« There But For The Grace Of God ... | Main | Get Inside their Heads, Love their Loves »

June 18, 2009

Comments

GOP is not interested in health care reform. They are interested in protecting profits.

I agree that this proposal is a bad one.

Now there's a perfectly sensible starting point Mr. V.

The false conclusion, Eric, is that if the Republican proposal is bad, the Democratic proposal must be good.

But that's not my conclusion. The Dem proposal is good on the merits. Engaging a GOP that is this compromised is pointless.

Engaging a GOP that is this compromised is pointless.

pointless but necessary, apparently. after all, if the bill isn't acceptable to the GOP hive mind, they could threaten to fillibuster (!) and that would make the baby Reidus cry.

oops

Fnck the fillibuster. Go through the reconciliation process. All we need there is 51 votes.

Who determines comparative effectiveness and how is that concept folded into an individual patient's total clinical picture?

I've seen as much over-treating as I have under-treating, but the worst overall is insurance company 'gate keepers' who determine from several states away that a patient doesn't need a particular course of treatment--at least with a private insurer there is a theoretical right to sue on the contract. What is the remedy when the feds dictate what you can and cannot have?

Comparative effectiveness seems like a predetermination of which treatment modalities will be allowed and which will not with one of the major driving forces in making the determination being cost containment. This may hold down costs, but at the expense of patient care. Of more concern is that the concept assumes a government with an established record of not getting entitlements right from the get go will somehow acquire the competence to quintuple (or more) its involvement in entitlement spending.

The Dem proposal is good on the merits.

Umm.... WHICH Dim proposal is "good on the merits?" The one which, according to HSS Sec. Sebelius, would NEVER EVER EVER EVER EVER EVER permit even a discussion of a 'universal care' option? Would preserve the prohibition against the Feds negotiating price with Big PhRMA?

Hard to see the merits in that, imho.

What's gonna finally eventuate izzat there is going to be a big, glitzy, frothy PLAN upon which everyone can agfree will LOOK very good (but will be mainly cosmetic) and will allow EVERYBODY in Official DC-dum to posture and preen and pretend that they ded something very difficult and it's a HUGE VICTORAY...

and nothing will change...as usual...

mckinneytexas. You are of course explaining exactly what health insurance companies are doing right now, denying coverage for new or experimental treatment techniques. They are doing their own "comparative effectiveness" studies and basing coverage on that.

Of course a patient can sue to get coverage for one of these techniques, but by the time the suit is concluded, either the patient has gone bankrupt by going ahead and paying for that treatment out of pocket, or the reason for the treatment has disappeared, sometimes because the patient has died.

A novel idea would be for insurance sompanies to sell plans that cover those techniques they are currently refusaing to cover for when the government refuses to provide coverage.

They the insurance companies win as well.

"I've seen as much over-treating as I have under-treating, but the worst overall is insurance company 'gate keepers' who determine from several states away that a patient doesn't need a particular course of treatment--at least with a private insurer there is a theoretical right to sue on the contract. What is the remedy when the feds dictate what you can and cannot have? "

You go get a private insurer. Or pay for it yourself out of pocket.

This proposal is bad. However for an interesting take on the politization of evidence based medicine in a universal health care system, see decidedly non-conservative writer Daniel at crookedtimber, here

Which Democratic proposal is good on the merits?

As for: "For example, if keeping government expenditures on health care lower is really the primary goal, then stripping the government's ability to negotiate drug prices for Medicare purchases is the exact opposite course to take."

This actually doesn't strike me as a good example.

First, it depends on the importance of the secondary goal ensuring that new drugs continue being discovered at the enormous pace of the past 30 years continues.

Second, it also depends on how important drug costs are to the financial health of the Medicare program.

For me, the secondary goal is very important as new drugs have proven in the long term to be excellent cost savers and wonderful vehicles for previously unheard of therapies. Also, drug costs aren't one of the biggest problems in Medicare. They are ideologically convenient, like earmarks, but not one of the top important things at all.

mckinneytexas: "a government with an established record of not getting entitlements right from the get go"?

Really? What exactly are you talking about here? Which entitlements? Social Security? Medicare? The VA? The Medicare drug benefit, whose hole only exists because of negotiating with Republicans who wanted to pretend it was cheaper?

What is the remedy when the feds dictate what you can and cannot have?

As Eric says: you get it via private health insurance.

BTW: when private insurance companies have to compete with a national health service, they are required by market forces to provide a much better service. (In the UK, this seems to come to: 1. Comfier hospitals; 2. Better food; 3. More options to set your own treatment date.) I have never heard of any dicking around with denial of payments as apparently is SOP in the US, but then I hardly know anyone with private health insurance.

Also, drug costs aren't one of the biggest problems in Medicare.

So, when I hear self-styled conservatives rail against the cost of the Medicare Part D "entitlement", I should assume they're making a mountain out of a molehill as usual?

--TP

And, if your government sets regulations you don't like, you can try and get them changed. Political process and all that. Try telling Blue Cross or Aetna that you'll vote for UHC if they don't change their coverage.

The other nice thing about a public option is transparency. Nobody would ever say government regulations are clear, but they're public. There is no "sorry, this is a trade secret" list of what is and isn't covered.

I agree with this bill. I see no reason why actual research into what works and what doesn't should be allowed to affect government policies.

First, it depends on the importance of the secondary goal ensuring that new drugs continue being discovered at the enormous pace of the past 30 years continues.

If it's important to subsidize research, then subsidize research. Surely it's a less efficient subsidy to simply hand the drug companies money through the back door by preventing Medicare from negotiating prices.

"You go get a private insurer. Or pay for it yourself out of pocket."

I’m confused. If that is an acceptable response to a criticism of government denial of coverage for a treatment, why isn’t that an acceptable response to a criticism of private denial of coverage for treatment? You can get a different private insurer or pay out of pocket if your current insurer won’t cover you. If cost cutting denial of coverage is such a strong attack on the private system, why would cost restricting denial of coverage from the public system get such a brush off?

I think if Obama wants truly effective health care reform he is going to have to take the bull by the horns and ram it through under the reconciliation process.

I doubt that he can even get all the Democrats to back him on strong health care reform, much less any Republicans.
Its time to go for the real deal on health care, and let the chips fall where they may. Sometimes you just have to use brute force. This is one of those times.
If Obama tries the bipartisan approach, the best he will get is a watered down reform with the weakest public option possible , if there is a public option at all. Even then, he will get only 2-3 Republicans at most, so it won't really look like a bipartisan bill. What's the point?

Because the public system would be far less likely to not cover people just to make money, and would encourage early prevention and checkups, because it should cover everyone for life, and not just be dedicated to raking in profits for the guys at the top. So the sorts of things not covered under a public plan would be a different class of things than the class of things not covered by private insurance, which is where the companies kick out expensive people and give bonuses for it.

That's the entire POINT of having a public single payer program, IMO.

"I’m confused."

