Why is American health care so expensive?

I've been thinking about police violence, crime, the criminal justice system and its horrors, racial barriers to success, fear and racism in general. It's been a busy few days as I've tried to educate myself on problems that have been impacting black and brown people for a long time. The video clips that are now circulating are bringing the reality of police violence and disrespect to even people like me, who are protected from that reality by accidents of birth and the privilege of living in a peaceful place.  I've been able to generalize those visuals a bit. I have also listened to the stories of my formerly incarcerated patients. The experience of people in poverty, especially when non-white or vulnerable due to homelessness or mental illness, is that police are to be feared. We are now seeing people die because of interacting with police, but that isn't even the biggest problem. There are far more people who are injured physically, mentally or through inappropri...

I have recently become aware that some people are mistakenly getting suspicious that Covid 19 death counts are an overestimate. That is probably because the numbers are awful and very hard to visualize. Nearly 110,000 deaths have been documented so far in the US, which is undoubtedly significantly below the actual number who have died from the disease (see my previous blog on the subject, from very early on in the pandemic.) Our freshman US representative in Idaho, who serves a dark red district of a very conservative state, recently wrote a letter to the CDC concerned that the guidance they have given regarding filling in death certificates will lead to a falsely elevated number of people who have died of the disease. I just wrote Mr. Fulcher a letter explaining why this is wrong. "I saw your letter in your recent email encouraging the CDC to count Covid deaths accurately. I think you may not know some of the nitty gritty of documenting cause of death from a doctor's standpoi...

I am not especially qualified to write on the subject of racism or the militarization of policing or how the criminal justice system perpetuates poverty and loss of opportunity based on race. I am white, grew up in predominantly white neighborhoods and have always had certain expectations based on those privileges. Like most people I have my own story flavored by my own challenges. None of these challenges are based on race. I have watched from my safe community where police generally act like good people. (Obviously this is from my standpoint which may not represent everyone's experience.) As a doctor I have cared for police refugees from big cities, retired officers whose experiences of police culture drove them away and marked their personalities. I have enough connection with people on the receiving end of the criminal justice system in other communities that I am not entirely ignorant, but my experience is definitely limited. So in this time of Covid 19 and now widespread...

It is 2 weeks since Governor Brad Little of Idaho issued a statewide "stay at home" order and about 3 weeks since my little town has been staying at home because of an earlier mayor's order. The whole US has been increasingly moving toward self quarantining. People throughout the world are being asked to avoid sharing space and sharing germs with others. Buying and selling and traveling aren't happening much. There is very little going to school, receiving non-essential services, partying, touching or breathing on people outside of our immediate biological or chosen families. Some people are getting bored. Many are feeling challenged by having to do things that aren't normal for them, things like cooking, cleaning, childcare. Many of the things that filled our days are just not happening. There is a whole lot of quiet. The creativity that is happening in the absence of whatever it was we used to do is pretty stupendous . People are writing for each other an...

This morning the total number of deaths in the US from Covid-19 was said to be 994. That sounds kind of low, since influenza has already killed 30,000 this season. In the places where coronavirus has hit hard, it's much worse than the flu, in New York and New Orleans for instance. People are much sicker and the whole healthcare system, including emergency medical services, is stressed to breaking. We know that coronavirus is more severe and more contagious and more deadly than the flu by at least a factor of 10. Why are the numbers of deaths presently so low? The thing that nobody is talking about with regard to Covid deaths is that our data about who has died is going to lag by weeks, months or even years and will probably fail to represent all of the deaths for which Covid is responsible. Why is this? People are dying at home of Covid. How do I know this? Because 25% of people die in their own homes. People with symptoms of coronavirus are being encouraged to stay at hom...

When we are all trying to avoid deadly spread of coronavirus infections, can we still have sex ? This is a GREAT question. Luckily the New York City department of health has answered this and many more questions you may hesitate to ask in their very complete and unabashed 2 page primer on the subject. Please follow the link. It is a brilliant document leaving just enough to the imagination. The most controversial and absolutely true statement they make is that "You are your safest sex partner."   Sex is the most physically intimate activity that most people engage in. Coronavirus is transmitted when virus from one person's respiratory tract (usually lungs, mouth or nose) finds its way to another person's respiratory tract where it infects vulnerable cells. Not all cells are vulnerable. Coronavirus is found in certain other body fluids but it is less practical for the viruses in, say, stool or tears to be involved in transmitting infection. But sex betw...

Idaho has 42 cases of Covid-19 as of this morning. It feels like nothing, but that's because very few people are being tested and we are on the leading edge of the exponential growth curve. Some of us feel bad for feeling happy because these are serious times, some people feel sad in expectation of feeling sad in the future and others are just scared. It feels a little like a snow day, though, and we are knee deep in possibilities. Young people who never cook are learning to cook. People are doing crafts and hunkering down. I've heard from friends who I'd lost touch with. Much of my day is eaten up by learning more of what's known and what's known today may be wrong tomorrow. Things you should know which are likely to be true: The coronavirus has a median incubation period of just over 5 days and nearly everyone who gets it will get it within 12 days of exposure. This is from China's data, reported in the Annals of Internal Medicine.  Symptoms ...

