The Health of the Healthcare System

We can look at this topic from two perspectives. If we consider the treatments that have been developed in the past quarter century, the healthcare system has performed phenomenally well. But if we try to evaluate the way treatment for just about everything from minor complaints to deadly diseases has actually been delivered to patients in the US, the picture is not so rosy.

Let’s look at the rosy side first. Just in the past year or so, several new drugs have turned up that could bring really significant benefits to many individuals. Doc Gumshoe has discussed them comprehensively in previous missives, so this will be just a brief reminder.

We’ll start with Alzheimer’s disease, which looms as a threat to all of us. Up to now, the most positive news has had to do with a class of drugs called BACE inhibitors, such as aducanumab/Aduhelm and lecanemab/Leqembi, which slow the progression of Alzheimer’s, at least to some degree. The news here is that a new drug, so far known only as UB-SCG-74, targets an inflammatory response in the brain that precedes Alzheimer’s. It remains to be seen whether treatment with UB-SCG-74 will actually prevent the manifestation of Alzheimer’s, and clinical trials could take a long time, but the prospects are good.

A bit of news that is unequivocally positive is the development and FDA approval of Journavx (suzetrigine), which is the first non-opioid pain medication to get the FDA’s nod of approval in 20 years. This is hugely significant from two perspectives. First, and most obvious, it provides pain relief to persons that are acutely in need of pain relief – individuals who have sustained injuries or have just had surgery. Those persons up to now have mostly relied on opioids of one type or another. For example, when I had knee replacement surgery I was prescribed oxycodone, which is an opioid. I was super careful to limit my intake. I could tolerate pain, but I did not want to risk becoming addicted. The availability of an effective pain killer that does not involve the risk of addiction is truly important.

And just about a month ago, the FDA approved a drug that was highly effective in preventing HIV, the human immunodeficiency virus that leads to AIDS. AIDS, in case you don’t remember, is acquired immunodeficiency syndrome, which makes infected persons susceptible to a wide range of diseases, some of them fatal. The drug, Yeztugo (lenacapavir, from Gilead) is given by injection twice a year. In a clinical trial, 99.9% of subjects remained HIV-negative a year after injection. Yeztugo is a member of a class termed PrEP (pre-exposure prophylaxis) agents. Before Yeztugo’s approval, the standard PrEP drugs were Truvada and Descovy, which are pills that need to be taken daily. Yeztugo was significantly more effective at preventing HIV than Truvada or Descovy. Also, a twice-annual injection likely has an advantage in terms of compliance – non-compliance has been a major factor in the effort to contain HIV.

Obesity and type-2 diabetes frequently go hand in hand, often leading to severe cardiac consequences and, less often, some forms of cancer including breast and colon cancer. A cluster of related drugs has recently been FDA-approved to treat both obesity and diabetes. The drugs act as agonists for two hormones that have multiple effects. The hormones, glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are normally present in the intestinal tract. These hormones improve insulin secretion and the body’s sensitivity to insulin, and help suppress the release of glucagon. (Glucagon increases glucose production by the liver). The newly-approved drugs also slow the rate at which food leaves the stomach, thereby decreasing appetite. These mechanisms make the agents effective not only as weight-loss drugs but also as treatment options for type 2 diabetes.

The drugs are Mounjaro/Zepbound (tirzepatide, from Eli Lilly) and Ozempic/Wegovy (semaglutide, from Novo Nordisk). Even though they have four trade names between them, the drugs work basically the same way. Mounjaro and Ozempic are specifically drugs for diabetes, but many individuals use them for weight loss, since they also function as appetite suppressants. Zepbound and Wegovy, even though Zepbound is identical with Mounjaro and Wegovy with Ozempic, are marketed as weight-loss drugs. I can see why a non-obese patient with diabetes would be somewhat put off by being given a drug that treats obesity, and, conversely, why an overweight patient who is non-diabetic would be skeptical about being prescribed a drug to treat diabetes. Best to give the drug separate names for each condition.