Then read what Nate said. Also, denial of coverage is not ideal - but in the present instance, it's based on science and not profit motive. Regardless, in a world where the GOP is pushing for 100% denial of coverage from the government, the critique is a bit rich.

If government provided insurance doesn't cover it, get a private insurer or pay for it. That is an acceptable outcome where government is providing an insurance option to all.

Sebastian, are you genuinely confused about the difference between a private entity acting in bad faith and in violation of a contract, and a government entity providing a minimum, fixed amount of a public service?

Government is not driven by profit. This can be both good and bad. In the context of health care, it means government has no financial incentive to hide information about what it covers, nor to deny valid claims for compensation. Private, for-profit insurers do.

"has no financial incentive"

But financial incentives are not the only incentives. Government has other incentives to be less than completely transparent in it's operations.

"Government is not driven by profit. This can be both good and bad. In the context of health care, it means government has no financial incentive to hide information about what it covers, nor to deny valid claims for compensation."

The second sentence doesn't follow at all. Governments still operate under cost constraints which means that in fact they do have financial incentives to hide information about it covers and to deny valid claims.

"Then read what Nate said. Also, denial of coverage is not ideal - but in the present instance, it's based on science and not profit motive."

Do you think that most denials of coverage in the private system are not based on science? I think insurers would be successfully sued far more often if your supposition were true. (By the way, are we giving the government sovereign immunity on health care issues? Are we going to treat health care decisions like prosecutorial discrection decisions? Any way you can forsee that could be problematic...?)

"Regardless, in a world where the GOP is pushing for 100% denial of coverage from the government, the critique is a bit rich. "

Sorry, I thought you were discussing issues with me. I didn't realize your disinterest was because your mistakenly believed I was the GOP. So it is your argument that valid concerns can be justly brushed aside because the GOP makes other arguments. Hmm...

What's the point?

It's my impression that President Obama truly believes that if he explicitly reaches out to his opponents, bargains in good faith, and avoids statements and actions that could be interpreted as a continuation of the partisan tit-for-tat pattern that Republicans seem to perceive as the governing pattern of American politics since Nixon -- that if he does all these things, the nation will gradually unite behind him, the Republicans will lose further seats in the 2010 mid-terms as they alienate their remaining moderates, and he will have then achieved a ruling consensus and a Senate that backs him.

In this long game, success is measured by how well he maneuvers the Republicans into destroying their own credibility. A health care bill made worthless by Republican intransigence is a bad bill, but will play badly among voters, and so might be a long-term win. Sotomayor is not the greatest liberal he could have nominated, but is rather an actual moderate; Republican attacks on the nominee are thus limited to sexist and racist tropes that play badly with large segments of the electorate. Prosecution of Bush crimes is off the table because it will inflame defensive partisan tribalism among exactly the voters he hopes eventually to turn blue-ish.

To pull off this strategy, Obama needs some bad outcomes, unpopular outcomes, that are clearly caused by Republican intransigence. I think it likely that this first health-care bill will be one such.

This is not my fondest hope for the Obama administration, but it's what I think I see.

@hanes

You know, I'd be just happy with effective health care reform this year, rather than have ineffective health reform in return for electoral success down the road, but that's just me, I guess.

Joel,

If you are right, then it's a bad strategy. The public is not going to understand that some bill could have been better but for Republican intransigence. They are going to see a bad bill and blame it on Obama.

The media won't help much either, since it's impossible to explain these things given the standard shouting of talking points by people whose only qualification is partisanship that constitutes "analysis."

"Do you think that most denials of coverage in the private system are not based on science? "

Not sure anybody is claiming "most" but there is no doubt that some are not based on science, but totally based upon cost.

As was pointed out either earlier in this thread or another, insurance companies know that many of their insured (particularly when covered through their employer) will not be their responsibility in a few years, so long term impact is not necessarily part of their thinking process.

Thus, by rejecting newer treatment modalities, particularly more expensive ones, now does not necessarily impact them later on. Nor do the insurance companies really care about what the longer term societal costs are for failure to treat in the current day.

"Do you think that most denials of coverage in the private system are not based on science? "

Rescission are based on contract technicalities and loopholes. Thus, not science. Thus, unsuccessful suits. Although some suits do succeed. There's also the cost of the suit in question, which must be borne by the plaintiff.

"So it is your argument that valid concerns can be justly brushed aside because the GOP makes other arguments"

No! The point is, if the alternative is no government provided insurance, then insurance with some lapses in coverage is preferable. Correct me if I'm wrong, but you're against expanding health insurance. Right? Well then, what do you care if the expanded coverage includes some limitations?

Or is it that you are fighting for a defense of the current Medicaid/Care structure?

I'd be just happy with effective health care reform this year

Oh, me too. I'd like to see Obama smite the money power and win.

IMHO, Obama has judged that the money power is currently politically stronger than he, and that the sort of screw-the-insurance-companies version of "health care reform" that I personally would favor is not among the achievable outcomes.

Most of us who have concerns around the notion of rationing healthcare do not have in mind the denial of medically useless treatments but rather the denial of effective treatments because of an interpretation on cost-effectiveness (patient is past the age allowed for the treatment, for example) or delays in accessing treatment because of unavailability of required resources (long waiting periods). We also see the endgame of the public option being the virtual elimination of other options.

The advocates for extensive government involvement will oppose actions designed to improve the market-based system such as switching the tax deduction benefits from the employer to the employee or a universal tax credit for all to defray the cost of acquiring health insurance (among many others) because these might actually result in overall improvements that could take the government control option off the table.

GOB: Most of us who have concerns around the notion of rationing healthcare do not have in mind the denial of medically useless treatments but rather the denial of effective treatments because of an interpretation on cost-effectiveness (patient is past the age allowed for the treatment, for example) or delays in accessing treatment because of unavailability of required resources (long waiting periods).

I didn't know you had concerns around the notion of rationing healthcare, Good Ole Boy, but it's nice to know you're against the current US system of denying effective treatments based on cost-effectiveness (the patient is too poor to be allowed the treatment) or delays in accessing life-saving treatment because of unavailability of required resources, which seem to be inevitable in the present US system, unlike the NHS, which bases its queuing system not on "how much can you pay?" but "how much damage will be caused by a long wait"?

The advocates for extensive government involvement will oppose actions designed to improve the market-based system

The advocates for profit are the ones who are opposing actions designed to improve the market-based system. A socialized health care system ensures that private health care providers really have to work for their money: they can't just dick around the way they do in the US right now, giving you crap because they know you have no choice but to eat it.

You think it's right and proper that your health care should be provided only by people who want to make a profit out of giving or denying you treatment: fine, GOB, nothing about a socialized health care system will prevent that. You can continue to put your life in the hands of those who value your health only at the market rate.

But is that a reason for enforcing your values on everyojne else in the US?

Do you think that most denials of coverage in the private system are not based on science?

Yes. At the very least, insurance companies fail to use coverage denial to encourage evidence based medicine in many cases. How else do you explain phenomena like this? Since insurance companies are motivated by profit to reduce costs, you would expect that in the presence of such clear evidence they would change their reimbusement policies or deny care or require extra paperwork from doctors justifying certain choices. Yet we don't see that in this case.

