Mark Pine

In a stunning medical discovery, neuroscientists at U.C. Irvine restored nerve function a month after inducing strokes in the brains of laboratory rats.

A postdoctoral researcher, Magda Guerra-Crespo, blocked the middle cerebral arteries of rats. A month later (equal to about a year in a human lifetime), she injected into the animals’ brains a growth factor protein that stimulates nerve stem cells to proliferate. A month after that, the rats had regained almost all of the behavioral function that they had lost after the induced stroke.

In the first report of the research, published a year ago in the journal Neuroscience, the scientists showed that the protein, transforming growth factor alpha (TGF-α), stimulated nerve cell proliferation, migration of new cells to the cite of stroke injury, and differentiation of the cells into appropriate neuronal cell types. Then this week, the same group reported success in restoring 70% of the rats’ behavioral function by administering TGF-α intranasally. Previously, they had injected the protein directly into the rats’ brains.

The possibility of administering the substance without having to inject directly into the brain greatly advances the possibility of a viable treatment for humans. The work raises the prospect that, long after their brain injuries, human stroke victims could experience significant restoration of their motor abilities simply by spaying the growth factor into their nostrils. Nevertheless, such a treatment is a long way off. Not only must the research be replicated and validated by other neuroscience groups, but an actual medical therapy would require further animal testing and clinical trials of safety and efficacy in humans.

The possibility of a treatment that cures strokes is the outcome of an amazing chain of neuroscience research that overturned a century of scientific belief that the brain cannot regenerate. First in birds in the 1980s and then in mammals in the 1990s, scientists demonstrated that new brain cells do arise. Since then, nerve regeneration has been discovered in humans. In the past year, scientists reported that neural stem cells can arise throughout the brain.

The potential for stroke treatment opens a hopeful therapeutic window for one of the most common and intractable diseases.

When copays increase for outpatient care, elderly patients on Medicare visit doctors less often but end up in the hospital more often, according to a study by health policy researchers at Brown University and the V.A. Medical Center in Providence, RI. The results were reported in the New England Journal of Medicine today.

Using a Medicare database, the researchers compared the behavior of 900,000 Medicare patients, 65 years old and older, enrolled in 36 managed care health plans. Among these plans, 18 plans (called the “case” plans) increased copays for outpatient doctor visits between 2001 and 2006, without increasing copays for prescription drugs. Those plans were matched with 18 other plans (called the “control” plans) that did not increase outpatient copays for visits or drugs. For each case plan and its control, and for the case and control groups, they compared annual outpatient visits per 100 members in the year before and year after the date that the case plan raised outpatient copays.

The researchers found that the annual number of outpatient visits increased by 18.5 (2.6%) per 100 members in the case plans and 45.5 (6.0%) in the control plans. Although the case plans had less of an increase in outpatient visits, they had a greater increase in inpatient utilization. Per 100 members, the case plans experienced increases of 2.3 (9.1%) more admissions and 12.4 (9.3%) more hospital days between the two years. In comparison, the control plans had increases of 0.3 (1.1%) admissions and 1.1 hospital day (0.9%).

These effects of increasing outpatient copays in the case plans were magnified for their low-income and less educated members, and for their members with hypertension, diabetes, or history of heart attack. The authors also reported that in Medicare managed care programs nationally, outpatient visits increased by an average of 4.7% per year during the five years examined.

Thus, for the case plans, their increase in revenue and reduced expenses related to raising copays for outpatient visits cost them money, when inpatient care is considered. The authors reported that for an average case plan, outpatient savings would amount to about $7,000 per year per 100 members. But inpatient costs would rise by $24,000.

Last evening President Obama said that the nation must enact “health insurance reform,” despite the fears and objections of many Americans expressed in the recent Massachusetts election. This research report, which shows how efforts of managed care insurance companies to control costs may backfire, supports the president’s assertion.

