Author: A.T.

What Congress should really be working on.

From the Wall Street Journal:

The Smart-Medicine Solution to the Health-Care Crisis
Our health-care system won’t be fixed by insurance reform. To contain costs and improve results, we need to move aggressively to adopt the tools of information-age medicine

By Eric Topol

. . . No matter how the debate in Washington plays out in the weeks ahead, we will still be stuck with astronomical and ever-rising health-care costs. The U.S. now spends well over $10,000 per capita on health care each year. . . .

. . . Our health-care system is uniquely inefficient and wasteful. The more than $3 trillion that we spend each year yields relatively poor health outcomes, compared with other developed countries that spend far less. . . .  more than 1 in 4 patients harmed while in the hospital; more than 12 million serious diagnosis errors each year; a positive response rate of just 25% for patients on the top 10 prescription medications in gross sales.

. . . Radical new possibilities in medical care are not some far-off fantasy. Last week in my clinic I saw a 59-year-old man with hypertension, high cholesterol and intermittent atrial fibrillation (a heart rhythm disturbance). Before our visit, he had sent me a screenshot graph of over 100 blood pressure readings that he had taken in recent weeks with his smartphone-connected wristband. He had noticed some spikes in his evening blood pressure, and we had already changed the dose and timing of his medication; the spikes were now nicely controlled. Having lost 15 pounds in the past four months, he had also been pleased to see that he was having far fewer atrial fibrillation episodes—which he knew from the credit-card-size electrocardiogram sensor attached to his smartphone.

In my three decades as a doctor, I have never seen such an acceleration of new technology, both hardware and software, across every dimension of medical practice. . . .

Smart medicine offers a way out, enabling doctors to develop a precise, high-definition understanding of each person in their care. The key tools are cheaper sensors, simpler and more routine imaging, and regular use of now widely available genetic analysis. . . .

One obvious practical effect of these developments will be to replace hospital stays with remote monitoring in the patient’s home. The Food and Drug Administration has already approved wearable sensors that can continuously monitor all vital signs: blood pressure, heart rate and rhythm, body temperature, breathing rate and oxygen concentration in the blood. The cost to do this for weeks would be a tiny fraction of the cost for a day in the hospital. Patients will be able to avoid serious hospital-acquired infections and get to sleep in their own beds, surrounded by family.

We do more than 125 million ultrasound scans a year in the U.S., at an average charge of well over $800 — that’s $100 billion. But we now have ultrasound probes that connect with a smartphone and provide exquisite resolution comparable to hospital lab machines. It is possible to examine any part of the body (except the brain) simply by connecting the probe to the base of a smartphone and putting a little gel on the probe’s tip. When I first got a smartphone ultrasound probe last year, I did a head-to-toe “medical selfie,” imaging everything from my sinuses and thyroid to my heart, lungs, liver, gallbladder, aorta and left foot.

That experience came in handy when I recently developed pain in my flank. Seeing my very dilated kidney on my smartphone screen helped to confirm the diagnosis that I had a kidney stone. The CT scan later ordered by my doctor showed a nearly identical image, but the charge for that was $2,200. If this single tool was used in a typical office visit, a large proportion of expensive and unnecessary formal scans could be avoided.

Smart medicine can also bring some sanity to how we handle medical screening, which today results in an epidemic of misdiagnoses and unnecessary procedures and treatments. The leading culprits are routine tests for breast and prostate cancer for individuals at low risk for these diseases. Because the tests have such extraordinarily high rates of false positives, they result all too often in biopsies, radiation and surgery for people in no medical danger.

It would not be hard to use screening tests in a more discriminating way, for the much smaller population that really should worry about certain serious health problems. Genome sequencing for an individual — identifying all three billion base pairs in a person’s genetic makeup — can now be done for about $1,000, and we know a great deal about which genes predispose someone to conditions such as cancer and heart disease. . . .

Routine use of individual genetic information could also allow us to prescribe drugs more effectively, avoiding the waste, in clinical time and in money, caused by medications that misfire. . . .

