Hospitals increase cost of health care...and pick and choose what they market to whom

The greed of pharmaceutical and insurance companies is the stuff of legend. There can be no justification for the huge costs that the American people have to bear as a result. Their administrative costs and profits alone are unconscionable and drive up the cost of health care so much that it takes a completely self-serving and willfully ignorant Democratic presidential candidate to disingenuously ask “how will we pay for” Medicare for All – and we  have a lot of them. The financial cost is, however, is not the most evil part of what they do. That would be the deaths and disability and bankruptcy that affects so many Americans because the insurance companies deny them care and the pharmaceutical companies make their drugs unaffordable. (This is a mild term for drugs that can cost $30,000-$100,000 a year and more!)

I have written about these issues many times. More recently I have also written about the role that providers (mainly hospitals and “health systems”, but also some physicians, nursing homes, etc.) play in the two-pronged scandal of the US health care system – too expensive and too unavailable to too many. There are some hospitals (I include “health systems” but will use “hospital” to avoid confusion with the “health care system”) that are actually for-profit, but most are officially “non-profit”. This means that they don’t have shareholders – and don’t pay taxes – but they otherwise behave just the same, trying to make as much money as possible. They say that they plow this back into the services that the hospitals provide, but it also includes salaries for C-suite executives that look just as outrageous as those in the “for-profit” sector.

More important, the “improvement” in services does not always – or even usually – create new services that were absent from the community previously, or make them available to more people than previously, say the poor and uninsured. They are usually efforts to attract insured, paying, profitable patients away from other hospitals by building a new, fancier cancer center, or heart center, or orthopedic center. Hardly ever pediatrics (except neonatal intensive care) or mental health – they only want to expand those services that are big profit centers. In this way, it is parallel to the behavior of drug companies; they prefer to minimally modify existing big sellers to get a piece of that market (“me-too” drugs) rather than to develop drugs to meet needs not currently being met.

It is good to see the hospitals being called out by major health system critics. Elisabeth Rosenthal, president of Kaiser Health News, wrote an important article on September 1, 2019 in the New York Times (where was once the health reporter) titled “That Beloved Hospital? It’s Driving Up Health Care Costs”, in which she makes many of the same points. She writes that

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

The reason, of course is the political clout that the big hospitals can buy (with, of course, our money!).The Democratic presidential candidates are beholden (with the exception of Sens. Sanders) to both hospital contributions and the role of big hospitals as major employers and economic drivers. “In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.” Could this have anything to do with why “The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia”? Ya think? Ask you politicians what they are going to do about it…

The media, including Kaiser Health News, has been running stories on hospitals that are aggressively pursuing lawsuits against patients who have been unable to pay their bills. On September 3, 2019, the Times ran a long piece on the poster child for this practice, Carlsbad Medical Center in New Mexico, in “As Patients Struggle With Bills, Hospital Sues Thousands”, but Carlsbad is by far not the only one. The practice is most common in towns with just one hospital, and of course, patients do not know how much they owe – or for what. It doesn’t matter if you are insured: “Ms. Price, 40, a nurse and local 4-H leader, has been sued five times by Carlsbad Medical Center, for bills totaling more than $17,000….Ms. Price said she had never received an itemized bill outlining exactly what she owed money for. The collection agency wanted the balance in full, and she was not able to work out a payment plan until after she was sued.”

This article names other hospitals that sue patients as a core business practice, and mentions over 20,000 suits in Virginia. Turns out that this was in no small part driven by the state-owned University of Virginia hospital in Charlottesville, documented by the Washington Post and MSN in “‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”. In a quick response, the Governor of Virginia and the University vow to stop suing patients, but this has apparently not affected those already sued: ‘“Fixing the problem “is complicated,” in part because “we are legally obligated as a state agency to collect debts,” he [UVA president Ryan] said. “But we have discretion within those legal constraints to make our system more generous and more humane.”’ It also has not hurt the CEO of the hospital “…Pamela Sutton-Wallace, who will leave in November to join New York-Presbyterian Hospital as a senior vice president”. Maybe she can teach them to sue their patients…

Many of us have sort of emotional attachments to our local hospitals, where we were born, or delivered our babies, or had our life-saving surgery or other treatment; for which we raised money through bake sales and car washes, or maybe volunteered in the gift shop. But these are not the warm fuzzy hospitals you remember. Rosenthal acknowledges that many rural hospitals are in financial trouble – and they are – but supporting the fantastic (“non-”) profit of these major hospitals is not going to change that. As in every other sector of society, we have two classes of service. One is to those in major metropolitan areas with money or good insurance, with conditions that are highly-profitably reimbursed, like cancer. Preferably all of the above. There is no limit to what will be invested in them. Then there are those without money, or good insurance, who live in rural areas, or have problems that are not well reimbursed, like mental health or substance use. They will not get investment. Simple as that.

