David MacKay “Perhaps my last post – we’ll see”

David MacKay

Prof. David MacKay has done more than any other human to improve our understanding of practical energy policy. His famous book Sustainable Energy Without the Hot Air is on the bookshelf of everyone who is seriously interested in making the future better. 

Yesterday David wrote:

I noticed that the posts of a friend who died of cancer trickled away to a non-conclusion, and this seems an inevitable difficulty, that the final post won’t ever get writ.

I’d like my posts to have an ending, so I’m going to make this my final one – maybe.

Ever the scientist, he has been documenting his experience as a cancer patient. For example Bye-bye Chemotherapy, Hello TP53! explains how he and his oncologist discuss prospects and options. I hope that David recovers so well that he can write a new book – a scientist’s perspective on how he became a former cancer patient.

WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health

The nightmare bugs are multiplying because our antimicrobial team has no real leadership and has shockingly inadequate funding. We don’t have much data on what is really happening, but my guess is the deaths-from-resistant-microbes curve is increasing at an increasing rate. Every year more patients discover that the post-antibiotic world has already arrived for them.

A new report by WHO–its first to look at antimicrobial resistance, including antibiotic resistance, globally–reveals that this serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country. Antibiotic resistance–when bacteria change so antibiotics no longer work in people who need them to treat infections–is now a major threat to public health.

“Without urgent, coordinated action by many stakeholders, the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill,” says Dr Keiji Fukuda, WHO’s Assistant Director-General for Health Security. “Effective antibiotics have been one of the pillars allowing us to live longer, live healthier, and benefit from modern medicine. Unless we take significant actions to improve efforts to prevent infections and also change how we produce, prescribe and use antibiotics, the world will lose more and more of these global public health goods and the implications will be devastating.” 

Globally we are falling further behind. Every year more resistant bacteria are discovered, more people die. The most recent data I have shows 2 million U.S. cases of antimicrobial resistance, resulting in 23,000 deaths. We know the actuals are higher because there is no requirement for hospitals to report cases or even outbreaks of resistance. Here is an example from the transcript of the PBS special “Hunting the Nightmare Bacteria”:

Nationally, most hospitals aren’t required to report outbreaks to the government, and most won’t talk publicly about them. (…snip…)

Dr. BRAD SPELLBERG: It’s not that the government agencies are not aware of the problem and are not— and are not doing anything. It’s that we have not had a comprehensive plan for how to deal with antibiotic resistance. We don’t have reporting mechanisms, like they do in Europe, to know where resistance is occurring, who’s using the antibiotics, are we overusing them?

DAVID E. HOFFMAN: Wait. You’re telling me we don’t know the answers to the extent of the problem?

Dr. BRAD SPELLBERG: That’s correct.

DAVID E. HOFFMAN: We don’t have the data?

Dr. BRAD SPELLBERG: That is correct. I do not know how many resistant infections are occurring right now. I don’t know what the frequency of resistance in different bacteria are. We do not have those data.

NARRATOR: FRONTLINE requested an interview with the secretary of Health and Human Services, Kathleen Sebelius. We wanted to ask about the lack of data and the about the priority the department is giving to the new superbug crisis. But she declined to be interviewed.

The “nightmare bacteria” have caught governments and public health authorities napping. They didn’t seem to notice that over the past twenty years the development of new antibiotics has collapsed. From the 2013 report by the CDC Antibiotic Resistance Threats this graphic illustrates that there is now almost no new antibiotic development.

Antibiotic development collapse

The fundamental reason for the collapse in new antibiotics is the pharma marketplace doesn’t reward developers enough to pay for the R&D and the drug approval process (USD $600 million to $1 billion for a new drug). Those numbers inhibit every kind of drug – but let through those that sell to the chronic patient markets (cholesterol, hypertension, …). A successful new antibiotic may be sold to a patient for 10 days, not 30 years like a hypertension drug.  And sadly there is nearly no high level level focus on the new antimicrobial market failure.

Resistance is an everyday process – microbes begin exhibiting resistance as soon as a new compound is deployed. There was already penicillin resistance when the drug was first commercially introduced. This issue didn’t start making the headlines in at the beginning of the 21st century because there were still a lot of drugs in the cabinet that could be tried when a new resistant bug surfaced. Today, for an increasing number of infectious diseases, the antibiotic cabinet has fewer effective drugs every year. From the  CDC Antibiotic Resistance Threats report, this graphic illustrates key resistance events:

Timeline of antibiotic resistance

The PBS Frontline special is a useful introduction to this subject — with video, audio, transcript and a number of useful resource links. The CDC report Antibiotic Resistance Threats is an excellent, well-researched overview as of 2013. CDC has a Antibiotic / Antimicrobial Resistance websitethat can be your home base for researching and tracking progress on this issue. CDC is asking congress for $160M [Antibiotic Resistance Solutions Initiative — $160M: A Comprehensive Response].

So what can you do? Most important is to make it clear to your representatives that you expect them to support a major government focus.  In the U.S. there should be at least an NIH Assistant Secretary devoted to antimicrobial resistance, whose mission should be new antimicrobial drug research and development, high-efficiency testing to fast-track diagnosis of new cases, case tracking/reporting, and OBVIOUSLY to radically slash the agricultural misapplication of antibiotics at sub therapeutic doses (about 80% by mass of US antibiotic sales).

To give you an idea of how inadequate the US response is read Can a New White House Plan Catch Up to the “Superbug” Threat?

Although that initiative represents the government’s first-ever attempt to broadly address the issue of antibiotic resistance, the plan has been quickly dismissed by some scientists and lawmakers for not going far enough. In an interview with Politico, Rep. Louise Slaughter (D-N.Y.), the only microbiologist in Congress, said that goals set for 2020 are too far off to make up for lost ground.

“I’ve said to people, ‘Right now your government is not going to protect you,’” said Slaughter. “They’re about 10 years behind.”

PS – if you have some elective surgery on your horizon, say a knee or hip replacement, you might want to think about getting that done while there are still a few antibiotics that could help save your life (or your leg).

Homeopathy: Dead Sharks and Hufflepuff Meds

Happiness is waking up to a fresh Ecomodernist Mom post. However today the topic is definitely not a happy one. Amy’s topic is quackery – homeopathy in particular.

As far as I’m concerned, homeopathy falls into the same category as all unproven supplements and herbal “medicine” and everything else under the alternative umbrella. I think it’s all bullshit but I’m not trying to ban it. If people want to buy magic water and pretend it does something, then by all means, they should knock themselves out.  But why not label it correctly?

Amy knows a great deal about the suffering that quacks can inflict on patients like her mom.

The Panic Virus: A True Story of Medicine, Science, and Fear

In Why the ‘Prius Driving, Composting’ Set Fears Vaccines Greg Miller interviews author Seth Mnookin on his new book. Here’s a fragment of the Q&A:

Q: There’s a perception that vaccine refusal is especially common among affluent, well-educated, politically liberal parents—is there any truth to that?

S.M.: It’s dangerous to make broad generalizations about a group, but anecdotally and from the overall data that’s been collected it seems to be people who are very actively involved in every possible decision regarding their children’s lives. I think it relates to a desire to take u ncertainty out of the equation. And autism represents such an unknown. We still don’t know what causes it and we still don’t have good answers for how to treat it. So I think that fear really resonates.

Also I think there’s a fair amount of entitlement. Not vaccinating your child is basically saying I deserve to rely on the herd immunity that exists in a population. At the most basic level it’s saying I believe vaccines are potentially harmful, and I want other people to vaccinate so I don’t have to. And for people to hide under this and say, “Oh, it’s just a personal decision,” it’s being dishonest. It’s a personal decision in the way drunk driving is a personal decision. It has the potential to affect everyone around you.

Q: But why liberals?

S.M.: I think it taps into the organic natural movement in a lot of ways.

I talked to a public health official and asked him what’s the best way to anticipate where there might be higher than normal rates of vaccine noncompliance, and he said take a map and put a pin wherever there’s a Whole Foods. I sort of laughed, and he said, “No, really, I’m not joking.” It’s those communities with the Prius driving, composting, organic food-eating people.


How to find reliable, evidence-based medical information

The image of a handsome doc doesn’t tell you anything about the quality of the medical information!

There is so much health and medical information on the Internet that it can be dangerous to start searching for guidance on some concern that you have. If you are in a big hurry to find evidence-based information start here:

The Cochrane Collaboration: this is a first stop for many physicians who need to check on what is the current best evidence-based information based on Systematic Reviews.

A systematic review attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making. (See Section 1.2 in the Cochrane Handbook for Systematic Reviews of Interventions.)

If you need more, visit CAPHIS, the Consumer and Patient Health Information Section of the Medical Library Association. CAPHIS maintains Top 100 List: Health Websites You Can Trust. We have downloaded the whole database for easy reference. If you are a US or Canadian resident and you need a medical library, see Find a Library.

Lastly, new-media startup VOX has a page that seems to fulfill the VOX promise of current, accurate information on a topic: Stop Googling your health questions. Use these sites instead.  This page is produced by Burden of Proof:

a regular column in which Julia Belluz (a journalist) and Steven Hoffman (an academic) join forces to tackle the most pressing health issues of our time — especially bugs, drugs, and pseudoscience thugs — and uncover the best science behind them.

Belluz and Hoffman do a nice job explaining why you won’t want Dr. Oz but you do want Cochrane Collaboration. They also have a useful page on Study Design, where you can read a tutorial that will help you assess the daily “health headlines” (if you must read them). I like their chart:


“Eroom’s Law: the cost of developing a new drug doubles every nine years”

Arnst Drug Approval 610x408

Eroom’s Law is Moore’s Law spelled backwards. Sadly it describes the reality of declining drug approval rates. Diagnosing the decline in pharmaceutical R&D efficiency was published in Nature Reviews Drug Discovery March 2012. The abstract: 

The past 60 years have seen huge advances in many of the scientific, technological and managerial factors that should tend to raise the efficiency of commercial drug research and development (R&D). Yet the number of new drugs approved per billion US dollars spent on R&D has halved roughly every 9 years since 1950, falling around 80-fold in inflation-adjusted terms. There have been many proposed solutions to the problem of declining R&D efficiency. However, their apparent lack of impact so far and the contrast between improving inputs and declining output in terms of the number of new drugs make it sensible to ask whether the underlying problems have been correctly diagnosed. Here, we discuss four factors that we consider to be primary causes, which we call the ‘better than the Beatles’ problem; the ‘cautious regulator’ problem; the ‘throw money at it’ tendency; and the ‘basic research–brute force’ bias. Our aim is to provoke a more systematic analysis of the causes of the decline in R&D efficiency.

For some commentary on the Scannell et al paper, this is useful Why Drug Development is Failing – and How to Fix It. BTW Derek Lowe is my favorite observer of pharma research – I highly recommend In the Pipeline.

The new drug drought was highlighted in January by Derek Lowe, a pharmaceutical scientist who writes the influential blog In the Pipeline. He asked his readers to name the most worthwhile new drug that had been introduced since 1990. Of the many candidates nominated, the vast majority were brought to market in the first half of that 20-year span.

One reason for the industry’s meager R&D productivity is the sheer complexity of the human body, argue four analysts at Sanford C. Bernstein, led by Jack W. Scannell. In their article in Nature Reviews Drug Discovery, “Diagnosing the Decline in Pharmaceutical R&D Efficiency,” they examined R&D projects for more than 28,000 compounds investigated since 1990. During that 20 year period the pharma industry increasingly concentrated its R&D investments on drugs that address unmet therapeutics needs and untargeted biological mechanisms—areas where the need is great but the risk of failure highest. This is the widely-held “low hanging fruit” theory of the drug drought: the easier disease targets, such as high cholesterol, asthmatic airway passages, migraines, and ulcerous digestive systems, have been met. Complex diseases such as cancer and neuro-degenerative conditions are much harder to solve.

But Scannell and his colleagues also laid out four additional, interlocking arguments that may explain the decline in R&D output:

  • The ‘better than the Beatles’ problem: Imagine how hard it would be to come up with a successful pop song if any new song had to be better than the Beatles . Unlike cars, or electronics, with drugs there’s no interest in novelty for its own sake. And there’s no point in creating something that’s only just as good as what’s already available, especially since today’s hit drug is tomorrow’s inexpensive generic.
  • The ‘cautious regulator’ problem: The progressive lowering of risk tolerance, particularly after the pain treatment Vioxx was removed from the market in 2004 for safety reasons, raises the bar on safety for new drugs, which makes R&D both costlier and harder.
  • The ‘throw money at it’ tendency: The tendency to just keep pouring more money and resources into a research project or a widely-held theory until something sticks. Could also be called throwing good money after bad.
  • The ‘basic research-brute force’ bias: The industry’s tendency to overestimate the probability that advances in basic research and large scale screening processes will show a molecule safe and effective in clinical trials.

As an outsider I find it easy to place a lot of the blame on the ‘cautious regulator’ problem. A similar disease afflicts the US nuclear power industry. A standout example of the impact on drug development is the near impossibility of gaining approval of new drug “cocktails”. The ‘personalized medicine’ concept exploits our ability to combine very fast sequencing of the patient’s DNA with exploding ‘big data’ containing detailed cases of patients-symptoms-drugs-outcomes. Sadly it’s nearly impossible to get such drug-combinations approved. 

Scannell and his fellow authors throw water on the personalized medicine theory by pointing out that despite the shift to targeted drugs and high tech screening tools, the probability that a small-molecule drug will successfully complete clinical trials has remained almost constant for the past 50 years. And those treatments that do succeed can cost patients and insurers hundreds of thousands of dollars per year, because they will by definition only work on the small number that have the cellular target. Physicians who prescribe drugs and the scientists who invent them are increasingly embracing a more nuanced view of drug discovery, the idea that most diseases require a combination of targeted drugs, often called a cocktail, to be held in check. The cocktail approach proved effective against AIDS, and medical experts believe the same approach may be necessary for cancer, Alzheimer’s, and a range of other diseases.

The problem with cocktails, however, is that it can be difficult if not impossible for two different companies to test experimental drugs in concert, for both competitive and safety reasons. Companies are beginning to overcome those competitive challenges, however, and collaborate on some of the most difficult challenges in medicine, most notably Alzheimer’s disease, the only one of the top 10 causes of death in the U.S. with no known cause, cure or even a way of slowing its progression. In 2004 the National Institutes of Health, the FDA and 20 drug companies joined forces to start the Alzheimer’s Disease Neuroimaging Initiative (ADNI), a landmark public-private partnership tasked with mapping all the biological markers connected to Alzheimer’s. The ADNI’s defining principle is to publicly share and relinquish ownership of all data and findings as soon as possible. More than 57 sites are collecting data from thousands of patients, and the results to date have already been incorporated into research and trials by pharmaceutical companies.

The gluten-free contagion



Another good piece of journalism by Michael Specter writing for the New Yorker Magazine What’s So Bad About Gluten? Yes, that’s the same Michael Specter who wrote the excellent expose of Vandana Shiva [I’m a card-carrying anti-Shiva activist].

People seem to be afraid of an increasing range of things, and gluten anxiety has grown until it seems to be the hot new ingredient to avoid.

Why? We know that about 1% of the population has Celiac disease – which means truly dangerous gluten intolerance. There is some evidence that the incidence grew since the 1950’s to that 1% level. Since the chemistry of wheat is unchanged the implication is the cause is environmental. But the gluten panic isn’t about Celiac disease – it seems to be largely self-diagnosed quite possibly just a popular myth.

Here’s a couple of excerpts from Michael’s essay that will give you some hints:

Myhrvold wasn’t in town that day, but I caught up with him later. He is highly opinionated, and delights in controversy; saying the words “gluten-free” to him was like waving a red flag at a bull. “When I was a kid, I would watch National Geographic specials all the time,’’ he told me. “Often, they would travel to remote places and talk to shamans about evil spirits. It was an era of true condescension; the idea was that we know better and these poor people are noble, but they think that spirits are everywhere. That is exactly what this gluten-free thing is all about.” He stressed that he was not referring to people with celiac disease or questioning the possibility that some others might also have trouble eating gluten. “For most people, this is in no way different from saying, ‘Oh, my God, we are cursed.’ We have undergone what amounts to an attack of evil spirits: gluten will destroy your brain, it will give you cancer, it will kill you. We are the same people who talk to shamans.


Peter H. R. Green, the director of the celiac-disease center at the Columbia University medical school and one of the nation’s most prominent celiac doctors, says that the opposition to gluten has followed a similar pattern, and that it is harming at least as many people as it is helping. “This is a largely self-diagnosed disease,’’ Green said, when I visited his office, at New York-Presbyterian Hospital. “In the absence of celiac disease, physicians don’t usually tell people they are sensitive to gluten. This is becoming one of the most difficult problems that I face in my daily practice.”

He went on, “I recently saw a retired executive of an international company. He got a life coach to help him, and one of the pieces of advice the coach gave him was to get on a gluten-free diet. A life coach is prescribing a gluten-free diet. So do podiatrists, chiropractors, even psychiatrists.’’ He stopped, stood up, shook his head as if he were about to say something he shouldn’t, then shrugged and sat down again. “A friend of mine told me his wife was seeing a psychiatrist for anxiety and depression. And one of the first things the psychiatrist did was to put her on a gluten-free diet. This is getting out of hand. We are seeing more and more cases of orthorexia nervosa”—people who progressively withdraw different foods in what they perceive as an attempt to improve their health. “First, they come off gluten. Then corn. Then soy. Then tomatoes. Then milk. After a while, they don’t have anything left to eat—and they proselytize about it. Worse is what parents are doing to their children. It’s cruel and unusual treatment to put a child on a gluten-free diet without its being indicated medically. Parental perception of a child’s feeling better on a gluten-free diet is even weaker than self-perception.”


FODMAPs, an acronym for a series of words that few people will ever remember: fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Not all carbohydrates are considered FODMAPs, but many types of foods contain them, including foods that are high in fructose, like honey, apples, mangoes, and watermelon; dairy products, like milk and ice cream; and fructans, such as garlic and onions.

Most people have no trouble digesting FODMAPs, but these carbohydrates are osmotic, which means that they pull water into the intestinal tract. That can cause abdominal pain, bloating, and diarrhea. When the carbohydrates enter the small intestine undigested, they move on to the colon, where bacteria begin to break them down. That process causes fermentation, and one product of fermentation is gas. In Gibson’s new study, when the subjects were placed on a diet free of both gluten and FODMAPs, their gastrointestinal symptoms abated. After two weeks, all of the participants reported that they felt better. Some subjects were then secretly given food that contained gluten; the symptoms did not recur. The study provided evidence that the 2011 study was wrong—or, at least, incomplete. The cause of the symptoms seemed to be FODMAPs, not gluten; no biological markers were found in the blood, feces, or urine to suggest that gluten caused any unusual metabolic response.

In fact, FODMAPs seem more likely than gluten to cause widespread intestinal distress, since bacteria regularly ferment carbohydrates but ferment protein less frequently. Although a FODMAP-free diet is complicated, it permits people to eliminate individual foods temporarily and then reintroduce them systematically to determine which, if any, are responsible for their stomach problems. FODMAPs are not as trendy as gluten and not as easy to understand. But, biologically, their role makes more sense, Murray says.

Michael Specter happens to be a dedicated whole wheat baker. Based on what he learned researching this story, he says he has dumped his vital gluten additive in the trash. ” I have returned to baking whole-wheat bread the way it is supposed to be made: water, yeast, flour, and salt. I will try to live without the magic wand. But I am certainly not going to live without gluten. That just seems silly.”

Science funding is broken. Thinkable wants to help fix it.

Logo thinkable

Thinkable is a promising new crowd funding connection between researchers and sponsors (including the public at large). Founded by oceanographer and chief scientist Ben McNeil “the idea for Thinkable comes out of Ben’s frustration over the lack of funding for basic research and a passion for blue-sky thinking.” Ben’s recent arstechnica essay is a good introduction to why he believes science funding is broken; paired with the solution proposed by Thinkable: Is there a creativity deficit in science? If so, the current funding system shares much of the blame.

I won’t try to outline how the Thinkable platform and ecosystem works — the Thinkable website is very well-designed, so you’ll learn more about the venture by just jumping in — and be sure to sign up in your role as a sponsor or a researcher. I decided that the best way to evaluate Thinkable is to participate: I’ve subscribed to sponsor Martin Rees whose current project funding is passing the 50% level: How can we stop blood vessels becoming damaged and sticky during inflammation?