Another notable finding in the article gives even more support. The researchers also compared dropout rates among members of the case plans and control plans. Among the 900,000 patients in the cohort, those in case plans showed a dropout rate of 12.2% in the year after the increase in copays. In comparison, 11.1% of those in control plans left their plan. The difference was statistically significant, and so it’s likely that many of the dropouts did so in relation to the increased fees.

What happened to those dropouts who exited because of the increased costs? If they left because of costs, many of them might have foregone insurance altogether, deciding to rely on emergency room care. That form of care is, of course, the most expensive, least cost-effective form of health care that our nation offers.

On January 18 in the NY Times, Stanley Fish, a columnist at the newspaper, wrote a column on Barbara Herrnstein Smith’s book on science and religion, Natural Reflections: Human Cognition at the Nexus of Science and Religion. This week the author responded. My post today addresses one aspect of the issues raised by Herrnstein Smith and Fish:

Might it be said that science and religion not only can coexist but be consistent, even reinforcing? I think it might. This assertion concerns the ontological question that science and religion address, their dispute about the fundamental ground of existence.

Scientists (when they are doing science) understand the world as composed of material things: atoms, molecules, cells, organisms, etc. Science involves observations and experiments in the material world, and it develops theories about how that world works.

In contrast, religions reject the concept of the material world as the fundamental reality in favor of nonmaterial existence—usually called spirit, God, or Nirvana. In the religious context, material reality is understood as a more or less illusory and transient form of existence.

This divergence, in my view, constitutes the core ontological conflict between science and religion. The conflict cannot be eliminated by viewpoints that see science and religion as valid each in their own spheres or both as the products of the human intellect, as I think Fish and Herrnstein Smith hold.

But the conflict does cease (or is greatly reduced) if both science and religion can be shown to allow for both material and nonmaterial existence.

Religion already does this, since no religion denies the reality of material existence, even if it is considered an illusory reality, as in Buddhism. But science also supports both concepts of reality in quantum mechanics, which is the scientific explanation that most directly addresses the fundamental nature of existence.

The core principle of quantum mechanics is called duality, and it asserts that everything that exists can be described equally well in two alternative forms: as a particle or as a wave function. Both descriptions are equally valid, the theory asserts, but if you choose to use one of them, you cannot contaminate the description with concepts from the other one. They are both true but also mutually exclusive.

The particle description applies to material things. Its concepts refer to mass, energy, charge, location in space and moment in time. When using the particle description, one asserts that reality consists of particles.

The wave function description, in contrast, refers to ideas: mathematic relationships, probabilities, and operations. Indeed, quantum mechanics holds that the wave function, which is a mathematical relationship, actually exists. When using the wave function description, one asserts that reality consists of mathematical relationships, which are nonmaterial things that exist in the realm of ideas.

In my view, since this fundamental physical theory permits descriptions of the universe in both material and nonmaterial terms, the conflict between science and religion regarding the nature of existence is abrogated.

In describing the universe as made of wave functions, one uses language appropriate to conceptual things. Wave functions can combine, overlap, and apply to disparate and widely separated things. Wave functions do not exist within space and time but span them and therefore transcend them.

In quantum mechanics there is even the concept of the wave function of the whole universe, which specifies all the possible forms that the universe may assume. Moreover the universal wave function assigns to all possible forms of existence probabilities that determine which forms the universe actually assumes. That sounds remarkably like the religious concept of God, at least to me.

I am a member of your political base. Everyone in my family voted for you for president. I’ve contributed to Democratic campaigns, and I’ve worked for Democrats in all the most recent elections, calling out voters on Election Day, going door-to-door in the weeks before, even traveling around the country to help Democrats in several recent elections. You cannot win without people like me.

But you will lose me as a supporter if you don’t lead the way to pass a strong health care reform bill.

This morning, The New York Times implored you to continue the health care reform struggle. Last week, the newspaper’s columnist, Paul Krugman, urged House Democrats to pass the Senate bill, which he said is “much, much better than nothing.”