Major hospitals are big businesses and act like it. You are a customer – but, compared to other industries in which you are a customer, a particularly uninformed one. Need a car? A refrigerator? Financial services? Dental care in Mexico (had to get that one in)? You can find out what it will cost and compare prices. Hospital care? In the US? You gotta be kidding.

The answer? Improved an expanded Medicare for All, a single-payer system in which, as in Canada, hospitals get global budgets, and separate capital budgets so that they cannot use the money (profit) they earn on your care to build spas to attract high-paying patients from competitors. Where everyone gets the care they need, and no one gets excessive care. Possible? Too expensive? Ask the Canadians. Or Australians, where the average hospital bill is less than $800. Or British, or French, or Swedish, or Danish, or Dutch, or German, or Taiwanese….

Some medical care may not help. Alternatives may not either.

‘Why Doctors Still Offer Treatments That May Not Help’, by Austin Frakt in the New York Times, August 27, 2019, is a well-done article that, despite its title, is fairly optimistic. He reports that while about 50% of current medical treatments no not have good evidence supporting them, only 3% have evidence showing them to be harmful, and another 6% unlikely to be helpful. This means about 41% (or only 41%, if you prefer) have good evidence that they are helpful.

Frakt cites some of the research on health interventions that do not work, or may even harm, quoting leading researchers Vinay Prasad and Adam Cifu (although he does not mention John Ionannidis, arguably the father of the field). He discusses the important “Choosing Wisely” campaign, initiated by the American Board of Internal Medicine Foundation, that asks each medical specialty society to identify at least 5 things often done in their specialty which usually should not be done. There is not, however, always consensus. For example, among its 20 recommendations (a high number that continues to grow, perhaps because of its discipline’s broad scope), the American Academy of Family Physicians (AAFP) recommends against imaging (including MRI and CT) for uncomplicated back pain, as does the American College of Physicians (Internal Medicine) (see ‘Medicine should not be primarily a business: choosing appropriate care for all, not excess testing for some, August 19, 2018).  Yet, neither the American Academy of Orthopaedic Surgeons, or the various groups of radiologists who perform these procedures, make this recommendation. Of course, both stand to benefit financially from doing these procedures.

It is concerning to think that, at least in some cases, financial benefit may influence the selection of some medical societies’ “Choosing Wisely” recommendations. Sadly, it is not a surprise, and financial benefit is, I believe, the reason for the use of many unproven treatments. Another important reason is an understandable reluctance for providers to abandon therapies that they have used for many years and believe to be successful. After all, if 50% of treatments do not have good evidence that they help or harm, many probably often do help, even if most of the evidence is anecdotal. Much more malicious, however, is the intensive marketing of new drugs and therapies to physicians by drug and device makers with a strong financial profit motive.

Frakt provides a litany of therapies-since-found-not-to-work-or-even-do-harm, including hormone replacement for post-menopausal women. The only drug he specifically names is Vioxx®, the “miracle” anti-inflammatory pulled from the market when it was found to cause heart disease (at least publicly found; the manufacturer actually knew it before it was released!). He also mentions “tight blood sugar control in critically ill patients” (and actually, probably most patients). This certainly relates to drug. The plethora of new, expensive, and marginally advantageous diabetes drugs is a testimony to their profitability. Ironically, it is often the same physicians who are unwilling to give up on treatments that are unproven or even proven to be of no benefit or of harm who are the first to begin using new (and, redundantly) more expensive drugs heavily promoted by the manufacturers.