GOB, please tell me how a public option eliminates other options. That would be unique in the world as it exists today.

Secondly, tell me how the reforms you talk about do anything to curb the problems with the way for-profit (and some not-for-profit) insurance companies handle reimbursement, or lack thereof, under the current system. We are not just talking about affordability, we are talking about access to coverage.

In terms of you very first statement about denial of effective treatments, first of all that is happening now, and secondly, under the proposed system it would happen less.

will oppose actions designed to improve the market-based system such as switching the tax deduction benefits from the employer to the employee or a universal tax credit for all to defray the cost of acquiring health insurance (among many others) because these might actually result in overall improvements that could take the government control option off the table.

Well, that might be one consderation.

But your argument ignores :

- the fact that healthcare is already "rationed", completely irrationally, in a manner that effectively shuts out the working poor and the unlucky, and that grossly hinders the effectiveness of the care delivered in many cases (uninsured people get no care until they're in crisis, when the cost of treatment is highest, and the prognosis after treatment the least favorable)

- the completely perverse incentive structure inherent in private insurance, in which the insurer is rewarded for denying reimbursement. (See yesterday's "recission" testimony before Congress)

But mostly, it seems to me that Good Ole Boy cannot imagine himself among the swelling ranks of the uninsured or uninsurable.

But that's not my conclusion. The Dem proposal is good on the merits. Engaging a GOP that is this compromised is pointless.

To repeat McKinney's question, which hasn't been answered: Which democratic proposal?

Do you think that most denials of coverage in the private system are not based on science?

Yes. I think that most denials of coverage in the private system are based on pre-existing condition exclusions.

"Which democratic proposal?"

There are a number of decent proposals in the mix. I prefer single payer. That's one.

As was pointed out either earlier in this thread or another, insurance companies know that many of their insured (particularly when covered through their employer) will not be their responsibility in a few years, so long term impact is not necessarily part of their thinking process.

If your goal for healthcare is to provide the best quality of life for the population given a fixed amount of resources, private insurance won't do this. It's not really because of profits; it's not because of inefficiency; it's really because the incentives of each individual insurance company do not combine in the marketplace to give anywhere near this goal.

The goal of each insurance company is to increase the amount of money coming in and decreasing the amount of money going out. The easiest way to decrease the amount of money going out is to not pay claims. So either you try to deny the claim as a preexisting condition, fob it off on another company, or drag your heels and hope that the patient either changes companies, gets better, or dies. By the time any of these actions happen, the patient is well past the stage (if it ever existed) where they can take advantage of the market to change insurance providers. When you put a bunch of insurers together in a marketplace, there's no magic fairy dust that makes this benefit the consumer: you simply get a number of different insurance companies trying to deny claims.

When you have one risk pool and no feasible way to get a troublesome patient off your books, then you can actually get down to the goals of trying to keep people healthy and apportioning resources in some reasonable manner.

A market isn't magic. It might optimize certain things, but it doesn't magically optimize things you like.

(clapping for ericblair)

the secondary goal ensuring that new drugs continue being discovered at the enormous pace of the past 30 years continues. ... new drugs have proven in the long term to be excellent cost savers and wonderful vehicles for previously unheard of therapies.

The pharma industry is very good at devising new drugs for chronic conditions of the affluent -- depression, high cholesterol, high blood pressure, erectile dysfunction, etc. That's where the profit is -- so much so that much pharma "innovation" is expended on finding a new (and thus patent-protected) drug to treat these conditions even if it is less effective than existing drugs.

On the other hand, there's little research on the kinds of drugs that could save many lives, but for which the course of treatment is short (hardly any new antibiotics in decades, because there's much less profit making a drug that the patient only takes for fifteen days than in making a drug that the patient takes for fifteen years). And very little research on the diseases of the worldwide poor, because of course they have no money, so do not count.

I wonder if Sebastian is aware that Elsevier has just been found to have published an entire line of fake peer-reviewed journals, devised specifically to publish drug effectiveness studies that would not pass peer-review, but to make it appear that the studies are legitimate ? That some of the biggest pharma companies he seems to so admire have thus been once again exposed as fraudulently pushing drugs of doubtful effectiveness but outstanding potential profitability?

"Correct me if I'm wrong, but you're against expanding health insurance. Right?"

No. I'm for expanding health insurance. I'm against leaving large numbers of people uninsured. I'm for figuring out a solution (almost certainly governmental) for covering uninsured people. I'm against a general takeover of the health care system as a whole (which wisely doesn't appear to be on the table at the moment anyway). I'm against a process which squeezes drug companies for cost savings without having an already demonstrated replacement for their excellent drug discovery function.

I'm against ideologically blaming the profit motive for cost overruns when it is much more likely that things like the US approach to end-of-life care are driving the cost craziness. Which doesn’t completely exclude the profit motive as a factor, perhaps doctors are overprescribing expensive end-of-life care in the hope of squeezing more money out of insurance companies.

If all you want to do is get all the uninsured people insured in a Medicare level program, I’m right there with you.

You seem to want well more than that, and it is ok to raise objections to that, especially when you repeatedly talk as if cost issues are purely an artifact of profit in the private system.

I haven’t once seen you explain why you think the government can already spend as much as Canada and cover less than 30% of the population. It is an important question. My very tentative answer is that we pay doctors a lot more, that we make much more aggressive interventions at the end of life, and that there is a large though not enormous portion of the middle class that overuses doctor’s services when going to a pharmacy for cough syrup would be sufficient.

Your answer has never been directly made, but it appears to be drug prices and profits. Drug prices aren’t as big a deal as you think, and the government already doesn’t have a profit motive so that can’t be right.

My point is that if you are contemplating a massive intervention in the health care system beyond merely getting insurance for the uninsured (and you are), it would make sense to understand what is going wrong with the current government intervention such that it isn't able to get Canadian, or at the very least UK universal coverage now even though it is spending enough for it.

I'm really becoming convinced that the Democrats are going to blow it for us, deliberately, on national health care. The fact that they continue to parrot right wing talking points and that they fail to make the strong case for a Public Option or, better yet, Single Payer is just mind boggling to me.

Here's the thing. I *have* good health insurance right now. And I pretty much always have. But I know, as most sensible adults know, that that is a purely temporary situation. I'm insured through my husband's job. The day his boss decides to sell out the business, our health care coverage goes to COBRA, and then is dependent on the next employer's mercy. We are in our late forties--we have "pre-existing conditions" like everyone else who lives long enough.

Furthermore, we have children. One of my children has asthma. Once we took her to a "therapist" for some behavioral modification training for her fear of doctors, shots, and dogs. Those are all "pre-existing conditions." I have no doubt that she will be, essentially, uninsurable as soon as she hits eighteen.

