Mark Pine

Passing health care reform is not a game of chess. In a way, that’s too bad, because the president reminded me of the stories of legendary chess masters who could play a dozen games of chess at the same time and win them all. He debated every objection of each Republican, pointing to health care facts, legislative rules, and common sense ideas.

Who won the health care summit yesterday? The question was asked by a number of news analysts last evening. Was it the Democrats or the Republicans? Actually, it was President Obama, personally. He demonstrated command of the forum, competence as the leader of his party, and comprehension of the health care issue. He maintained a civil and personable demeanor for himself and conveyed that tone to the meeting as a whole, which might otherwise have degenerated to a political brawl.

The political fight, however, remains undecided as yet. The outcome depends on whether the summit provided wavering Democrats enough of political rational and support for those in the House to pass the Senate bill and for those in the Senate to pass through reconciliation a few fixes favored by the House.

During the meeting, the president said simply that he did not intend to start over and spend another year of his presidency negotiating health care. At bottom, that is what the Republicans are asking him to do. Acceding to this demand—when so many in both chambers of Congress have labored long and hard and come so close to succeeding—would be gross political incompetence and malpractice.

Angela F. Braily defended the notorious rate increases averaging 25% this year, which her health insurance company, Anthem Blue Cross, planned for its individual policyholders. She said,

We believe this was the most prudent choice, given the rising cost of care and the problems caused by many younger and healthier policyholders dropping or reducing their coverage during tough economic times. By law, premiums must be reasonable in relationship to benefits provided, which means they need to reflect the known and anticipated costs they will cover.”

Braily is the CEO of Anthem, a California subsidiary of Wellpoint, the for-profit insurance conglomerate. She is quoted this morning in the NY Times.

At the same time as healthy young adults are dropping her policies, she explained, charges for services of doctors, hospitals, drug companies, and other suppliers are increasing, and the population her company serves is aging and needing more care.

No one can doubt the fundamental truth of her explanation. Funny thing, though, these circumstances are exactly what justifies health care reform and show why her company and other for-profit companies aren’t well-adapted to cope with the surging health care costs and needs of Americans.

The primary obligation of a profit-making public company, like Wellpoint, is to protect and increase the value of the equity held by its stockholders, who own the company. Wellpoint must direct Anthem to produce a profit from the policies it sells. The company cannot choose to forego rate increases because times are hard, people are hurting, and health care needs are rising. To do so would violate the fiduciary obligation that Wellpoint owes to its owners.

But what would happen if new insurance regulations under health care reform prohibited such huge increases? Then Wellpoint executives would have no choice. They could forgo increases of that magnitude and still satisfy their obligations to shareholders. (Although the value of their stock might drop and their executives might not command such high salaries.

And suppose health care reform created a the option of buying coverage from public insurance plan, which could postpone big rate increases in hard economic times, because it would be non-profit and have no obligations to stockholders? Then Wellpoint executives would have to compete with that public plan and postpone or limit premium increases. They could forgo increases of such magnitude and still satisfy their obligations to their stockholders. (Although they might not be able to send their executives to lavish retreats costing millions of dollars each year.)

The health care summit the president has organized for today will give both Democrats and Republicans an opportunity to discuss fundamental problems with our American health care system. I will be watching to see whether one of the problems that gets discussed is the inherent conflict of interest between making a profit and providing affordable care of many health insurance companies like Anthem.

The genetic basis of many diseases is well-established and has been recognized for centuries at least and probably for millennia. Single-gene disorders are caused by a mutation in a single gene and an abnormal protein into which its mutated DNA gets translated. Examples include autosomal dominant disorders, like Huntington’s Disease; autosomal recessive ones, like sickle cell anemia; and sex-linked conditions, like hemophilia. In each case, a single protein functions abnormally. Polygenetic disorders involve several abnormal genes and the production of several abnormal proteins. Examples of such diseases include Type II diabetes and peptic ulcer disease.

But in the last decade it’s become clear that many genetic diseases may be associated with regions of the genome that don’t translated to proteins at all. An article this week in NatureNews reports that a mutation of an untranslated stretch of DNA on chromosome 9, one that is known to be associated with heart disease, causes an increased risk of atherosclerosis, the common form of cardiovascular disease involving the build up of fatty plaques in the arteries.