Of course, it is not just diabetes drugs that are expensive. Compared to some of the newer drugs for rare diseases they seem like a bargain. In “The $6 million drug claim”, Timeswriters Katie Thomas and Reed Abelson discuss a woman who has $1 million in drugs to treat her condition in her refrigerator! While in her case they were paid for by her husband’s union, the cost can still be backbreaking: “At one point in 2018, for every hour that one of the union’s 16,000 members worked, 35 cents of his or her pay went to Alexion to cover the Pattersons’ prescriptions.” And what about those who have poor insurance, or no insurance? Or a union that goes bankrupt paying for them? Alexion, of course, does well, though.

A new law allows “gravely ill” patients the “right to try” drugs that the FDA has not approved. It sounds good; as a friend told me “I figure if I’m going out and they want to try something that might kill me I haven’t got much to lose. At best I’m cured. At worse, I go out but knowledge is gained.” Except for maybe dying sooner or more painfully, or possibly going bankrupt. It is not uncommon for doctors to suggest something new, unproven, or even a treatment that has already failed, one more time. Not everyone in this country has good insurance, and if your insurance company appropriately refuses to pay because there is no evidence of efficacy (yes, they are sometimes right!), you are on the hook for the bill. You may be dying, but your family may need the money you were saving for retirement. Thus, there may be a great deal to lose.

A certain percentage of people will take all this to mean that mainstream medicine is not to be trusted. This is definitely an overreaction, although a healthy skepticism is warranted, especially when the treatment is incredibly expensive and it is obvious that somebody (or some corporation)is making a killing on it. Some people will decide to pursue only what used to be called “alternative” medicine. These practices, often with hundreds or thousands of years of experience, are often called “complementary” and are now frequently offered along with mainstream medical therapies in “integrative” practices. But the same cautions must apply; because something is different, or traditional, does not make it necessarily either effective or safe.

For example, while people sometimes believe it is safer to choose only “natural” medicine, because a therapy grows in nature does not mean it is necessarily safe. Earlier in my career, medicine virtually abandoned the use of digitalis, made from the natural plant foxglove, to treat heart disease, after it had been used for decades. The key point is that if a substance works biologically and has “good” (i.e., desired) effects it can also have “bad” (i.e., undesired, or “side”, effects). This is true if it is straight from the plant, modified and standardized, or completely created in the laboratory.

Another real danger is what Frakt calls “wishful thinking”. Being optimistic and hoping that things will turn out well is good, and often useful when confronting serious illness. But when this transitions into the realm of “magical thinking”, being convinced that something good will happen to you because you want it to (or vice versa, that something bad will not happen because you don’t want it to), or believing a treatment will work because it is “natural”, or because your doctor recommended it in the absence of evidence, it is a real risk. “Magical thinking” is normal in three year olds, but dangerous in adults.

So what to do? Be open to new treatments, but do not reject the old, whether “traditional” or medical. Ask for evidence for treatment, such as when just changing a drug from an inexpensive standard (say, metformin for diabetes) to a new, costly one. Learn to understand probability, and ask for numbers. Do not reject anything out of hand, but do not believe that something will work just because you want it to.

Stay skeptical but not intransigent. Look for the evidence. And look also, when something is expensive, for the profit motive. Cui bono? It may not always be you.

"Medicare for All" means ALL -- Accept no substitutes!

Let’s start with the good news. “Medicare for All” is definitely trending. It is the central domestic issue for the Democratic primary. This is because of the absolute crisis in the health system. It is also, let us remember, because of Bernie Sanders, who has supported a single-payer universal health system for decades and made it a central part of his 2016 presidential campaign. He didn’t win the nomination, but he won the battle of ideas, which is why it is so important in this campaign.

People love the idea of being covered for their healthcare needs, and having that coverage untethered from where they work (assuming that where they work provides health insurance), whether they can work if they have been laid off, can’t find a job, or are disabled, or whether they are quite old enough to qualify for Medicare, whether they are quite poor enough to qualify for Medicaid (and let’s be straight, you have to be REALLY poor, even in the most generous states, and in some states it is just ridiculous). This is because the current healthcare system in the US really stinks. A huge percentage of those who are insured have terrible coverage, those who have reasonable coverage pay (often along with their employer) an extremely high amount for that coverage in premiums, deductibles and co-pays, and an unconscionable number of Americans are completely uninsured. The health outcomes in the US are terrible, trailing all other developed countries (discussed here many times). The only thing we lead in is the cost of the system, and of course the amount of profit made by the predatory components of it such as insurance companies, drug companies and some providers – which is of course totally related to why it costs so much.