We pay for our health care right now. We would pay for our health care under a robust Public Option and under Single Payer health care. All this democratic waffling about "costs" fails to grapple with the fact that people pay premiums and co-pays right now for services which they are later denied either by recission (when they need the services), or by aging out of the system (as when your children cease to be covered as part of your family), or by the insurance company changing the plan so that all your previous premiums simply vanish.

If we, as a people, choose to pay our premiums *in the form of taxes* it doesn't really make less of a pot of money to pay for health care, does it? It just eliminates the element of gambling from the process by eliminating the middle man who collects and distributes the fees after taking his cut.

This is not rocket science. If health care can be bought through insurance premiums it can be bought more effectively through taxes levied on everyone who works, while they work.

I despise the Democrats for failing to make this obvious point over and over again. The public that has health insurance knows, full well, how fragile the situation is. They are begging for leadership and the Democrats are allowing themselves to be bought by the industries involved. Its an absolute disgrace.

aimai

the US approach to end-of-life care are driving the cost craziness

I agree that this is an important factor.

Further, I claim that the hideously-expensive US approach to end-of-life care is primarily driven by patient demand (or their families) -- that for some patients cost is no object, quality of life no consideration, just keep Gramps alive as long as possible. Such persons will perceive any attempt to moderate their demands as "rationing", and intolerable.

Perhaps Sebastian and I can agree that the growing hospice-care movement is a good thing?

OT,
But I would really have liked to see Obama address some medical bodies *other than* the AMA. As it turns out the AMA does not represent most doctors in this country anymore. The percentage that it does represent is now vanishingly small and many professionals have opted into other medical groups and these are by no means opposed to serious revisions of our health care system.

A really robust push by the administration and the dems in congress would have looked like this--what do we want to see in ten years and how do we get it? We want to see full coverage for everyone and that means we'll be bringing tons of new people in for coverage. So we need lots more doctors and especially internists who are willing to take on our public option patients.

So--incentivize them. How about no federal taxes on the income of internists and pediatricians and nurses for whom 75 percent of the patients are "public option" patients? So in addition to cutting out the paperwork involved (a massive overhead for doctors and nurses and a tax on their time as well as their professional income) you have a positive reason to welcome public option patients. And an even better reason to go into primary medical care instead of specalization.

There are literally hundreds of good arguments, and great ideas, out there to make a Public Option work and work well. But we see the Democrats make none of those arguments because they are so deterimined to avoid rocking the boat. Single Payer should never have been taken off the table. And every single person who is asked their opinion on health care should be asked first:

what is your health insurance status
how much does it cost you and your family
are any family members uninsured
what would you do if you couldn't get insured
and how much have you received from interested parties in the health care debate.

That would reveal at once the immense bias in the debate since the "experts" are all chosen from among the class of people who are never uninsured and imagine that they aren't underinsured. But the rest of us, living in the real world, get treated like mere anecdotes and dreamers.

aimai

aimai

will oppose actions designed to improve the market-based system such as switching the tax deduction benefits from the employer to the employee or a universal tax credit for all to defray the cost of acquiring health insurance (among many others) because these might actually result in overall improvements that could take the government control option off the table.

I'd like to see some discussion on the merits of such"market based" solutions although I note that it's kind of a stretch to call solutions based on jury-rigging the tax system "market-based").

What's interesting is that the Republicans weren't interested in offering ANY health care reform solutions until public pressure became overwhelming.

But let all that pass. Someone please answer these questions:
1) what are the merits and drawbacks of the "market based" alternatives?

2)Why haven't any other countries adopted these solutions, if they are so wonderful?

I note that Hong Kong, one of the freest economies in the world, has adopted the same socialized medicine option as those pinko British- and have had some of the best health care outcomes in the world.

http://en.wikipedia.org/wiki/Healthcare_in_Hong_Kong

of course the Dems are gonna blow it. they are most of all feckless and fearful; some are clearly corrupt. which is different from the malign incompetence of the GOP, though the results are often similar.

I'm trying to come up with an analogy, here. Something along the lines of "The two of us spend more dining at Peter Lugar's Steakhouse than that group of people spends feeding themselves at the farmers' market. Why isn't everyone already eating at Peter Lugar's, huh? And how much higher would the tab be if everyone actually did?"

A better wordsmith than I should be able to figure out a better way to express this thought.

No. I'm for expanding health insurance...

Well that's good. We agree on the basics. Forgive my misunderstanding.

Cost overruns have numerous causes. The article in the New Yorker refers to overprescription. Administrative costs are through the roof in the US due to the plethora of insurance carriers and the antiquated record keeping functions. Drug costs (there is room in the enormous profit margins for a bit more realistic approach, and much of the funding goes for erectile dysfunction and other frivolous but lucrative causes. I would be open to common sense tort reform (John Edwards actually put forward an excellent plan) - which could lower doctor costs which could be passed down. More preventitive medicine (and changing incentive structure to pay for prevention rather than treatment). And numerous other causes that I could give you if my name were Ezra Klein.

I would be open to common sense tort reform (John Edwards actually put forward an excellent plan) - which could lower doctor costs which could be passed down.

As I noted in a previous thread, according to the CBO malpractice costs are less than two percent of total healthcare costs, and almost half of that is due to malpractice insurance providers having to cover their investment losses. Nor has there been any empirical sign of the putative high costs of "defensive medicine." So I wouldn't be open to giving ground on something with such minimal effect on health care costs, at least in exchange for the "nothing" that most conservatives who repeatedly invoke tort reform are offering.

There are literally hundreds of good arguments, and great ideas, out there to make a Public Option work and work well. But we see the Democrats make none of those arguments because they are so deterimined to avoid rocking the boat.

and they are determined not to rock the boat because insurance company contributions fund their campaigns, and insurance-agency profits the Chamber of Commerce and the WSJ to oppose any change, and thus our Congressmen and Senators are afraid that if they piss off the insurance industry, they will not be re-elected.

Corporate profits are more important than people to our lawmakers of both parties. Every time.

"The pharma industry is very good at devising new drugs for chronic conditions of the affluent -- depression, high cholesterol, high blood pressure, erectile dysfunction, etc. That's where the profit is -- so much so that much pharma "innovation" is expended on finding a new (and thus patent-protected) drug to treat these conditions even if it is less effective than existing drugs.

On the other hand, there's little research on the kinds of drugs that could save many lives, but for which the course of treatment is short (hardly any new antibiotics in decades, because there's much less profit making a drug that the patient only takes for fifteen days than in making a drug that the patient takes for fifteen years). And very little research on the diseases of the worldwide poor, because of course they have no money, so do not count."

Argh. First, you can make ENORMOUS profits on a new antibiotic. So you're wrong from the get go. There aren't new anti-biotics because it is tough. Second, why hasn't the NIH or the Canadian system come up with all these new anti-biotics that you think are so easily accessible? The US system isn't the only one around. Where are all the non pharma company discoveries in Canada and the UK? There are some, but nothing on the scale of the pharma companies. On this I'm very conservative. If you believe an alternative drug discovery method would be as good but cheaper, do it first THEN attack the pharma companies. (For example if you think a prize system would be better, set it up!).

