will become so much easier to grow a new organ from a person’s own cells, which already have all the right chemical signatures. These “implants” will become a huge part of medical practice. And the whole business of matching donors with recipients, fraught with issues of desperate need, fairness, and compensation, will wither away.

2. And I won’t even speculate on the issue of “designer” genes, so that new organs and tissues confer particular preferences beyond the normal human range—like the desirability of orange- or silver-colored eyes, or the ability to see in the dark by detecting ultraviolet or infrared radiation.

3. Consider that, today, prescribing a medication to treat a condition is a matter of the doctor’s experience and judgment—and luck. The active ingredient in any medicine is selected and developed according to a drug researcher’s particular theory of the disease. The medication is then tested in clinical trials against a limited number of people—usually about 3,000 at the third-stage trial. The medication remains under prescription, with strict requirements for reporting adverse effects, until about a million patients have used it. But not every medicine works for every patient. Genetic differences control how an individual responds to the disease, or to the medicine’s operative chemistry, or to its recommended dosing. In the future, we’ll know how those genetic differences interact with the disease process and the therapeutic process. Prescriptions will then be targeted not only to the disease but also to the patient’s genetic inheritance. The practice of medicine will become much more effective.

4. Of course, it will help if the patient is already mindful and careful about lifestyle and health. Yes, we’ll be able to replace lungs damaged by years of smoking, but complete replacement of smoke-damaged arteries will be a little trickier. And it’s easier to replace a liver if you don’t have to cut through cubic centimeters of belly fat to find it.

5. Under the Affordable Care Act, health insurance does remain the primary responsibility of employers. But the legislation offers them the alternative of paying a fine for every employee they fail to cover—usually at a much lower rate than the cost of insuring the employee in the first place. This fine becomes a tax to defray the expenses in the state insurance pools to which the newly uninsured citizens will have to apply.