I agree. If you lead with strength, vigor and purpose, I believe, you can persuade the Speaker and the members of the caucus to follow this route and pass the Senate bill. The Senate could promise in return to pass measures dear to House Democrats through reconciliation.

Your own political advisor, David Plouffe, argued for passage of health insurance reform without delay. Cost control measures, particularly those that reward effectiveness and efficiency—like identifying the best treatments and bundling payments with incentives for good outcomes—could come later, perhaps through reconciliation also, since they might target budgetary expenditures.

So far, in my view, you and many Democrats have taken your base supporters for granted and have let us down. Your policies until now have yielded to Wall Street bankers, who caused so much trouble, and Republicans, who adamantly oppose you and will never compromise, at least not this year after the Massachusetts debacle. You have shown your strongest supporters to the tail end of the priority queue.

I am no longer certain that it is better that we elected you than John McCain. I’m not sure that your policies are so different.

What I am saying is that if you don’t show strong leadership to pass progressive policies—especially health care reform, which would help members of my own family—by pushing hard to get legislation through Congress, using the substantial majorities you still have in both chambers, then I won’t see any reason to continue working, contributing and voting for you.

Please give me a reason to continue to support you and the Democrats.

The American system of government was spelled out 220 years ago in the Constitution and the Bill of Rights. The honored document has guided the nation through good times and bad, times of peace and war. But writ by men, it is not perfect, and it contained substantial flaws when adopted—the discrimination between “free persons” and “all other persons,” the indirect election of the president and senators, and the omission of universal suffrage, as examples.

The events of the past year perhaps suggest that time may have caught up with the Constitution, which like other human documents, cannot not be expected to excel forever.

Our government seems nearly paralyzed. The work of the Senate, in particular, has ground to a halt. The election of one senator in Massachusetts seems to have scuttled the entire Obama agenda. Yet the Democrats still have significant majorities in both houses of Congress. And the bruited rationalization that they’ve lost their supermajority is questionable, since they almost never had one in practice.

The nation faces immense problems: reducing unemployment, fixing health care, reversing the increase in carbon emissions and climate temperature, enacting financial regulations and regulating immigration, to cite a few. But chances are none of these issues will get addressed this year. And it looks as though the consuming, excruciating, yearlong health care struggle just wasted time and enervated political will.

When the structure of the Senate was originally specified, with two Senators from each state, the United States was a newly created federation and the main challenge was establishing a lasting, successful union. In 2010, the main challenge is maintaining the strength and vigor of the American nation, as one among the nations of the world. To do that, we must be able to act as one nation, not a federation of 50 governments.

But the Senate requirement for supermajorities and the individual rights of each senator encourage regionalism and fragmentation of government rather than strengthen unity.

Our system contrasts with the parliamentary system, exemplified by the British House of Commons, which Americans can watch regularly on C-Span. In that unicameral legislature, party unity is paramount, and the prime minister, as chief executive and legislator, must enact a program or the government quickly falls and new elections ensue. That system reinforces unity of purpose and action.

America vitally needs more of that unity, as the polls of the populace and the present paralysis suggest.

The suitability of some of the first Constitutional amendments, adopted concurrently with the main document, also seems questionable in the modern era. The recent Supreme Court decision adds even more power to the political speech of the most powerful speakers, and it makes one wonder about the near-absolute guarantee of free speech of the First Amendment.

Open public discourse remains central in the lives of Americans and vital to the unalienable rights guaranteed in the Declaration of Independence. Yet in the current era of science and technology, the nature of the discourse is often so specialized and complex that many citizens do not have the knowledge to understand it or come to sensible conclusions. Consider the convoluted debates over health care, climate, energy, fiscal and economic policy, etc.

At the same time, unconstrained free speech, protected by the Constitution in this era of pervasive mass communication, paradoxically raises the volume of the moneyed speakers and the outrageous screamers. Examples include direct-to-consumer drug ads, other infomercials of huge corporations, ads by political organizations, as well as diatribes by partisan commentators on radio, television and the internet.