"If government provided insurance doesn't cover it, get a private insurer or pay for it. That is an acceptable outcome where government is providing an insurance option to all."


How does this work in a Single Payer system? And isn't this de facto rationing, i.e. the gov't gives coverage X, and that is all you get, regardless of your condition?

The rescission issue can be dealt with legislatively and cleanly: cy pres all contracts to require continuity of coverage and eliminate 'material misrepresentation' by requiring coverage for pre-existing conditions.

On a slightly unrelated subject, doesn't the 47 million uninsured include people moving to the US without permission? Will the coverage the Democrats propose extend to these folks?

"How does this work in a Single Payer system?"

In a single payer system, if it is medically necessary, the government pays for it. If not, you pay for it yourself. Governments with single payer don't deny necessary medical treatments. If they did, the voters would boot them. This has been historically proven out, and there's little reason to think the US would be some hoary outlier.

"The rescission issue can be dealt with legislatively and cleanly..."

I'd support that. But it wouldn't be clean. There would be a bloody battle.

"On a slightly unrelated subject, doesn't the 47 million uninsured include people moving to the US without permission? "

No. Specifically excludes them, so the number is actually a bit higher.

"Cost overruns have numerous causes. The article in the New Yorker refers to overprescription."

Which is one of the things I said. Of course the solution to overprescription in the private context would be called denial of service by you. Will it be something different if done by the government? Will the government be cracking down on what the doctor and patient want?

It probably should. Why doesn't it now?
Why is trying to figure out why it doesn't now off limits?

mckinneytexas -- "...doesn't the 47 million uninsured include people moving to the US without permission? Will the coverage the Democrats propose extend to these folks?"

Actually, we were planning on building a quarantine facility next to your house for all of the sick undocumenteds we find...

Maybe we'd have more luck with you if we classified them all as bioterrorists and labeled their treatment as 'de-weaponizing'?

"Of course the solution to overprescription in the private context would be called denial of service by you."

No!

Did you read the article about rescission? It's about deliberately targeting expensive insurance cases (cancer patients, for example) and denying them coverage based on contractual fineprint (the person incorrectly filled out a certain section, for example).

That's different Seb.

I quote:

"But [the health insurance execs] would not commit to limiting rescissions to only policyholders who intentionally lie or commit fraud to obtain coverage, a refusal that met with dismay from legislators on both sides of the political aisle."

They want the technicalities. That's not the same as effectiveness studies.


I'm sorry for muddying the issues here. Pharma reaction to profit incentives bears small relevance to this discussion of nationaly healthcare systems; I shouldn't have brought it up.

why hasn't the NIH or the Canadian system come up with all these new anti-biotics that you think are so easily accessible? The US system isn't the only one around

None of the national health care systems do much pharma research; it's almost exclusively the province of for-profit multinationals. So your question about why the Canadian or British health-care systems don't find new antibiotics seems strange to me -- the apples-to-apples comparison is with US for-profit insurance companies and with HMOs, which don't discover many new drugs either.

As to whether a new antibiotic would be very profitable, such that for-profit multinationals would give it a priority appropriate to its importance in health-care outcomes, your assertion is contrary to everything I've read over two decades of interest in this matter. For example, this:

Until recently, research and development (R&D) efforts have provided new drugs in time to treat bacteria that became resistant to older antibiotics. That is no longer the case. Over the past 60 years, a total of ten new classes of antibiotics have been discovered, but only two of these were in the past 40 years. Since 1998, only 10 new antibiotics were approved by the FDA, two of which were truly novel. In 2002, among 89 new medicines emerging on the market, none was an antibiotic. Particularly disturbing is that there is no antibiotic class for which a bacterial resistance mechanism does not already exist. Unfortunately, most of the large pharmaceutical companies have ended or down-sized their antibiotic R&D efforts and do not have new antibiotic drugs in the pipeline. A recent study estimates that an aggressive R&D program initiated today would likely require 8 to 10 years and an investment of $800 million to $1.7 billion to bring a new drug to market. In part, the rate at which antibiotic resistance to a drug arises is a major profit-killer for pharmaceutical companies and does not encourage the allocation of substantial resources to the problem.

Let's say that Merck discovers new wonder antibiotic called "quux". It works like penicilin and tetracycline formerly did; it outright cures most bacterial infections. Let's further stipulate that half the people in the US get a bacterial infection for which quux is the treatment of choice every year, and that quux costs $50 per dose. That's about two hundred fifty dollars per year per capita over the general populace.

Because they are taken every day for years, drugs for chronic conditions can sell for $5/dose or even $1/dose and still make greater profits than my rosy quux scenario.

"In a single payer system, if it is medically necessary, the government pays for it. If not, you pay for it yourself. Governments with single payer don't deny necessary medical treatments. If they did, the voters would boot them."

So, the gov't will decide what is medically necessary, and we can depend on it to do so without regard to cost.

Not so comforting, particularly since no one can reliably forecast the cost.

"So, the gov't will decide what is medically necessary, and we can depend on it to do so without regard to cost. "

McTex: The government already does this, and does it pretty well, with medicare and medicaid. Also, governments in other countries do this very well. It's not new, untried or untested.

Medical necessity is a scientific inquiry.

And if it doesn't work, don't take the government plan. Stick to the private insurers who, you know, never do this kind of thing.

Single Payer should never have been taken off the table

Hell yes. The Democrats unilaterally disarmed themselves before the Republicans fired a shot.The biggest problem that I have with the Democrats is their defensive cringe on an issue that they have strong support on.They should have started by saying that ALL options were on the table and that we would look at studies showing which option was best. Instead, they conceded half the field and set up at the 50 yard line { that's an American football analogy for all those who are US sports challenged:-)}.

So, the gov't will decide what is medically necessary, and we can depend on it to do so without regard to cost.

Not so comforting...

i really don't see why this is any less comforting than having a faceless, for-profit mega-corp decide what is medically necessary, while paying out as little as possible in order to maximize that profit.

Let's say that Merck discovers new wonder antibiotic called "quux". It works like penicilin and tetracycline formerly did; it outright cures most bacterial infections. Let's further stipulate that half the people in the US get a bacterial infection for which quux is the treatment of choice every year, and that quux costs $50 per dose. That's about two hundred fifty dollars per year per capita over the general populace.

Because they are taken every day for years, drugs for chronic conditions can sell for $5/dose or even $1/dose and still make greater profits than my rosy quux scenario.

Multiply your numbers out. Your quux scenario suggests that Merck would happily forgoe *annual* profits of $37.5 billion dollars. I'm pretty sure they wouldn't avoid that kind of profit if they could get it.

Speaking of Merck they've made a tidy profit on their vaccines for HPV, rotavirus and shingles. And vaccines are another area that is often cited as being a large market failure.

Pharma companies would love to have a new antibiotic. The low hanging fruit in that area are gone.

"(clapping for ericblair)"

Seconded.

As of 2007, 18% of the population under age 65 had no health insurance. That's 46 million people.