Smart medicine can also transform the doctor-patient relationship. Most medical services today are still provided in the traditional outpatient setting of a doctor’s office. It takes an average of 3.4 weeks to get a primary care appointment in the U.S., and there’s little time allotted for each visit. Most doctors provide a minimum of eye-to-eye contact as they busily record the session on a keyboard.

The frustrations and inefficiencies of this system are obvious — and unnecessary. In the era of telemedicine consults, there is no reason to wait weeks for an appointment. For the same copay as an office visit, connection with a doctor can occur instantly or within minutes. With increasing use of patient-generated data from sensors and physical exam hardware that connects with a smartphone, the video chats of today will soon be enriched by extensive data transfer. . . .

. . . In a paper last year in the Journal of the American Medical Association, authors Andrew Beam and Isaac Kohane, specialists in biomedical informatics, calculated that advances in artificial intelligence now make it possible for computers to read as many as 260 million medical scans in a day, at a cost of $1,000. The advances in diagnostic power would be enormous, to say nothing of the cost savings. . . .

Fortunately, serious ventures in smart medicine are well along. . . .

But more could certainly be done to move us toward better health outcomes at lower costs. Perhaps some enterprising member of Congress will propose a Frugal Health Care Innovation Act, providing government incentives for technology, research and implementation. Such public support for electric cars has rapidly changed the face of the whole auto industry. American medicine today is no less antiquated than the Detroit of a generation ago, and it needs to find its way into the present century.

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Dr. Topol is a cardiologist and professor of molecular medicine at the Scripps Research Institute in San Diego and the author of The Patient Will See You Now: The Future of Medicine Is in Your Hands. He consults for Illumina and Apple on some of the issues discussed here, sits on the board of directors of Dexcom and is a co-founder of YouBase.

First — magic!  (How do they DO this?)

But now, what could be true magic:  How to Make Congress Bipartisan, by National Review executive editor, Reihan Salam, and FairVote executive director, Rob Richie, in the New York Times.

You already know the bad news — a completely dysfunctional, polarized legislature.

 . . . The good news is that there is a way out: replacing our winner-take-all elections with a form of proportional representation where every voter matters in every election. It comes in the form of the Fair Representation Act, a bill introduced recently by Representative Don Beyer, a Democrat from Virginia, that is centered on two key changes.

Step 1 is to elect House members with ranked-choice voting in primary and general elections, a system proven in a dozen cities and adopted in Maine for congressional elections. Voters are able to rank candidates in order of choice, and their votes go to second choices if their first choice is in last place and loses.

Step 2 is to establish congressional districts with multiple representatives. Smaller states with fewer than six seats would elect all seats statewide. In bigger states, independent commissions would draw districts designed to elect up to five seats based on traditional criteria like keeping counties intact. Multi-winner districts were used in some House elections as recently as the 1960s and remain common in local and state elections.

What would transform politics would be combining [the two]. . . .

Consider Connecticut, where Democrats in 2016 easily won all five congressional seats, and Oklahoma, where Republicans won all five seats by landslide. Under the Fair Representation Act, House candidates would run statewide in both states. Voters would rank the candidates on their ballots. In the first round of counting, any candidate with one-sixth of the vote plus one would win a seat, while the last place candidate would be eliminated and her votes redistributed among the remaining candidates. This process would continue until all five seats were filled. The complex math of the process is in service of a simple principle: ensuring that a majority group elects the most seats, but not more than its fair share.

The result: Republicans would likely win two seats in Connecticut, and Democrats a seat or two in Oklahoma. And the same result would be replicated across the nation: A computer projection of how the law would work showed that in all states with at least three House seats, there would be no single-party districts.

That means there would be rural Democrats and urban Republicans. Members of both major parties would share districts, with new incentives to collaborate on legislation addressing their shared constituents’ needs. Candidates would be forced to reflect a greater mix of views and voters would have real choices, including third party and independent candidates. A more representative and functional Congress would regain legitimacy.

Congress not only has the power to act to reform its elections, but the obligation. In the past, it mandated single-winner congressional districts to avoid partisans manipulating outcomes with at-large elections, but that approach has led to today’s polarized politics. It’s time for a better standard.

Spread the word.  And could we please get rid of the Electoral College?  Here’s how we get that done: The National Popular Vote Interstate Compact.  Spread that word, too.

