Detailed Abstractions

Over @ HBR Blogs, Jeff Goldsmith asks the following question: Has the U.S. Health Technology Sector Run Out of Gas?.  Looking historically, he notes the amazing progress since the 1970s, but a decline in that growth since 2000:

…Technological innovation — in pharmaceuticals, biotechnology, medical devices including imaging, and enterprise IT — exploded in the thirty year period 1970 to 2000…

…Then about a decade ago, the US medical technology sector entered a prolonged innovation drought. In pharmaceuticals, new drug introductions declined by almost two thirds, while drugs patented in the latter part of the boom period lost protection, this despite a near tripling in R+D outlays. (New drug introductions rebounded modestly in 2008 and 2009, but still haven’t regained their 2004 levels)….

He goes further to note that this dip in activity wasn’t just about new drugs:

…The drought wasn’t confined to pharmaceuticals and biotechnology. Imaging, a dazzling success story for three decades, has seemingly run out of gas. Imaging equipment sales collapsed precipitously in the US, by roughly 40%…

…Enterprise clinical information technology seems to have hit a similar flat spot. The major commercial IT platforms for hospitals and health systems are more than a decade old.

& all of that makes complete sense based upon what we know about the last couple of decades.

Since the mid-1990s (well really, since the 1960′s), we have increased regulation on the medical industry on a constant basis.  From minor changes in who qualifies, to new regulations such as HIPA, to very large new regulatory pressures such as the Medicare Prescription Drug Benefit, resulting in an explosive growth in government expenditures of health care:

There have also been additional pressures.  Increases in financial and IT regulations through SOX and other legislation have increased companies’ weariness to put themselves at risk and increased costs of doing business.

These pressures in increasing the costs of doing business, combined with the federal government expenditures crowding out private spending, has resulted in higher costs for businesses and therefore consumers as well.  The new heath care and financial overhaul bills will continue this pressure.

The big cost however is what the author notes:  the lack on innovation.  When the government seeks to consistently erect new and more costly barriers to entry, competition will naturally decline.  The correlation to that behavior is that costs will grow more rapidly as we know competition in the long-term generates downward pressure on prices.

As we see now – prices are increasing, availability is decreasing, as the government decreases the availability of future competition in industries the government tightly controls such as health care.  Conversely with those industries with fewer barriers to entry have downward pressure on prices, such as cell phone or internet providers.

While I consider this failure of centralized control as a major factor, Mr. Goldsmith posits three contributing factors, risk aversion from management, size and increasing bureaucracy, and the fact that we are losing out globally for scientific talent:

1. Firms that used to be run by scientists and engineers are now run by attorneys and marketing executives….
2. Their ability to foster innovation has succumbed to a bureaucratic management culture….
3. Bright young foreign science and technology graduates are returning to India or China instead of staying here and creating new products or companies….

While I agree with all of these things, I think reasons 1 & 3 can be combined easily to a more basic point about government interference and centralized control.  Indeed they are symptoms of the problem and not necessarily the disease.

Having said that, I think it’s also important to note that reason number 2 exists due to the same thinking reasons 1 & 3 do – the belief that centralized control is a nominal good (DA post on business trends here).

The author seems remiss in not making the connection, even if he did eloquently, maybe unwittingly, stumble across it when writing about global competition:

…If they have more freedom to innovate in their home countries, that’s where they’ll go….

For as long as we continue to discuss symptoms and not the actual disease, we will continue to miss the point.

It’s been a full five years since Thomas Friedman gave us the book and idea that The World is Flat. While I’ll never be one to completely agree with Mr. Friedman, he proffers from an economic perspective that national boundaries are becoming less and less a barrier.  The consequence in America, as with all other western societies, is a need to prepare to compete with other countries for jobs.

As outsourcing becomes easier and developing countries access to highly skilled resources in developing countries, citizens have been or will soon be forced to compete for jobs not only with their local competition, but with their global competitors as well.

DA noticed for a little while now, that the US seems to moving backwards in terms of competitiveness (here):

…Odd thing is – those without freedoms or with lesser freedoms around the world have been pushing for market reforms, including Germany, France, China, Russia… while the US is pushing centralized control over banking and health care (to name two things)….