An excellent example of the insanity of our current profit-driven system is provided by the Kaiser Health Network and covered by CBS Morning News and the medical news site “Medscape”, detailing how a dialysis patient received a half-million dollar bill because the dialysis center he went to, which was closest to his home (70 miles) was “out of network” for him. This particular patient will probably have his bill written off because of the extensive national coverage, but it happens all the time; it is the norm, not the exception. No wonder people are fed up!

The less good news is that, although most of the Democratic presidential candidates (notably excluding front-runner Joe Biden) have endorsed the words “Medicare for All”, their proposals are all over the place. Most of them do NOT guarantee universal coverage, not to mention the necessary expansion of benefits (“Improved and Expanded Medicare for All”) needed to ensure that the American people get ALL the health care that they need (including mental health, vision, hearing, long-term care, substance abuse treatment, etc.) The New York Times, which has made a crusade of limiting coverage of Bernie Sanders and trying to minimize or denigrate him when they do cover him, and is also an opponent of truly, universal, comprehensive single-payer health care, does have a very useful graphic in an article originally from the “Upshot” in February but in the print edition of August 13. It portrays the characteristics of many of the health plans proposed currently, and makes clear that only two, those sponsored by Sanders in the Senate and the bill in the House with Pramila Jayapal (D-WA) as the primary sponsor and over a hundred co-sponsors, actually would provide what we need.  

A clear exposition of many issues, including facts misrepresented about universal single payer, is summarized in an elegant piece in the Washington Post by Rep. Jayapal. It is an excellent point-by-point response to various criticisms and concerns that have been raised, and is well worth the time to read, even if you don’t have time to read the whole bill (Medicare for All Act of 2019).

Two of the most important criticisms to which she responds are particularly telling, since they are deeply tied. One is that people want to be able to keep their private insurance (presumably those who have, or possibly mistakenly think they have – good insurance). The “evidence” provided for this claim is that the percent of people who say that they support “Medicare for All” goes down if the question “even if you have to give up your current insurance” is added. Of course, the question is misleading; when people are told that they would be fully covered for everything, with no co-pays or deductibles or co-insurance, and that they will have completely free choice of providers, this objection goes away. Let’s be honest; no one cares about having a choice of which insurance company will deny them what they need; this is a nonsense concern. And, yet, this is driving the proposals of some presidential candidates and members of Congress to do a less-than-universal solution, some version of Medicare-for-More, or “buy-ins” or expansion of Obamacare.

The other objection, “how will we pay for it”, is also frequently heard, even from those who know how but just don’t want to accept it. The answer is very closely tied to the answer to the question above, because the cost only becomes impractically expensive if insurance companies – and their overhead and profit – are built back into the equation. A comprehensive Medicare-for-All program, when fully implemented, will be funded by the money that Americans and their employers pay for health insurance currently, including all the money spent by the federal government and states on Medicare and Medicaid, supplemented by additional taxes on corporations that do not already provide comprehensive insurance and on the wealthiest Americans. Yes, most people’s taxes would increase, but for the vast majority, the increase would be far less than they pay now in insurance premiums, co-pays, and deductibles, and would “buy” them comprehensive care for all medical problems with no limited ‘panels’ of providers. Those who would pay more can well afford it. But the key here is not having insurance company profit and overhead built into the system; this is one big reason that the US health care system is so expensive, and leaving it in makes it much less affordable. To suggest such solutions is like saying “the cost of business is so high, especially including payoffs we make to gangsters for protection -- but of course it is really important that any new system we develop include those gangster payoffs!”

Why would many pundits and “liberal” media outlets like the NY Times, CNN, etc. want to create such confusion and undermine efforts to create a truly universal, comprehensive single-payer system? I can’t know. I do know that they are all in the upper tiers of income, have good insurance, and are surrounded at work and in their neighborhoods by those in similar situations. Maybe this makes them blind to the needs of most people; maybe they believe that the top 10% of income of which they are a part is in fact typical. Or maybe they realize their privilege and want to keep it, and don’t want everyone else diluting their access.

