The Messy Middle

Globalhealthsquare

Uncertain Health in an Insecure World – 101

                         

The Messy Middle

When my 100th blog post landed on December 22, 2016, I literally did not know what more to say. And haven’t we all been on quite a ride since then, round and round, and round again. In fact, the wheels are whirling so fast and wobbling so erratically that like many, I just spun off.

It’s been 109,693,582 seconds since midnight on January 20, 2017. But who is counting?

Back in the square, we now find ourselves in The Messy Middle… between a novel illness and uncertain health… awakening social justice and enduring systemic racism… all while things are mutating faster that many governments and their “leaders” can decide what to do about it.

In truth, nothing has really changed while we were apart.

You understand, of course, that as time inexorably passes, things just change in ways that are impossible to predict. I mean, even the magical algorithms are only as powerful as the data that they ingest… right? And their mathematical biases are quite real, even when their masters aren’t vigilant enough to see them. Sorry, but the intelligent machines cannot save us from ourselves.

As I’ve written since we last spoke, “Not all facts are true, and not all data are valid.”

While we empiricists want to think that only new science and big data point the way forward, it’s becoming clearer to me that only emotional connection truly informs the human journey. And sad to say, mere facts are not enough to sway some of us, or to influence our collective actions.

While I was away from the blogosphere, the transcendental global crisis continued.

In January 2020, land and ocean temperatures were 0.04F (0.02C) above the previous record breaking warmest winter months in 2016; both records were 1.8F (1.0C) above the fifty year running averages. And while some low grade oil price futures actually went negative on April 20, 2020 (North Dakota ‘sour’ priced at below U.S.$0.00 per barrel ), at $37 per barrel the 2020 average light-sweet crude oil prices are below the 2016 $43 per barrel average price. Arctic Sea ice has declined 4.06% per decade since 1979, about 18,400 square miles or twice the size of Vermont per decade. In June of 2020, the Laptev Sea ice north of Siberia shrunk by a record amount (see red line on graph)! 

Who or what lifts us from that global morass?

Who is a sixteen year-old Swede with Asperger’s autism, ADHD and selective mutism, Greta Thunberg, who became a global climate crusader when she led a 2019 “school strike for climate” campaign that captured the world’s flagging attention span. Her relentless logic spoke to the 2030 climate decline that would create an irreversible global chain reaction, an alarm compelling enough for the Swedish government to nominate her for the Nobel Peace Prize… twice! 

What is some surprisingly good news from the COVID-19 pandemic. Government lock downs have measurably reduced auto and airplane exhaust-driven atmospheric CO₂ levels in many parts of the world. Humans have learned that we can actually heal the Earth’s fragile atmosphere in just weeks by doing fewer mindless drives, shops, trips and commutes. Ironically, wet we cannot wait to restart our air polluting economies.

                                                                        January 2020

                                                                        March 2020

Wars, forced migrations and human rights violations are man-made plagues with no vaccine.

While there may be a debate about the oriental origins of COVID-19, these plagues continue, albeit for non-infectious reasons. Before we could tell a pandemic from an epidemic (a Pandemic is an epidemic with a Passport), the “Us First” march of strongmen bullies had begun to isolate us. With centrist leaders seemingly cowed, it took women-led countries with 6-times lower national COVID-19 death rates to show their clotted testosterone counterparts the way. 

Great movements are made so by & through a fight-to-the-death conviction for change.

The #blacklivesmatter hash tag created in 2013 by three women became a movement in 2014, after the Ferguson Missouri police officer shooting of an 18 year-old Black American, Michael Brown. BLM has gone global because this shit just keeps happening! Protesters confronting the deep and festering wound of systemic racism helped many of us to recover from our collective ennui. Others cling to a past way of life, dog whistling their way among monuments to preserve it.

Since our last conversation, there are fewer monuments, and their defenders are very worried.

Truly bad actors have attained influencer status by circle-jerking each other with actual or perceived threats. They’ve only “succeeded” as a result of guileless global passivity and a lack of will for effective containment. But just as U.S. exceptionalism had devolved into Twitter wars, and U.S.-China relations into 5G hostage exchange diplomacy, COVID-19 rendered them oddly vulnerable. Messrs. Trump, Bolsonaro, Modi and others have seen their power erode and their oppression partly undone. But as we saw in Post 100, Mr. Putin keeps smiling.

https://www.google.com/search?q=putin%20smiling%20gif

Yet there is reason for hope here in The Messy Middle.

