Why is American health care so expensive?

  Artificial Intelligence (AI) has been on the edge of my consciousness as a great hope for solving many of the problems in clinical medicine for maybe a decade. In 2011 IBM created a program called Watson which was able to answer questions in plain English and search data sources for answers quickly enough that it beat 2 humans in a game of Jeopardy. After its success in a game show, the program was used to make a chatbot to help people buy diamonds, to write recipes for Bon Appetit and by various financial firms to increase profits. It also has healthcare applications, including diagnosis and treatment recommendations as well as decision support for imaging. But that's just Watson, which isn't the big name in AI right now. ChatGPT came out in 2018 and by 2021 it was available to users. Last year I signed up for it and used it a little bit for what it seemed to be good for. I tried asking it questions, mainly medical ones, and I used it a little bit to generate text to explai...

The earliest cases of the novel coronavirus seem to have been in Hubei Province, in the city of Wuhan in China, possibly in November of 2019. The virus shares a family name with other more common viruses that are known to cause upper respiratory infections, such as the common cold. I won't go into Covid's origins, other than to say that there has been lots of obfuscation about them and I look forward to seeing the original streaming video series of the pandemic in about 5 years when perhaps the truth will be accepted fact. I first heard about this new virus before I went to South Sudan for the last time in early 2020. I wasn't worried. There had been flu pandemics in my lifetime and we had muddled through. How bad could it be? People were starting to wear masks in the airport, which I thought was silly. As it spread to western Washington state, it looked like it might be more serious than I had predicted. Then it got awful in Europe, then finally the US became a disaster of...

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 giv...

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...