But including everyone is key, not only for the financial reasons, but for quality reasons. When the upper income and well-educated are in the same system as the poorer and less empowered, they can be depended upon to ensure that the system is of quality, and this benefit then applies to everyone. It is why we cannot let them opt out.

Out health care system is a mess, delivering poor outcomes for lots of money, and is a maze of different programs and eligibility. We don’t need more of that; we need to simplify it and have one outstanding system that covers everyone.

Opioids, deaths, and capitalism: It's the capitalism, people!

The opioid epidemic is real. Far more opioids (the term that includes opiates, naturally-derived from opium, and synthetic drugs) are consumed than could conceivably be used for medical reasons, whether for short-term use post-surgery or injury, or chronic use for terminal diseases like cancer. The explanation, at one level, is the excessive use of opioids for pain relief for chronic conditions (like back pain, for which other drugs are often more effective) or excessive duration for what should be short-term (acute) reasons, and the fact that they are very addictive. This last has led to the creation of new addicts, who have been placed on prescription opioids for pain, and means that they can be used to substitute for opiates (such as heroin) for those who became addicted to street drugs. This is especially true with the increased availability of extremely potent synthetic opioids, such as fentanyl (50-80 times more potent than morphine), but can go both ways; when those who have become addicted to prescription opioids find the supply drying up, they often move to heroin.

But, like most things, it is complicated. The biggest complication is that many of those who have become “hooked” on opioids are suffering in pain, and opioid withdrawal is, to put it mildly, not fun. The pain relief is greater than that of other pain relievers, for many (but not all) problems, but opioids increase tolerance, so the doses people need to take to relieve their pain, or get their high, continually increases. The “consensus” pendulum has swung, from the message that people are not getting sufficient pain relief (“pain is the fifth vital sign”) to “doctors are creating addicts by overprescribing opioids”. Patients – people -- are caught in the middle.

Another complication is, as is usual in any big issue in the US, race. Opiate addiction and problems were a focus more of criminalization than treatment when it was perceived as mainly a problem for minority populations. The increasing revelation of white, albeit often poorer, less educated, and more rural, white people suffering from the prevalence of opioid abuse, has changed the discussion. Not that this is unimportant – the message that for the first time in a century a portion of the population – middle aged white people – have an increasing death rate (discussed in Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015, and based on the work of Case and Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”) is shocking. So is the finding that poor white women born in 1950 will live shorter lives than their mothers born in 1920 (“Life expectancy, socialism, and the determinants of health”, February 14, 2016). None of this to deny or ignore the fact that death rates for minorities, although dropping are still higher than those of whites.

The New York Times has had a series of exposé articles on the opioid crisis, and a recent installment completely pulls back the curtain on the marketing and sales practices of opioid manufacturers. “3,271 Pill Bottles, a Town of 2,831: Court Filings Say Corporations Fed Opioid Epidemic” reveals that many manufacturers, not simply Purdue, the maker of Oxy-Contin®, and many pharmacies including all the big chains, have been complicit in the spread of this epidemic. Its content is damning, and the evil acts of these companies are made public, and the information needed to ascertain the reason for the problem is clear.

But the Times does not explicitly call it out. That is because the problem is capitalism, specifically “unfettered” capitalism, essentially unregulated capitalism that not only permits, but encourages, anything that will make more money, regardless of the cost, including (and perhaps especially) the human cost. These corporations are responding to the pressure of Wall St. and their stockholders not only to make more money, but to “exceed expectations”. The value of a stock is not based on whether the company is actually earning a profit, but whether it is earning enough of a profit to please the casino players. This is augmented by the incentives for often huge bonuses for the top management based upon – how much profit the company makes. There are no bonuses for actually helping more people, or even not killing them, or not destroying the world. Sorry, you who die from opioids or suicide, you are collateral damage. Oh, yes, you also, future generations.

To be clear, this is not a result of Republican or Trumpian policies, although they have been both more open about it and have further pushed the envelope with their gargantuan tax cuts for corporations and the 0.1%. It has been the policy of every government at least since Reagan in the 1980s, Clinton and Obama certainly included. Of course, every US government has been pro-capitalist, but for much of the 20^th century, starting with (Republican) Teddy Roosevelt, there were both implicit and explicit limits set. Even conservative economic guru Milton (“the only goal of a business is to maximize shareholder profit”) Friedman believed that monopolies were ultimately not a problem because technology and the market would take them down. He was wrong; there are no limits to what they will do for more money.