Because as Thomas Jefferson put it in 1816 (later inscribed on the Southeast Wall of his Memorial): “I am not an advocate for frequent changes in laws and constitutions. But laws and institutions must go hand in hand with the progress of the human mind. As that becomes more developed, more enlightened, as new discoveries are made, new truths discovered and manners and opinions change, with the change of circumstances, institutions must advance also to keep pace with the times. We might as well require a man to wear still the coat which fitted him when a boy as civilized society to remain ever under the regimen of their barbarous ancestors.

And what country looks to us for leadership now?

Here is the view of Trump from Australia — an “uneasy, lonely, awkward figure” who was left “isolated and friendless” with “no desire and no capacity to lead the world.”

. . . we need to give up on any hope that the speeches written for Trump and delivered by the man himself are any reflection of his true thoughts.

It’s the unscripted Trump that’s real: a man who barks out bile in 140 characters, who wastes his precious days as President at war with the West’s institutions like the judiciary, independent government agencies, and the free press.

Mr Trump is a man who craves power because it burnishes his celebrity. To be constantly talking and talked about is all that really matters… and there is no value placed on the meaning of words, so what is said one day can be discarded the next.

Here is the view from Germany — Trump “has transformed the United States into a laughing stock and he is a danger to the world. He must be removed from the White House before things get even worse.”

Donald Trump is not fit to be president of the United States. He does not possess the requisite intellect and does not understand the significance of the office he holds nor the tasks associated with it. He doesn’t read. He doesn’t bother to peruse important files and intelligence reports and knows little about the issues that he has identified as his priorities. His decisions are capricious and they are delivered in the form of tyrannical decrees.

He is a man free of morals. As has been demonstrated hundreds of times, he is a liar, a racist and a cheat. I feel ashamed to use these words, as sharp and loud as they are. But if they apply to anyone, they apply to Trump. And one of the media’s tasks is to continue telling things as they are: Trump has to be removed from the White House. Quickly. He is a danger to the world.

Here is the view from Nick Kristof:

Did Putin Have Trump for Lunch?

In Hamburg, Germany, President Trump is thundering against the free press that covers him, while getting lovey-dovey with the leader of a country that attacked American and French elections, that invaded Ukraine, that helped slaughter civilians in Syria, that was involved in shooting down a civilian airliner over Ukraine, that murders critics, and that brutalizes gay people in Chechnya.

I can’t help thinking: If only Trump confronted Vladimir Putin with half the energy with which he denounces CNN and other news organizations!

He goes on to note that at least 58 journalists have been murdered in Russia.

Yet Russia — “if you’re listening” — is his friend.

(What?  You think our country’s so innocent?)

Tomorrow: Magic To Make Congress Bipartisan

. . . I was 10 or 11, at Camp Wigwam.  Maybe I was 12.  I can’t remember, but I sure remember the rifle range and the ammo and all the NRA safety posters.  Because that’s what the NRA was about way back then — safety and sportsmanship.

Even as late as 1999, the NRA advocated universal background checks at gun shows — “no loopholes anywhere for anyone.”  Fourteen seconds.  Watch.  Same guy who still heads the far darker NRA.

But now look.  Bill Moyers comments on a new 60-second NRA spot that could hardly be more sinister.

Take a look at the ad below and ask whether the National Rifle Association can go any lower. Ponder this flagrant call for violence, this insidious advocacy of hate delivered with a sneer, this threat of civil war, this despicable use of propaganda to arouse rebellion against the rule of law and the ideals of democracy.

On the surface this is a recruitment video for the National Rifle Association. But what you are really about to see is a call for white supremacy and armed insurrection, each word and image deliberately chosen to stir the feral instincts of troubled souls who lash out in anger and fear:

[WATCH]

Disgusting. Dishonorable. Dangerous. But also deliberate. Everything deplored by the NRA in the ad is committed by “they” — a classic manipulation turning anyone who disagrees with your point of view into “The Other” — something alien, evil, foreign.

“They use their media to assassinate real news,” “They use their schools to teach children that their president is another Hitler,” “They use their movie stars and singers and comedy shows and award shows to repeat their narrative over and over again.”