We humanoids do evolve, both individually and as a species, even in the most troubling and potentially most dangerous of times. It’s not those clever Coursera courses, Audible books or behavioral apps that we learn from. We decode The Human Condition by learning from each other. It’s messy in that emotional middle. But up close, with or without a mask… on or off a vent… present or absent antibodies, is where it’s real… hurtful and heroic and frightening.

There, we learn from each other that with respect for each other, we go on.

So we go on, here in The Messy Middle. I hope that if you can, you will visit me there from time to time. We have much to share, and more to learn.  

Uncertain Health in an Insecure World – 100

“Does Putin-care?”

Eponymous references can be complementary – The Marshall Plan (for U.S. General C. George Marshall) was a model of massive resource mobilization to reconstruct post-WWII Europe. But eponyms are often pejorative – the Ponzi scheme (for U.S. Italian immigrant Charles Ponzi) symbolizes a seemingly legit investment model operated by a swindler.

Recall, Nazism was never eponymized as Hitler-ism.

The Atlantic magazine dubbed Obamacare the “grand bargain” of modern U.S. domestic policy. This eponym was coined by the plan’s Republican opponents in order to attach incendiary linkages to socialized medicine. In the 2010 U.S. mid-term Tea Party election, it almost worked! Donald Trump’s campaign drumbeat to “repeal and replace” the policy resonated successfully with much of his electoral base. But the present President and his loyal supporters still view The Accountable Care Act as his greatest enduring legacy.

Like life, literature is replete with examples of ironic adoration and sarcastic perjoration, often imbuing characters with a skewed sense of their actual role in events.

In The Cancer Ward (published in English, 1968; published in Russian as Rakovy Korpus, 1991), 1970 Nobel Prize winning author Aleksandr Solzhenitsyn deftly weaves the dark course of a terminal disease with the decay of Soviet society under ruthless Stalinism.  Like the novel’s protagonist, Oleg Kostoglotov, Solzhenitsyn was exiled to a Kazakhstan gulag under Article 58 (above), and officially rehabilitated in 1957. Shortly after his release, like Oleg, Solzhenitsyn was diagnosed with terminal cancer. For decades after Stalin’s death in 1953, the prognosis for the Soviet Union remained as bleak as that of a malignant tumor.

An “evil man” at the zoo had thrown tobacco in the Macaque Rhesus monkey’s eyes, blinding it.

President Vladimir Putin met briefly with a frail Solzhenitsyn before the author’s 2008 death from heart failure.

In 1991, Vladimir Putin retired from the Komitét gosudárstvennoj bezopásnosti (KGB) as a lieutenant colonel. Not a model KGB operative, Putin was relegated to posting in East Germany until he was rescued by President Mikhail Gorbachev. Twenty years later, and coincident with the launch of Obamacare, Putin announced his own ambitious Russian public healthcare policy reforms that did not (until today) ever reference his name.

Obamacare and Putin-care were separately and nearly simultaneously launched!

Since the 1980’s, the quality of healthcare and availability of medical technology in The Russian Federation fell far below the standard of other western developed countries. Russian healthcare spending per capita lagged behind Europe at US$158 per year. In 1996, like other European countries and most of the former British Commonwealth, Russia passed a law providing Mandatory Medical Insurance – nationwide socialized medicine for socialists, at long last.

During Putin’s first two terms as President (2000-2008), the Russian economy boomed. Putin was named 2007 Time Magazine Person of the Year. But in 2007, the OECD also reported that Russia’s public healthcare transition to a more decentralized, contested and insurance-based system remained stalled (purple line below). 

  

In 2011, then Prime Minister Putin pledged a US$10 billion healthcare investment (above), partly by boosting the obligatory employer contribution to compulsory medical insurance from 3.1% to 5.1%. This tax infused the funds needed for a May 2012 Decree to double healthcare staff wages by 2018. In 2013, there were 9.3 hospital beds per 1,000 person population in Russia – twice the OECD average. By 2014, higher wages increased healthcare employee costs, prompting the closure of 15 Moscow hospitals. 