Energy apparently skipped my mind that day, but either way… with more evidence at hand, Ron Hart wrote a great piece The dangers of ‘Crony Capitolism’. He begins with a a prescient Winston Churchill quote:

Some people regard private enterprise as a predatory tiger to be shot. Others look on it as a cow they can milk.  Not enough people see it as a healthy horse, pulling a sturdy wagon.

His basic premise is that through increased economic regulations in America and a movement away from the free market, we are in real danger of losing our economic edge:

…But the real damage done by his taking control of our major banks and car companies (and now one-sixth of our economy with his health care grab), is that private capitalism, one of the great drivers of our country’s abundance for all of us, has been damaged….

& due to these anti-market policies combined with ever increasing regulation, we are not only in danger in the future, but the signs are already here:

…The result, per Forbes magazine, is that we are losing ground to foreign competitors.

Korean automaker Hyundai registered record sales in August. Chinese telecom manufacturer Huawei might soon pass Cisco in sales. Brazil’s jet maker Embraer is, according to Cessna CEO Jack Pelton “scaring us to death.” And more IPOs are happening away from America’s overly regulated capital markets. In addition, India has heart bypass surgery outcomes equal to the U.S. at half the cost, and Singapore is willing to pay U.S. biotech research stars about $715,000 in annual salaries….

Concluding with:

…In short, we do not have a monopoly on capitalism. We risk losing out to a world market that moves faster and with more resolve today than ever before. Our new political class does not seem to care that innovation and capitalism are fleeing….

Well said.

Late last week, Michael F. Cannon @ Cato released a study entitled, Yes, Mr. President A Free Market Can Fix Health Care in response to a challenge made by President Obama in March 2009:

“If there is a way of getting this done where we’re driving down costs and people are getting health insurance at an affordable rate, and have choice of doctor, have flexibility in terms of their plans, and we could do that entirely through the market, I’d be happy to do it that way.”

This is very much a presumption based question, like “When did you stop beating your wife?”  It holds within an assumption the only plausible answer is one which uses the power of the government to control the market, and by extension individual citizens, with complete skepticism about any power of the free market.

While this seems to be the default assumption of many of my fellow citizens these days, I don’t know that I’ll ever understand how an objective look at market success versus an objective look at governmental success would lead one to believe the government is capable of much more than simple, repetitive tasks.

Having said that and even knowing the Democratic leadership and the White House is likely to ignore the answer, Mr. Cannon presents a pretty convincing case about a market solution (@Cato).  He explains:

how Congress can remove the impediments that currently prevent markets from doing so:

Whole thing here.

If you’re anything like me, you too are getting nauseous about the “public option” in the health care debate.  One day it exists, the next day it will never exist.  The day after, it’s required…

Well, apparently legislators might have a compromise to pass a bill including an “opt-out public option” (@theHill.com):

Democratic senators continued to remain bullish on the chances of creating a government-run public option as part of health reform….

…Schumer echoed the calls of several senators who this week said that Democratic negotiators has garned the 60 votes necessary to invoke closure on the measure. Sen. Arlen Specter (D-Pa.) last week put it in even stronger terms, saying that Reid had 60 votes for a “robust” public option.

…According to Schumer, Reid “is leaning strongly” toward including a provision that would allow states to opt out of public health insurance if they want to keep private insurers.

Schumer added that the liberal senators are “able to live with” an opt-out public option under which states could decline to participate in a public program….

So there we are;  in a compromise between moderate and liberal Democrats only, a public option seems likely.  Not only has the White House and Democratic leadership dropped any pretense of working across the isle, but people at large seem unwilling to question the claims of their leaders.

One suc spurious claim, is that this option will result in increasing competition:

…”We need some competition for the insurance companies,” Schumer said on NBC’s “Meet the Press.” A government-run insurance plan would “have to play by the same rules as the insurance companies and it would negotiate rates with the providers,” Schumer said. Having a public option would bring competition to states that only have one or two insurance providers, Schumer said….

Proponents everywhere continue to take this stance, even though a public option is logically inconsistent with their stated goal of increase competition.

If Mr. Schumer and others truly wanted to add some competition for insurance companies, adding a new company would not be necessary.  In deed, removing the laws the disallow selling of insurance over state lines doesn’t cost the tax payers one single dime, yet increases competition dramatically, both in the total number of competitors and the speed at which they can begin competing.    Additionally, given the benefits a public option will have over its private competitors, this isn’t really competition.

As Michael Tanner wrote over @ Cato, this support for a public option isn’t likely what it seems (@Cato):

Cognitive dissonance is defined as holding two completely contradictory ideas at the same time.