So we have Americans dying by the tens of thousands from opiate and opioid overdose, and from the “suicides of despair”. We have children being separated from their parents and migrants being housed in prisons because it makes money for the private prison industry, a major donor to politicians. (Kudos to Illinois for being the first state to ban private prisons.) We have the environment being irreparably destroyed for the profit of some companies, with government complicity. We have wars being fought across the globe, killing hundreds of thousands, and each being the potential spark that could destroy the world more quickly through nuclear war. We continue to increase the defense budget although we already spend several-fold more than all our potential adversaries put together, because it is the way that the federal government subsidizes US industries.

Why do we do these things? Our oligarchs (a term the media seems to reserve only for foreigners, especially Russians, even though the US has so many more of them) demand it, and pay for it, essentially through kickbacks. They care not for the future, even for their grandchildren, or for whether there is a world.

They must be stopped. Our health, and our lives, depend upon it.

"People will believe anything": Snake oil salesmen and bad health advice

The other day, I took a nephew to see the new Spider Man movie, “Far from home”. No review here; just to say that a big part of the plot revolves around the bad guy using a high-tech virtual reality system to project fake images that everyone takes to be real. Several times in the film he and his henchmen say “people will believe anything”. The parallels to the daily reality of our times, to “fake news” and distrust of science, are too obvious to be coincidental. Of course, in the movie the bad guy loses and the good guy (Spider Man) wins.

It is still far from clear if the “good guys” (and here I speak not of specific individuals, but of those who advocate for truth, a real reality, and science) are going to win in the actual world. The forces of darkness and reaction, wearing the face of Donald Trump and facilitated by the Republican Party, but actually representing and funded by the corporate elite – gangster capitalists – may not wear capes and fly around or use astral projection, but they have enormous resources to control the dialogue, provide misinformation, and serve themselves. They are resilient not only because of their wealth and power, but, sadly, because so many people are happy to try to deal with their own oppression by hating, oppressing, and believing bad things of others.

Health and medicine are clearly not immune from the reach of “fake news” and false beliefs and those willing to exploit our willingness to believe what we want to be true rather than what is. This is often a result of also a logical fallacy, wishful thinking (which is only a fallacy when it is expressed as true; not when it is expressed as a hope or wish) but may be more appropriately called “magical thinking”, a developmentally appropriate stage for young children that is always pathological in adults. Those who promulgate false scientific, medical and health theories and advice can be doing so to make money, to exert power and control, because it derives from a pre-existing belief (sometimes but not always religious). Sometimes it is also self-delusional, especially when the proposed solution is easier, more palatable, less painful, and requires less discipline than the medical alternative (take these simple pills – or snake oil -- and you won’t have to diet/exercise/stop smoking or drinking/have radiation or chemotherapy or surgery and you can be more youthful or beautiful or sexual). I once wrote about a patient who was obsessed with getting mammograms for breast cancer, a condition for which she was not at elevated risk and was far too young for routine screening, but was uninterested in addressing her actual risks resulting from heavy smoking, uncontrolled high blood pressure, and unprotected sex with multiple partners (Healthful Behaviors: Why do people adopt them? Or not?, October 8, 2011). Because, I inferred, it was easier, and would require no real effort or difficulty on her part. This is why it is an attractive option. But it is not a good idea.

The trend toward getting health and medical advice from those who are not medically trained has always been with us, but the same easy dispersion of information (or misinformation) through the Internet that allows us to hear anything we want and, to a large extent, only what we want, impacts health care as well as politics. The “anti-vax” movement is very popular, and promoted by celebrities. (Why should we not get our health advice from those whose qualification is that they are celebrities?) In addition to being wrong, it is very dangerous to the public health. I say that with absolute certainty. The anti-vaxxers are wrong. Period. There is some risk that individuals will have a reaction, very rarely a serious one, but this impact is totally miniscule compared to the benefit of preventing disease through vaccination. Indeed, vaccination is one of the few areas in which we actually can prevent, and thus not have to treat, diseases!