The Second Amendment seems another example of the anachronism of the founding document. In a time when America was mostly wilderness and the military power of the national government minimal, the arms of individual citizens were indeed “necessary to the security of a free State.” It is highly questionable whether that assertion of the amendment remains true today.

Of all the Constitutional stipulations, the most out-of-date may be the requirement for ratification of amendments by three of four states. The provision preserves the particulate nature of the American polity, to the disadvantage of its unity and coherence. It makes modifications contingent upon ratification by 37 separate governments, an almost impossible task. Notably, the actual Constitutional article did not specify ratification by three-quarters of the states but by nine. The Seventh Article was evidently a concept of its moment in history.

A revered guiding document, which has served us extremely well, the Constitution should not be abandoned. Yet a parliamentary system in some ways better integrates the two opposing requirements of a successful modern democracy: efficient government and responsiveness to the electorate. Perhaps it’s time to reconsider the Constitution, to ponder possible modifications to incorporate some strengths of that other major system of government by the people.

“Freedom of the press,” wrote A. J. Liebling, the correspondent for the New Yorker in the 1930s and 1940s, “is guaranteed only to those who own one.” Yesterday’s Supreme Court decision extended that cynical, circumscribed guarantee to corporations in regard to all the media.

The freedoms of expression guaranteed by the First Amendment are inescapably bound up with the costs of publicity. In political expression and especially in political campaigns, the essential issue is not whether free expression is permitted at all. Nowadays anyone with an Internet connection can have a say. But a real guarantee must entwine freedom with equality. True freedom of expression must do more than prohibit its restriction; it must also level the field.

In Citizens United v. Federal Election Commission, the court has dealt with only one side of the balance. It has tilted the scales in favor or the wealthiest and most powerful interests in our society. As the editorial in the NY Times said today, “If a member of Congress tries to stand up to a wealthy special interest, its lobbyists can credibly threaten: We’ll spend whatever it takes to defeat you.”

The 5-4 decision intervened directly and willfully in support of one side in the political life of the nation. It is reminiscent of the court’s obdurate intrusion in the 2000 election in Bush v. Gore.

Commenters, especially on the left, have cried foul, asserting that American political discourse in forever changed. Barney Frank (D-Mass), chairman of the House Financial Services Committee, said the decision called into question the meaning of democracy.

But the Massachusetts Democrat also has a plan. His committee has jurisdiction over corporate law. The court overturned election laws. But corporations exist in consequence of corporate law, which establishes them, grants them privileges, and regulates their behavior.

“We have the power in the public sector to regulate the behavior of corporations,” Frank said last evening. He and his committee will “cooperate with the administration in drafting the toughest possible Constitutional legislation to prevent the drowning of American democracy in corporate dollars.”

Now is the time for Democrats to fight and fight hard. Obama extended an open hand across the political fence. The Republicans spat in his face. The Democrats tried to build a bridge across the political chasm. The Republicans put up a stone wall.

Some politicians urge the Democrats to slow down in the aftermath of their loss in Massachusetts. Critics everywhere advise them to trim their plans, diminish their programs. Perhaps the Democrats should seat Scott Brown before moving forward, since doing otherwise would be playing dirty. So seat him. And then ram health care legislation through to victory, by whatever legislative means.

Last evening on the Rachel Maddow program, Pennsylvania Governor Ed Rendell, flush from the triumph or rescuing dozens of orphans in Haiti and bringing them to this country, was asked by the host about advice from some Democrats like Joe Lieberman that the party should dial down its agenda. Rendell responded,

It’s time for us to fight back. If we’re going to go down in 2010, lets go down doing something and fighting for things we believe in as Democrats.