The mutation in the non-coding DNA, it turns out, affects two genes that do get translated into proteins. Researchers at Lawrence Berkeley National Laboratory deleted the mutated non-coding DNA in an equivalent region of the mouse genome. Aortic muscle cells from mice with the deletion made less of two proteins and multiplied much more rapidly. The reason was that the two proteins inhibit the multiplication of muscle cells in the walls of blood vessels (as well as other tissues). Such an effect might cause the growth of tissue blocking blood flow to the coronary arteries.

Over 90% of the DNA of the human genome is not translated into proteins. It was assumed to be nonfunctional DNA, consisting of remnant of once-functional genes, and has sometimes been called “junk DNA.”

In recent years, however, scientists have discovered that some non-coding DNA may get conserved in evolution—i.e., the frequency of mutations may be low, which suggests that it may serve important functions. Many non-translated genes have been found to have a regulatory function, serving as sites for the binding of proteins that control the translation of the coding DNA.

In the case of the non-coding DNA reported in NatureNews, the stretch of DNA is located more than 100,000 base pairs away from the protein-coding genes that it affected. It used to be thought that one gene produced one protein. But it’s now clear that this was a great oversimplification. Much of the genome that was thought to be junk does not get translated but does serve important functions.

On Sunday at the National Governors Association winter meeting in Washington, two physicians gave presentations on improving health care and cutting costs. Atul Gawande, a Harvard heart surgeon and writer for the New Yorker, and Jack Cochrane, executive director of the Permanente Foundation made a convincing case that health care in America could be improved at the same time as it was made less costly.

Gawande said that a lot of extra illness and high costs in health care come from mistakes that doctors make and the resulting complications. Many of these errors can be avoided by using simple checklists to make sure, for example, that blood and antibiotics are on hand in the OR, knowing the names of all the staff members, reminding staff to wash hands—things often forgot or overlooked.

Modern medicine is just too complicated, he said, for even the most brilliant doctors to hold all the information in their heads and remember all the proper procedures. When checklists bring the number of errors down, lives are saved and so is money. See Gawande’s appearance on The Daily Show.

Cochrane spoke about the computerized medical record system, KP HealthConnect, which is used throughout the nation in the 421 medical clinics serving Kaiser Permanente’s 8.6 million members. The system allows for better communication among the medical staff and between the staff and the patients.

Communication among staff encourages consultation, standardization, and mutual support and, which improves care. Contact between the patients and the doctors through a secure email system often facilitates solving care problems, while it cuts the time and expense of doctor visits.

Just as important, KP HealthConnect continuously and rapidly provides the organization with data on the health care it provides: usage, cost, and outcome. This yields improvements in practice, resolution of problems, and reductions in mistakes.

As a member of Kaiser Permanent of the Mid-Atlantic States, and a physician, I know that KP’s system works and saves money. I get care at a clinic about three miles from my home in Maryland. It costs me about $100 per month.

Most of the consultations I have with my personal physician occur via email. Because he knows my case well and has my medical record immediate available at his terminal, my doctor can often resolve my issue and prescribe medication and order tests, if needed, without seeing me and by writing orders electronically.

I can drop by the lab whenever I have the chance and can pick up the prescription immediately or have it sent by mail.

The cost of health care CAN come down, and health outcomes can be improved. But that won’t happen unless a new form of integration comes to our health care system. At bottom, that is the best reason for having a national health care system. What Gawande advises what Kaiser Permanente does can be applied nationally, but it won’t get done unless our whole system changes.

At the Unitarian-Universalist church I attend, the subject of the sermon yesterday was change. The senior minister is leaving after serving the congregation for twelve years. As is his wont, he began considering the subject from the largest perspective. He spoke of the universality of change, the paradox of change as the only constant, and of the value-neutrality of change, which in itself, is neither good nor bad.

His perspective narrowed as he went on, focusing on the intricacies of his personal transformation and that of the congregation and the church. But my mind remained with the large subject and a problem I have wondered about for years: What is the nature of time—that which makes change possible and brings it about? Surprisingly, I arrived at a new insight, one that took a major step toward clarifying the mystery for me. I put it out here on the web, for what it’s worth.

One part of the puzzle of time comes from the most fundamental ontological theories of physics, relativity and quantum mechanics. Both theories take time as a given, using time as parameter like space, and do not explain it. They are silent about time’s ceaseless progression from moment to moment and its unidirectional flow from past to future.