When it comes to cancer treatment, the healthcare system has been putting the pedal to the metal for quite a while. That’s basically because cancer treatment has moved beyond the old formula of “cut, burn, poison” to a much more targeted approach. “Cut, burn, poison” (i.e., surgery, radiation, and chemotherapy) was the highly negative summary of the treatment options that prevailed before the emergence of the current targeted treatments. Chemotherapy was termed “poison” because it meant administering drugs that were capable of killing normal human cells, and relying on the greed of cancer cells to ingest killer doses of the drug without inflicting excessive harm to non-cancerous cells.

But current cancer treatment has mostly put that formula on the shelf. Drugs are now developed to address a specific cancer in a specific location. In the past ten years, 193 cancer drugs have received FDA approval. Another major recent advance is the development of cancer immunotherapies. Immunotherapy targets the unique features of each patient’s tumor and immune system and generates smarter immune cells that can adapt and persist in the body. One form of immunotherapy employs cells termed checkpoint inhibitors. Checkpoints are proteins that prevent the immune system from attacking cancer cells. By inhibiting these checkpoints, the immune system can be reactivated to recognize and destroy cancer cells. Immune checkpoint inhibitors have been approved for more than 25 types of cancer.

Immune checkpoint inhibitors adapt and modify our own T-cells to attack and destroy cancerous tumors. T-cells normally attack cancer cells, but solid tumors build multiple defensive walls that prevent the killer T-cells from entering and destroying the tumors. However, the T-cells engineered by the researchers deliver interleukin 2 (IL-2), a naturally-occurring inflammatory molecule produced by the immune system that has powerful anti-cancer effects. IL-2 supercharges T cells, making them more effective cancer killers. The anti-cancer effects of IL-2 have long been known; however, systemic administration of IL-2 has been limited due to the severe side effects it can cause. Simply infusing patients systemically with IL-2 can cause high fever, leaky blood vessels, and organ failure.

The researchers were able to avoid this problem, which would have prevented the T-cells from doing their job, by programming the tumor-infiltrating T-cells to make their own IL-2 only when they recognize a cancer cell. The therapy, employing the engineered T-cells, effectively eliminated both melanoma and pancreatic cancer in mice, with minimal side effects.

To engineer T-cells that could sense when they were in the tumor, the researchers used a synthetic Notch (or synNotch) receptor, a flexible type of molecular sensor. These receptors span the cell membrane, with ends that protrude both inside and outside the cell. The outside portion recognizes and binds to tumor cells, triggering the inside portion to set the production of IL-2 in motion.

The possibility of modifying T-cells to treat cancers in specific patients has been a reality for a number of years, but treatment of this sort required tailoring the T-cells to a specific cancer, not just to a class of cancers, and had not been successful in treating solid tumors. The innovation in this study was tailoring the T-cell to release the cancer-killing IL-2 only when it had entered the solid tumor. It was not necessary to tailor the T-cell to the specific tumor. The technique is designed to be effective in solid tumors as a class.

If the preceding disquisition on T-cell therapy for cancer seems unnecessarily complicated, please take it as an example of just how complicated current cancer treatment has become. No longer are cancer patients lumped together and routinely given a toxic drug in the hope that the drug will kill the cancer before it kills the patient – although for some forms of cancer, the old time chemotherapy options are still put to work for cancers for which T-cell therapy and other targeted therapies have not yet been developed.

However, to return to the main point of this piece, let’s take a look at how these truly amazing treatment options, and healthcare in general, is made available to the human population in need of treatment, and how this is reflected in the health of the population.

The health of the population as shown in life expectancy data

One would think that advances in medical treatment would be reflected in basic statistics, such as life expectancy. Indeed, life expectancy in the US has been increasing year over year, at least until 2015. Here are the statistics starting in 1980.

Year Life expectancy at birth

1980 73.25
1985 74.37
1990 74.89
1995 75.65
2000 76.47
2005 77.18
2010 78.19
2015 78.94
2020 78.81
2023 78.40

That’s an increase in life expectancy of 5.56 years over a 35-year time span, about a 7.5% boost over the 1980 expectation. Women’s life expectancy is significantly higher than men’s. In 2023, women’s life expectancy was 81.1 years and men’s was 75.8 years – thus, girl babies were projected to live 5.3 years longer than boy babies. The small decline between 2015 and 2020 is probably due to the effects of the COVID 19 pandemic, which was just starting. Then, by 2023, when the pandemic had been going for more than three years, the decline was larger.

