Sunday, December 28, 2014

Brothers Under the Exoskeleton

Anyone who has been following my weekly blogs will know that I am a convinced evolutionist. For ten years I worked at the biotech company that supplied genetic sequencing equipment for the Human Genome Project, DNA analysis tools for forensic and paternity testing, and the machines and reagents for hundreds of other research and clinical applications. I worked alongside chemists, biologists, and engineers and picked their brains whenever I could, as well as doing my own reading on the subject. In later years, it was my job to explain their work and the company’s products to our nontechnical employees as the industry moved from the genome and proteome to the epigenome, the metabolome, and other areas of study, deeper and deeper into life’s molecular secrets.1 From all of this, I know—not just believe, but know—that evolution is the model for the development of life on this planet. It’s literally written into our DNA.

The implication of this is that all life on Earth is related. We share a heritage not just with other mammals but with all the animals and even with plants, bacteria, and fungi. For one example, the DNA/RNA/protein coding system that these organisms use is the same as in our human cells.2 The proof of this is that we can manufacture a human protein in a mammalian or yeast host cell through the process of recombinant DNA. The resulting protein is not “just as good as” the ones made in our own bodies; it is chemically indistinguishable.

For another example, consider our shared structure. You wouldn’t think that an ant and a human have much in common. Apart from the size difference, ants are structured with a tough, inflexible outer shell—an exoskeleton—and hold their organs and other soft parts inside each jointed segment, while we humans have a bony internal skeleton that supports our vital organs by wrapping them in a bag of skin and connective tissue.

But ants and humans, along with every other insect and animal you know—except for worms, jellyfish, and all the radially symmetrical sea life, like sea urchins and octopi—have a common arrangement. We all have a head that encloses our major neural ganglia, or brain. The head also holds our external sensory apparatus for sight, sound, and chemical receptors—that is, our eyes, ears, nose, and tongue—which connect directly to the brain. Further, the head contains our mouth for ingesting food. Human, dog, horse, cow, kangaroo, sloth, dinosaur, reptile, frog, fish, ant, spider, scorpion—we all have this same structural arrangement at what we generally think of as the “top” or “front end” of the body.

After the head comes our thorax, or chest, with the heart, lungs, and other equipment for breathing and circulation. And after the thorax, lower down or toward the rear, comes the abdomen—whether separated by a muscle called the diaphragm in humans and other mammals, reptiles, and amphibians, or by segmentation of body parts in insects. Organs in the abdomen process food, eliminate wastes, and engage in reproduction. Human, dog, dinosaur, fish, spider—all put these functions in more or less the same place.

And while ants may have six legs that grow out of their thorax segment—and spiders the same general arrangement, except with eight legs—we humans along with every other vertebrate animal that walks on land and descended from the line of fishes all have two limbs that grow from shoulderblades attached to the thorax and two limbs that grow from a pelvis attached to the spine near the abdomen. This is the tetrapod—or “four-footed”—super class of animals. Count the front limbs—whether arms, wings, or flippers—and you only come up with two. Count the hind limbs—whether tipped with claws, hooves, or toes—and again only two.3

This is why the chimeras of classical mythology and the medieval bestiaries seem so strange and mysterious. Pegasus has the four legs of a horse plus a pair of wings. Griffins have the wings and legs of an eagle with the hindquarters and tail of a lion. Centaurs have the legs of a horse and the torso of a human. Angels have legs, arms, and wings.4 All of these supposed creatures are six limbed, like the insects, and that violates the tetrapod morphology.

More than this, can we imagine a creature whose mouth was in its stomach? That would make the most sense, wouldn’t it? Give the stomach direct access to the outside world, rather than processing all that bulky food inside the head first and then passing it with a long tube—through the constriction of the neck, which must already contain the spine, muscles, tendons, arteries, and veins supporting the head—down past the heart and lungs and into the abdomen. Or can we imagine a creature with its eyes mounted on stalks alongside or atop its wrists and ankles? That would make controlling the feet in running and the hands doing in close work more convenient, wouldn’t it? We could also look around corners and over windowsills without exposing our fragile faces and heads to surprise attacks and hurled objects.

But these morphological improvements are not the way our bodies work—not in fish, frogs, reptiles, dinosaurs, dogs, or people.