After a term limit hiatus, Putin was re-elected as Russian President in March 2012. Soon thereafter, he ordered tanks into Crimea. Crippling sanctions hit Russia’s economy hard as the 2014 Sochi Winter Olympic Games unfolded. Despite his dodgy global record in Ukraine and Syria (or because of it?), Putin has been ranked #1 on Forbes Magazine annual list of most influential people in The World since 2013. 

In 2015, Mark Britnell exposed the modern Russian healthcare system’s vulnerability in In Search of the Perfect Health System. In 2004, per capita healthcare spending was US$441, or 4.4% of GDP. By 2013, Russian healthcare expenditures had doubled to US$957 or 6.5% of GDP. Under Putin’s Decrees and reforms, private medical clinic chains like Doktor Ryadom (below) treat some patients at low cost under the official public insurance plan, while legally charging other patients higher fees to generate a profit.

Despite this higher public spending and the creation of a public-private mosaic model of healthcare financing, in November 2016 the OECD reported that Putin’s reforms have actually worsened the Russian healthcare system, with broadly deteriorating population health status. The system remains too complex. The country’s >300 private insurers remain inefficient as purchasing groups. Reimbursement rates fail to cover the costs of care. The informal payment system, like the barter system used in The Cancer Ward, still permits “line jumping” that improves healthcare access for the wealthy and the privileged.

Mr. Britnell reflected that the Russian constitutional right to healthcare is “blocked by opaque and bureaucratic systems of (public) planning and regulation”, at both the federal and state levels

Just what’s a poor sick Russian to do?

Since mystic faith-healer Grigori Rasputin (above) tended to the sicklier and more anxious of the last Romanovs, alternative medicine has had a prominent role in Russian healthcare. Today, alternative medical providers operate in the shadows, practicing homeopathy at best and alchemy at worst. In remote regions and rural villages outside of the healthcare system mainstream, they peddle listening devices, herbal creams and nutritional supplements that promise to restore good health and cure various “dependencies.” Home remedies abound, used by millions of Russians who do not trust flu shots, but who firmly believe in their grandmother’s home cures – raspberry tea, chicken soup, and steam infusions made from boiled potatoes.

In 2008, there were 621,000 doctors and 1.3 million nurses employed by the Russian public healthcare system. Russia has since become a popular European location for medical education. Students flock from non-communist countries around the world, largely because tuition is affordable and the curriculum often uses English language instruction. Russian medical degrees (M.B.B.S.) are recognized globally, and are highly rated by UNESCO and WHO.  In 2016, Lomonosov Moscow State (below) was listed among the world’s best medical universities by QS World University Ranking.

In March 2012, during the politically rancorous heyday of early Obamacare implementation, then Russian President Dmitry Medvedev and Barack Obama had a chummy chat into an open mike, during which Obama asserting greater post-reelection “flexibility” to deal with global issues like missile defense. By contrast, at the 2016 G20 Summit in China, Putin and Obama exchanged a Syrian foreign policy/U.S. election hacking death stare (below).

Pending a post-election Trump Administration reversal, Obamacare rolls on and U.S. sanctions continue to crush the Russian economy.

It can be fairly stated that all that The World’s two most powerful people share in common is incomplete healthcare policy reform. For different reasons, neither Putin nor Obama will see their bold healthcare reform plans fully implemented.

Both men have handily won multiple national presidential elections.

But in the process of governing, through global chess moves, both men have achieved mutually assured domestic legacy destruction!

We in the Square call "Checkmate"!… Now enter Trump to flip over the playing board. 

Uncertain Health in an Insecure World – 99

“Fecal Matters”

Humans are made up of 50% somatic cells and 50% microbes!

Long before next-generation gene sequencing (NGS) technology, using a simple little device (the compound microscope), Dutchman Antonie van Leewenhoek (1632-1723; below) showed that the body’s oral and fecal bacterial populations were very different. 

Van Leewenhoek, the “father of microbiology”, also proved that the microbial flora he called ‘animalcules’ (below) differed between healthy and diseased humans.

