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!

The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 2

This talk was presented at the 29th Conference on Primary Care Access, Monterey, CA April 16, 2018

Many officials and policymakers pay lip service to the importance of health, but most of the actual support (spelled M-O-N-E-Y) is for treatments for individuals, often with uncommon diseases. Being on the “frontiers of knowledge” is much sexier than rather than the old, pedestrian “taking care of people”. And such policies ensure enormous profit for drug manufacturers, who, like military contractors, are guaranteed huge returns while most Americans are not even guaranteed subsistence.

We abhor the individual excesses of Martin Shkreli and Turing jacking up the price of pyrimethamine (Daraprim ®) from $13.50 to $750 a pill (he has been sent to prison but not for this action against the health of the people; rather he committed the much worse sin of defrauding investors), or Heather Bresch and Mylan raising the price of Epi-Pen ® from $100 to $600, or the manufacturers of colchicine (URL Pharma), with the complicity of the FDA, being allowed to patent a drug that was identified as effective for gout in Egyptian papyri in 1500 BC and raise the price from a few cents to $5 a pill. And what is there to say about the scammer Elizabeth Holmes and Theranos and its A-List Board of Directors?

The Atlantic recently told us the history of the creation and marketing of Oxy-Contin ® by the Sackler brothers. When they bought Purdue, they inherited an expiring patent for extended-release morphine. So they not only developed extended-release oxycodone and marketed it, taking advantage of the public (and physicians’) caution about morphine, they greatly broadened the indications for this drug, which is just as addictive, from cancer and sickle-cell and the like to any chronic pain, especially back pain. Thus, we almost all are eligible users, and we see the results with our nation’s opioid crisis.

If we are still practicing, we see the results of the “breakthroughs” in recombinant DNA “-ab” drugs (actually, anyone who watches TV will see the ads for them), promising (occasionally with some validity) new hope for sufferers from cancer, auto-immune disease, and a variety of neurologic conditions. The TV ads do not contain, and I hope that we as physicians are aware of, the prices, often $30,000 to $100,000 a year or more, far more than the average family income in the US. The frequency of serious side effects, including death, from these drugs is very real – many are immune system stimulants that frequently, not rarely, cause autoimmune hepatitis, pancreatitis and the like – and these are not clearly portrayed on TV, or in marketing to physicians.

Even when the individual is partially shielded from the cost by insurance, the out-of-pocket costs to patients can still be enormous. In any case, no matter who is paying, the pharmaceutical companies are making out like the bandits they are, and less and less money within the whole system is actually available for population health, for prevention, for public health, for treatment of common diseases like hypertension and diabetes. And even for those conditions, we keep seeing newer – and always more expensive – drugs. While all the new diabetes drugs have some use for some individuals, many people with diabetes are still getting inadequate basic treatment with metformin, insulin, and good counseling and support for diet and exercise.

And what can be said about “precision medicine” (sometimes called “personalized medicine”)? Tens, or hundreds, of millions of dollars spent or promised by the federal government, promoted by former President Obama as part of the “moonshot on cancer”, the idea that every individual will have a relatively unique treatment based upon learning and understanding her genetic makeup. The promise is that we will be able to prescribe treatments for cancer and other horrible diseases as precisely as we target antibiotics to the culture results (and, I imagine, overprescribe them as we do with antibiotics). Pursuit of the money being allocated for these “cures”, as well as the cachet of being “scientific industry leaders”, has become a major motivator of medical school deans and chancellors, with every academic medical center developing Institutes for precision or personalized medicine.

What, by the way, has been the outcome? Not much, so far. Two genes have been shown to, themselves alone, cause cancers, and they have been well-known for a long time, BRCA-1 and BRCA-2. And the amazing precision/personalized medicine treatments? Well, get mammography earlier and more often and maybe consider prophylactic bilateral mastectomy. Where are the precision cocktails that cure each person? Do not fret; billions more will be spent on looking for them for years to come.

Is there a problem with this? Taken in isolation, pursuing effective treatments for terrible diseases that affect a significant (if relatively small) proportion of our population is not intrinsically a bad thing. But nothing is done in isolation. Those dollars that NIH spends on looking for these treatments, those insurance company dollars spent paying for outrageously overpriced drugs, the infrastructure development in our academic medical center that continues to support high-tech, high-specialization research and care, are dollars not being used for population health, public health, prevention and primary care, not being used to actually, effectively and broadly implement the treatment strategies that we know work so that they are not only available to but used for the benefit of everyone.