These arrangements go back to an ancient set of genes called the homeobox, which is sometimes shortened to “hox.” These genes don’t code for proteins, because we don’t have a “head” protein or a “chest” protein. Instead they code for “transcription factors,” which are bits of RNA that stay inside the cell’s nucleus and promote other genes during the earliest stages of embryonic development. Hox genes control the cascade of gene activity and the resulting proteins that create our most basic structure.

Animals, plants, and fungi—practically any organism with more than one cell, and so the need to tell each cell in the developing organism where to go and what to become—has a set of hox genes. They are arranged differently and create different structures in animals and plants. But in the blueprint of the final organism, they are the first sketches that set the whole building job into motion.

The hox gene set is remarkably conserved. That means we share a lot of our genes and our resulting structure with most animals but less so with plants.5 Molecular biologists have studied the homeobox gene set most closely in the genus Drosophila, or fruit flies. They have—but did not originate—the same head-with-brain-and-eyes, thorax-with-heart-and-lungs, abdomen-with-stomach-and-reproduction arrangement that fish, frogs, reptiles, and mammals all have.

The interesting thing about fruit flies is that researchers can play with the hox gene set and not get a reprimand from the Society for the Prevention of Cruelty to Animals—that, and the flies breed new generations relatively fast, so you can study changes on a convenient time scale. What we’ve learned is that if you mutate these genes, or silence them, you can change the animal’s structure. You can breed fruit flies with legs growing where their antenna should be, or with eyes in the middle of their wings. Of course, if you change the number and arrangement of these genes too much—say, trying to place the head between the thorax and the abdomen—you simply kill the embryonic fly by creating a totally scrambled, nonviable structure.

The fact that we share so many proteins, so many of the genes that make them, and the genes that create our basic structures with other animals—and the DNA/RNA system that records and transmits all this with all other life on Earth—is proof enough to me that we are all related. And that relationship is mediated by gradual adaptation through many generations. The foreleg of the early tetrapod changes and adapts over time to become the wing of a bird or bat, the leg of a horse or cat, or the grasping hand of a monkey or a man. The compound, prismatic eye of the fruit fly occupies the same position in the head as the single-focal-plane, liquid eye of the horse or the human.

We are all brothers under the exoskeleton.

1. What are all these “omes”? In current molecular biology, an “ome” is the domain of a particular system under study. The genome is concerned with the operation of the genes: the DNA/RNA system. The proteome is the study of proteins and their interactions. The epigenome concerns itself with environmental and chemical effects that modify DNA expression. And the metabolome deals with the metabolism, its inputs and products, on either the cellular or bodily level. The field of molecular biology is widening all the time and simultaneously becoming intertwined, as researchers explore and link up all these different pathways and their effect upon one another.

2. With minor mechanical exceptions. For example, the ribosome—the RNA-based molecule which translates the coding of messenger RNA to assemble amino acids in making the body’s proteins—differs between eukaryotes (multi-celled organisms whose DNA sits inside a nucleus) and prokaryotes (single-celled organisms whose DNA floats around in the cell). Almost all antibiotics work to inhibit the operation of the ribosomes in prokaryotes but not in eukaryotes—which is why they kill the bacteria inside our bodies but not us or our livestock and plants. This is also why antibiotics won’t protect you from a virus, because viruses hijack the host’s genetic system to transcribe and translate their DNA.

3. But what about whales and dolphins? They descended from land animals that went back into the sea, and they have no legs. Neither do snakes. But these animals generally have vestigial hips and leg bones hidden inside their bodies. Even if they don’t use them, the genes for these features remain to make themselves felt. And of course, the tails of whales and dolphins are a different, boneless appendage not related to the organism’s skeletal structure.

4. How does the musculature of the angel’s human-appearing upper arm and shoulder cross over and coincide with the musculature of its birdlike wing? And which muscle system dominates the mechanics of the shoulderblade? It’s all a mystery.

5. Consider that most plants have their food-processing organs in their deep roots, their reproductive organs in their flowering tops, their lungs in their leaves, no hearts to speak of, because they rely on capillary action to pass fluids up and down, and no need for legs, because they spend their adult lives in one spot.. They all share a homeobox organization that is just downright alien compared with that of mice and men.