The insight that healthy humans coexist with bacteria and other bugs in a “microbiota” won Joshua Lederberg (1925-2008; below) the 1958 Nobel Prize for Medicine & Physiology. Lederberg and his colleagues showed that bacteria can mate and exchange genes (i.e., bacterial conjunction). 

At just 33 years of age, the new Nobel Laureate went west to found the Department of Genetics at Stanford University. In the 1950’s he and Carl Sagan raised concerns about the biological effects of space travel, advising NASA to isolate returning astronauts and sterilize equipment to prevent extraterrestrial microbes from contaminating to Earth. In the 1960’s he worked with Stanford Computer Science Department chair, Edward Feigenbaum, to develop the first artificial intelligence platform, DENDRAL (a portmanteau of dendritic algorithm).

And in 2001, Dr. Lederberg coined the term “human microbiome.”

Since 2008, the U.S. National Institutes of Health Human Microbiome Project (HMP) has been characterizing the distribution and genomics of the microbial communities found at multiple body sites, to determine whether and how changes in the human microbiome impact health. In conjunction with other members of the international Human Microbiome Consortium, the HMP used NGS to characterize 3,000 genomes from bacteria, viruses and protozoans (below). 

These projects generated a human metagenomic big data repository for comparing microbes to the human cells with which they co-exist (below). The 5-year US$115M HMP has studied the sharing of common microbe-cell metabolic pathways and the exchange of genomic material, in both healthy symbiotic and disease-producing states.

In June 2016, the Obama Administration launched the follow-on US$121M Microbiome Initiative. Like the Precision Medicine Initiative (PMI) and the Cancer Moonshot, it’s unclear if this program will be part of the Obama legacy, or be euthanized by the new Donald Trump Administration.

Fun Fact – the newest effective human transplant material is feces.

Yes… you heard correctly!

Doctors can obtain fresh stool from healthy donors to replenish the normal gut bacteria of patients with recurrent Clostridium difficile (C. diff.; above) infections. C. diff. toxin causes colonic inflammation and chronic diarrhea. Annually, in the U.S. C. diff. infects between 640,000 and 820,000 Americans, killing 14,000. Fecal microbial transplant (FMT, a.k.a. “bacteriotherapy”) was shown to be more effective than oral vancomycin therapy in preventing further infections in a study of 16 Dutch patients with recurrent C. diff. colitis (New Eng. J. Med. 368: 407-415, 2013).

Not surprisingly, FMT patients have a preference for related donors.

To address the problem of potentially lethal hospital-acquired C. diff. infections and the FMT “ick factor”, doctors at Canada’s Kingston General Hospital and the University of Western Ontario have now developed a 33 gut bacterial species of “pseudo-poo” that serves as a stool substitute, precluding the need for fecal material infusion. The lead doctors, Elaine Petrof and Gregory Gloor, like to think of the mixture a rectally administered yogurt! Microbial cocktails are now being tested in patients with inflammatory bowel disease (IBD; Nature Biotechnology 33:787-788, 2015). 

Investigators from the University of Ottawa have reported significant differences in the metagenomics of gut microbes in children with two genetically similar IBD's – Crohn’s Disease and ulcerative colitis (UC). They have also shown that the microbial dysbiosis of Crohn’s disease is associated with down-regulation of mitochondrial proteins that detoxify H₂S, and that Atopobium parvulum is the network controller of other H₂S-producing pro-inflammatory gut microbes (Nature Communications, 7: 13419, 2016).

In the last few years, recognition of the immunomodulatory effects of the human microbiome has led start-ups and Big Pharma to seek out novel therapies.

Boston-based Vendanta Biosciences has been working on a “bug drugs” since 2012, backed by private equity funds from PureTech Ventures. In 2015, they announced the successful development of a 17 C. diff. strain called VE202. This VE202 cocktail is thought to push out the bad C. diff. bugs by rejuvenating T-reg lymphocyte immune functions, thereby reducing gut inflammation. In January 2015, the Janssen Biotech division of Johnson & Johnson (JNJ) Pharmaceuticals licensed this novel technology from Vendanta for an initial fee of US$241M. The Jansen Human Microbiome Institute (JHMI), established in Cambridge MA in 2014, is intensively plumbing microbiome therapeutics with numerous partners. The head of JNJ Innovation at the JHMI, Anuk Das (below), believes that this pipeline will be effective in autoimmune, inflammatory and infectious diseases.