Both relativity and QM are symmetrical with respect to time. Their laws hold whether time moves forward or backward—or whether it doesn’t move at all, just rests as an infinite expanse where the events of the universe play out.

Only thermodynamics—also a fundamental theory, but not an ontological one—clarifies the nature of time by describing change quantitatively and specifying a direction. The second law requires that events move in sequence from states of fewer possibilities to states of more possibilities.

Thus, if salt and pepper are layered one above the other in a shaker, then shaking will mix the substances irreversibly. Underlying this change is the reality that that the number of different ways separated layers can occur is much less than the number of ways the mixture can occur. Because the probability of a state increases with the number of ways it may occur, it is almost impossible to shake the salt and pepper mixture back to separation.

But while thermodynamics deals with change quantitatively and probabilistically, it doesn’t account for the two things to my mind most characteristic and problematic of time—the specialness of present instant and its relentless forward march.

Indeed, none of the three theories explains why the present moment exists. Their laws do not change in the present moment and confer uniqueness upon it. For all three, the present is not different from any other moment.

As I wondered about time, listening to the minister, I suddenly came upon an idea that blended concepts from each of the three theories. This is that thought, as well as I can express it:

Relatively teaches that although time seems to move continuously, there is no one speed at which time moves. Time is like a train traveling from station to station, but the train can move at any speed (less than or equal to that of light). We perceive time only because the stations change from one moment to the next. Time is the sequence of events (the stations we pass through), not their rate of progression.

QM teaches that this sequence of events, which constitutes time, is a sucession of moments of observation. It describes the universe as a continuous expanse, consisting of the probabilities of all the events that can possibly occur: It is a probability function—the so-called “wave function of the universe”—which extends throughout the expanse of space and time. Time arises as material reality is observed at each instant, from one moment of time to the next. In the language of the theory, the universal wave function “collapses” to one actual universe at each moment of the present. By an act of observation in the present moment, from all the universes possible, the one actual reality comes to pass.*

Thermodynamics appears to join with QM and relativity in requiring that the probability function (wave function) of the universe be constrained so that the number of possible states of the universe (the number of possible universes) increases with each moment of time. Thus, thermodynamics specifies an order to the sequence of events that relativity and QM describe. In the past, the number of possible universes was less than at present. In the future, the number will be greater than now.

We human beings are participants in the process of observation, which determines which of the greater number of universes is actualized. By being among the observers, we experience from one moment to the next the sequence of observations of actual reality as they appear to us. We define the present moment (our present, at any rate) through our participation in the universal process of observation. We contribute to the actualization of the universe by adding our observations of it.

In that sense, time is a sequence of tasks that we take on and carry out, from one moment to the next.

*This idea makes use of the traditional Copenhagen Interpretation of Neils Bohr, one of the originators and formulators of QM. It ignores, the multiverse interpretation, according to which all possible universes exist simultaneously in any instant of time.

I received an email newsletter Wednesday from Scientific American, which included a link to a teaser on an article in the March issue of Mind. It concerned the effect of romantic fantasy on mental concentration. The note struck a chord in my memory about a phenomenon I experienced I repeatedly years ago.

The reporter wrote that “fantasizing about sex gets more than just your juices flowing—it also boosts your analytical thinking skills.” And as the author of the reported research paper , Jens Förster, was reported to have said, the effect was very strong, and I often wondered about it.

The article suggests that fantasizing about love enhances “holistic thinking and creative thought,” but in contrast sexual stimulation revs up “analytic thinking.”

As a student and young professional, I spent much time studying or researching in a library. (Now retired and past the age of needing to do that, I do my explorations on the internet.) But it often happened back then that at some table nearby by would be sitting a disconcertingly attractive young woman. Her presence would often provoke me to romantic fantasies, as well others of a more explicitly interactive variety.

Here’s what I noticed: When I succeeded in taking my mind off the woman and got myself back to work, I would remain in state of arousal that would provoke creative ideas, usually connected to the subject I was pursuing. I didn’t notice any difference in this regard from the effects of fantasies of romance and those of sex. Both types turned up my mental energy.

Did anything useful come form the increased creative energy, any new insight or understanding? Not often. Usually the efficiency of my work was cut considerably, as I would be distractible and thinking of extraneous things. But on at least one occasion, when I happened to be reading a research paper that reported a novel mechanism, I came up with a new hypothesis. And I used the creative energy productively to begin work on an article, which was published eventually.