Sunday, December 21, 2014

On Graffiti and Vandalism

Let me say right at the beginning that I hate both graffiti and vandalism. They are visual blights, signs of decay, and represent a loosening of the social order. You see scrawled signs, elaborate and indecipherable signatures, and spiky paint bombs in places where nobody is watching. You see broken windows, wrecked cars, shot-out street lights, and shot-up road signs in places where nobody cares. At the very least, they are marks of carelessness and disrespect for property rights. At the worst, they signal anger, despair, frustration, and hopelessness. Scrawled curses and broken windows are too often the salt crust left over from tears of rage.

And yet … I try to imagine a world where no one sprays graffiti, where no one breaks untended panes of glass. I think through the logical implications of this, and I don’t much like them.

Consider a world in which whole square yards of empty concrete and the sides of railroad cars and bridge abutments remain as visually empty as the day they were made. Consider a world in which abandoned buildings are never broken into and entered, where abandoned cars are allowed to rust gently into the topsoil, and where windows with nothing going on behind them gather only dust and sunlight and never the occasionally thrown stone. Perhaps that’s a world where everyone has good intentions, a liberal education, and a solid middle-class upbringing, with parents who teach their children to respect the property rights of others, think of the consequences of reckless impulse, and keep their hands to themselves. Such a world would belong to the proper little Ralphs among us.1

But not everyone—not by a long shot—has such a proper and respectful upbringing, such positive influences on their young impulses. For those among us humans who were not raised by a stern father and a reproachful mother, what would such a clean and orderly world signify?

Something missing, is my guess. A world in which young people—and those who still had the impulses of youth—did not itch to leave their mark in fresh paint, to break the abandoned windowpane, to rebel against the clean surfaces and orderly functions that others had left behind … such a world would be inhabited by drones. When left with idle time and no instructions to follow, they would fold their hands in their laps and sit quietly. They would contemplate the infinite and sink into their souls, like little Zen masters. Or they would simply switch off, like robots which had outrun their programming. Such is not human behavior.

Imagine a world where the young did not act out, did not test their strength against the inanimate landscape, did not break the rules. Imagine a world where idle people did not break into empty buildings to see what might be inside. Imagine a world where children did not roam the neighborhood, climb trees and walls so they could leap from their heights on a dare. Where they did not dig into rocky hillsides, looking for gold and treasure. Where they did not climb over the construction sites of new housing, free to hang from the door frames and scuff across the bare boards with their sneakers.2 It would be a world of little old people—or of insects and reptiles, hard-wired into certain mental and emotional patterns from birth. It would be an inhuman world.

Now I try to see graffiti as a sign of human creativity. Some person with a need for personal expression is experimenting with a new and exotic signature. Or trying to draw an elaborate haiku in unknown glyphs without ever lifting the brush and stopping the flow of paint. Some artist is trying to express the inexpressible, in loops and twists of an untrained imagination, using the only canvas that may be available to him or her, an unmarked wall or a sidetracked railcar.

I try to see broken windows as a sign of untested energy. Some bored youngster—or someone young in spirit—has picked up a stone and tested his or her skill in throwing it accurately; the crash and tinkle of breaking glass is his or her reward for a well placed shot. Note that I’m differentiating here between the broken windows, stripped doorknobs, and trashed interiors of an obviously abandoned building and the damage done to an occupied home where people live behind the windows and inside closed doors. The former is idle play and reckless disregard; the latter is premeditated terrorism, which is wholly evil in intent.

Graffiti and vandalism are expressions of the human soul in rebellion. It would be better, of course, for the graffiti artist to be given a clean sheet of vellum, an orderly box of colored crayons or paints, and instruction in useful visual expression. It would be better if the vandal were given a hammer, nails, fresh boards, and the invitation to build up rather than tear down. But those, again, are the responses of a socially motivated, middle-class mentality. Spray paint on concrete and a stone breaking a window are what the untamed human being finds in the wild and seizes on for his or her own satisfaction.

These expressions are part of what makes us human. We are a restless, invasive, encroaching, seeking, striving, overturning species. We are not respecters of limits. We are not mindful of the ghostly property rights left behind on empty walls and in abandoned buildings. We climb fences and sleep in other people’s barns. We break windows to test our own skill and strength. We spray paint to mark our passage through the world. Graffiti and vandalism are part of what drives us forward.