Seres Therapeutics (NASDAQ:MCRB) became the first company in the human microbiome sector to go public. Backed by Flagship Ventures, Seres began as a 2010 Cambridge MA start-up. Their June 2015 IPO netted US$139M ($18 per share), based on the promising results of phase-1 clinical trials with SER-109 (Nature Biotechnology 33: 787-788, 2015). SER-109 (ECOSPOR™) is a carefully controlled mix of 50 bacterial spores obtained from healthy donors. Although FDA-designated as a “breakthrough therapy,” in July 2016 Seres announced that SER-109 “unexpectedly” failed to meet its goal in a phase-2 clinical trial – it did not reduce the relative risk of C. diff. recurrence compared to placebo. Not unexpectedly, MCRB share prices tumbled 75% from $35.77 to $8.74 per share. 

Of course, Seres has other drugs in the pipeline. For example, SER-262 is a synthetically-derived microbiome modifying agent for C. diff. infection now in phase-1b trials. Seres’ other Ecobiotic^R drugs are entering phase-1b studies for treating patients with inflammatory diseases like Crohn’s, UC and non-insulin dependent type-2 diabetes.

Among the many emerging companies attracting Pharma and VC attention in the human microbiome therapeutics space are Enterome, Second Genome, EpiBiome and uBiome.

The World Health Organization reports 1.7 billion global cases of diarrheal disease per year, with 760,000 deaths per year in children under the age of 5 years. The primary associations of this potentially lethal illness are malnutrition, poor sanitation and contaminated drinking water. While this disease is far more of a global public health risk, Pharma and VC will follow Sutton’s Law, focusing their funds on the developed world’s perceived needs for new technologies and drugs for C. diff., UC or Crohn’s disease.

We in the Square don’t pooh-pooh these fast emerging human microbiome innovations. 

But we loudly lament a market reality that sees “the others” impatiently waiting for the constipated global diffusion of such benefits.

Uncertain Health in an Insecure World – 98

“Best and Worst of Times”

In every era, writers portray the reality of modern life through fiction. Charles Dickens (1812-1870) did this in his sweeping novels, giving the world and subsequent generations a glimpse into mid-19^th century Victorian Britain. Anton Chekhov (1860-1904) wrote plays and short stories that were social commentaries and sharp critiques of a feudal Romanov Russia. No strangers to pathos and irony, their protagonists and bit players written lives reflected their times.

So too has it been this year, in most dramatic fashion.

In June, the 52% pro-Brexit referendum vote transformed the face of European immigration, trade, law, science and business. Bloodless exits, whether “soft” or “hard”, create and kill many jobs, and change millions of lives.

Last week, with just 47% of the presidential vote, Donald J. Trump transformed the U.S. electoral map and the ground rules of American politics.

These two surprising events were not simply about change.

While wildly unpredictable, by and through the will of The People, these events became binding upon their governments.

While peaceful, through neither war nor coup d’ état, the outcomes are being described as revolutionary.

While the leaders and forces at work differed in many ways, these sentinel events grew out of popular movements, whether reasoned or misguided.

And while these two jurisdictions operate different democracies, the administrative course of the related policy, regulatory and procedural sequelae will massively impact their governments for decades.

Historians relate these two eruptions to pent up emotions – people longing to feel “great again” – pining for the gilded eras of The British Empire and broad-shouldered American Determinism. In those days these two countries were indeed “great”, uniquely projecting their military might and commercial power across the known world.

But now the globe is flat, and nine countries have deployed nuclear weapons (above).

Britain and America were victors in two World Wars, and allies against aggression, totalitarianism and genocide. Their post-Nazi refugee scientists ushered in the atomic age, discovered new drugs & vaccines, and pierced Earth’s atmosphere.

But since those good old days, and absent a 21^st century cataclysm – a world war, revolution, depression or nuclear detonation – to wipe the slate clean, incremental innovation begins to feel… well, unsatisfying.

Transformation – peaceful or otherwise – is a much more potent stimulus to the masses, especially when incrementalism feels like two steps forward, one step back. Transformation can also be framed as a rallying cry against a common enemy.