That seems to be the case with the American public, with a new poll showing rising support for a so-called public option in health care, even as the public continues to oppose greater government control over the health care system….

All in all though, the Democrats hands seem to be very strong hand right now with recent polls showing 57% of the country expressing approval of a public option.   With uninformed voters, an uninformed and uninformative press, and politicians more worried about winning than engaging in honest debates, this compromise might soon become law.

That’s freedom for you – as unfortunate as it seems, whether most people truly understand what the public option entails is irrelevant.  So long as they are willing to approve things they know little about and skip any hard work necessary to critically analyze the problem and various solutions, this new government boondoggle will just continue going forward.

Since the Cap & Trade bill is getting hammered from quite a few angles throughout the halls of Congress, recent news has started pushing the much fated plan for Health Care.

They do this, by first admitting the need to increase the insured, the move to hyping the number of uninsured individuals, and finally discuss plans on how to insure them.

For serious thought – Cato and others have noted that the system itself is creating our current problems and by expanding the current system, we will only expand those problems(here):

A free-market approach would move away from employer-provided insurance and increase competition among both insurers and health providers.

Going further of course, they try to give some reasons the system operates as it does:

There are two key components to any free-market healthcare reform. First, we need to move away from a system dominated by employer-provided health insurance and instead make health insurance personal and portable, controlled by the individual rather than government or an employer.

Employment-based insurance hides much of the true cost of healthcare to consumers, thereby encouraging overconsumption. It also limits consumer choice, because employers get the final say in what type of insurance a worker will receive. It means that people who don’t receive insurance through work are put at a significant and costly disadvantage. And, of course, it means that if you lose your job, you are likely to end up uninsured.

Changing from employer-provided to individually purchased insurance requires changing the tax treatment of health insurance. The current system excludes the value of employer-provided insurance from a worker’s taxable income. However, a worker purchasing health insurance on his own must do so with after-tax dollars. This provides a significant financial reward for those who have employer-provided insurance. That should be reversed….

Not to be locked out, John Stossel just wrote a piece over at Reason giving the reader very colorful examples of how the current insurance system has actually done more harm to having efficient and cost effective medical care than any other piece of legislation on health care (here)

…Insurance, whether private or a government Ponzi scheme like Medicare, means third parties pay the bills. When someone else pays, costs always go up.

Imagine if you had grocery insurance. You wouldn’t care how much food cost. Why shop around? If someone else were paying 80 percent, you’d buy the most expensive cuts of meat. Prices would skyrocket.

That’s what health insurance does to medical care. Patients rarely even ask what anything costs. Doctors often don’t know. Often nobody even gives a damn. Patients rarely ask, “Is that MRI really necessary? Is there a cheaper place?” We consume without thinking.

By contrast, in areas of medicine where most patients pay their own way, service gets better, while prices fall.

Take plastic surgery and Lasik eye surgery: Because patients shop around and compare prices, doctors work hard to win their business. They often give customers their cell-phone numbers. Service keeps increasing, but prices don’t. “In every other field of medicine, the price is going up faster than consumer prices in general,” says John Goodman of the National Center for Policy Analysis. “But the price of Lasik surgery, on average, has gone down by 30 percent.”

And honestly, I encourage everyone to read what they can, because this is the very beginning.  Through an extensive societal system, we limit the number of doctors graduating each year.  We, by law, force doctors to do certain procedures lesser trained individuals might be able to do for my less money.  If you recall, 10 years ago, a fully registered nurse (RN) had to draw blood.  Now, it’s a 6 week course and they’re called phlebotomy techs.

So yes, Mr. Obama: I and millions think our health care is pretty good, but could use some changes.  We just don’t think the government has proven to be more inefficient in any endeavor when compared to a private company has in that same endeavor (excluding government allowed monopolies).

The only real question – is why are we looking for several trillion dollars, which will be pushed into all these different feel good remedies, most of which will show no measurable improvement?

And therein lies the selectorate theory, which basically reads that heads of states and other major players got to their positions of power through a winning coalition of others and those are the people they will be the first to covet.

As for those people that didn’t vote for Mr. Obama, and are therefore not in the winning coalition, well, they’ll get hurt.  It’s just too bad that my daughter someday will feel the pain from not being apart of that winning coalition, even though she was completely unable to vote.