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Out of Control Health Costs or a Broken Society

Flawed Accounting for the US Health Spending Problem

By Jeff Goldsmith

Source: OECD, Our World in Data

Late last year, I saw this chart which made my heart sink. It compared US life expectancy to its health spending since 1970 vs. other countries. As you can see,  the US began peeling off from the rest of the civilized world in the mid-1980’s. Then US life expectancy began falling around 2015, even as health spending continued to rise. We lost two more full years of life expectancy to COVID. By  the end of 2022, the US had given up 26 years-worth of progress in life expectancy gains. Adding four more years to the chart below will make us look even worse.  

Of course, this chart had a political/policy agenda: look what a terrible social investment US health spending has been! Look how much more we are spending than other countries vs. how long we live and you can almost taste the ashes of diminishing returns. This chart posits a model where you input health spending into the large black box that is the US economy and you get health out the other side. 

The problem is that is not how things work. Consider another possible interpretation of this chart:  look how much it costs to clean up the wreckage from a society that is killing off its citizens earlier and more aggressively than any other developed society. It is true that we lead the world in health spending.  However, we also lead the world in a lot of other things health-related.

Exceptional Levels of Gun Violence

Americans are ten times more likely than citizens of most other comparable countries to die of gun violence. This is hardly surprising, since the US has the highest rate of gun ownership per capita in the world, far exceeding the ownership rates in failed states such as Yemen, Iraq and Afghanistan. The US has over 400 million guns in circulation, including 20 million military style semi-automatic weapons. Firearms are the leading cause of deaths of American young people under the age of 24. According to the Economist, in 2021, 38,307 Americans aged between 15 and 24 died vs. just 2185 in Britain and Wales. Of course, lots of young lives lost tilt societal life expectancies sharply downward.

A Worsening Mental Health Crisis

Of the 48 thousand deaths from firearms every year in the US, over 60% are suicides (overwhelmingly by handguns), a second area of dubious US leadership. The US has the highest suicide rate among major western nations. There is no question that the easy access to handguns has facilitated this high suicide rate.

About a quarter of US citizens self-report signs of mental distress, a rate second only to Sweden. We shut down most of our public mental hospitals a generation ago in a spasm of “de-institutionalization” driven by the arrival of new psychoactive drugs which have grossly disappointed patients and their families. As a result,  the US  has defaulted to its prison system and its acute care hospitals as “treatment sites”; costs to US society of managing mental health problems are, not surprisingly, much higher than other countries. Mental health status dramatically worsened during the COVID pandemic and has only partially recovered. 

Drug Overdoses: The Parallel Pandemic

On top of these problems, the US has also experienced an explosive increase in drug overdoses, 110 thousand dead in 2022, attributable to a flood of deadly synthetic opiates like fentanyl. This casualty count is double that of the next highest group of countries, the Nordic countries, and is again the highest among the wealthy nations. If you add the number of suicides, drug overdoses and homicides together, we lost 178 thousand fellow Americans in 2021, in addition to the 500 thousand person COVID death toll. The hospital emergency department is the departure portal for most of these deaths. 

Maternal Mortality Risks

The US also has the highest maternal mortality rate of any comparable nation, almost 33 maternal deaths per hundred thousand live births in 2021. This death rate is more than triple that of Britain, eight times that of Germany and almost ten times that of Japan. Black American women have a maternal mortality rate almost triple that of white American women, and 15X the rate of German women. Sketchy health insurance coverage certainly plays a role here, as does inconsistent prenatal care, systemic racial inequities, and a baseline level of poor health for many soon-to-be moms.     

Obesity Accelerates

Then you have the obesity epidemic. Obesity rates began rising in the US in the late 1980’s right around when the US peeled away from the rest of the countries on the chart above. Some 42% of US adults are obese, a number that seemed to be levelling off in the late 2010’s, but then took another upward lurch in the past couple of years. Only the Pacific Island nations have higher obesity rates than the US does. And with obesity, conditions like diabetes flourish. Nearly 11% of US citizens suffer from diabetes, a sizable fraction of whom are undiagnosed (and therefore untreated). US diabetes prevalence is nearly double that of France, with its famously rich diets. 