But when the adrenaline rush ends, and real change crashes back to Earth, it falls to the least innovative and most risk-averse among us – the bureaucrats – to plod the path forward and quietly attend to their chores.

Absent a pressing political or military upheaval, the masses have wed an easily adopted and widely accessible mate – hand held technology. Statista projects there will be 4.8B humans using mobile phones in 2017! What is the first thing you do in the morning? Tell the truth…

The constant, unfiltered, seductive whir of social media was the Enigma machine of Brexit and Trump-ism.

Not to be confused with New York’s CA Technologies that powered CNN’s fail fast election analytics, Cambridge Analytica (above) crunched big data into “psychographic" profiles of voters for both of these winning campaigns. Cambridge Analytica is a U.S. subsidiary of the British behavioral research firm SCL Group Ltd. that worked with the Leavers in the Brexit vote. The company is partly funded by Robert Mercer (below), the computer scientist co-CEO of the secretive quant hedge fund, Renaissance Technologies.

In the months leading up to the final U.S. presidential vote, Cambridge Analytica also crunched Donald Trump’s numbers and by the election eve, their models predicted a 50% chance of victory when CNN's poll of polls had him down 4-6%. While political pundits and other predictive models were blowing it BIG at the BBC and CNN, Trump’s 3 AM tweets were winning hearts and bending minds. While Hillary’s email words were being redacted and refuted, spin machines and influencers were dashing her hopes & dreams and converting his big data into votes.

Cambridge Analytica’s motto, “We know what you want before you want it…” is both clever and chilling.

Whether dreaming of walls or glass ceilings, or having nightmares about terrorists or refugees, in the deep dark recesses of voters’ brains something began resonating.

Neuroscience can always explain what we humans do, but it cannot defend it. 

The neo-cortex is the unique home of human creativity and intellect. Great literature evokes a higher consciousness. Dickens makes us sad, and Chekhov brings us to tears.

But the hind brain is the deep seat of behavioral psychology. Before conscious thought occurs, fearful cues trigger fight or flight reflexes. We remain or leave. Such Pavlovian stimuli make us drool…

The edgy rant of Chicago-based blogger David Wong (below and at www.cracked.com), who ripped Clinton voters for ignoring years of blue collar suffering and decline in rural America, now rings true – “Are you assholes listening now?”

We in the city Square can now hear the “Others” voices.

And we all need to listen more carefully going forward. 

Uncertain Health in an Insecure World – 97

“Whatever… Wherever”

In 1956, the United States legally changed its official motto from “E pluribus unum” to “In God We Trust.”

Sixty years hence, as the 2016 U.S. Presidential Election results roll in, we will learn whether the “wherever” misogynist Donald Trump or the lyin’ “whatever” Hillary Clinton will become the leader of The Free World. Regardless of the outcome, the future of American Healthcare is at best uncertain and at worst unsustainable.

No subject has been studied so deeply, yet so stubbornly defiant of a solution.

Why is that?

Healthcare, prescription drugs, elder care and child care sectors are all characterized by rapidly rising prices and limited technological innovation.

Venture capitalist and Netscape founder Marc Andreessen (above) recently opined (Oct. 5, 2016 www.vox.com>new-money>2016/10) about a “technology bust” in the healthcare and life sciences sectors, which have historically demonstrated inflexibility to change. He cited market inelasticity for innovations that would increase productivity or reduce costs. According to Andreessen, these sectors suffer from “dysfunctional behaviors that lead to rapid increases in prices… monopolies, oligopolies, cartels, government-run markets, price fixing.” He added, when “government injects more subsidies into those inelastic markets… (they) cause prices to go up further.”

He’s totally right!

There are no other markets like healthcare and Pharma. 

 

Andreessen believes that Theranos’ 2016 collapse occurred as a result of a “beta release as production” business strategy that may only work in Silicon Valley. But the blood-testing start-up failed fast, never impressing either Wall Street or the U.S. Centers for Medicare & Medicaid Services (CMS). Theranos CEO Elizabeth Holmes (below) has laid off 340 workers, and the company plans to close all of its clinical labs. Now Theranos is being sued by one of its original hedge fund investors, Partner Fund Management (PFM).