I suppose we could change human nature to erase these blighted landscapes. We could try to eliminate the impulse to put our mark where nobody has made a claim, to break the glass that nobody seems to own. With enough patience—or sufficient socially focused violence—we could turn these restless humans into good drones.

The justification would be that we are no longer creatures living in the wild. Those social scientists bent on changing human nature would say that humans must now become more sociable animals, mindful of the feelings and property rights of others, because every square foot of the Earth by now belongs to someone else, somewhere else. And anything that is not already claimed, either here or out among the planets and the stars, must be left in its natural, untouched state, because wilderness has its own set of rights and priorities.

Sure, we could change our innermost nature. Some would say that we must change in order to build a stable, urban society. But I doubt it can be achieved with any amount of patience or socially focused violence. Humans cannot become insects or reptiles, hard-wired to calm obedience. We cannot become drones or robots or little old people with our hands quietly folded. We are a violent, untamed mammalian species, and that has been the key to our success in the world.

If you take away our fierce natures, we will surely begin to die as a species.

1. From William Golding’s Lord of the Flies. Ralph is the fair-haired protagonist who stands for personal responsibility, social order, fair treatment of others, and individual rights. As I recall the story, he doesn’t fare well.

2. When I was a youngster in my aughts and early teens, we lived in a new housing subdivision in the Boston suburbs. There the expanding periphery consisted of cleared lots, poured concrete foundations, and the rising frames of single-family homes nailed together in two-by-fours and one-by-eights. Exploring these building sites—not to damage them but simply to climb and play—was part of my childhood. From this experience, I also learned a fair amount about concrete forms, carpentry, and house construction just by observing how these new homes progressed.

Sunday, December 14, 2014

The Art of the Possible

German Chancellor Otto von Bismarck is quoted as saying, “Politics is the art of the possible.” He also said, “Politics is not an exact science.” I subscribe to those notions.

In any group—clan, tribe, municipality, state, nation, or empire—you will find people having different ideals and needs, holding to different values and opinions, following different paradigms, and drawing upon different bases of information. Whether your system of government is a pure plebiscite democracy like the ancient Greek city-states, a republic like ancient Rome, a monarchy or dictatorship with some kind of council of nobles or ministers if not a full-blown parliament, or even an absolute autocracy supported by a cabinet of hand-picked bureaucrats—at some point politics will enter the picture. People will have different ways of doing things and form into groups of like mind.

Even if the dictator or autocrat has stated his wishes and commands in excruciating detail, he must eventually leave them to his administrators for execution. In any endeavor larger than fetching the king or tsar a cup of tea, those supporters will have to interpret the commands, decide how to carry them out, and make sensible decisions when questions and conflicts arise. Politics is inevitable, because nothing having to do with human beings is ever simple and obvious. And the more human brains and voices that are involved in any question, the more complex it becomes.

Sometimes—rarely, but it happens—one group of like mind will be so strong that its values, paradigm, or interpretation of the information at hand is paramount, and its members have the power to override all discussion and work their will. But if the group is too large, that consensus will not last for long. Even the most monolithic authority base quickly develops its own splinter groups, offshoots, and intent contrarians arguing on the most closely held of questions. Ask the Muslims about Sunnis and Shiites. Ask the old Russian Social-Democrats about Mensheviks and Bolsheviks. The party in power always has its internal feuds.

And when monolithic power breaks down, the result is politics.1

Politics is all about negotiation and compromise. Lacking the power to force your will, you must resort to working with your opponents, bartering concessions for cooperation, giving in order to get. It’s a messy business, because you don’t know, can’t know, ahead of time, what positions your opposition will value most, or be willing to trade for, or could care less about surrendering. Politics is that “inexact science,” because every negotiation is different, as different as the people sitting around the table. Politics is also the “art of the possible,” because until you sit down to deal, you don’t know what you can actually achieve.

The older generation—the ones, at least, who have survived and now thrive—knows this. They have fought their battles and, having lost about as often as they’ve won, are prepared to make the best bargain they can. It’s the young and idealistic who are fixated upon their ideals, who are absolute in their loyalty to the current paradigm, who view concession as capitulation, who vow never to give up, never to surrender.