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THCB Gang Episode 136, Thursday October 5

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday October 5 at 1pm PST 4pm EST were delivery & platform expert Vince Kuraitis (@VinceKuraitis); author & ponderer of odd juxtapositions Kim Bellard (@kimbbellard) and policy expert consultant/author Rosemarie Day (@Rosemarie_Day1).

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

We’re All In The Hot Seat Now.

BY MIKE MAGEE

It’s not that easy living in the “Big Easy” these days and co-existing with a world dominated by water concerns. When Times-Picayune gossip columnist Betty Guillaud (as the folklore goes) “coined New Orleans’ undisputed nickname” in the 1960’s, it was a lifestyle eponym meant to favorably contrast life in “The Big Easy” with hard living in “The Big Apple.”

That was well before August 23, 2004, when the levies failed to hold back the Gulf waters, and 1,392 souls perished leaving two names to last in infamy – Katrina and Brownie, of “Brownie, you’re doing a heck of a job” fame.

Now it’s not as if it’s been all smooth sailing for New York City and water. I mean, look at the history. When the British overran the Dutch in 1667, one of the first priorities was to dig the first public well and include a marvelous technologic attachment – a hand pump. That was in front of an old fort at Bowling Green, near Battery Park.

But by the early 1700s, the absence of a sewage system and saltwater intrusion from the Hudson and East Rivers, plus a crushing population explosion, had foiled the clean water supply. The solution – temporary at best – haul in fresh groundwater, in limited quantities, from Brooklyn.

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Altman, Ive, and AI

BY KIM BELLARD

Earlier this year I urged that we Throw Away That Phone, arguing that the era of the smartphone should be over and that we should get on to the next big thing.  Now, I don’t have any reason to think that either Sam Altman, CEO of OpenAI, and Jony Ive, formerly and famously of Apple and now head of design firm LoveFrom, read my article but apparently they have the same idea.  

Last week The Information and then Financial Times reported that OpenAi and LoveFrom are “in advanced talks” to form a venture in order to build the “iPhone of artificial intelligence.”  Softbank may fund the venture with as much as $1b.  There have been brainstorming sessions, and discussions are said to be “serious,” but a final deal may still be months away. The new venture would draw on talent from all three firms.

Details are scare, as are comments from any of the three firms, but FT cites sources who suggest Mr. Altman sees “an opportunity to create a way of interacting with computers that is less reliant on screens.” which is a sentiment I heartily agree with.  The Verge similarly had three sources who agreed that the goal is a “more natural and intuitive user experience.”

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THCB Gang Episode 135, Thursday September 28

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday September 28 at 1pm PST 4pm EST are futurist Jeff Goldsmith: author & ponderer of odd juxtapositions Kim Bellard (@kimbbellard); and patient safety expert and all around wit Michael Millenson (@mlmillenson).

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

War — and Health Care — on the Cheap

By KIM BELLARD

Like many of you, I’m watching the war in Ukraine with great interest and much support. For all the fuss about expensive weapons — like F-16 fighters, Abrams tanks, Stryker and Bradley armored fighting vehicles, Patriot missile defense systems, Javelin anti-tank missiles, Himars long range missiles, and various types of high tech drones — what I’m most fascinated with is how Ukraine is using inexpensive, practically homemade drones as a key weapon.

It’s a new way of waging war. And when I say “waging war,” I can’t help but also think “providing health care.” It’s not so much that I think drones are going to revamp health care, but if very expensive weapons may, in fact, not be the future of warfare, maybe very expensive treatments aren’t necessarily the future of healthcare either.

Just within the last two weeks, for example, The New York Times headlined Budget Drones Prove Their Value in a Billion-Dollar War, AP said Using duct tape and bombs, Ukraine’s drone pilots wage war with low-cost, improvised weapons, ABC News reports: Inside Ukraine’s efforts to bring an ‘army of drones’ to war against Russia, and Defense News describes how Cardboard drone vendor retools software based on Ukraine war hacks.

This is not the U.S. military-industrial complex’s “shock-and-awe” kind of warfare; this is the guy-in-his-garage-building-his-own-weapons kind of warfare.

Ukraine’s minister for digital transformation, Mykhailo Federov, says the government is committed to building a state-of-the-art “army of drones.” He promises: “A new stage of the war will soon begin.”

NYT detailed:

Drones made of plastic foam or plastic are harder to find on radar, reconnaissance teams said. Ukraine buys them from commercial suppliers who also sell to aerial photographers or hobbyists around the world, along with parts such as radios, cameras, antennas and motors. The drone units mix and match parts until they find combinations that can fly past sophisticated Russian air defenses.