How does this compare with life expectancy estimates in other parts of the world? The UK does better than the US, with an estimated life expectancy of 81.15 years as of 2020. But the US does better than China (76.02 years), Russia (72.21), India (69.27), and way better than Africa (63.8). Surprising, and definitely positive, is the improvement in life expectancy in Russia, from 23.6 years in 1945 to the present level, and also in India, from 21.16 years in 1920 to the present level. My assumption is that the exceedingly short life expectancy in Russia in 1945 was principally due to the devastation of World War II. As to the even briefer life expectancy in India in 1920, that was likely the result of extremely poor health conditions and endemic poverty.

In the US there are wide disparities between life expectancy in the various states. The top figure – 80.7 years – is for the state of Hawaii, due, perhaps in part, to a lifestyle where people go to the beach for a healthy swim or hike up the slopes of a volcano. But more likely it’s because of the population mix, with a high proportion of healthy Pacific Islanders. After Hawaii, the state of Washington (79.2 years), North Central, Northeastern and Mid-Atlantic States top the list, with life expectancy figures well above 78 years. At the bottom of the list are mostly Southern states, with life expectancies below 75 years. The data for the individual states is as of 2020.

Life expectancies also vary considerably between different ethnic groups. Asian and Hispanic persons have somewhat higher figures than white persons. Here is a small table showing life expectancies for five groups over four years.

Group 2019 2020 2021 2022

Hispanic 81.9 77.9 77.8 80.0
Asian 85.6 83.6 83.5 84.5
White 78.8 77.4 76.7 77.5
Black 74.8 74.5 71.2 72.8
American Indian/ 71.8 67.1 65.6 67.9
Alaska Native

As you can see, there were dips in life expectancy in all groups from 2019 through 2021, no doubt due to COVID, and then a lift from 2021 to 2022.

My assumption regarding the much higher life expectancy figures for Hispanic and Asian populations is that those groups largely consist of relatively recent immigrants, which means that infant mortality data is mostly absent. Infant mortality is a major factor in life expectancy calculations. Once children get through the first four or five years of life, the probability of mortality diminishes significantly and does not increase until the late 20s. The probability of mortality during the first year of life is about ten times higher than in children more than one year old.

The only explanation I can think of for the very low life expectancy figures for American Indians and Alaska Natives is that they are relatively isolated from healthcare services. It is also likely that these groups are more susceptible to the many harmful lifestyle factors that pervade American culture. I can recount a personal experience. When I visited a Hopi Indian reservation in Western Arizona, I saw a bunch of youngsters kicking a soccer ball around. They were in close proximity to one of those ubiquitous fast-food joints, whose particular brand I will not disclose. What struck me is how grossly overweight many of those youngsters were. Here was a community that had lived and survived in the desert for many generations, probably on meager rations. Then, more recently, fast, easy, and relatively inexpensive food arrived in their environment. This adds up to a formula for quick and excessive weight gain, with harmful consequences.

In the medical literature that I could find that in any way attempted to identify the reasons for the racial disparities in life expectancy, what struck me was the marked reluctance to attribute at least some of these disparities to lifestyle factors. As you can see from the table above, White persons have four to five years greater life expectancy than Black persons. The easiest explanation is that Black persons are less likely to be covered by health insurance of any kind, and are therefore less likely to seek medical treatment. This explanation is undoubtedly correct. But there are other factors that are only hesitantly mentioned.

The Black population has a slightly higher rate of tobacco use than their White counterparts. In 2023, 20.9% of African-American males smoked, compared with 17.3% of White American men. In contrast, fewer African-American women smoked (13.3%) versus 16% of White women. Even though the rates of tobacco use are not that different, Black Americans have higher death rates from tobacco-related causes.

The tobacco industry has targeted Black Americans with advertising in media that is mostly directed to Black viewers, and has strategically marketed its products to appeal to the that community for decades, including by placing more advertising in predominantly Black neighborhoods and in publications popular with Black audiences. The most striking example is menthol cigarettes, which are easier to smoke and harder to quit. Currently 80.9% of Black American smokers use menthol cigarettes, and about 45,000 Black Americans die from smoking-related disease each year.