We’re facing that situation today in the United States. The two parties, Democratic and Republican alike, have both—but at different times in the last couple of decades and under different circumstances—fallen prey to the opinions and ideals of their extreme wings.2 They have both tried to force their centrists, their “squishy middle,” into lockstep with their most extreme policies. And in both cases, the spell of pure thought and lofty ideals über alles has worked for a while, and the party has wielded power in an almost dreamlike state.

But then reality returns, as it always does, as it must, because the people of a clan, a nation, or an empire are not all of one mind. And the essence of what consensual mind does emerge is never at either extreme of the political spectrum of the day, but instead somewhere in the middle. That’s why they call it “the middle.”

Any politician or political party which does not understand this and tries to impose their programs by conducting one-sided votes, issuing executive orders, and making regulations beyond the scope of the legislative mandate is acting like a naïve child. Such a politician reveals him- or herself as either an inexperienced neophyte or someone who has confused winning an election with staging a revolution.3 It may feel good to remain pure of heart and wedded to your ideals, but it’s not the way to remain in power long.

But it sometimes happens. I can think of a few cases—the Nazis under Hitler, the Soviets under Stalin—where a clique at the top maintained both a relatively pure ideal and their own vision of power. But these examples do not bear repeating, because their methods included harsh repression, purges and cleansings, scapegoating, prison camps, and—when all else failed—a resort to war to steel the population and conceal the government’s true purposes under the flag of patriotism. And in the end those systems collapsed anyway, causing widespread confusion and misery. Not, in my opinion, the way to go.

So, at the end of the day, at the end of all your speeches and campaigning, you have to sit down and deal with your fiercest opponents and your squishy middle. It’s inexact, it’s messy, but in a universe of competing values and ideals, it’s the only sensible way to govern.

1. Or war, which is “a continuation of political intercourse carried on with other means.” That’s a quote from Carl von Clausewitz, another German political theoretician.

2. I have a litmus test for finding those extremities: simply ask someone if there is a difference between the two parties. If he or she can see no difference, then that person is operating from a paradigm far to the left or right of where the two parties rub shoulders.

3. So, I’ll reveal my conservative bias here. The extreme left wing of the Democratic party has, in my view, never weaned itself from the revolutionary politics to which its now aging, Baby Boomer members pledged themselves the heyday of the 1960s. They self-identified with guerrilla opposition groups in Cuba and Vietnam, and with underground, iconoclastic movements within the industrialized West. They became intent on bringing down the monolithic power of the “military-industrial complex,” on opposing “the man,” and on achieving an impossibly utopian state of being. Such dreams and ideals make one an inspiring advocate for a radical viewpoint but a poor candidate for actually taking power, resolving crises, and governing successfully. Every revolution that ever succeeded has had to go through a period of struggle where power-holding realists had to contain and eventually eliminate the revolutionary idealists. Ask Leon Trotsky. Ask T. E. Lawrence.

Sunday, December 7, 2014

The Insurance Model for Health Care

I’ve written on this topic before, but it’s time to repeat some obvious—at least to me—truths in the matter of modern medicine, health care, and the insurance model that pays for most of the care in this country.1 That model would seem to have outlived its usefulness.

The concept of “insurance” grew out of mercantile transactions in the coffee houses of 17th century London, when transoceanic shipping was a relatively new and dangerous business, subject to piracy, storms, navigation errors, and sudden groundings. The loss of just one ship could break the finances of the merchant who moved his goods with it. So the merchants as a group and the moneymen of the time got together and paid into a pool that would pay out on the loss of any covered ship and cargo that met with such a mishap. If nineteen ships out of twenty returned to port and only one foundered, the deal was pretty good for the insurers. They would collect nineteen initial payments and suffer only one claim of loss, keeping the rest of the money for themselves and future ventures. However, if only fifteen out of twenty ships returned, then the ship owners would be relieved of worry while the insurers might be broken financially. The transaction was all about the odds, and figuring those odds more and more closely increased humanity’s understanding of issues like probability and risk.