To answer mckinney's question, 80% of those people are native or naturalized citizens.

Not quite 1 out of 5 people in this country have NO health insurance. Not crappy health insurance, not health insurance with an insane $10K deductible for a single person, not health insurance that will cut them loose as soon as they get sick in any expensive way.

Those scenarios are all lagniappe.

1 out 5 have NO health insurance, at all.

If the "free market" meant that 1 out of 5 people had no place to live, no food to eat, no clothes to wear, and no heat in the winter, we would not (I sincerely hope) put up with it.

I don't see a reason to put up with this.

Other places do it. We should do it, too. To address Seb's enduring question, it shouldn't be that freaking hard to figure out where the money is going. Figure it out and make whatever adjustments we need to make.

Just get it freaking done.

In this context, the free market is killing people. We owe it nothing.

much of the funding goes for erectile dysfunction and other frivolous but lucrative causes.

I take it, Eric, that you have not yet been in a long-term relationship in which erectile dysfunction was an ongoing problem. I imagine that you would not characterize it as a frivolous cause quite so easily if you had.

I'm against ideologically blaming the profit motive for cost overruns when it is much more likely that things like the US approach to end-of-life care are driving the cost craziness.

Sebastian, your ideological insistance that the free market must be the solution won't become any less ideological just because you keep trying to claim that the profit motive has nothing to do with cost overruns.

EDguy, it's all relative.

Is it frivolous compared to cancer? Yeah, it is.

But regardless, it can be a debilitating condition, and I'm all for finding cures.

However, the marketplace is currently inundated with products (and ads for those products) while drugs for less lucrative but more essential medical challenges are absent.

Viagra was experimentally a pulmonary arterial hypertension drug.

And cancer isn't a single disease. Quite a few cancers have lots of money being thrown at them (take breast cancer for example). The fact that there is still no cure is a testimony to our overall lack of understanding, not because we are throwing too little money at the problem or that ED is siphoning away the money.

"while drugs for less lucrative but more essential medical challenges are absent."

Identifying a problem isn't the same as identifying a solution, or even that there is a solution. Pharma companies have become so ridiculously successful at creating new drugs that you are at the point where you feel like a lack of a cure means they aren't trying hard enough. I guarantee that if they had even the slightest chance of say curing diabetes, they would have done it. (In fact there are all sorts of diabetes drugs in trials, because they really do want to come up with a therapy.)

"I take it, Eric, that you have not yet been in a long-term relationship in which erectile dysfunction was an ongoing problem. I imagine that you would not characterize it as a frivolous cause quite so easily if you had."

Seriously, my equipment is still working pretty well, but it doesn't work as well as it did when I was 17, and if it got to the point of working half or a quarter as well as it currently does, I'd be an unhappy camper, "frivolous" as merely having sex may be.

On top of that would be the embarrassment of discussing it with my doctor. But that's trivial compared to simply not having working equipment. It's always someone else's sex life that is frivolous....

"I take it, Eric, that you have not yet been in a long-term relationship in which erectile dysfunction was an ongoing problem. I imagine that you would not characterize it as a frivolous cause quite so easily if you had."

Seriously, my equipment is still working pretty well, but it doesn't work as well as it did when I was 17, and if it got to the point of working half or a quarter as well as it currently does, I'd be an unhappy camper, "frivolous" as merely having sex may be.

On top of that would be the embarrassment of discussing it with my doctor. But that's trivial compared to simply not having working equipment. It's always someone else's sex life that is frivolous....

Multiply your numbers out. Your quux scenario suggests that Merck would happily forgoe *annual* profits of $37.5 billion dollars. I'm pretty sure they wouldn't avoid that kind of profit if they could get it.

My quux scenario is purposely contrived to exaggerate the potential profits from a new antibiotic, precisely to demonstrate that even the exaggerated profits are enough smaller than the potential profits from something like Lipitor or Effexor that the pharma companies _do_ in fact choose to pursue the Lipitor/Effexor class to the exclusion of new antibiotics. I thought that was obvious; I apologize for not making it more obvious.

And I presented evidence that, following the principle of fiduciary responsibility and the reality of opportunity costs, pharma companies are not, in fact, pursuing new generations of antibiotics. I can present more evidence for this claim if you like -- there's no shortage in the literature.

You have responded by reiterating your own touching faith that the profit motive is of course and always sufficient to make companies deliver what people need.

Diabetes is a chronic condition; treating it is very profitable so long as it remains chronic. Can you not see that it is self-defeating for a pharma company to develop a cure for diabetes, if that cure costs the patient substantially less than the drugs for life-long palliative treatment? Do you really think that multinational corporations commonly choose to pursue lines of research that might threaten one of their existing sources of revenue?

Digby points to:

Those of you who are struggling to pay for your generic medicines or wondering why the doctor is charging you a $5.00 co-pay, give some thought to these facts about how our health care dollars are allocated. At the end of this post, there is a list of 23 health companies I found on Forbes.com, what the CEO was paid in 2005, and the average paid to the CEO in the past five years.

Imagine adding vice presidents, Board of Directors, stock holders and the other 200-300 other companies all cashing in on your health to that total at the bottom...

* United Health Group
CEO: William W McGuire
2005: 124.8 mil
5-year: 342 mil

* Forest Labs
CEO: Howard Solomon
2005: 92.1 mil
5-year: 295 mil

* Caremark Rx
CEO: Edwin M Crawford
2005: 77.9 mil
5-year: 93.6 mil

* Abbott Lab
CEO: Miles White
2005: 26.2 mil
5-year: 25.8 mil

* Aetna
CEO: John Rowe
2005: 22.1 mil
5-year:57.8 mil

* Amgen
CEO: Kevin Sharer
2005:5.7 mil
5-year:59.5 mil

* Bectin-Dickinson
CEO: Edwin Ludwig
2005: 10 mil
5-year:18 mil

* Boston Scientific
CEO:
2005:38.1 mil
5-year:45 mil

* Cardinal Health
CEO: James Tobin
2005:1.1 mil
5-year:33.5 mil

* Cigna
CEO: H. Edward Hanway
2005:13.3 mil
5-year:62.8 mil

* Genzyme
CEO: Henri Termeer
2005: 19 mil
5-year:60.7 mil

* Humana
CEO: Michael McAllister
2005:2.3 mil
5-year:12.9 mil

* Johnson & Johnson
CEO: William Weldon
2005:6.1 mil
5-year:19.7 mil

* Laboratory Corp America
CEO: Thomas MacMahon
2005:7.9 mil
5-year:41.8 mil

* Eli Lilly
CEO: Sidney Taurel
2005:7.2 mil
5-year:37.9 mil

* McKesson
CEO: John Hammergen
2005: 13.4 mil
5-year:31.2 mil

* Medtronic
CEO: Arthur Collins
2005: 4.7 mil
5-year:39 mil

* Merck Raymond Gilmartin
CEO:
2005: 37.8 mil
5-year:49.6 mil

* PacifiCare Health
CEO: Howard Phanstiel
2005: 3.4 mil
5-year: 8.5 mil

* Pfizer
CEO: Henry McKinnell
2005: 14 mil
5-year: 74 mil

* Well Choice
CEO: Michael Stocker
2005: 3.2 mil
5-year: 10.7 mil

* WellPoint
CEO: Larry Glasscock
2005: 23 mil
5-year: 46.8 mil

* Wyeth
CEO: Robert Essner
2005:6.5 mil
5-year: 28.9 mil


TOTAL 2005: 559.8 mil

TOTAL 5-Year: 14.9 billion

Seems like a smidge of savings might be available there.