Some celebrities deserve a special call-out for their comprehensive and ubiquitous denial of fact, reason, and science – amazingly, often in conjunction with a profit motive from the brand of snake oil that they are selling; Gwyneth Paltrow is the exemplar. Of course, Ms. Paltrow deserves some credit for being able to convince people that they should do things that are actually unpleasant and painful for the sake of their health and beauty, like getting stung by bees, even though these are of no actual value to her clients. Obviously, they are of financial value to her. And, while I admire much of what she does in the world, Oprah Winfrey is also a big proponent of false health information.

Sometimes, bad policies are advocated by the self-righteous, as is the case with the current Israeli Education Minister, the most recent bigot coming out for “conversion therapy” for gay people. This is an example of falsely medicalizing a condition by suggesting it requires therapy, something that should not be. Sometimes, as in Paltrow’s case and many others, it is at least in part motivated by the opportunity for profit. Often, and this is sad, it is motivated and believed because people do not trust doctors and other health professionals. One reason it is sad is because people eschew treatments that could be of benefit to them in favor of those that will not help and may even hurt. But another major reason is that many doctors and other health professionals have been themselves guilty of pushing treatments that do not benefit, and may hurt, their patients. They do this for the same set of reasons as those I criticize above: to make money themselves, to make money for drug and device makers who pay them directly or in gifts including drug samples, because they are too lazy (or “too busy”) to actually read and evaluate the evidence and so taking the advice of drug or device salespeople is easier, and because they think that because they are doctors everything they think is right. I wish this were not true, but it often is. Holding physicians to a higher standard than non-medical people is appropriate, but this is not an argument for believing people because they are not doctors, no matter how confident. Iit absolutely in no way justifies listening to the advice of non-medical people who know even less!

It is also the case that some “alternative” suggestions for treatment are helpful, and many others are probably benign (except for the cost), even if the evidence is that they are not helpful; one example is taking vitamin supplements. If you can afford them, and don’t take excessive doses, they probably don’t hurt. It is certainly a better way to waste your money than on cigarettes, but if you can’t afford them, skip them. Other medical interventions can be good, and of benefit, but the benefits are often overstated, or reified as totally important. This is especially true when it is promoted as more “natural”, a word so overused as to have almost no consistently definable meaning. One example might be the use of birth attendants, called doulas. For many people, especially those who do not have a support system such as a spouse or parents or siblings or friends (and, likely for some who do) it is very helpful to have a knowledgeable, supportive person during your labor, focused entirely on you. But they are neither magic nor necessary.

Having someone who can help you deliver your baby, like a midwife or physician, is often necessary. A birth support attendant is a nice addition. Nurse-midwives train as registered nurses then do additional years of midwifery training and attend many births, including many doing deliveries under supervision. They can deliver babies as well as support women in labor.  In contrast, becoming a doula, according to https://www.naturalhealers.com/midwifery/doularequires a total of about 2-3 weeks including the need to attend a few births. So what scientific basis could there be for NY State Gov. Cuomo is advocating the expansion of the use of doulas to decrease maternal mortality, something for which there is not only no evidence, but no rational basis for thinking.

Come on, Governor! Come on, people! Not harmful is good, helpful is even better, not breaking the bank is important, and sometimes natural is nice. But let’s not choose magical thinking over science. That helps no one, except the snake oil vendors.

The high cost of US Healthcare: It's not mostly the demanding patients!

Did you know that American healthcare is the most expensive in the world? And did you know that health outcomes here are way lower than in other developed countries? Well, since you’re reading this blog, you probably did. But here’s a scoop: one of the main reasons for this high cost is apparently the demanding nature of American patients!

Wow, you’re thinking! I was under the impression that it was greedy drug manufacturers who sell drugs in the US at many times the price they are available in other countries! And insurance companies, making huge profits by collecting high premiums, co-pays, and deductibles and then trying their best to not pay for care! And the health industry itself, providers like hospitals and health systems, who, even when ostensibly “non-profit” act like for-profits trying to make the most money possible and paying their executives in the millions (although maybe less than the C-suites of the drug and insurance companies). You probably thought it was the whole corrupt end-stage gangster capitalist system that never met a dollar it didn’t want, no matter who it hurts.

Well, sorry you’re so naïve! Just read this article by David H. Freedman in the July, 2019 Atlantic, “The Worst Patients in the World”. The reason health care in the US is so expensive is the fault of people like his 74-year old father: “An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health.”