He proposed that the Senate leadership should break the health care legislation in parts. One bill would ban insurance companies from discriminating on preexisting conditions and denial of coverage for expensive treatments, and it would take away the companies’ antitrust exemptions. Dare the Republicans to vote against that bill, Rendell advised. Then when it passed, he predicted, the insurance companies would come to Republicans and Democrats and push for legislation to mandate universal health care, since it would have become a financial imperative for them to collect premiums from all Americans, both the sick who need care and the healthy who refuse coverage or skimp on it.

Rendell also recommended Democrats get tough on Republican filibusters, which they used time an again, twice as often in 2009 as any other party in a legislative year. If the GOP wants to talk a bill to death, make them do that in real life, not in the virtual world of legislative procedure. Americans should be able to watch Republican senators talk the country to a stalemate on C-SPAN. Because if there is one thing that the Massachusetts election showed that Americans despise it’s gridlock and paralysis in Washington. Force the Republicans to demonstrate to the country what stumbling blockheads they have become.

We Democrats are predisposed to seek community, consensus, and compromise. These are core liberal values. In contrast, Republicans are inclined to be warriors. They support the use of force. They decry Obama’s offer of an open hand in international relations with America’s enemies. Instead they would twist arms and deploy armaments. In their views and attitudes, the Republicans are telling Democrats how to treat them and what kind of treatment from Democrats they would respect.

In America, nothing succeeds like success. Nothing wins like being a winner. Democrats must fight. Democrats must win. Democrats have the advantage. Now is the time press forward and use their superiority to achieve legislative victories on their immensely important programs on the economy, health care, the environment, and energy. The nation would be grateful, the world would be grateful. History would judge them great.

Can the national government govern?

The headline today in the NY Times says that health care reform legislation is imperiled.Yet the Democrats had a supermajority and they still have the advantage in the Senate 59-41. If they can’t they pass health care reform, Americans should wonder why they cannot and why the election in one of 50 states should exert such national impact.

In the British parliamentary system, the government of prime minister and cabinet is composed of members of parliament. The PM insists on party discipline and can dissolve parliament if it fails to move forward on the government’s agenda. Consequently, all the members of the governing party usually support the government in all legislative actions.

Our House of Representatives also has a strong legislative leader, with key powers vested in the Speaker. But the Senate is different. Members are legislative powers in their own right and often choose their own course. The Senate’s 60-vote rule enhances the power of each member, and the Senators individually can block certain actions by fiat, like confirmations of appointments.

Throughout our history, the Senate system has given expression to the diversity of the American nation, and it has allowed a large degree of regionalized choice. But nowadays, America needs to act decisively as one nation on vital issues. Difficult and complex problems – health care, the economy, global warming, the environment, energy, confronting terrorism – require strong leadership and effective execution.

In reaction to the events in 2009 – the painfully drawn out health care struggle and the dysfunctional, senseless partisanship – I believe the time has come to reevaluate the nature of our government, particularly the organization, role and functioning of the Senate.

We are brought to the current situation, which may bring stalemate to the entire agenda of the president and the Democrats, by the Massachusetts party’s choice of a dour, ineffective candidate. But I don’t think Coakley would have failed had it not been for the excruciating year-long struggle on health care, which caused so many Americans doubt, dismay, frustration and anger at government, as it went on and on and on.

Can anyone deny any longer that our system of government seems paralyzed? Much of the blame lies with Republicans. In reaction to dramatic legislative setbacks, they determined that only ironclad opposition and unswerving party unity could bring them back to power. They may have been right.

And although Democrats had to play they hand they were dealt – impending financial disaster, massive unemployment, numerous other intractable issues – they lacked effective leadership in the administration and the Senate.

Only Speaker Pelosi led forcefully and decisively. But hers is but one part of two legislative and one part of three effecting divisions of government. America needs all three to work capably to move forward in this century.

On this day when America awaits the outcome of the Massachusetts election that may determine the fate of health care reform, it’s worth reading a remarkable article in the Houston Chronicle about health care costs in that city. The newspaper reported yesterday that one expensive provider in Houston charges 7 times more ($869) for a brain CT scan as the lowest cost facility ($128). This kind of scan is ordered often, probably for most head injuries and even severe headaches (just to make sure); so this finding has huge implications for the overall cost of health care in Houston.