“And then they use their ex-president to endorse the resistance.”

Well, we all know who “they” are, don’t we? This is the vitriol that has been spewed like garbage since the days of The Protocols of the Elders of Zion, blasted from lynch mobs and demagogues and fascistic factions of political parties that turn racial and religious minorities into grotesque caricatures, the better to demean and diminish and dominate.

It is the nature of such malevolent human beings to hate those whom they have injured, and the NRA has enabled more injury to more marginalized and vulnerable people than can be imagined. Note how the words “guns” or “firearms” are never mentioned once in the ad and yet we know that the NRA is death on steroids. And behind it are the arms merchants — the gun makers and gun sellers — who profit from selling semiautomatic rifles to deranged people who shoot down politicians playing intramural baseball, or slaughter children in their classrooms in schools named Sandy Hook, or who massacre black folks at Bible study in a Charleston church, or murderously infiltrate a gay nightclub in Orlando.

Watching this expertly produced ad, we thought of how the Nazis produced slick propaganda like this to demonize the Jews, round up gypsies and homosexuals, foment mobs, burn books, crush critics, justify torture and incite support for state violence.

It’s the crack in the Liberty Bell, this ad: the dropped stitch in the American flag, the dregs at the bottom of the cup of freedom. It’s a Trump-sized lie invoked to bolster his base, discredit critics, end dissent. Joseph McCarthy must be smiling in hell at such a powerful incarnation on earth of his wretched, twisted soul.

With this savage ad, every Democrat, every liberal, every person of color, every immigrant or anyone who carries a protest sign or raises a voice in disagreement becomes a target in the diseased mind of some tormented viewer. Heavily armed Americans are encouraged to lock and load and be ready for the ballistic solution to any who oppose the systematic looting of Washington by an authoritarian regime led by a deeply disturbed barracuda of a man who tweets personal insults, throws tantrums and degrades everything he touches.

Look again at the ad. Ask yourself: What kind of fools are they at the NRA to turn America into a killing ground for sport? To be choked with hate is a terrible fate, and it is worst for those on whom it is visited.

Take one more look, and ask: Why do they get away with it?  What is happening to us? How long do we have before the fire this time?

I was a pretty good shot; won some merit badges.  Back then, it was all innocent fun.

IBM is building an artificial brain.

If only Trump hard a healthily functioning one.

Meanwhile, look at some of the ways Baby Boomers may age more successfully than their parents or grandparents did.

. . . I strongly believe that technology will change the face of aging as we have known it since times immemorial,” said Dilip Jeste, director of UC San Diego’s Center for Healthy Aging. “Just as presbyopia is no longer a major problem — thanks to eye glasses — many physical impairments of old age will cease being disabilities with the use of technology. The notion that aging means disability will be laid to rest — and with that, the stigma of being old.” . . .

From the indispensable New York Times:

Counseled by Industry, Not Staff, E.P.A. Chief Is Off to a Blazing Start

WASHINGTON — In the four months since he took office as the Environmental Protection Agency’s administrator, Scott Pruitt has moved to undo, delay or otherwise block more than 30 environmental rules, a regulatory rollback larger in scope than any other over so short a time in the agency’s 47-year history . . .

. . . And he is doing all this largely without the input of the 15,000 career employees at the agency he heads, according to interviews with over 20 current and former E.P.A. senior career staff members. . . .

. . . Instead, Mr. Pruitt has outsourced crucial work to a network of lawyers, lobbyists and other allies, especially Republican state attorneys general, a network he worked with closely as the head of the Republican Attorneys General Association. Since 2013, the group has collected $4.2 million from fossil fuel-related companies . . . businesses that also worked closely with Mr. Pruitt in many of the 14 lawsuits he filed against the E.P.A. . . .

Mr. Pruitt’s supporters, including President Trump, have hailed his moves as an uprooting of the administrative state and a clearing of onerous regulations that have stymied American business. Environmental advocates have watched in horror . . .

Mr. Pruitt, a former Oklahoma attorney general who built a career out of suing the agency he now leads, is moving effectively to dismantle the regulations and international agreements that stood as a cornerstone of President Barack Obama’s legacy. . . .

. . . [even] reversed a ban on the use of a pesticide that the E.P.A.’s own scientists have said is linked to damage of children’s nervous systems . . .

But as the White House Spokesperson explained in a different context last week, the American people knew what they were getting when they elected Trump “overwhelmingly.”

And think of it this way: sure, some children may suffer damage to their nervous systems.  But thanks to Trump and the Republican Congress, those kids and all the rest of us will shortly have great health care at a tiny fraction of the cost.  So it shouldn’t be hard to fix them.

Pearl Harbor devastating.  But we instantly recognized the enemy, came together, regained our balance, and — after a tremendous struggle — came out stronger than ever.

Putin’s sneak attack has proved devastating as well.  But part of its sneakiness is that there’s no newsreel footage.  You just have to trust the unanimous findings of our 17 intelligence agencies.

And because the attack has been poo-pooed by our commander in chief (who knows? it could have been the Chinese — or some 400-pound guy on a bed), we have not come together or regained our balance.  If anything, this attack on our democracy has driven us even further apart.  Thrown us even more off balance.

It’s hard for some to know what’s true when you have the President saying repeatedly that  he won the 2016 election by a wider margin than anyone since Reagan (actually, he did much worse than George H.W. Bush in 1988, much worse than Bill Clinton in 1992 and 1996, and much worse than Barack Obama in 2008 and 2012 — but why quibble?).

Or when as recently as last week his spokesperson, Sarah Huckabee Sanders, in defending his attack on Mika Brzezinski, told the world that the voters knew what they were getting when they voted for him — and he “won overwhelmingly.”

Think about that.  This is his official spokesperson saying that the man who got millions fewer votes than his opponent — did worse by that measure than any president in our history — “won overwhelmingly.”

So maybe the intelligence community, like the courts and the press (with the exception of the National Enquirer and Fox News) — and your own lying eyes, when you compare Inaugural crowd photos — are not to be trusted.  Maybe it was just some 400-pound guy sitting on his bed.  Maybe ripping hundreds of billions of dollars out of health care to cut taxes on investment income is the way to give “everybody great health care at tiny fraction of today’s cost.”

But you know it’s not true.  And for now, Putin is winning.

Will we recognize the enemy, come together, regain our balance and — after what is likely to be a significant struggle — come out stronger than ever?

(And, while we’re at it, right a system where one party can win 83,468 more votes for a state’s 18 Congressional seats — yet be awarded just 5 of them?)

It’s my July 4th wish.

Remember?

It was little more than six months ago.

Competence, compassion, civility.  A deep knowledge of history.  Respect for democratic norms.  Science.

With “45,” our luck appears to have run out.

As smarter minds than mine have noted, it’s important to remember “it’s not normal.”

. . . The idea, [Amy Siskind] said, came from her post-election reading about how authoritarian governments take hold — often with incremental changes that seem shocking at first but quickly become normalized. Each post begins with: “Experts in authoritarianism advise to keep a list of things subtly changing around you, so you’ll remember.” . . .

More than most years, Tuesday would be a great day to re-read our founding documents (“When, in the course of human events, . . .” “We, the people . . .”) . . . and such treasures as “Ask not . . .” and “I have a dream . . .” both of which you surely know . . . his letter from a Birmingham jail (that you surely know of) . . . “We, the people,” reaffirmed in 2013 . . . and what has been called “the second bill of rights.”

It’s that last one, from 1944,  that came to mind as I read this note from one of you just now:

John Grund: “Some years ago, a friend and I were walking on a downtown street when a homeless man came walking the other way.  My friend said, ‘Did you know he’s part owner of the Statue of Liberty?’  I was stumped for a moment, then replied, ‘Right, like we all are part owners of the Statue of Liberty.’  Over the years, that example has stuck with me. I work at an investment bank, where ownership of assets — and the privileges of owners — becomes a religion. I keep getting stumped by the example of the homeless man: If he owns an equal share of America, from the highways to the parks to the aircraft carriers to the public buildings, why is he destitute? Why is the owner of a share of America destitute, while the owner of a share of America plus a run-down duplex gets enough to live on?  I hear the recipients of public ‘safety net’ benefits, including subsidized health care benefits, described as ‘moochers,’ ‘the undeserving poor,’ ‘people who don’t understand how capitalism works,’ and worse. Why not describe them as ‘owners’? Does that change how the arguments sound? I think it does — it makes the safety net seem like a small, probably inadequate, way to give them a proper dividend on what they own.  There are a lot of reasons to think that people have a right to health care — religious reasons, moral reasons, ethical reasons, practical reasons. If a person finds none of those reasons compelling enough, perhaps the fact that every American is an owner will be convincing.”