We doctors are worrying about shortages of personal protective equipment. PPE is what we call it. When we see a patient with a disease that could be transmitted to others, we wear things that cover our bodies that can either be washed or thrown away. Infections can be spread by contact, by droplets or aerosols. We have different precautions for each type and within these categories, what we do depends on precisely which kind of infection we are worried about. We also, since the advent of HIV, use "universal precautions" to protect ourselves and our patients from bloodborne pathogens that we may have no reason to suspect but might be present anyway. Universal precautions include wearing gloves for any procedure that involves contact with a patient's blood or body fluids or presents a significant risk for that, such as drawing blood or cleaning wounds. Diseases such as influenza or certain pneumonias are transmitted by droplets. For those infections we need to use a m...

In and around town there are people who are looking at all of the rest of us who are hand sanitizing and social distancing like we are crazy. I feel for them. They are simply trusting their own experience. They don't see people dropping like flies. Nobody they know even has a cough. Restaurants are closing and it looks like everyone is needlessly panicking. What gives? Why are they wrong? The reason it seems like nothing is happening while governors and doctors are predicting huge numbers of people who will be sick and dying is something called exponential growth. That means that the number of cases of this disease are increasing faster  each day.  In a time of exponential growth things seem really mellow at first, as the number of cases goes from 2 to 4 in one doubling time, just 2 more cases, what's the big deal? Then the next doubling time the 4 cases become 8, but that's not so bad, just 4 more cases. Days go by... when you get to the tenth doubling period with 102...

Still vigorously healthy, thank you. I sneezed once yesterday afternoon and my voice was just a wee bit gravelly. Today my nose runs when I'm out in the cold. It always does that. No exposures that I'm aware of. My clinic is functioning as well as it can, consistent with keeping almost everyone out of our waiting room. We have agreed to keep meetings to no more than 10 people with everyone at least 6 feet apart. We have all been instructed to self screen every morning for new significant cough, sore throat, shortness of breath or fever over 100. Most of my patients have been phone visits rather than in person but I saw a few. I do a better job in person, but spending a good amount of time with someone on the phone is not without its benefits. The counselors and psychiatric nurse practitioners will be working from home until this is over. They had one day to figure out how to do this. Their patients are kind of reeling. Nobody had typical coronavirus symptoms. Things are kin...

Today I went to work. I am so lucky to have a job that I can still do. Our two universities are closed for the duration of the year, going online. All of the restaurants and bars, all the places that aren't healthcare facilities, groceries, pharmacies or social services are closed in Washington, a stone's throw away. Most of ours are too, other than drive up and take out. I saw a few patients in person, people who were dangerously ill in a way that couldn't be managed on the phone or in an online visit. The visits over the phone were surprisingly gratifying, but I forgot to do things because it turns out having a patient in front of me triggers a whole lot of complex thought processes. I assume this will get better. One of my patients may have coronavirus, mild case, young person, but with lots of contacts with similar symptoms. We have tests. We will test her tomorrow. I am well. No typical symptoms. My work will give paid sick leave if I need it, after I have used up my...

No I don't have it yet. No cough, no fever, just the expected occasional sneeze as spring is coming on. But Washington has closed all the restaurants and bars and I realize today that we all have Covid-19 as the community that is the world is connected, each person to every other person in ways we now are just starting to understand. A couple of ER doctors have been tweeting their lung ultrasounds daily as they go through coronavirus infections. I have been watching eagerly, hoping they will get better soon which will reassure me (for no good reason, but hey.) They use the hashtag #mycoviddiary. I'm thinking I will blog-journal the top thoughts and ideas that come to mind in the next weeks. Why not? I'll have time, until I won't have time anymore. Then I can journal that, too. Thoughts today: 1. We should forgive ourselves and everybody else for being stupid about this. Nobody has ever done this before. Only a few of us are global pandemic experts. Hoarding toil...

Not yet facing the emotionally draining horror of working to take care of people in a system that is overwhelmed, I am full of ideas. I am fascinated with the way the response to this global pandemic has transformed pretty much everything. People are willing to do very difficult things and large, slow systems are speeding up their processes to try to mitigate this disease's bad effects. Could have been faster, but that's in the category of regrets for which we have no time. The first cases of acute respiratory distress syndrome from a novel coronavirus were in Wuhan, China in December 2019. At first they were thought to be SARS (another coronavirus with a different scary history ). By the beginning of January the virus was characterized and found to be a different respiratory virus. It was called SARS-CoV-2 (I think that is an acronym for "severe acute respiratory syndrome coronavirus-2"--sort of like Terminator-2. Except that there were nearly 18 years between ...

Yesterday I read an article by Ezekial Emanuel, a professor and former adviser to President Obama on health care policy. Dr. Emanuel is a very nuanced thinker and had some great ideas around the time that the Affordable Care Act was crafted. He speaks out about how rising healthcare costs stem from inefficiencies, wasted testing and treatment and perverse incentives that encourage us to do what is expensive and ineffective rather than what is cheap and effective. He tells difficult truths. So I read his article, "The Inevitable Reimagining of Medical Education" in February 27, 2020 JAMA magazine with great interest. Medical school is painful and expensive and produces some pretty bad doctors so could definitely benefit from some reimagining! I learned that medical education is already being changed in ways that are hard to imagine and that it may become nearly unrecognizable. To which I initially said hooray, but am reconsidering. Medical school, when I attended it in ...