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The Way of All Flesh

03/25/2019

The topic of artificial intelligence (AI) is a vast and complicated one. It’s alluring to the wacky and visionary, a source of terrifying possibility to the unhinged uncle standing before the half-closed blinds and looking into the grey empty street. The experts say it’s the way of the future and when the entrepreneurial technocrats start making prophesy, it’s best, as the last twenty years have indicated, not to drag your heals too much in opposition. It’s more favorable to look into what it’s all about.

AI is, simply put, a branch of computer science that develops machine learning. This makes it seem like something you can shake hands with, be friendly. Though it’s become a hot-button topic in recent years, it’s not necessarily that new a concept. In the early 1940s Alan Turing predicted that digital computers would ultimately be sophisticated enough to engage in logical reasoning. MIT, circa 1950, dedicated a program of study to it. That was three decades before the first digital wristwatch, twenty-four years before the first pair of Nike shoes swooshed into the market, and forty-four years before Mr. Zuckerberg’s birthday.

In the chaotic world of healthcare, AI offers far-reaching possibilities geared toward addressing problems that have materialized out of our reliance on unsustainable processes and procedures. In “Patient, Heal Thyself,” Roy Smythe puts these clumsy holdovers succinctly, writing, “[w]hile modern medicine has made amazing contributions to acute care, reducing mortality and mass epidemics, the organized structure of it is not effectively serving the general medical needs of the world’s population, and those chiefly responsible for patient care—physicians, nurses, and other caregivers—are being pushed to the point of physical and psychological burnout.”

This is where experts say AI can play a vital role in protecting doctors and other medical professionals from oversaturation in inefficient practices—repetitive tests, monitoring, reliance on limited databases, workflow and administrative tasks, clinical judgments and diagnosis, image analysis—leaving them more opportunity for engagements that require keen human supervision. And of course someone will need to keep an eye on the technologies.

AI also empowers patients to play a more active part in their own care through the utilization of apps, virtual consultations, remote monitoring, and other technologies that prevent avoidable hospital visits and excessive expenses. For remote populations lacking accessible medical care, the technologies will be, in many ways, a salvation.

This all makes AI seem jolly good and warm saline sea breezes and something to anticipate, something to look forward to watching mature, like the neighbor’s five-year-old who seems to be fascinatingly competent with a tennis racket. You look forward to its adulthood. And to a large extent this promise is appropriate.

But, on the other hand, maybe we shouldn’t altogether forget that paranoid uncle tracking a residual unease, surveying the boulevards. A lot of AI’s future rests in cost-saving practices and financial incentives, not altruism. Maybe we should ask questions if the physician shows up for the pre-op consultation and explains a machine will be wielding the scalpel. Maybe we should feel somewhat unsettled when our EHRs are abstracted to some cloud-based data center to live an eternal life alongside electronic reports on other people’s bodies. Maybe we should feel dubious when we can’t get into our GP and, as recourse, a series of codified multiple-choice answers prescribes us antibiotics for our kid’s sore throat.

Subdued paranoia and articulate skepticism have always played important roles in improving revolutions in their infancies. A new form of healthcare is moving inevitably in the direction of AI technologies. The current system is unsustainable—there’s unanimity on this. But that doesn’t mean a dose of slack-jawed skepticism isn’t a boon in our approach to these new, mesmerizing technologies.

Obamacare Embattled, Again

01/14/2019

In 2007, George W. Bush nominated Judge Reed O’Connor to a federal court judgeship. We went on living our lives, and he his, frequently making controversial rulings on how the law interprets sexual orientation, gay rights, and yes, the merits and demerits of Obamacare.

Then, late on Friday afternoon, December 21st, 2018, when we were all going about our business, preparing for holiday parties, driving home from work, wishing motorists ill or well, reluctantly shopping, or simply looking forward to a vacant weekend before Christmas really asserts itself, he produced a hostile 55-page opinion deciding against the constitutionality of Obamacare. Our phones dinged. We collided with other disheveled shoppers—there were fender-benders. We released a long pensive exhale, and asked, Again?

As we will recall, when the ACA appeared before the Supreme Court in 2012, Chief Justice John Roberts, casting the deciding vote, interpreted the individual mandate as a constitutional exercise of Congress’s taxing power. Well, the 2017 Republican Tax Bill got rid of the individual mandate penalties, and on 12/21/18, its absence became the deciding factor in O’Connor’s courtroom.

According to O’Connor, it is “essential and inseverable from the remainder of the ACA,” and without it, “[the] architectural design [of the Bill] fails.” In conclusion, O’Connor wrote, “[t]he court finds the individual mandate can no longer be fairly read as an exercise of Congress’s tax power and is still impermissible under the interstate commerce clause—meaning the individual mandate is unconstitutional.” This means that once again the ACA will have to sit through months and months of dissection, defense, mutilation, insults, and heralding before the various courts likely punt it back to the Supreme Court, where that venerated body will either agree to review it or not.

Be on the lookout come Christmas, 2019.

Shortly after O’Connor’s decision, praise and disapproval came surging out of the various camps. President Trump hastened to Twitter to dispatch his sense of vindication: “As I predicted all along, Obamacare has been struck down as an Unconstitutional disaster… [g]reat news for America.” (At least someone feels predicative and comprehending these days.) And its usual supporters put out vehement promises of appeals and fights.

