Life without Disease

UNIVERSITY OF CALIFORNIA PRESS

Life without Disease

THE PURSUIT OF MEDICAL UTOPIA

WILLIAM B. SCHWARTZ, M.D.

BERKELEY

LOS ANGELES

LONDON

University of California Press Berkeley and Los Angeles, California

University of California Press, Ltd. London, England

Library of Congress Cataloging-in- Publication Data

Schwartz, William B., 1922-

Life without disease: the pursuit of medical utopia / William B. Schwartz.

p. cm.

Includes bibliographic references and index.

ISBN 0-520-21467-6 (alk. paper) 1. Medical innovations—social aspects. 2. Medical technology—social aspects. 3. Managed care plans (Medical care) I. Tide. RA418.5.M4S39 1998 610—de 21 97-41639

Printed in the United States of America 987654321

The paper used in this publication is both acid-free and totally chlorine-free (TCF). It meets the minimum requirements of American Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984.

To my precious wife, Tressa, and in memory of my son Kenneth

Contents

Contents

Preface

Prologue The Dream of a Medical Utopia

Part One Halfway to Utopia 1950 to 2000

1 The Birth and Growth of Big Medicine

2 Failed Attempts at Sustained Cost Control

3 Reorganization of the Health Care Delivery System

Part Two Utopian Promise and Real-World Problems at the Dawn of the Twenty-First Century

4 Medical Progress in the Near Term: 2000 to 2020

5 Health Care Rationing: The British Experience

6 Managed Care and Rationing in the United States

7 A Strategy for More Equitable Rationing

Part Three Molecular Medicine Comes into Its Own 2020 and Beyond

9 Molecular Medicine: A New Era of Therapy

10 On the Threshold of Utopia: Approaching 2050

Epilogue

Notes

Index

Preface

Millions of Americans find themselves by turns intrigued, mystified, frustrated, and downright scared by the constantly changing face of medical care in the 1990s. Scarcely a day goes by without major news stories on a medical breakthrough or on the impending insolvency of Medicare and the threat of rationing by health care providers. Even as the public is offered an endless string of medical success stories, they are reminded that health care insurers have unceremoniously thrown new mothers out of the hospital the day after delivery. Policymakers are one day touting managed care as the solution to spiraling health care costs and the next day beating the drum to outlaw measures used by managed care plans to save money. Competing hospital networks carry on confusing advertising wars that make the long distance phone companies look like duffers, and every week seems to bring a new buyout or merger between health care conglomerates. A welter of medical, ethical, economic, political, and legal issues swirl around these developments, and it is small wonder that many Americans wonder whether the country is headed toward a medical utopia or a medical meltdown.

This book is my attempt to provide a framework for understanding how the pieces of this complex puzzle fit together. To understand this critical moment in the U.S. health care system, it is necessary to appreciate both how we have arrived at the current state of affairs and where we may be headed in the coming decades. For this reason, the book tells its story chronologically, beginning with the medical research boom of the 1950s and ending in 2050. The story is also of necessity a multidisciplinary one, embracing economics, public policy, ethics, medical research, and clinical care. Only by viewing these components in relation to one another is it possible to bring order out of the jumble of news flashes, editorial pronouncements, legislative edicts, and corporate PR with which we are all bombarded.

I bring to this task my experience as a physician-in-chief of a major teaching hospital who took a midcareer detour from clinical medicine into the field of health care economics and public policy. My experience as a clinician has made me an unashamed enthusiast for the triumphs of medical progress that have occurred since the beginning of my professional career some decades ago, and an optimist about the potential for even more dramatic successes in the decades ahead. However, in a series of op-ed pieces for the New York Times, the Washington Post, and the Wall Street Journal, and articles published in the Journal of the.American Medical.Association and the New England Journal of Medicine, I have espoused the impopular idea that the rapid rise in health care costs resulting from our medical successes cannot be controlled without the acceptance of painful but necessary limits on the availability of certain expensive treatments to some or all patients. The recent transformation of the U.S. health care system into one dominated by managed care organizations has only brought into sharper focus the inevitable clash between cost containment efforts and the view of medical care as an unlimited entitlement.