According to the Office of Minority Health, which is part of Medicare, the risk of stroke in Black males is about 50% higher than in White males, and the risk of death is about 70% higher than in White males. Black females are twice as likely to have a stroke as White females, and 30% more likely to die as a result. In 2015, Black Americans had the highest mortality rate from stroke of any racial group and were more likely to be disabled as a result. Black Americans are more at risk most likely because of a higher risk for high blood pressure, diabetes, and obesity, all of which contribute to stroke.

It may well be that Black Americans, who are mostly descended from individuals captured from deep in the interior of Africa by coastal African slave traders, have a genetic susceptibility to a diet high in salt, because salt was exceedingly scarce in the African interior. And that therefore, living in the US on a diet replete with salty snacks and all kinds of quick, tasty, salty food, they respond with elevated blood pressure and strokes.

… but what about ready access to those “truly amazing treatment options” and quality healthcare?

Yes, as we said earlier, medical science is moving forward at a quickening pace. But does the general population have ready access to the best in healthcare, including those recent advances?

Access, perhaps, but not “ready access.” Several issues get in the way. One is a shortage of physicians. By the end of this year, the US is expected to have a shortage of up to 64,000 MDs. The COVID-19 pandemic exacerbated the already substantial burnout among doctors and contributed to their unprecedented departure from the clinical workforce.  Looking ahead, the desires of doctors to step back from clinical care show no signs of abating, with current projections from the Association of American Medical Colleges indicating that the physician deficit could grow to up to 86,000 by 2036.

Until fairly recently, choice career options for young people were medical or law practices. These career choices required several years of intense graduate study – for would-be physicians, it meant not only medical school, but several years of internship and residency. Currently, fewer young people are choosing medical professions, opting instead for careers in areas such as artificial intelligence (AI).
Another reason for the expected shortage is that some 20% of physicians in clinical practice are 65 years old or older, and when these physicians retire, the stream of new doctors entering clinical practice is diminishing. The expanding gap in the physician workforce is particularly consequential given the projected growth in patient demand. The number of people aged 65 and up — a patient group essentially more in need of healthcare — is expected to increase to about 23% of the US population by 2050. Yes, we’re getting older – the over-65s are about 17% of the population – and more in need of medical attention, but the availability of that medical attention is getting more difficult to access.

It’s easy to point the finger at the COVID-19 pandemic as the chief underlying cause of the departure of doctors from clinical practice. That said, I suspect that official organizations, such as the Association of American Medical Colleges cited above, are reluctant to point the finger at another factor which, I strongly believe, is major. That is the tangled, complicated, and often arbitrary system through which doctors and other medical providers get paid for their services.

There was a time, and I remember it well, when one went to the doctor’s office, got treated, wrote a check for the bill and that was that. These days many physicians are part of a large practice system, and a patient’s telephone call to attempt to make an appointment goes to some central location Lord knows where. Or else the patient has to try to make the appointment online. “Practice management” has become a major part of the healthcare system, for better or for worse, but mostly for worse, from my perspective.

It’s frequently not easy to get an appointment with the physician one needs. To see a specialist for the first time, the patient usually needs a referral, and, since the patient is a “new patient,” the appointment will likely be a few months out. If the need for care is urgent, the patient may be told to go to a hospital emergency department or to a local “urgent care” facility. For example, a woman develops a small skin lesion. The obvious course of action is to try to schedule an appointment with a dermatologist. But to get this appointment, she needs a referral from her primary care physician, and the earliest appointment she can get is months out, so the appointment with the dermatologist will likely not take place for several months. So, should she go to the emergency department with her small skin lesion? But emergency departments are not adequately staffed to handle every medical issue.

And then there’s the issue of payment for the service. Over 90% of the US population has some sort of medical insurance. This does leave about 24 million people without health insurance, and according to whatever data I could find, most of those uninsured are in the lowest economic strata, which means that most likely they get no healthcare at all except in emergencies, at which time hospital emergency departments step in as a last resort.

However, for the fortunate majority that does have health insurance, the path is by no means straight and easy. Neither private health insurance nor any of the government funded plans simply provide coverage for all medical and health maintenance needs. And the coverage keeps changing. