Finally, we should give parole officers and prison personnel incentives to rehabilitate and educate offenders rather than merely warehouse them. Van Jones, my liberal Crossfire cohost on CNN, proposes a bonus for wardens whose former inmates get a job and do not return to prison.
We cannot simply write off 2.3 million Americans in prison. We need a breakout in our thinking about incarceration in America.
Safety, Housing, and Jobs
Individual improvement and a reform of the existing institutions are important steps toward a breakout from poverty. But public safety, housing, and jobs are essential parts of the picture. We need to achieve breakthroughs in all three areas.
No city can be economically successful if it does not maintain public safety, which is the first responsibility of government. Yet local governments across the country have neglected that responsibility as they have spent their money and resources on other concerns. There is no reason that American cities can’t be safe places to live and work if our local governments are smart and determined. As mayor of New York, Rudy Giuliani proved with his police commissioner, William Bratton, that technology and the prudent management of resources could produce a remarkable improvement in safety. Their CompStat program achieved a 75-percent reduction in crime between 1993 and 2005, making New York the safest big city in the United States. Mayor Michael Bloomberg and Commissioner Raymond Kelly have continued that trajectory. Bratton repeated the achievement in Los Angeles. It is clear that violence on the scale of Chicago or Detroit is a function of bad management and leadership.
If large cities are to enjoy safety, the authorities must control gangs. The FBI estimates that there are 1.4 million gang members in the United States (an astonishing 40-percent increase from 2009).25 These gangs, the FBI says, are responsible for “an average of 48 percent of violent crime in most jurisdictions, and much higher in others.” The Chicago police estimate that 80 percent of the city’s murders are gang-related. Defeating gangs while weaning young people away from crime with better opportunities should be a major goal of any program for safe neighborhoods.
Housing is one of life’s essentials, of course, and owning property is a key element of citizenship. The late Jack Kemp spent much of his congressional career helping the poor develop “sweat equity” in public housing. The idea is that the occupants of public housing assume responsibility for its maintenance and ultimately acquire equity in their homes. The prison guards of the past who most fiercely opposed this strategy were the public-housing unions. During one debate on sweat equity for public housing, one member of Congress from an inner-city district said to me privately that he agreed with Kemp but that a “yes” vote would be too expensive personally. When I asked how a vote in favor could cost him, his answer was simple: “If I vote no, I have no primary, and I can go on vacation for several months,” he said. “If I vote yes, the public housing employees union will run a candidate against me. I will win, but I will have to raise half a million dollars and campaign for three or four months. It isn’t worth the cost.”
At another point during the debates in the House, Congressman Barney Frank of Massachusetts objected that if we allowed poor people to acquire sweat equity in their homes, seven or eight years later, they could sell the homes for several hundred thousand dollars—and then they would no longer be poor!26
A sweat-equity model for public-housing occupants would help the poor attain pride in their neighborhoods and enable them to invest in their own future. The public-housing unions will hate being replaced by cooperative or condo associations, but the improvement in outlook and wealth for the poor they are supposedly serving will be clear.
Finally, jobs must be at the heart of any strategy for helping people work their way out of poverty. Opportunity for the poor has been scarce in the stagnant Obama economy. When millions of high school and even college graduates are out of work, why should they believe they can get a job?
We have already discussed the most promising and important ways of promoting employment: economic growth, lifelong learning, and ending the welfare state’s incentives not to work are all crucial steps. And yet millions of Americans are working every day for less than a decent living. They feel frozen in poverty, and that feeling is a disturbing departure from the historical American experience.
Tragically, the cities where the urban poor live are often among the worst places in America to do business. Poor neighborhoods tend to be expensive places to operate, with heavy city taxes, lots of red tape from the city bureaucracy, few skilled employees, and a limited market. Months before the city of Detroit went bankrupt in 2013, the Detroit Free Press reported on Lisa VanOverbeke’s attempt to open a cycling studio in the city. Her exercise business had already been successful in the suburbs, but “VanOverbeke didn’t count on a series of last-moment requests, fees and municipal red tape that doubled the start-up costs when compared to her Royal Oak and Rochester locations.” The obstacles proved too much: “VanOverbeke learned at the last moment that she would need to pay an extra $27,000 to soundproof the room to shield apartment dwellers from loud music during cycling classes. And that meant another city inspection and fee. Frustrated, she pulled out of the deal.”27 Detroit, in its spiral toward bankruptcy, lost the business.
To remove these barriers to job creation for the poor, Jack Kemp’s proposal for no-tax free-enterprise zones should be resurrected for the poorest neighborhoods. Cities should be challenged to create red tape–free zones as the prerequisite to becoming a tax-free zone. We also need a major initiative in Washington to eliminate all but the most essential red tape for small businesses. And Obamacare has to be repealed because no jobs program will work as long as the law is putting such a burden on employment.