“The doctrine of war is changing,” one Ukrainian commander said. “Drones that cost hundreds of dollars are destroying machines costing millions of dollars.” The AP discusses how an elite drone unit – “a ragtag group of engineers, corporate managers and filmmakers” — “assembled with just $700,000, has destroyed $80 million worth of enemy equipment.”

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The Carenostics Interview

In my other day job of advising companies, I was introduced to Carenostics by my friends at Bayer G4A. This is a super interesting company which is using AI to diagnose serious chronic diseases like kidney disease, asthma, and others much earlier. So far they are working with health systems like Hackensack in NJ and the VA, and have just raised a $5m round. Last week I spoke with father and son team, Kanishka Rao, COO & Bharat Rao, CEO. In particular look out for Bharat’s explanation of what has to go on behind the curtain to make AI become effective.

“PictureWhat” ??? Super-Human Poison Ivy. What’s Going On?

By MIKE MAGEE

Connecticut loves its’ trees. And no town in Connecticut loves its’ trees more than West Hartford, CT. The town borders include an elaborate interconnected reservoir system that does double duty as a focal point for a wide range of nature paths for walkers, runners and cyclists.

While walking one path yesterday, I came a tree with the healthiest upward advancing vine I had ever seen. My “PictureThis” app took no time to identify the plant. To my surprise, it was Toxicodendron radicans, known commonly as Poison Ivy.

The description didn’t pull punches. It read, “In pop culture, poison ivy is a symbol of an obnoxious weed because, despite its unthreatening looks, it gives a highly unpleasant contact rash to the unfortunate person who touches it.” And even that doesn’t quite capture the plants negative notoriety.

Its’ pain and itch inducing chemical oil covers every inch of the plant, and is toxic to 80% of humans. It was discovered by Japanese chemist Rikō Majima in the lacquer tree and named urushiol (Japanese for lacquer) in 1922. It is a derivative of catechol, an organic compound with the molecular formula  C₆H₆O₂.

But the giant vine this week was nothing like the creeping little three leaf plant most children have be taught to avoid. This was a giant – a very different aggressor worth investigating. Its leaves were impossibly large and its vine straight and thick, and its vitality unhampered by a need to support elaborate roots or bark.

Others have noticed it too including “Pesky Pete” who has made a good living removing the invader from properties in Massachusetts and southern New Hampshire. And recently business has been booming. This is because the plant, which up to this year has never appeared in the region before May 10th, suddenly appeared this year on April 23rd.

This was no surprise to Bill Schlesinger, resident of Maine and Durham, NC.  Officially, he is “William H. Schlesinger … one of the nation’s leading ecologists and earth scientists …a member of the National Academy of Sciences, …has served as dean of the Nicholas School of the Environment at Duke…”

Turns out Bill was in the lead on a six year project termed the “DukeUniversity Free-Air CO2 Enrichment Experiment” between 2000 and 2006 when the results were published.  They had been following tree declines in the Duke Forest where predatory vines had played a major role. They decided to encircle and isolate six giant forest plots and pump them full of CO2, and then catalogue the effects.

Their 2006 publication revealed that:

  1. CO2 enrichment increased T. radicans photosynthesis by 77%
  2. Increased the efficiency of plant water usage by 51%
  3. Stimulated the growth of poison ivy during the five growing seasons ambient plants
  4. Annual growth increase of 149% in elevated CO2 compared to ambient plants.
  5. Notably larger than the 31% average increase in biomass observed for woody plants

Poison Ivy was the fastest grower of them all in the experimental CO2 forests. Bill’s collaborator,  Jacqueline E. Mohan, carried the work further as head of the Harvard Forest project in Massachusetts. They reported out results, not on CO2  soil, but warmed soil. They heated the upper layer of soil by 9 degrees. Her response to the findings was surprisingly down-to-earth. She said, “My heavens to Betsy, it’s taking off. Poison ivy takes off more than any tree species, more than any shrub species.”