Medical treatments in the U.S. are among the most expensive in the world, but they are not necessarily the most efficient at improving health. With the cost of health care rising rapidly, comprising one-sixth of the economy at present and moving rapidly toward one-fifth of it, improving health care cost effectiveness is vital to the future of the nation.

This month public health researchers from four medical schools (N.Y.U., Albany Medical College, Yale, U. Pittsburgh) and one school of public health (U. Pittsburgh), have published the results of a computer simulation of cost efficiencies that might result from moving to a value-based system of health insurance.

In the present U.S. health care system, the vast majority of patients pay fees (copays) for treatments based on their cost, regardless of their value to improve health. In value-based insurance, in contrast, copays would be eliminated for high-value treatments, while those fees would be increased for low-value treatments. As a result health care utilization would shift to the most beneficial health care interventions. The researchers used the computer to model the effects of such a shift.

As an example, copays could be eliminated for visits to the doctor for diabetics to get treatment of high blood pressure, but they would be increased for PET scans for dementia patients. While the former intervention prolongs life and improves health, the latter does not. Another example could involve the prescription of statin drugs for controlling cholesterol, an increasingly common treatment. Patients with >5% risk of heart attack within 10 years, would get the drugs for free. But patients with < 5% risk could have their copays raised, although they could still get the medicines, if they wished.

Based on Medicare data, the authors calculated approximately 60% of health care expenditures go for low-value services, but only 20% for high-value ones. They estimated the cost effectiveness of treatments from the Medicare data, dividing them into three groups. High-value - costing < $100,000 per year of life saved; intermediate value - costing $100,000-$300,000; low-value - costing > $300,000. Then, they modeled several value-based insurance strategies. In all strategies, the shift from current insurance to value-based insurance was constrained to be cost-neutral—neither increasing nor decreasing total U.S. health care costs.

In one model, copays for high-value treatments were eliminated, those for intermediate value stayed constant, and those for low-value were raised 30%. In comparison, with the current system, the researchers showed the advantages of a value-based system in improving life expectancy. Among those currently insured, the value-based system would increase the benefit of health care by 0.44 year of life, on average. Moreover, applying the cost savings of value-based insurance to subsidize coverage for the uninsured would increase the benefit of health care for that group by 1.2 years of life.

The researchers work appears against the background this week of a report by the CDC of a dramatic rise in the use of expensive medical procedures in the last 10-15 years. Between 1996 and 2007, outpatient use of MRIs and PET scans more than tripled. The percent of people taking a statin drug increased 10-fold. Use of assisted reproductive technology for inducing ovulation doubled.

Because these treatments and many others are extremely expensive to perform, it’s vital to understand how much benefit to health they bring. To that end, it will be necessary to carry out a huge amount of cost-effectiveness research in the years to come, particularly on expensive therapies. But even when such data becomes available, it will be necessary to find some equitable way to allocate care. The authors of this value-based insurance research have elucidated an important strategy for doing that.

Scientists at the University of Illinois have identified a bacterial vulnerability that may permit development of a new class of antibiotics. The weak spot is a group of chemical components of bacterial cell walls that don’t occur in higher animals, making their synthesis a target for new drugs. The components are found in tuberculosis germs and many other bacteria, and they also occur in malaria parasites, raising the possibility of a new treatment for that disease, as well.

In recent decades, the rise of multidrug resistant (MDR) bacteria, including varieties of Staphylococcus and M. tuberculosis, have raised the threat of untreatable infections. Both MDR Staph and MDR TB have been reported in the U.S. Consequently, scientists are searching for new ways to treat infections. The new discovery raises the possibility of a new way to combat these diseases.

The chemical components are isoprenoids, which are biologically synthesized from the chemical isoprene, a small 5-carbon organic molecule, one of the most common compounds found in living organisms. The scientists worked out the structure of the enzyme, IspH, which carries out the synthesis. Then they were able to design a new compound, PPP, that inhibits the enzyme. They reported that the substance is 1000 times more potent an inhibitor than any other known compound. As a result, it may be possible to develop new class of antibiotic drugs based on PPP.

Many years of research and testing, including clinical trials in humans, would be necessary before such drugs could become available. “But,” said Eric Oldfield, the lead scientist, “there are a finite number of proteins unique to bacteria and malaria parasites that can be targeted for the development of new drugs. And everyone agrees that this enzyme, IspH, is a tremendous target.”