A new American breakout would help the poor more than any other group. And it can happen. It will require conservatives to care enough about their fellow citizens to engage in conversations that will often make both sides uncomfortable. It will require liberals to care enough about their fellow citizens to challenge some of their own most deeply held beliefs and some of their strongest allies.
Today, poverty threatens one out of five Americans, and that figure might rise to one out of four. That’s an unacceptable future, and it ought to blast us out of our complacency and our assumptions.
CHAPTER ELEVEN
BREAKOUT IN ACHIEVING CURES
As we saw in chapter three, we are on the verge of an extraordinary breakout in health. Developments in science and technology could transform how long we live, how well we live, and how independently we live. For individual Americans, this could be a breakout of enormous importance.
The implications for the government are enormous as well, and the topic deserves more thought than our elected officials have given it. Medical costs account for such a big portion of the government’s expenditures—between Medicare, Medicaid, and dozens of smaller programs and regulatory agencies, not to mention Obamacare—that curing the most common diseases will transform government.
If we can reduce to trivialities the real human problems for which many of our largest programs were established, we will find ourselves in a very different world. The problems of Medicare, Medicaid, health insurance coverage, and even Social Security—all of which appear daunting today—will assume an entirely different appearance, if they don’t disappear entirely.
Consider just one common malady: Alzheimer’s disease. A few years ago, I was privileged to serve on the Alzheimer’s Study Group. We discovered that this disease alone will cost taxpayers $20 trillion from now till 2050. This cold number hardly conveys the human pain and exhaustion that the disease inflicts on patients, families, and caregivers. But you can also imagine how quickly the fiscal burden of millions of Alzheimer’s patients adds up. Understanding Alzheimer’s enough to postpone its onset by only five years could cut those costs in half because it is largely (though not entirely) a disease of the elderly.
You can probably come up with several other medical co
nditions—diabetes or heart disease, for instance—that will cost taxpayers trillions in coming decades.
Almost nothing we could do to save taxpayers’ money would compare with the savings of curing the most common and expensive diseases. That’s because cures can dramatically reduce the cost of healthcare and of sustaining people in the later years of their lives. Such cures would also ensure that America remains the most medically advanced country in the world, creating jobs and keeping the United States a hub of innovation. Achieving that breakout could be among the most-effective ways to control the federal budget over the long term.
The opportunity to cure so many diseases arises from the interaction of four separate but parallel revolutions that could reinforce and magnify each other in ways few of our political leaders seem to understand. The four revolutions are in genetics, regenerative medicine, advanced brain diagnostics, and big data for health analysis.
Let’s consider each one separately.
First, the genetics revolution is providing new insights into how bodies (human and otherwise) work. We are still in the early stages of discovering and applying this knowledge, but over the next few decades, this field alone will yield tremendous breakthroughs in curing diseases. Even more exciting, it may allow us to anticipate diseases and “turn them off” before they start. So exciting is the potential that my friend Dr. Andy von Eschenbach, a former commissioner of the Food and Drug Administration, believes we could cure cancer within fifteen years.
The genetics revolution could also help us develop new levels of prenatal care to preempt certain genetically driven birth defects. In some ways the discovery that folic acid for the mother can help prevent spina bifida was an early forerunner of the kind of preventive prenatal care that could soon become much more sophisticated.
Second, regenerative medicine is still in the takeoff stage. But as the work of Dr. Anthony Atala demonstrates, within a decade we could begin to routinely replace whole organs by taking your own cells and growing a new one for you.
Third, as the example of Alzheimer’s suggests, advanced brain diagnostics is probably the greatest opportunity we have to truly transform the quality of life for tens of millions of people. Our brain is the most complex system we know of. Breakthroughs in understanding the brain could produce great strides in curing autism, Alzheimer’s, Parkinson’s, mental health problems, and a wide range of other conditions. These mental conditions can distort our lives as decisively as any physical condition. Depression alone is a major contributor to total health costs, as depressed individuals are much more likely to manifest other illnesses.
And fourth, “big data,” the ability to collect and analyze huge amounts of information, has enormous implications for health research. As we develop more and more electronic health records, we will have the ability to aggregate huge amounts of data and analyze them. Electronic epidemiology will become a rich source of health information.
These breakthroughs are real. The question is whether government will hinder them, as it is doing now, or accelerate them, which it could do even while spending less than it does today.
Taxpayers should demand six important steps from the government immediately.
One: FDA Reform
As we saw in chapter three, the FDA is a major prison guard stopping the breakout in health. It must be overhauled. Its standards for evaluating new treatments and therapies are completely unsuited for the age of regenerative medicine, and the cost of getting these treatments approved in the United States will be absurdly high even compared with the absurdly high cost of getting normal drugs approved. There is a grave danger that breakthroughs in regenerative medicine will be made in American laboratories and then be introduced to patients in China, India, Japan, and Europe because FDA approval is too time-consuming and too expensive.