Mohan and coworkers made it clear at the time that this was not great news for 8 out of 10 Americans who are sensitive to poison ivy. Not only did global warming and carbon footprints accelerate growth in the plant by 70% in its leaf size and biomass, but additional experiments revealed that these environmental enablers increased the amount of urushiol in the plant

As Duke was building those first towers to isolate their experimental forests in 2000, the International Geosphere-Biosphere Program was holding its annual meeting in Mexico.  A Working Group subsequently focused on defining planetary boundaries (PB) that would assure both planetary and human health.

Nine years later, the group published  “A Safe Operating Space For Humanity” in Nature. In it they proposed nine “planetary boundaries” to gauge “the continued development of human societies and the maintenance of the Earth system(ES) in a resilient and accommodating state.” In their view, measuring and ongoing monitoring of these boundaries would provide “a science-based analysis of the risk of human perturbations” that might “destabilize the Earth’s Systems (ES) on a planetary scale.” The work was updated in 2015.

The first Planetary Boundary listed was Global Warming with two measures, atmospheric CO2 and air and water temperature. As for human perturbation, as the picture above well illustrates, you can add super-human poison ivy to the list of unintended consequences.

Mike Magee MD is a Medical Historian and regular THCB contributor. He is the author of CODE BLUE: Inside the Medical-Industrial Complex (Grove/2020)

DNA is Better at Math than You Are

By KIM BELLARD

I was tempted to write about the work being done at Wharton that suggests that AI may already be better at being entrepreneurial than most of us, and of course I’m always interested to see how nanoparticles are starting to change health care (e.g., breast cancer or cancer more generally), but when I saw what researchers at China’s Shanghai Jiao Tong University have done with DNA-based computers, well, I couldn’t pass that up. 

If PCs helped change the image of computers from the big mainframes, and mobile phones further redefined what a computer is, then DNA computers may cause us to one day – in the lifetime of some of you — look back at our chip-based devices as primitive as we now view ENIAC.

It’s been almost 30 years since Leonard Adleman first suggested the idea of DNA computing, and there’s been a lot of excitement in the field since, but, really, not the kind of progress that would make a general purpose DNA computer seem feasible. That may have changed.

At the risk of introducing way too many acronyms, the Chinese researchers claim they have developed a general purpose DNA integrated circuit (DIC), using “multilayer DNA-based programmable gate arrays (DPGAs).” The DPGAs are the building blocks of the DIC and can be mixed and matched to create the desired circuits. They claim that each DPGA “can be programmed with wiring instructions to implement over 100 billion distinct circuits.”

They keep track of what is going on using fluorescence markers, which probably makes watching a computation fun to watch. 

One experiment, involving 3 DPGAs and 500 DNA strands, made a circuit that could solve quadratic equations, and another could do square roots. Oh, and, by the way, another DPGA circuit could identify RNA molecules that are related to renal cancer. They believe their DPGAs offers the potential for “intelligent diagnostics of different kinds of diseases.”

DNA tracking DNA.

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Poor Kids. Pitiful Us

By KIM BELLARD

Well, congratulations, America.  The child poverty rate more than doubled from 2021 to 2022, jumping from 5.2% to 12.4%, according to new figures from the Census Bureau.  Once again, we prove we sure have a funny way of showing that we love our kids.

The poverty rate is actually the Supplemental Poverty Measure (SPM), which takes into account government programs aimed at low income families but which are not counted in the official poverty rate. The official poverty rate stayed the same, at 11.5% while the overall SPM increased 4.6% (to 12.4%), the first time the SPM has increased since 2010.  It’s bad enough that over 10% of our population lives in poverty, but that so many children live in poverty, and that their rate doubled from 2021 to 2022 — well, how does one think about that?

The increase was expected. In fact, the outlier number was the “low” 2021 rate.  Poverty dropped due to COVID relief programs; in particular, the child tax credit (CTC).  It had the remarkable (and intended) impact of lowering child poverty, but was allowed to expire at the end of 2021, which accounts for the large increase. We’re basically back to where we were pre-pandemic.

President Biden was quick to call out Congressional Republicans (although he might have chided Senator Joe Manchin just as well):

Today’s Census report shows the dire consequences of congressional Republicans’ refusal to extend the enhanced Child Tax Credit, even as they advance costly corporate tax cuts…The rise reported today in child poverty is no accident—it is the result of a deliberate policy choice congressional Republicans made to block help for families with children while advancing massive tax cuts for the wealthiest and largest corporations.

Many experts agree: child poverty, and poverty more generally, is a choice, a policy choice.

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