On Sunday, the NY Times television reporter, Brian Stetler, wrote about the recent trend for politicians to become TV news analysts (e.g., Sarah Palin) and vice versa, e.g. (Chris Matthews, who was thinking about running for office last fall). The article unnerved and intrigued me. It and news of the recent SCOTUS ruling on corporate campaign spending, Citizens United v. F.E.C., provoked in my mind an afternoon of fantasy and imagination about things to come. This is one of my daydreams:

Article in the NY Times, February 16, 2016:

Comcast Corp. Backs MSNBC News Analyst, Rachel Maddow, As Presidential Candidate

Maddow Asserts Independence From Corporate Interests and Pledges to Build “New Consensus”

Flanked by her colleagues Keith Olbermann and Chris Matthews, who share with her prime time slots in MSNBC’s nightly news lineup, Rachel Maddow announced she would seek the presidency as the candidate of Comcast Corporation, the mammoth cable, internet, entertainment and information provider that owns NBC Universal, the parent company of MSNBC.

“I will work tirelessly and in the best interests of the American people to build a new consensus for unity and common purpose in government,” she said, pledging to end the “partisan division and political paralysis in Washington that has lasted for the past decade.”

She was introduced by Brian L. Roberts, the chief executive of Comcast, who said that Maddow had his full support, and he would refrain from “any and all efforts to influence Maddow’s positions and policies to benefit Comcast.”

The possibility that Maddow might run for president has been widely rumored for more than year, particularly because she has been featured in many MSNBC television advertisements, appearing on every television and cable network and the Internet, as an astute and incisive news commentator and political savant.

Comcast officials, who asked to remain anonymous because of the sensitive political nature of the announcement, confirmed that the company had been considering backing a presidential candidate for several years. All three prime time MSNBC news analysts had been discussed, but Maddow was chosen because of her popularity among a loyal and politically engaged segment of television viewers.

Maddow also enjoys the highest television viewership in the 9 p.m. slot, according to Nielsen Media Research.

Asked by a reporter about her status as the candidate of a corporation rather than a political party, she replied ….

The Biology of Political Affiliation

Each morning I listen to the call-in show on C-SPAN. If there’s one lesson that emerges day after day, no matter what the political subject or the viewpoint of the guest, it’s that the populace is bimodal on politics, to use the statistical term for a range of individuals with two different averages. One part of the range, the leftward, of which I’m a member, usually favors the Democrats and liberal or progressive ideas. The rightward part usually favors the Republicans and conservative ideas.

Recently, scientific discoveries have suggested that political philosophy may express biological traits. In the NY Times yesterday, the liberal columnist, Nick Kristof, wrote about research showing that when startled conservatives have stronger blink reflexes, and when they feel disgusted by something they see, their skin gets moister (indicating greater disgust) .

Moreover, as a group, women tend to get less disgusted than men, according to the research paper, “The Ick Factor” by political scientists at the Universities of Nebraska and Illinois, and Rice University. That finding might help to explain the well-known “gender gap” of politics that women favor Democrats more than men.

A research report in a similar vein appeared last month. Psychologists at Tufts University found that political affiliation may be reflected in people’s faces. The subjects of the study, undergraduate students, were able to predict political affiliation of other people (politicians and other students) significantly more often than chance by looking at the photos of their faces. The researchers elucidated the perceptions underlying the subjects’ judgments, showing that faces of Republicans appeared more powerful and faces of Democrats appeared emotionally warmer.

The research raises some interesting questions. Here are a few that cross my mind.

Callers to C-SPAN who profess no affiliation, the independents, often express an anger and weariness with the political partisanship and gridlock. They cast a plague on both political parties. I wonder how their startle and disgust reflexes would score and how their faces would be judged.

What effect would it have on the political discourse, if future researchers showed that a set of genotypes correlated highly with being a Republican or Democrat? Would we be forced to conclude that our political positions, no matter how well reasoned they seem to us, reflect predispositions, not facts?

In recent months, I’ve come reluctantly to consider that Democrats may not be able to put together among themselves the unity to accomplish their agenda. Could this be related to having a political affiliation based essentially on shared emotions? In contrast, Republicans seem to be able to forge a unity among themselves as strong as steel. Could that be related to a having a political affiliation based on the quest for power?

Could it turn out, at bottom, that one side (Democrats) is better at identifying the common good and the policies to bring it about, but the other side (Republicans) is better at achieving objectives?