You insure an asset against an improbable—or at least not all that likely—occurrence: against your car being wrecked or stolen, or your house burning down, or the liability for face with operating a car or owning a house. The less likely the event, the less you pay to insure against it. Most drivers can keep their car in a locked garage and use it responsibly, so the risk of loss is negligible. Most homeowners can build with fire-resistant materials, install smoke detectors, and keep a fire extinguisher handy, so the risk of loss is again vanishingly small. Most people can afford to insure these valuable items, whose loss might be financially devastating, because the risk is low. On the other hand, people who live on a flood plain or in an active seismic zone will find that flood and earthquake insurance are prohibitively expensive, because the river rises every spring and the earth’s crust is constantly moving.

Some people think this is unfair. They believe insurance companies should cover everyone equally. The insurers should just expand the pool of risk so that the near-certainty of the homeowner living on a riverbank being flooded out will be covered by flood insurance payments from people living on hilltops or in deserts. And people living in Iowa and Nebraska should pay significant earthquake insurance premiums in order to cover the losses of people in California, so the latter can more easily pick themselves up after the next Big One. But that is not the insurance model. Instead, it would be some kind of disaster-relief fund. It would be the promise that, come what may, whatever you do as an individual, your choices will be riskless, your life situation without discomfort, and your future protected from all serious losses.

Now that’s a nice idea—a heartwarming idea. But at the same time it would remove individual choice, foresight, and responsibility from the course of one’s life. It would also raise the insurance rates for everyone to uneconomic levels. And the more completely any insurance carrier, even one operating at government expense, tried to eliminate all risk, the more money it would have to collect against the inevitable losses.

Finally, no one insures a house for the costs of routine maintenance like painting the walls and repairing the roof, or a car for oil changes and wear-and-tear on tires. These are the expected expenses of ownership, not the results of catastrophic loss. And yet those who want a risk-free life also tend to expect a cost-free life as well.

For years, people paid “health insurance” that was really protection against the unexpected costs of a “major medical” complication like a broken leg or cancer treatments. The insurance covered big hospital bills and doctor’s fees, but not routine checkups and minor coughs, colds, cuts, and abrasions. Then in the 1970s and ’80s, Health Maintenance Organizations were formed to cover more of an individual’s or family’s health bills, including those checkups and preventive measures. This reflected the growing realization that sickness wasn’t something that just fell on people out of the blue but a condition they could, to some extent, control through good diet, exercise, restraint from smoking and drinking, and early discovery of potentially harmful conditions.

It was a good idea. But it obscured the realities of the insurance model. People came to think that every procedure related to health should be paid for by someone else. Insurance was no longer coverage against the big losses due to catastrophic accident and illness, but instead became the way to pay for all routine health care, minus a modest copay that did not rock your pocketbook. This was not that much different from expecting your car insurance to pay for oil changes and new tires, or your house insurance to cover a painting crew every five to ten years.

The insurance model as it applies to health is broken in another way. Sooner or later every asset reaches the end of its design life and then of its useful life. The timbers of a hundred-year-old house become too old, eaten by termites, or infected with dry rot to support the structure. The frame and body panels of a car—or at least those in the East, where they put salt on the roads in winter—become too rusted to last another season. The cost of repairs, compared with the cost of tearing down the house or scrapping the car and building or buying a new one, no longer makes sense. Unless the house is a national monument, or the car a rare and valuable model, or one with sentimental value, the owner makes the inevitable decision.

We don’t do that with our bodies, even though they also have a built-in design life and a point at which further health care will only prolong life on a constantly diminishing scale. People invoke more complex and invasive procedures as they age, spending increasing amounts of health-care dollars, to preserve their quality of life and indeed to preserve life itself. Traditionally, a person’s greatest medical expenses come in the last six months of his or her life. This is like demanding a new engine and transmission, new suspension, and new paint and seat covers on a rusted hulk that has 300,000 miles on the odometer. And yet, people are not cars, and we innately resist the idea that anyone should suffer for lack of adequate care, no matter at what point in his or her life.

The Patient Protection and Affordable Care Act (PPACA) that passed in 2010 was ostensibly designed to extend individual health insurance coverage at fair rates to all Americans. Indeed, it included rules that require employers to provide health insurance or pay a penalty, and rules for individuals to obtain health insurance or pay a penalty. It was sold to insurance companies as vastly expanding their customer base and so increasing the scale of their business. This would seem to be a resounding government investment in the health insurance model.