In the meantime, the Republican Party struggles mightily to shift hundreds of billions of dollars away from often-desperately-needed health care to a place they believe it more properly belongs: the brokerage accounts of people earning millions of dollars a year.

Have a wonderful weekend.

Paris is known for climate change.  Its winters, when it drizzles; its summers, when it sizzles; and its Climate Accords that, thanks to in good measure to American leadership, all the nations of the world signed onto except Syria and Nicaragua . . . the latter because they felt it was too weak.  As described here, “Even North Korea signed, along with 194 other nations, and North Korea is completely insane and run by a tiny-brained, quasi-dictator man-baby with an enormous head and puny hands and… oh wait.”

What an embarrassment Trump is.  Doing their best to ignore him, American usiness leaders and governors and mayors representing $6.2 trillion of the American economy have issued their own statement, signing on to the Accords.  And that already long list — at We Are Still In —  is likely to grow.

Speaking of climate nightmares, Bryan Norcross has written My Hurricane Andrew Story: The story behind the preparation, the terror, the resilience, and the renowned TV coverage of the Great Hurricane of 1992, reviewed here. (“Truly riveting.”)  Disaster though it was, had Andrew hit just 10 miles to the north, half a million homes would have been destroyed or damaged, 1.6 million Miamians left homeless.

(And speaking of Paris, those of you following WheelTug may be interested in this short video from last week’s Paris Air Show.  The voice-over has not yet been added, but there’s still much to see.  I especially like the “pyramid of tasks” you’ll find at 1:04, and how WheelTug cuts it down to size.)

In the current New York:

“Just Wait.  Watergate didn’t become Watergate overnight, either.”

The differences of course are many.  For starters, Nixon actually wanted the job, won it by the largest margin in history, and was both qualified and prepared to fill it — a brilliant student of history who’d been, among other things, Vice President for eight years.  His “flaws” were egregious . . . but pale beside Trump’s.

(A friend who used to golf with Trump calls him, “About the worst person I can imagine to be POTUS. A dangerous man with no sense of truth, proportion or ethics. Horrible. Just awful.  Full stop.”  This from a Romney supporter who knocks Clinton and Obama at every opportunity and would save millions in taxes if Trump succeeds at shifting health care to wealth care.)

But how about something hopeful for a change?

My pal Josh Gottheimer, former wunderkind Bill Clinton speechwriter and now a first-term Congressman from New Jersey, has joined with 20 D’s and 20 R’s to form the Congressional Problem Solvers Caucus.  In an ideal world, this caucus would have 435 members and change it’s name to . . . “Congress.”  But it’s a start.  Read all about it.

Okay,  Back to the nightmare.

How ridiculous is this 90-day Muslim ban?  It was first imposed without warning, lest the bad guys take advantage of even a few days’ notice to hop Air Iraq and start blowing us up.  Now, they’ve had five months to get in — with no apparent harm — and are we to believe, given the urgency with which Trump views the problem, his Administration has waited all this time before starting its 90-day review?

Surely someday, somewhere, a refugee who’s navigated the extreme vetting process Obama already had in place will do something awful.  But after 160 days’ review, not just 90, what have they concluded?  Is the extreme vetting that’s already in place enough to protect us from refugees, as this piece argues? (“In the 14 years since September 11, 2001, the United States has resettled 784,000 refugees from around the world, according to data from the Migration Policy Institute, a D.C. think tank. And within that population, three have been arrested for activities related to terrorism. None was close to executing an attack inside the U.S.  Two of the three were caught trying to leave the country to join terrorist groups overseas.”)