Furthermore, FDA reform must address the agency’s lethally low tolerance for risk. In addition to allowing Americans to obtain non-FDA-approved treatments with informed consent, the agency should begin to loosen its requirements in an age when we could track side effects and bad results in real time and make changes based on immediate data. Perhaps good preliminary results should be sufficient for doctors to begin prescribing many treatments as long as patients are connected to the constant monitoring technologies that Dr. Eric Topol described.
Two: Scoring Lifetime Savings instead of Annual Savings
As we begin to develop therapies that solve chronic conditions, government needs to develop new methods of scoring the costs of those therapies. Take, for example, the cost of kidney dialysis versus the cost of growing a new kidney. Kidney dialysis may be the cheaper treatment if you look at the budget for a single year, as Congress is apt to do. Once you are on dialysis, however, you remain on dialysis for the rest of your life. A debilitating experience, it requires two or three days a week at the clinic and the rest of the time spent recovering your strength. While the procedure may prolong your life, it also eliminates much of your ability to enjoy life and to earn a living. A regenerative kidney, on the other hand, would restore you to full health and enable you to return to work and to enjoy life to its fullest.
The challenge today is that a one-year score of the cost of dialysis versus a kidney replacement makes dialysis look less expensive. On the other hand, a lifetime cost of dialysis could soon make a regenerative kidney look like a bargain. This regenerative advantage becomes even more obvious if you include the difference between losing your job and depending on government payments and keeping your job and paying taxes.
There will be an explosion of research efforts if we can get to a fair scoring system for lifesaving breakthroughs.
Three: Prizes
Prizes should be developed for the most-important cures. As I discuss in depth in chapter seven, prizes can play a major role in raising funds, encouraging pioneers, and achieving big breakthroughs faster and cheaper than traditional bureaucratic efforts. Taxpayers pay nothing unless someone actually makes the defined breakthrough. At that point, we save money since we have technology that cures an expensive disease. An inexpensive kidney replacement to eliminate kidney dialysis would pay for itself in the first year or two. A cure for Alzheimer’s, too, would pay for itself almost immediately. Surely these breakthroughs would be worth substantial prizes.
Four: Creating Special Bonds and Taking Key Research Off-Budget
We should seriously consider taking major areas for basic research off-budget and issuing special bonds to pay them off. Today, we fund vital research at the pace the overall budget and the overall competition for resources allow. Yet if these fields of research could save tens of billions (or in some cases trillions) of dollars, we should not treat them the same way we treat standard earmarks. We should try to reach them as fast as possible. Every year of delay is money lost.
Instead of standard budgeting, we could fund them with money raised from disease-designated bonds. When the breakthroughs occurred that enabled us to save money, a fraction of the savings could go to pay off the bonds. This approach would liberate crucial basic research from the prison of congressional pork-barrel spending and enable us to achieve lifesaving breakthroughs as rapidly as possible.
Five: Reorganize the National Institutes of Health
The National Institutes of Health need a thorough reorganization to focus on the great breakthrough areas that could dramatically improve health. Each of the twenty-one institutes jealously guards its budget and its prerogatives. These include institutes for research in dentistry, “environmental health sciences,” drug abuse, alcohol abuse, and “minority health and health disparities,” among others. Much of the research is focused on esoteric topics with little prospect for achieving a real breakthrough. In fact, far too much of the NIH is a comfortable bureaucracy going through the motions, and the director does not have the ability to shift resources and create dynamic working groups in truly promising areas. The institutes’ work should focus almost exclusively on basic research in areas like brain science
, genetics, and cancer.
Six: Congressional Hearings and Continuous Learning for Health Decision Makers
If you were to test the bureaucracy that pays for healthcare and the bureaucracy that regulates healthcare on the state of the arts in medicine, you would almost certainly find tremendous gaps in understanding. Similarly, if you examined the members of Congress and their staffs who have oversight of health issues, you would find very fragmented understanding of the potential breakthroughs.
There are more scientists in the world today than in all of prior history combined. These scientists get better computers and better laboratory equipment every year. As they connect to each other all over the world, new discoveries spread with remarkable speed. Continuous learning will be essential for anyone trying to make decisions on health policy or to manage health outcomes. The American people must insist that public servants stay abreast of these changes.
Congressional hearings on the potential breakout may be one of the right venues for this learning. In the early nineteenth century, congressional hearings and reports played a surprisingly large part in opening up the West to settlement. In the twenty-first century, they could educate our leaders and the country about the breakthroughs that will help America break out.
CHAPTER TWELVE
BREAKOUT FROM DISABILITIES TO CAPABILITIES
In 2004, Tammy Duckworth was copiloting an army Black Hawk helicopter in Iraq when it was shot down by insurgents. She lost both her legs and severely damaged one of her arms.
Today, Tammy Duckworth is a Democratic congresswoman from Illinois. She didn’t go from a double amputation to Congress by focusing on what she couldn’t do. She made it there by focusing on what she could do—which turned out to be quite a lot.
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