Here’s another example: The cost in Houston of an MRI of the back ranged from $425 at one clinic to $2139 at one hospital.

Large differences also turned up when costs were analyzed by disease as well as procedure. The Chronicle found that the fees for treating breast cancer among physicians practicing within 10 miles of each other in southwest Houston ranged from $14,000 to almost $20,000.

Houston is a city where many residents increasingly choose consumer-driven health plans, which have high deductibles that result in patients paying for many services. But comparative price shopping for health care services is difficult or impossible for Houston patients, according to the newspaper. Prices are usually unavailable until the bill arrives.

The Dartmouth Atlas of Health Care, a project of Dartmouth Medical School, has documented variations in health care costs all across America. The data has informed the health care debate. In September, a summary of some of the results of analysis of the atlas was published in the New England Journal of Medicine.

Using the Medicare Current Beneficiary Survey data from 2004-2005, the authors of the analysis divided regions of the United States into quintiles based on cost of care. Patients in the most expensive regions cost the system 50% more ($3,300 per year on average) than those in the least expensive areas. Most of the difference (70%) was explained by regional cost variation and not by differences in the patients. That is, regional cost variation amounted to $2100 per year per patient on average. The researchers found that the main factors raising charges in the high-cost areas included longer hospital stays, more doctor visits, and more MRI and CT scans per patient.

But the extras did not result in better quality of care, according to [PDF] the Dartmouth analysis.

Republican Senate leader Mitch McConnell has called today’s Massachusetts election a referendum on health care reform. Perhaps it is. On C-SPAN’s Washington Journal program this morning, several callers opposed to health care, including some living in Massachusetts, agreed with the senator’s assessment. They seemed outraged by the prospect of government getting more involved in health care. Yet the Houston data suggests that government oversight is exactly what is needed.

I wonder why Americans should differ from citizens of other western nations. All advanced countries except the United States have systems of universal health care guided and regulated, and in some cases owned, by their national governments. Why should the prospect of such a system make so many Americans unhappy? If the Democratic reform passes and we get such a system, will we Americans feel so differently about it from the people in all those other countries? I think not. By all reports the people in other countries value their health care systems and wouldn’t change their governmental structure.

I spend 5 months a year in the Bay State. I understand that despite its concentration of the liberal intelligentsia, the state is populated predominantly by regular working people. Their concerns are local and personal, and in an ongoing jobs recession, mostly focus on making ends meet. That is as it should be.

Except right now.

Coming at this moment, when the Congress pushes forward on the final steps of health care reform, the special election will have a huge national impact. Not only will it decide whether the Democrats keep their 60-vote supermajority, but probably also whether the program of the President and Democrats remains feasible.

A Republican victory in Massachusetts will raise doubt whether the American people can tolerate the uncertainties and adjustments required to make the major changes that Obama and his party have promised. In particular, the health care struggle of 2009 has demonstrated the difficulty and precariousness of enacting reforms in America.

The Massachusetts electorate, usually among the most progressive in the nation, has watched the battles in Congress with mounting alarm, as has the rest of America. The negative reaction of so many voters, even in one of the bluest states, shows how intense feelings have become.

It is an irony of ironies that the health care reform hangs in the balance in consequence of the fate of the late Senator Kennedy, who championed the cause for so much of his life. Yet his death has undermined his cherished goal: first by eliminating him as the leader of the Congressional effort, and now with the election to replace him a day ahead, by providing an opportunity for the voters to voice anxiety and dismay.

If Reid and the Senate Democrats had foreseen this possible effect of their drawn out legislative process, letting it extend into the next year, they might have acted more quickly. As things stand now, we have to hope that Massachusetts voters come to understand that theirs is not simply—not even primarily—a state decision. We have to hope that they choose for the good of the country as a whole.