Why is American health care so expensive?

I have been working at CHAS Health, a community clinic serving Eastern Washington and Northern Idaho for a little over 3 years now. This is a different experience for me than my prior 35 years of practice for many reasons. CHAS originally started as a small clinic associated with a homeless shelter and provided mainly care of people without health insurance. It has expanded, but it still serves primarily people with various kinds of barriers to getting health care. CHAS provides support for people who are at risk of losing their homes and who have trouble paying copays. We are happy to take care of people with drug and alcohol problems, people who have just gotten out of prison, people who have trouble following recommendations from health care providers and may have been "fired" from other practices. We also see people who don't have any of these challenges, but just happen to like us. We are set up to make it possible for all sorts of people to navigate the very fragmen

In the JAMA (Journal of the American Medical Association) there are occasionally amazingly interesting snippets of information, not long enough to be articles, written as letters. In the early June 2022 issue, a letter entitled Trends in Prescription drug Launch Prices 2008-2021 was an eye opener. I have known for a long time that new drugs come out with high prices. In general, for this reason, I rarely prescribe new drugs unless they substantially improve my patients' lives and  are covered by their insurance. The costs of new drugs are absolutely beyond what anyone but the most fabulously rich people can afford.  Harvoni, a drug to treat a very common form of blood borne hepatitis that is responsible for a substantial proportion of cases of liver failure, costs about $90,000 for a 12 week course. Ozempic, a weekly injection that works great for type 2 diabetes and is very effective in helping people lose weight, costs over $1000 per month. Humira, an injection sometimes given tw

On June 24, 2022, the Supreme Court overturned Roe v. Wade, the 1973 case that provided women with a legal basis for a right to get an abortion. (Full text of opinion and dissent here --pay attention to page 148 to the end, the dissent.) This will make it difficult and dangerous for women in states whose legislatures oppose abortion to terminate a pregnancy. Many women, regardless of what state they live in, now believe that it is illegal for them to get an abortion. The amount of misinformation going around regarding this subject has been large, and now it is frustratingly larger. In the face of all this confusion, I would like to praise the JAMA (Journal of the AMA) for publishing a very nice, straightforward article about how to provide medical abortion in the first 10-11 weeks of pregnancy. By medical, I mean pills. There is a pretty simple combination of a couple of common medications, one to reverse the effects of progesterone and the other to permit the cervix to open to allow p

I have been a practicing physician since finishing medical school in 1986. The year after that, I started my internship at the Johns Hopkins Hospital on the Osler medical service. I remember how excited I was about my salary of $17,000 that year. I called my mother. She was so proud. It was plenty to cover my food, apartment, gas for my VW Rabbit and essentially nothing else since I worked all the time. By the time I finished my medical residency I was 28 years old and lived in Seattle where I was able to buy a house with my boyfriend (now husband) who was a scientist in a company that paid him a decent salary. My first job out of residency was with a healthcare cooperative, doing primary care and consulting internal medicine. After 4 years of that, I moved to rural Idaho where I have been ever since. For 17 years I was a "traditional internist" meaning I took care of my own patients in the office, took care of them when they were admitted to the hospital and provided some ot

It was a beautiful early spring day. I was working in a little patch of native plants, clearing away some pine needles and pulling dandelions. It was pretty much perfect weed picking soil, moist with spring rains but not muddy. In order to avoid stepping on the plants, I grabbed a vertical handrail support and swung myself up to the sidewalk and directly into the end of the rail. I felt and heard my rib cage crunch. Ow. When I could breathe I found that, although it was painful, I could still do some things around the yard. I was pretty sure that it would get worse, so I worked a bit and then rested inside. It did get worse. Daily it became more painful so that on day 3 almost anything I did was excruciating. Twisting, leaning over, taking a deep breath, yawning, sneezing, coughing and taking a shower. Lying down in bed was a trick. As the song goes, the rib bone's connected to the everything else bone. There was no really pain free way to lie down, though there were positions that

Happy 2022--let it be filled with good things. And on that note, I wrote a poem. (After reading Manifesto of Encouragement by Danielle LaPorte) Even now   All is not lost-- even now your frozen pipes are melting. Cells in your body are repairing what is broken and injured. T cells and B cells are working together to keep the bacteria and viruses in balance with the cells that make up what you think of as you. Macrophages are cleaning up the mess. Thanks for your service. That cancer cell? Nope. Sorry buster, not today. Natural killer cells. You don’t even pay them. Certain very bad jokes aren’t being told. The last person to tell them has just died. He didn’t use the internet so the ripples of their passage only exist in the vibrations of rocks. That thing you did that still makes you cringe? Even now the last person, other than you, who knew about it has just forgotten. Just yesterday you learned a new thing and at this very moment you remembered what it was. P