But they are innovating, Gary, let them work in peace!

On top of that would be the embarrassment of discussing it with my doctor. But that's trivial compared to simply not having working equipment. It's always someone else's sex life that is frivolous....

Sure ED is important, but did we really need to market three different PDE5 inhibitors that are very similar chemically? I'm sure there are some people that are helped by one that gain no relief from the others, but how many people are we talking about given how chemically similar Viagra, Cialis, and Levitra are?

If big pharma wants to make an ED drug, that's great. When big pharma decides to blow billions of dollars on copycat ED drugs, well, that doesn't look very clever to me. It is not a question of thinking other people's problems are frivolous but of questioning the marginal benefit of massive R&D efforts aimed at producing a second and a third and a fourth copycat drug for a condition that is not life threatening.

As far as cost control is concerned, Atul Gawande makes it crystal clear that is simply isn't being tried. People-doctors, hospitals, and health insurers- are charging what they like, under a system that gives them every incentive to overcharge and no incentive to seek the best health outcomes at the least cost. When Sebastian asks " Why aren't costs being controlled?' the answer is simple enough. Powerful lobbies prevent effective cost control measures, because they like things as they are. THE END.
Those same lobbies are trying hard to prevent effective health insurance reform. I wonder if there is a connection? Let me think.............

You know, ED drugs are great, but anti malarial vaccines would really be much better-at least for the millions of people in the Third World dying from malaria.
What we need is an effective anti malarial drug that helps the sexual performance of westerners.

This article may provide grist for the mill, especially in relation to the symptoms versus causes discussion.

Sure ED is important, but did we really need to market three different PDE5 inhibitors that are very similar chemically? I'm sure there are some people that are helped by one that gain no relief from the others, but how many people are we talking about given how chemically similar Viagra, Cialis, and Levitra are?

I'm not going to defend pharma companies generally here, and I can't comment on the specific case of ED medications, but I can comment from another viewpoint. For several years I've had to take medication for overactive bladder. There are several on the market and, much like the ED medications, they are chemically similar: Detrol, Vesicare, and Enablex are the major ones.

Research -- and my own personal experience -- shows that their effectiveness decreases over time. After taking Detrol for a year, I noticed almost no effect at all. So my doctor has had me on a rotating prescription, six months at a time on each medication. If nobody was making copycats, I'd be getting up from my desk at work to urinate about every half hour, all day long, and then again at home and at night. Which, while not life-threatening, is obviously problematic.

One of the reasons that it's hard to take GOP critiques of health care reform seriously is because, quite frequently, it is apparent that they are not arguing in good faith.

This may be true of the GOP, Eric, but it doesn't necessarily make it true of ideological conservatives as a whole. Despite being fairly conservative I've never had any involvement with the Republican party and have voted for precisely one GOP politician in my life (Arlen Specter, who no longer even counts), but I do think conservative critics of liberal approaches to healthcare make some very salient points. The fact that those points are then regurgitated by venal Republican politicians who are motivated by something other than pure untarnished principle does not, ipso facto, invalidate them - a bad man can speak the truth, even if not for the right reasons. If you want to convince people that healthcare reform has to happen your way, it's necessary to acknowledge and engage the arguments themselves, not just undermine the credibility of the people making them.

"Multiply your numbers out. Your quux scenario suggests that Merck would happily forgoe *annual* profits of $37.5 billion dollars. I'm pretty sure they wouldn't avoid that kind of profit if they could get it.

My quux scenario is purposely contrived to exaggerate the potential profits from a new antibiotic, precisely to demonstrate that even the exaggerated profits are enough smaller than the potential profits from something like Lipitor or Effexor that the pharma companies _do_ in fact choose to pursue the Lipitor/Effexor class to the exclusion of new antibiotics. I thought that was obvious; I apologize for not making it more obvious."

Very few drugs make $37.5 billion per year. Most don't even make $1 billion. There are numerous drugs in the pipeline that won't even make $1 billion over their life cycle much less $37 billion per year. If your intent was to show that antibiotics can't be profitable you did exactly the opposite. And a new antibiotic could easily make $1 billion. The reason they aren't in the pipeline is that most of the current candidates are way too toxic to make it into useful trials.

Diabetes is a chronic condition; treating it is very profitable so long as it remains chronic. Can you not see that it is self-defeating for a pharma company to develop a cure for diabetes, if that cure costs the patient substantially less than the drugs for life-long palliative treatment? Do you really think that multinational corporations commonly choose to pursue lines of research that might threaten one of their existing sources of revenue?

This is essentially 'Ford has a water engine' conspiracy level thinking. Even if it were true that discovering a cure would be bad for the industry as a whole, it would be AMAZINGLY good for the company that had it.

When Sebastian asks " Why aren't costs being controlled?' the answer is simple enough. Powerful lobbies prevent effective cost control measures, because they like things as they are. THE END.

If true, why precisely will politics fail to intrude once the government is running things more?

Following up on liberal japonicus' link above, there's good reason to suspect that a big chunk of expense is being cultivated by the race not to find better treatments, but to find and publicize new treatments in order to forestall widespread adoption of generic treatments based on the old drug being replaced. This Health Affairs article [abstract] puts the cost of this to the public at $1.5 billion over a four year period.

I think we should shorten the protection period and push for generics over patented drugs except in the few cases where the new treatment is clearly more effective.

Just one more area of IP that is overbalanced towards corporate profits to the detriment of public good.

@sebastian

of course politics will be involved. There is no politics free zone where government is involved. But the political playing field will be tilted away from the powerful interest group lobbies and toward the consumers of health services.

That's what we all should want

Possibly, as long as we don't push it so far that we harm the profit motive for new research. Pharmaceutical profits may fund Caribbean vacations and private jets for pharma CEOs, but they also fund R&D on new drugs (which is expensive).

Research -- and my own personal experience -- shows that their effectiveness decreases over time.

This certainly happens with a variety of diseases. I'm not sure if having multiple companies offering alternative versions meant to be virtually identical is the most efficient way to deal with this, though, since the chemical modifications are driven by "different enough to market" rather than by addressing the effect you describe. A similar argument would apply in a more urgent way to antibiotic research, yet drug companies have dragged their feet on the whole antibiotic resistance threat.

Pharmaceutical profits may fund Caribbean vacations and private jets for pharma CEOs, but they also fund R&D on new drugs (which is expensive).