In writing this book during the past five years, I have reached out to many friends and colleagues for advice and assistance. Three individuals in particular have made invaluable contributions:

David Morse, Associate Director of the Norris Medical Library at the University of Southern California, who served throughout this project as editor, critic, and sounding board, and without whose assistance the book could not have reached the level of clarity it has; Daniel Mendelson, vice president of the Lewin Group in Fairfax, Virginia, who generously shared his considerable expertise on matters of health policy and made available the efficient factfinding resources of the Lewin Group; and my wife, Tressa Miller, who at several stages of this project read the entire manuscript and helped me to make the story more understandable, more humane, and more relevant to the concerns of the general reader. My wife also withstood for three years the erratic and preoccupied behavior of a struggling author with singular forbearance and generosity of spirit, for which I am forever in her debt.

Among the many colleagues at the University of Southern California who provided helpful advice are: Michael Bolger, David Faxon, Donald Feinstein, Eva Henriksen, Laurence Kedes, Michael Kline, Aruna Patil, Arnold Platzker, Kumar Rajamani, and Andrew Stoltz. I have also called upon the assistance of colleagues from my years at the Tufts University School of Medicine, including Marshall Kaplan, Barry Fanburg, Herbert Levine, Nicolaos Madias, and Stephen Pauker.

A further group of individuals who generously shared their expertise are Kurt Isselbacher, Toshihiro Shiodo, and Sheridan Kas- sirer at the Massachusetts General Hospital/Brigham and Women’s Hospital; Donald Schon at the Massachusetts Institute of Technology; Barry Baristi at the California Institute of Technology; Belding Scribner at the University of Washington School of Medicine; Charles van Ypersele at the University of Louvain; Daniel Ortiz at the University of Virginia; Andrew Dreyfus of the Massachusetts Hospital Association; and Kellie Mitra and Jennifer Shapiro, Daniel Mendelson’s assistants at the Lewin Group.

Several individuals reviewed the entire manuscript and provided valuable criticisms: Edward Crandall, David Goldstein, and Steven Ryan at the University of Southern California; and Joseph Miller, a Los Angeles—based attorney. Henry Aaron of the Brookings Institution, who has over many years been a stimulating and valued colleague, provided a particularly thoughtful review of the chapters on health economics.

I am indebted to Provost Sol Gittehnan of Tufts University, whose unflagging encouragement and enthusiasm were so important to me during my years of research at Tufts. I also want to express my deep appreciation to Richard Tannen, former chairman of the University of Southern California Department of Medicine, who invited me to join the faculty at USC.

Funding support provided by the University of Southern California School of Medicine, the Pacific Center for Health Policy and Ethics, and the Distinguished Physician Program of the Department of Veterans Affairs gave me time to undertake the extended research and writing that this book has required. The David and Sylvia Weisz Foundation also provided financial support in the preliminary phases of my research.

To all of these individuals and organizations I again offer my heartfelt thanks.

William B. Schwartz, M.D.

Department of Medicine University of Southern California School of Medicine

Prologue

The Dream of a Medical Utopia

Humankind’s age-old attempt to stave off disease has been influenced not only by the progress of science but also by a changing vision of what science can achieve. That vision may now be due for a major transformation as our exploding knowledge of the genetic mechanisms of disease begins to make plausible the once impossible dream of a largely disease-free existence. The fulfillment of the dream is of course dependent on a host of future developments that cannot be predicted accurately, but at least the possibility of a broad-based victory over disease and a dramatic increase in the human lifespan in the not too remote future must now be taken seriously. This reimagining of our medical future seems all the more important in light of growing scientific evidence that the aging process itself may be subject to medical intervention. The myriad social and economic repercussions likely to result from these scientific victories make it prudent to begin envisioning the benefits as well as the attendant problems of the medical utopia that may be on the horizon.

