Why is American health care so expensive?

As I come closer to actually retiring, one might think I would stop reading the journals that arrive weekly. But they're too interesting. Sounds strange, with a whole world of interesting things to learn about, that they would continue to call to me, but wow. They are full of cool stuff. Take, for instance, today's JAMA Open, a compendium of recent articles in all of the subspecialty journals from the American Medical Association. I wanted to get to other things on my always a little too long list, but there it was, so I read it: 1. Should we use Octenidine wipes (a less bad antibacterial-- it kills bacteria, fungi and viruses, used in Europe) or sterile water to clean babies in the ICU to prevent sepsis? Turns out sterile water works just as well. Yay biomes! Yay plain water! Don't kill all the things on the skin and babies are just as safe! 2. If the government requires cigarettes have very low nicotine, will people just smoke more cigarettes? Mostly, no. Will they smoke ...

  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...

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....

I've noticed that when I'm at work, I generally love my patients. I may have complaints about them, wish they would behave differently, get frustrated with their choices, but I do feel a warm connection with them. (OK, there are people/patients who I find I am violently allergic to, but they are rare.) I work in an area which votes differently than I do, and I don't necessarily agree with my patients, but I have their backs and want what's best for them.  I don't necessarily feel that way about my fellow Americans. As a group many of them seem to act in ignorant, short sighted and often hateful ways. But when I meet them in a stuffy little office, I like them and on the important stuff, we usually see eye to eye. Why is that? I think I'm being hacked. My brain, that is. I think that there may be a concerted effort going on to make me feel like I'm not a powerful and loving part of a valued whole. It seems like what I read and what I'm exposed to in news ...