This is what we, as family doctors and primary care providers, and public health workers, can do. It is important, cost effective, and will make a real difference in the health of the population. But because it is cost-effective, it is not profitable for those corporations that have great influence in public policy, and so it continues to be recognized mostly with words and not resources.

Some years ago the VCU Center for Human Needs developed the County Health Calculator. You can click on any state, or any county, and find out the number of deaths per year, number of people with diabetes, cost of diabetes, percent of people with greater than a high school education, and percent of people with an income of at least twice the poverty level. You can compare to the best and worst county or state, and a neat slider lets you see how many lives and dollars would be saved if you had higher or lower percents. Here is Monterey County, CA, where we are. Despite the impression that might be generated by Reese Witherspoon’s HBO show “Big Little Lies”, it is not the richest or best-educated county in the state, but closer to the middle.  Allocating more of our money to addressing core societal functions, like education and poverty, will make a big difference in health, much more than any individually-directed medical care.

It should be obvious that the emphasis in medicine and health care to focus on individual treatments, despite (and maybe because of) huge costs (and remember, costs are someone’s profits!), rather than on interventions to improve the health of our overall population, is totally related to the political and social conditions and circumstances I spoke about at the beginning. We not only feel we are alone, we are actively being encouraged and directed to feel alone, and that we just need to look out for ourselves, and the treatments for our diseases, and our housing and food and children’s education and tax burden, and not for anyone else.

This serves the dual purpose of 1) pursuing, as I hope I have demonstrated for medical care (and others have also demonstrated for military contracting and other areas), strategies that maximize corporate profits, as well as 2) limiting the probability that people will organize together to attack the core structure of cynicism, exploitation, and greed that has become so ubiquitous that we can often not imagine any other way of society being organized.

I have talked about a number of issues, which I think are all related to our health, as individuals and as a nation. I have talked about social isolation, consumerism, a health system that is organized mainly for profit, the excesses of pharmaceutical manufacturers, “precision” or “personalized” medicine, and community health. Changing all of this is about changing society, but I think we, as health professionals, definitely have something to contribute. Whenever we think about these issues, whenever we are confronted by the false idea that we are each alone, that we cannot band together, that we should not care for the others in our society, that there is not value in social cohesion, we need to resist it and increase our efforts to work with others. As physicians and health workers, especially in public health and primary care, we need to continue to demand that most health dollars are spent on the strategies that benefit the health of most of the people.

       While policymakers and subspecialists and deans talk about “personalized medicine”, we as family doctors and other primary care providers, talk about personal medicine.  We are talking about the interactions between people – the medical term for whom is “patients” -- who need to be heard, and validated, and supported, with doctors and other providers who have enough time to do so. This is where the magic of personalmedicine happens, not mainly in the provision of ever-more-expensive dangerous drugs and procedures. It is what we know how to do, and need to continue to teach others to do, and it is where we need to direct our efforts. It will not be easy, given the poor pay and resultant shortages of primary care doctors, and the mega-mergers that employ strategies such as retail clinics, currently being adopted. These strategies combine two major themes I have mentioned –  it is “corporate profit meets social isolation and instant gratification”, where people are encouraged to no longer value the relationships that come from continuity and community-based practices. 

We may well be on the road to 1984, even though it’s 34 years late. But I think we can still band together and resist going all the way there.

Making contraception easy and available: we are going in the wrong direction!

It is 2017. It is more than 100 years since Margaret Sanger advocated for contraception, and more than 50 years since the oral contraceptive pill became available. The last two generations of women – and men – have never known a world where there was no effective form of contraception. They probably do not recall when even condoms, although “over the counter” (in that no prescription was required) were stocked “behind the counter” and required requesting them from the pharmacist often with (if you were young) a disapproving glare, and maybe worse, a raft of questions.

The verbal and physical indignations and worse, including even murder committed on unmarried women who got pregnant and were unable, of course, to have access to abortion should be things of the past. They are, horrifically documented in Dan Barry’s New York Times piece “The Lost Children of Tuam”. The film “The Magdalene Sisters” shows the intolerable treatment of girls who may not have even gotten pregnant but were, perhaps, just a little too familiar with boys. Both the Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic Church, but the treatment of women in England and the US were also inexcusably harsh. The British drama “Call the Midwife” tells the story of an unmarried teacher who gets pregnant in the early 1960s and is fired from her job (morally unfit to care for children!), tries to self-induce abortion with a coat hanger, and almost dies. Finally, post-hysterectomy so that she will never be able to have children, she is driven out of town. The most sympathetic characters in the show see it as sad, but none indicate it is horrific, immoral, and inhuman. And this was commonplace, even in the 1960s and beyond.