Here’s some of the reasons I’m excited about Thinkable:

  1. Taking risks is absolutely fundamental to real progress in science and technology. The existing institutional funding channels are highly risk averse — “crazy ideas need not apply here”.
  2. The path to breakthroughs is cobbled by mistakes. Mistakes are where most of the learning happens.
  3. Those characteristics are familiar to entrepreneurs who are successful innovators. The venture capitalists who consistently make superior returns know this very well. That’s why Silicon Valley slang is peppered with phrases like “Fail fast” and “Pivot”. “Let’s invest through the pivot” has probably been spoken more than once by a VC looking at superb founders (translation: “these guys are so good we want to work with them, even though their idea is probably going to fail”).
  4. Thinkable looks to be administratively very lightweight — so that funding goes to support research, not overheads. I understand that 87% of sponsor funding is delivered: after 10% to support the Thinkable platform and about 3% for payment processing fees (Visa etc. Note that once Thinkable can rely on crypto currency payment processing that 3% will fall near to zero) 

In my next post on Thinkable I hope to be able to explain who is funding the venture. Please help spread awareness of the Thinkable platform. If this takes off in a big way we could be helping to Change the World.

Should we force drunks to drive? Compulsory Voting: For and Against


I’ve not yet read the June-release of Compulsory Voting: For and Against, but it comes well-recommended. Here are two blurbs by George Mason colleagues of the authors:

“The frustrating thing about arguments over citizenship in democracies is that everyone is right, meaning that everyone is also wrong. There are powerful arguments in favor of asking citizens to act on a moral obligation to become informed, so as to move toward an ideal world. In that view, argued ably here by Jason Brennan, anyone who fails to become informed should voluntarily abstain. Lisa Hill argues that Brennan has it backwards: ‘good’ elections are not the result of an informed citizenry. Rather, a broadly accepted electoral process, legitimated by universal participation, is what creates an informed citizenry. Who is right? An extraordinary and very fair-minded treatment of significant issues in democracy around the world.”
Michael Munger, Duke University

“Should the government force citizens to vote? Brennan and Hill’s Compulsory Voting crisply presents the strongest case in favor as well as the strongest case against mandatory participation in the electoral process. Although the two authors defend opposite conclusions, both show that philosophy is better with careful social science – and that social science is better with careful philosophy. A book full of ideas, clarity, and candor.”
Bryan D. Caplan, George Mason University

Incidentally, prof. Bryan Caplan is the author of one of our favorite Public Choice books The Myth of the Rational Voter.

For more background try my post Public Choice: rational ignorance, pork and rent-seeking.

How will we know if the ACA is working?

I don’t know the answer to these five concise questions formulated by Tyler Cowen. Do you?

I have read a good deal on this topic and I am not very satisfied with most of it, from either side.  Too often citing and then refuting weaker claims from the other side is conflated with showing that one’s own view is right.  Here are a few issues we ought to consider and indeed focus on:

1. Five to ten years from now, how much do we think employment will have gone down as a result of ACA?  (That is from the employer mandate, high implicit marginal tax rates because of the subsidies, and also from a lesser need to stay employed to have health insurance.)  By the way, you can’t in other contexts believe strongly in rigidities and then confidently point to a small employment response within a one year time frame and claim to know these labor market effects are small ones.

1b. How will the effort to introduce greater equality of health care consumption fare if wage and income inequality continue to rise?  Will this attempt at consumption near-equalization require massively distorting incentives?

2. Given your answer to #1, and given how much employment itself boosts health, will ACA even have improved overall health in America?  Whatoutcome indicators might show this?

3. Given that prices in the individual insurance market already seem to have gone up 14-28 percent, and may go up more once political scrutiny of insurance companies lessens, what is the overall individual welfare calculation from this policy change?  I mean using actual economic policy analysis, of the CBA sort, not just noting that more people have health insurance.

4. Given supply side constraints, how much did ACA increase the consumption of health services in the United States?  (I take the near-universal bafflement over the first quarter gdp revision a sign of how poorly we understand what is going on.)  And how good or bad a thing is the ongoing but accelerated shift to narrow provider networks?

5. How much of the apparent slowdown of health care cost inflation is a) permanent, b) not just due to the slow economy, and c) due to ACA?  Or how about d) the result of trends which have been operating slowly for the last 10-20 years?

I have lifted Tyler’s complete post to serve as a checklist for monitoring the results. It will take a while – especially solid outcomes data. It isn’t at all obvious how the outcomes can be measured.