The private equity bubble that created highly valued unicorns like Uber, Airbnb, Snapchat and Theranos has not produced typical initial public offerings (IPO’s). Instead, it has spurred big money late round investing by hedge funds (like PFM) and institutional investors (like Fidelity). Typically, the pre-IPO / pre-acquisition VC vetting process is much more robust, and is better suited to the nature of these increasingly rare exits.

As politics inevitably creep in, the U.S. healthcare sector is irreparably harmed.

According to Harvard Business School (HBS) Baker Foundation Professor Leonard Schesinger, after the “fall and fix” of Obamacare’s  Healthcare.gov website, the situation has gone from bad to worse (www.hbswk.hbs.edu Cold Call Podcast Oct. 20, 2016). Variable state-by-state interpretations of the Affordable Care Act (ACA) have been bungled because the creation of state insurance exchanges requires complex managerial tasks.

As gleefully pointed out by the Trump campaign, the opting out of many insurance carriers and the depleted numbers of ‘healthy’ enrollees has ballooned Obamacare health insurance premiums for those trying to comply with ACA mandates (above). Many young people faced with >US$500 per month premium bills are just opting out, instead taking the much lower Internal Revenue Service penalty charge on their federal taxes.

HBS case studies describe the adverse outcomes associated with the multiplayer accountability gaps of Obamacare and the failure to adopt open innovation at NASA (‘Houston we Have a Problem’, May 5, 2014, www.hbs.edu). Both have suffered from the same quasi-governmental “Who’s on first?” confusion. The private sector players see the blood in the water, swooping in with standard management tools or hyperbolic IT solutions, while securing nicely leveraged financial positions.

Increasingly, Fintech approaches may be a key to overdue solutions for healthcare malaise.

The average ATM transaction is $60. The average hospital transaction is $1,600. The Smart Card Alliance reports that 140 million smart cards have now been issued by hospitals around the world to identify patients, instead of using paper-based demographic and personal information validation.

Governments have repeatedly tried to foster innovation to hold down healthcare prices, without taking any market risk. They recognize that the price problem is largely due to insufficient technology adoption. But despite penalties and incentives, the healthcare system holds out and holds on. Such slavish orthopraxy is resulting in continuing delays in the adoption of ‘meaningful use’ of the electronic health record (EHR) required by the Obamacare law.

The U.S. healthcare industrial complex increasingly controls the data. This dis-intermediates doctors from patients.

Widespread unhappiness with EHR technology has created unlikely bedfellows – consumer and health IT advocates – to push for more personal health record keeping. The 3^rd phase of Obamacare policy meaningful use requires that EHR vendors certify that they use open application programming interfaces (API’s) for exchanging EHR’s. In response, Epic, Cerner and Allscripts announced that their API’s would employ the Fast Health Interoperability Resources (FHIR) standard and be open. Ideally, these changes will allow greater user access to their PHI.

According to health guru Eric Topol (tri-cording Stephen Colbert, below), access to our personal health information (PHI) will become a human rights issue in coming years.

Now that would indeed be disruptive innovation!!

Of interest, Dr. Topol’s Scripps Translational Science Institute recently received a $20M federal Precision Medicine Initiative grant, and also signed a partnership agreement with Apple. POLITICO reports (http://www.politico.com/story/2016/10/apple-expansion-health-care-229111 ) that Apple is moving into healthcare, including FDA-regulated sensors, clinical decision support, and EHR’s. Apple-philes hope that the company will make patients the guardians of their own health data. When patients can download their PHI onto iPhones via a platform of API’s, the smartphone could emerge as the middleman in healthcare.

The reason that Healthcare is economic kryptonite to the globe’s greatest superpower is simple.

In its uniquely manifest destiny mindset, America has rejected the complete overhaul of its public-private quasi-market healthcare system because it’s simply too big to concede failure.

Whether in politics or business, changing a president or CEO is not transformation.

Deeply entrenched dysfunctions of bureaucracy and management will survive the peaceful transfer of power that follows the U.S. Presidential Election on January 20, 2017.

Brexit and this damn election have damaged Trust.

So, by God, we in the Square suggest resurrecting, “Out of many, one…”