Why is American health care so expensive?

  Several days ago I read a New York Times opinion piece by Zack Cooper about how extension of ACA premium tax credits would be a good thing, but would not solve our problem of health care affordability. The piece was right in my area of interest and expertise (read rabid opinionatedness). I figured I could just write a review of the article which included my experience in why the cost of health care was so high which therefore drives the cost of health insurance, how new trends have made everything worse or different (AI, corporatization of medicine) and what could be done to nudge things in the right direction. Unfortunately I will not be able to just jot off a short and informative post. The whole story is quite a bit more complicated. A little research has revealed to me my ignorance of some of the basic facts that are relevant to this question. So, to start from the beginning, the US Congress has not voted to renew subsidies for insurance policies under the affordable care act...

Constipation is apparently not interesting. Even the large bowel is apparently too boring to have a presence on the internet. On Amazon I found a lovely volume by several experts published in 1992 about the large intestine in health and disease, but it is out of print. I suspect there are researchers even now figuring out amazing things regarding bowel function, especially with increasing belief in the importance of the intestinal microbiome. The neurology of the gut is fascinating. How exactly does food that is chewed and swallowed transit through a flexible tube, get stripped of its water and nutrients and eventually depart the body as perfect little packages of indigestables, fats and bacteria?  Not to say that they completely failed to teach this subject in medical school. I definitely remember stuff about digestive enzymes and acid secretion in the stomach, the presence of bile in the small intestine aiding in fat absorption, semipermeable membranes, the portal vein which tran...

  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...