Good point. I don't think anyone's yet brought up R&D expenses vs. marketing expenses vs. CEO compensation, or the role of publicly-funded research in drug development.

"I'm not sure if having multiple companies offering alternative versions meant to be virtually identical is the most efficient way to deal with this, though, since the chemical modifications are driven by "different enough to market" rather than by addressing the effect you describe."

That isn't how it works in most cases (pretty much the main clear case where it worked like that was Claritin/Clarinex). In general it takes far too long for a drug to get to market (6-10 years) for that to be the case. You can't wait 10 years to compete with someone else's product and get the results you are describing.

What actually happens when you get similar drugs released a year or two apart is that two or three companies decided a decade ago that some channel or idea was worth investigating, and then they did it.

This is a GOOD thing, because in many cases only one of those drugs will make it through the toxicity trials and efficacy trials and you can't know in advance which one it is going to be. And if more than one make it through, they almost always have different side effects and/or patient profiles. Which again, is a good thing.

"A similar argument would apply in a more urgent way to antibiotic research, yet drug companies have dragged their feet on the whole antibiotic resistance threat."

People keep talking about this, but the lack of success at finding a good broad spectrum anti-biotic is not the same as a lack of trying. Bacteria has millions of years of evolution at adapting to harsh conditions behind them and they evolve quickly in the present. There have been repeated attempts to find new anti-bacterial agents, but at the moment they tend to get washed out for toxicity, and in some cases have serious adverse effects which don't show up until general release. Recent examples are: Trovafloxacin (liver damage) and Omniflox (severe allergic reactions and anemia) which were both withdrawn soon after release. Vanomycin and Zyvox are two recent antibiotics which have had their use sharply limited because they are so toxic.

(Part of this story is also FDA hyper-sensitivity, the sulfa family of antibiotics with 3% serious allergic reactions would almost certainly not have made it through the modern FDA).

But antibiotics are a very difficult thing to create. Bacteria is very resilient, and things which kill them will also kill you. Any pharma company would love to be able to find a new anti-biotic that isn't going to destroy your liver and/or kidneys.

People keep talking about this, but the lack of success at finding a good broad spectrum anti-biotic is not the same as a lack of trying.

However, as the IDSA, the ESCMID, and Institute of Medicine have all noted in recent years, there actually has been a broad "lack of trying" on the part of industry, especially relative to the weightiness of the public health issues involved. Zyvox is the only member of its defined-in-the-1980s class currently on the market, though there has been a laudable uptick in industrial interest in oxazolidinones lately, thanks to MRSA. But there was a really long dry spell for about 30 years where no new antimicrobial compound classes were commercialized by industry. And even the early stages of the pipeline are still a long way from overflowing.

"But there was a really long dry spell for about 30 years where no new antimicrobial compound classes were commercialized by industry. And even the early stages of the pipeline are still a long way from overflowing."

The ones I cited were in the last 20 years. There have been wipe outs in the last 3. The current obvious routes are mostly tapped out. We are likely to need another breakthrough in scientific understanding. Which could happen at any time. But you can't plan it. (See also why we haven't had any dramatic battery power breakthroughs in 20. It sure as hell isn't because the industry doesn't want a better battery).

There aren't new antibiotics for the same reason there is no AIDS vaccine: the obvious routes have been tried, and they failed. It isn't a conspiracy. Any company who had a good lead would/will jump on it.

The current obvious routes are mostly tapped out. We are likely to need another breakthrough in scientific understanding. Which could happen at any time. But you can't plan it. (See also why we haven't had any dramatic battery power breakthroughs in 20. It sure as hell isn't because the industry doesn't want a better battery).

There aren't new antibiotics for the same reason there is no AIDS vaccine: the obvious routes have been tried, and they failed. It isn't a conspiracy. Any company who had a good lead would/will jump on it.

Posted by: Sebastian

You don't see how this is consistent and indeed part of a piece with this:

Following up on liberal japonicus' link above, there's good reason to suspect that a big chunk of expense is being cultivated by the race not to find better treatments, but to find and publicize new treatments in order to forestall widespread adoption of generic treatments based on the old drug being replaced.

To put it in your terminology, the low-hanging fruit, starting with penicillin, pronosil, etc, has been pretty much picked over. The pharmaceutical houses are just ringing through the changes because they are unwilling or unable to do the basic research to open up new avenues of investigation (that part is left up to the inefficient government, apparently.) And at the same time, they want to protect their revenue stream :-(

To say that this produces nonoptimal outcomes, what some of us technically call a 'market failure' is to understate the case. In no way can this be called an example of the 'free' market working the way it should.

I don't believe in conspiracies; I just don't believe that the profit motive always aligns perfectly with public health needs, despite the extensive documentary evidence... Oh, wait, never mind.

You can't wait 10 years to compete with someone else's product and get the results you are describing.

This is shorthand for continuing something through the pipeline even after someone else has gotten there. ICOS was not very far along with their phosphodiesterase inhibitor (Cialis) when Pfizer noted the salutatory effects of their compound (Viagra). Whereupon it took 9 more years for them to get their competitive product to market. And since the arrival of Cialis and Levitra, progress on more selective phosphodiesterase inhibitors, which could be more suitable for the originally targeted cGMP-related phenomena, has stalled because the ED market is considered saturated. Though perhaps some of the academic research into NO-related processes targeted by Viagra will bear more fruit.

The ones I cited were in the last 20 years.

Right, which is why I said classes, as in classes of compounds with novel mechanisms. Because if they aren't novel classes, then you're using substitution on a known scaffold, or synthesizing a similar (usually 2D) shape. Trovafloxacin and Omniflox are fluroquinolones, a class first commercialized in the 1960s. Zyvox is a oxazolidinone, which was commercialized in the 21st century, and of which there is only one other variant in a major drug company's pipeline. There's the roughly thirty-year window with no novel classes emerging to market. And vanomycin isn't less than twenty years old, so perhaps you were thinking of something else.

So if we're distinguishing pathway breakthroughs from extensive application of substitution to known binding sites, the former is the thing that it's nearly impossible to plan for (though it helps to be looking), while the latter is much less of a bottleneck. Which is why we have all those oxazolidinones.

Anyway, this is an awful lot of work with no chance of getting anywhere, and the baby is fussy. joel hanes already posted a link to a view from UNC, which got conveniently ignored in favor of his attempt at an example that followed it. The Infectious Diseases Society of America's 2004 whitepaper should be online somewhere, for those interested, and presumably the Institute of Medicine's work as well. And perhaps someday I'll rant about industry's handling of more selective tiazofurin analogues for chemotherapy, but not today. So in the meantime, we can just blame the hyper-sensitivity of the FDA.

Also, I highly recommend NX Server / Client. Much easier than dealing with a VPN when one needs to access online journals from "on campus."

"Its time to go for the real deal on health care, and let the chips fall where they may. "

The best sentence of all here. Those disingenuous pols who block progress will get over it. Hell, they may even quit politics and get a real job.

The comments to this entry are closed.

Blog powered by Typepad