Since the ruling marks an immediate termination of the law, to quell fears for those insured through ACA exchanges, Seema Verma, administrator of the Centers for Medicare and Medicaid Services, wrote on twitter that “the recent federal court decision is still moving through the courts, and the exchanges are still open for business and we will continue with open enrollment. There is no impact to current coverage or coverage in a 2019 plan.”

In 2010, the ACA introduced voters to imperfect medical insurance while also, crucially shaping up and admonishing the industry for its decades of profitable misconduct. Whether the issues come from the compromises and provisions Democrats had to stuff into the law to get it passed in 2010, or Obama’s signature legislation is altogether hogwash, no bill faces nearly a decade of enmity without having at least something wrong with it. In it each party finds the reflection of everything they dislike about the other side and revere about themselves—Democrats protect it, and are often obtrusive about its limitations, because it marks a signature achievement that, in theory, advanced the livelihood of many Americans. Republicans abjure it because every recollection illustrates government overreach, the countless failed attempts to block and appeal it, its reputed costliness, etc. This is why it neither thrives nor dies.

But as the midterms reiterated, healthcare is a bipartisan concern for voters. Those who don’t have access to medical insurance through their employers would like to avoid crippling financial difficulties if and when they face health problems and as the polls indicate, prefer the humble safeguards offered by the ACA over returning to the unsustainable system pre-ACA, or indeed, the healthcare bills proposed during Trump’s presidency.

In any event, we can only hope that O’Connor’s ruling, tiresome as it may be, will help spawn a resolution that might end in either an enhanced version of the ACA or something altogether different—and better.  

A Season of Mergers

12/10/2018

Over the past few years a number of odd partnerships have formed between leading companies from different industries. Most notable among them might be Amazon’s acquisition of first the Washington Post and a bit later Whole Foods. It doesn’t take a professional cynic to see that more appealed to the corporation than plain intrigue about the grocery business or recommitment to the integrity of investigative journalism during a period when the freedoms of that institution seem in jeopardy.

Such ventures provide, or at least suggest the hopes of providing, some kind of future asset to the company absorbing them. On the one hand Whole Foods gives Amazon crucial data on the shopping habits of an affluent and targeted consumer population—the silver lining should be clear enough here. As for the newspaper business, historically a print medium slow to assert its place in an increasingly web-centric era, the procurement laid a foundation for Amazon to apply its unparalleled expertise in The Internet of Things (IOT) to an antiquated media platform.

In recent months, and perhaps with more cause for suspicion, there have been a series of mergers between the mammoths of the medical insurance industry and their equivalents in the pharmaceutical field—Cigna and Express Scripts, UnitedHealth Group and OptumRx. And just last month the Justice Department approved Aetna’s $69 billion acquisition of CVS Health granted Aetna divest of its private Medicare drug plans. However, this deal remains under review as a federal judge raises questions.

For many these mergers mark more tenuous ethical ground. Whereas Amazon’s eclectic side-projects are geared, ultimately, toward consumer satisfaction and profitability the consolidation of a large insurance company like Aetna, with $60 billion in revenue in 2017 and 22 million people on its health plans, and a large pharmaceutical house like CVS, with $185 billion reported revenue last year and 94 million customer prescription plans, further centralizes power in an industry that lacked competition and transparency to begin with.

While Aetna and CVS, and the long list of other insurance and pharmaceutical companies that have recently struck up partnerships, cite a diversifying industry as catalyst for the mergers, many outside the industry fear that the partnerships will harm patients in two central ways: (1) they will have even less oversight and control in the pricing of drugs and care, and (2) those with Aetna insurance plans (or Cigna etc.) might be confined to CVS retail clinics and consumers without Aetna care might face yet higher drugs costs. But advocates of the merger claim just the opposite, arguing that with the diversification the two industries can pool resources in an effort to better address patients’ needs.

To get behind the advocates of the mergers is no easy feat: the insurance industry has had a persistently poor reputation for a while now and largely well-deserved and due to its years of shameless denying of care to those with pre-existing conditions, its stinginess toward both doctors and patients, its fatal refusal of crucial and effective treatment plans for patients with rare cancers and other survivable diseases, amid countless other questionable practices. And the pharmaceutical people have fared little better in recent years: while the nation got hooked on its supposedly non-addictive drugs and started perishing in the streets the distributors boasted record profits.

People tend to get grouchy over such disparities, and that these two misbehaving conglomerates, on which we all, for good or ill, must rely, have decided to form such a brazen compact, should, with due reason, give us pause. But maybe we should do just that: maybe we should reserve judgment until full appraisal of what these partnerships might mean for the often uncourted and well-paying patients unfolds. And in the immortal words of the English poet Philip Larkin, for better or worse, “We shall find out.”

A BRIEF, UNHAPPY HISTORY OF HEALTHCARE CO-OPS: WHERE ARE THEY GOING, WHERE HAVE THEY BEEN?

One of the Internet’s gifts—and occasional annoyances!— is its space for people to self-publish their alleged expertise on a subject. Surely this must be some form of purging. I feel an odd mixture of depression and excitement toward these online message boards. The writers on healthcare forums vary from doctors, hospital executives, and private insurers, to young families whose finances have been wrecked by medical expenses.