The dream of a human existence freed from the scourges of disease and old age is probably as old as the human imagination itself, but it was the great Enlightenment thinkers of the seventeenth and eighteenth centuries who first suggested that the dream might have a scientific basis. The philosopher René Descartes wrote, for instance, that we might be free of an infinity of maladies both of body and mind, and even of the infirmities of old age, if we had sufficient knowledge of their causes and remedies.¹ A century later Benjamin Franklin echoed the scientific euphoria of the age in forecasting the day when all diseases may by sure means be prevented or cured, not excepting that of old age, and our lives lengthened at pleasure even beyond the antediluvian standard.²

However, in the years that followed, such dreams faded as scientists began to appreciate the complexity and elusiveness of human health. Even the prospect of dependable and sustained progress against disease—let alone the achievement of a medical utopia—emerged only after World War II, fueled by the explosive growth of the U.S. National Institutes of Health. A succession of major medical advances quickly proved the efficacy of government-supported medical research. The modern era of medical discovery—and the story of this book—gets its start in these years. Not coincidentally, these years also witnessed the discovery of the structure of DNA, by which the seeds were planted for a revival of medicine’s utopian aspirations through the tools of cellular genetics.

The period covered by this book is roughly the hundred-year span—of which we are now at the midpoint—beginning with the birth of the modern health care industry in the 1950s and ending in the year 2050, when many of today’s adults will still be living, and when it seems conceivable that most of today’s debilitating and fatal diseases will be preventable or curable. The first halfcentury of this period has been characterized by extraordinary advances in the way medicine can diagnose and repair the ravages of disease—from hip replacement and angioplasty to completely new diagnostic tools like magnetic resonance imaging (MRI) and computed tomography (CT). Significantly, however, few of these ad- vanees have offered a basis for utopian aspiration, focused as they have been on battling the effects rather than the root causes of disease.

In the half-century to come, the emerging field of molecular medicine, which exploits the science of molecular biology and genetics to attack disease processes at their subcellular origins, promises to usher in a new era of vastly more effective care. Dr. Alfred Gilman, a 1996 Nobel Laureate, described one aspect of the new era this way: In perhaps 50 years every molecule in the human body will be known. You’ll be able to design a drug that works only on the molecule you want and on no other molecule in the body.³ This new medicine, instead of treating the consequences of disease as in the past, will concentrate on the genetic causes of disease, on preventive measures for patients with genetic predisposition to disease, and on new ways to interrupt the pathways that lead from genes to diseases.

Given the immense therapeutic potential of molecular interventions, it does not seem at all unlikely that the child born at the close of this amazing hundred-year period could enjoy a life expectancy of 130 years or more and be free of the major chronic illnesses that now plague the aging. That is the utopian vision for medicine that now, for the first time, appears to have a scientific foundation.

The critical question is at what price—economically, politically, and ethically—that vision will be realized. As we will see, there is already ample evidence that the current turmoil in the U.S. health care system derives in no small part from its growing success in understanding and mastering disease.

Part One

Halfway to Utopia 1950 to 2000

1

The Birth and Growth of Big Medicine

As the United States emerged triumphant from World War II, scientists and government leaders came to a conclusion that was to have momentous implications. Looking at the obvious success of research efforts like the Manhattan Project, they reasoned that similarly aggressive government support of medical research could yield equally dramatic results. These were not utopian dreamers but simply pragmatists who understood how much could be accomplished by research scientists supported by a generously funded and well-coordinated government program. There is no evidence that they anticipated the scale of either the costs or the success of the technological revolution they were about to unleash on the American health care system. But they did understand that medical progress costs money, and they believed that the American people were ready to harness some of the nation’s growing economic muscle in the fight against disease.

One such believer was Mary Lasker, a wealthy and successful businesswoman, who, along with her equally wealthy and determined husband, Albert, helped weld together a coalition of public and private leaders dedicated to putting medical research funding on the national political agenda. The Laskers were able to exploit their friendships with influential physicians like Sidney Farber and Michael Debakey, and with powerful politicians like Senators Lister Hill of Alabama and Claude Pepper of Florida, to further their cause. One of Mary Lasker’s first accomplishments was to transform the American Cancer Society from a relatively unimportant support organization into a major source of money for medical research. She soon realized, however, that only the government sector could hope to amass the sums necessary to tackle such intractable medical challenges as cancer, heart disease, and mental illness. She therefore turned her forceful will, her unrivaled social connections, and her deep pockets toward the political arena, where she set a new standard for concerted and effective congressional lobbying. She contributed heavily to election campaigns, befriended presidents, charmed the press, and built a network of like-minded movers and shakers, memorably described by Elizabeth Drew in an Atlantic Monthly article titled The Health Syndicate: Washington’s Noble Conspirators.¹ As a