We should not, in 2017, even be discussing the availability of contraception, not to mention whether it works. Amazingly, we are. Teresa  Manning, appointed by President Trump in May to be the director of the Office of Population Affairs, the main family planning arm of the federal government, is not only a former employee of two anti-abortion groups, but has expressed skepticism of the effectiveness of contraception itself! Manning, a lawyer and not a health professional (although this is not an excuse), is completely wrong. The data is in. Contraception dramatically decreases unplanned pregnancy (regardless of marital status). Time recently ran an article accurately describing the science titled “No, birth control doesn’t make you have riskier sex”. That is the truth, but in fact, even if it is was associated with riskier sex for some people, that would be no reason to restrict access to it. The more contraception is available, the lower the rate of bad outcomes of virtually all kinds. It even, of course, reduces the rate of abortion; in fact, the only two things ever to have been shown to significantly reduce the rate of abortion are comprehensive and accurate sex education and easy and cheap availability of contraception. Indeed, the degree to which contraception is effective in decreasing the incidence of unplanned and undesired pregnancy is directly related to the ease of its availability, including financial availability. Unsurprisingly, reducing the cost of and increasing the ease of access to contraception has the greatest impact on teens and on the poor.

So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary” come to mind as better adjectives) has reversed the ACA’s requirements that employers and insurers provide contraception at no cost to women. Politically, it is part of the administration’s efforts to dismantle the ACA piece by piece, since they were unsuccessful in doing it as a whole. Morally, it is an imposition of a minority’s religious values on the rest of us, and is particularly ironic being spearheaded by Donald Trump. It will cause great harm to individual women (and men) and to the society as a whole. Arguments that the cost of contraception is “only” $50 a month may wash with those in the middle class and up, but for poor women and teens, $50 a month is a lot. The most effective methods of contraception, IUDs and implants (collectively referred to as LARC, long-acting reversible contraception) may have a lower amortized cost over the use period but a high upfront cost that is unaffordable, without subsidies, for many women. (The reason, lack of cash on hand, is the same one that leads many poor families, as described by Barbara Ehrenreich in her wonderful and depressing book “Nickel and Dimed”,  to live in expensive weekly motel rentals – the overall cost may be more than an apartment, but the upfront cost, including deposits, rent in advance, etc., is prohibitive for them.) The impact on the teens who will be denied free access is described movingly by a pediatrician in Vox.

The other important impact of such a policy would – and perhaps will -- be on the economy. This is articulately addressed in a column by Bryce Covert in the NY Times, October 29, 2017. The reasons start with individual women, and the cost of purchasing birth control, money which will not be available for them to spend on other goods – with more than 57 million women using contraception, in one year that is $1.3 billion. But the larger impact is societal – women who cannot control their own reproduction, who do not know when and if they will get pregnant – are in a poorer position to contribute to the workforce and to the economy. Again, going back to the history I address at the start of this piece, we know this empirically, not just theoretically:

… a raft of evidence has definitively found that when women gained greater access to the pill in the late 1960s and early ’70s, they were able to delay marriage and childbirth and invest in careers through education, job training and staying in paid work….Legal access to the pill transformed the economy in that era. It increased young women’s labor force participation by 7 percent….about a third of the increase in how many women attained careers in fields like law and business was due to birth control. Women with earlier access to the pill also made 8 percent more than their peers, and the pill was responsible for about a third of the decrease in the gender wage gap by 1990.

And it is still critical. Perhaps Trump himself is just cynically pandering to his base, and probably much of that base depends upon contraception, women directly but men just as much. Opposition to contraception cannot be justified except by the small minority of religious purists (and of course they are welcome to not use it); opposition to making contraception easily and freely available is almost as bad, as it is completely discriminatory. It is still, as Covert describes,

…still playing the economic role that it did in the 1970s. About half of women who use it say they do so to complete education or to get and keep a job. Contraception is still increasing the share of women who get educated and get paid work, particularly prestigious jobs.

Easy and affordable (affordable for all those who need to use it, not just billionaires or even the upper middle class!) is not a “women’s issue”, it is not a “special interest” issue. It is a core need for people. People with the views of Teresa Manning should not be given center stage, and certainly not given authority over contraception. We need to guarantee permanent access to contraception for all, and for accurate sex education. 

Now.