And yet, Freedman points out, he demanded tests when he was sick! And he not only did nothing medical to try to help his health (like going to get checkups or preventive care), he actively undermined it by

…practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.

He also punched a doctor.

Then Freedman goes on to argue that it is both these characteristics, abusing oneself and not taking care of one’s health, including eschewing tests that were “intended to benefit its bottom line rather than his health,” but then demanding that the medical care system provide all the most expensive possible of those tests once he was sick, that typify the behavior and approach of many Americans and account for, in large part, the high costs of health care. While Freedman acknowledges his agreement with the concept of Medicare for All, he suggests that “We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes.”

Wow again! If w. imported US people (“patients” is the medical term for people) to, say, Canada or the UK or Denmark or France, their healthcare costs and outcomes might be, respectively, as high and poor as ours. It is not the first time that this argument has been made, but it is being featured in a major magazine, and written by a presumed progressive (or at least supporter of Medicare for All). Maybe it is worthy of being considered!

Or rejected. Maybe it is a fallacy to presume that it is a flaw in the character of the people who live in the US, compared with those in other countries, that is responsible for the high cost and poor outcomes of our health care system. Or maybe not, considering everything else about us (which I will not now consider in depth), our collective national character illustrated by things like putting migrant children in cages, denying global warming and the climate crisis, supporting the fossil fuel industry with far more money than we spend on education, or maintaining a ubiquitous system of racist law enforcement and imprisonment, just to name a few. I think it is a fallacy, though. I am sure there is a wide range of personality types within the US as well as in other countries; people who are more or less hostile, people who are more or less demanding, people who are more or less suspicious of anything that smacks of authority, and people who are more or less willing to do what they themselves can do to help themselves. So why does it seem like there are so many more in the US, and that this is a major contributor to our health care costs?

Because it does seem as if there are. I have been a doctor for a lot of years, and I have seen lots of people who do little or nothing that should be in their own control to improve their health, and yet are very demanding of expensive resources being used not only when they get sick, but after there is little chance of it benefiting them. People who, like Freedman’s father, contrary to all that “should” happen, are kept alive many years after they “should” have died as a result of the bad genes, habits, environmental factors, and luck that led them to the diseases they had. Yup. Bad behaviors. Shame! And then wanting “everything done” when it is too late, and, oh yeah, you don’t have to pay – the insurance pays. Which raises everyone’s rates. Yup, selfish.

But why would Americans be so selfish, mean, demanding? Why would they be different from other people? Would, in fact, exporting Americans to other countries raise their costs and worsen their health outcomes? That’s not an experiment that we can do easily, although there is no evidence anecdotally of this occurring. The real issue is the one I talked about at the start of this piece: a health system designed to enhance profit for the companies who own it (and the pieces of it). It is their practices that encourage many of the sorts of behaviors that Freedman and others note.

The entire health system is built on high-cost, high-tech interventions. There is far less profit in controlling, say, diabetes, with cheap generic drugs than in the newest high-cost patented drugs. There is enormous emphasis on procedures, diagnostic and therapeutic, that have little evidence of benefit, or evidence of benefit in a very narrowly-defined population. It is absolutely NOT true that a screening test of benefit for a high-risk population, for example, is of benefit for lower-risk people. There is incredible expenditure at the end of life, when often all that can be done is prolonging suffering. It is done because people, and companies, make money on it. And to complain that people behaving relatively rationally in response to these incentives is the problem is to engage, as is all too common, in victim blaming.

And if we blame the victims, we are hardest on those who are victimized in the most ways. The poor, the uneducated, the jobless, the homeless, the imprisoned, the children. Those who “demand” care because, historically, they are members of a class, race, or group that was systematically denied it. You may not feel a lot of sympathy for Freedman’s father (or maybe you do) since he had so much – a scientist, presumably with a reasonable income – who took poor care of himself and then cost the system piles of money to keep him alive until 76. But the system is hardest on those with the least.

And that is why “compromise” solutions to increase health care access rather than make it universal are not only morally wrong but bound to fail. The biggest question about “Medicare for All” is how much it will cost. But the answer is that the cost will be made up for by eliminating exorbitant private-sector profits. Half-measures, “Medicare for More” or “Improved ACA” don’t do that.

Everybody in, nobody out!