And yet, the Affordable Care Act included many features that work against this all-inclusive vision. For one example, the penalties for employers and individuals are substantially less than the projected costs of the insurance which the act mandates. By forcing employers to offer coverage for all of a person’s health costs, including such maintenance items as birth control—similar to requiring auto insurance to include oil changes—the act increases the potential cost of that insurance. Although the employer penalties have been artfully delayed for political reasons, the actual effect will be to discourage employers—who are by far the greatest source of individual and family insurance coverage since the wage controls of World War II—from continuing to provide this benefit. For another example, the act requires insurers to cover all individuals at the same rate, regardless of their state of health. This “community rating” is like charging homeowners the same for fire insurance regardless of whether the house is made of brick or wood, or drivers the same for auto insurance regardless of their accident and arrest record. The actual effect will be to increase rates for everybody, like charging people in deserts for flood insurance to pay for the losses of people living along riverbanks.

In my mind, all of these conflicting features cannot be explained simply as sloppy rulemaking—politicians trying to give everyone on both sides of the deal, insurers and insured alike, everything they want. Instead, I think the act was actually designed to break the insurance model of health care. And then, when the insurance companies have been forced out of business, the state will be required to step in and provide public health care on the Medicare and Medicaid model. In my mind, this act was very carefully designed to destroy the existing payment system.

But then, I don’t like the insurance model in the first place. People are not like houses or cars. Human life is a different order of proposition, and its maintenance and continuation should not be subject to economic considerations. And finally, as explained in my earlier blog, the current and future advances in medical technology, from genetic analysis to stem cell reprogramming, are blowing apart our earlier conceptions of health, sickness, aging, and even death itself. Two hundred years ago—before the germ theory of disease and during the reign of the four humors, black bile, and bloodletting—medical practice was a matter for royalty and the very rich. Everyone else went to the local wise woman or witch doctor. Today, modern medicine serves a real purpose in life improvement and extension. It has become a necessity of life.

It is my belief that in twenty or thirty years, through the combined action of institutional and academic researchers across the country and around the world, we will have defined every chemical process and reaction in the human body. We will be able to manipulate and regenerate tissues. We will be able to address the causes of sickness and aging, repair broken and deteriorating bodies, and reshape the human destiny far beyond “three score and ten.” And because these technologies will be applied on the model of the printing press and the assembly line, with modularized components, the costs will come down dramatically.2 This is the point of my most recent novel, Coming of Age.

So I should be happy that the Affordable Care Act is rushing us toward a large-scale remaking of the health care industry. Except … I distrust large bureaucracies and globalized offerings. When the state tries to run everything along top-down, command-and-control principles—as it did in the Soviet Union for seventy years—the result is always stagnation, smothering of innovation, and loss of individual choice. As they say in the clothing business, one size does not fit all.

Instead, I would look for a multitude of patient-and-provider options, along the line of cooperatives and subscription services. Kaiser Permanente is a good model of this, where the doctors and support staff form a provider organization, and patients buy its services on the installment plan. Of course, it is common knowledge among users that the quality of your experience with Kaiser depends on how the local organization is run. Some areas provide great service, others not so much. But this is only a problem if restrictions exist on the formation of new, competing service organizations. When choice is restricted, the incentive to do better goes away. The tendency of people and organizations to excel when faced with competition on price and service offering is a built-in feature of free markets.

Taking the long view, I’m not too much bothered by the havoc that the Affordable Care Act will create in the current health care industry. A collapse was coming anyway, due to the changes in medical technology that are barreling down upon us like an express train. The old system of paying for catastrophic coverage and pre-existing conditions could not survive when every illness has its detectable precursor and every accident has its optimum repair.

But in the meantime, to paraphrase Bette Davis in All About Eve: “Fasten your seatbelts, it’s going to be a bumpy ride.”

1. See Personalized Medicine and the Insurance Model from December 26, 2010.

2. Anyone who doubts this should compare the cost of pioneering medical procedures, from organ transplants to laser vision surgery, with the cost of these services today. With widespread use and improvements in practice, the price comes down tenfold. For that matter, consider the cost of the first personal computers or cell phones with the equipment and prices available today. In a technologically oriented world, everything becomes relatively cheaper. See Gutenberg and Automation from February 20, 2011.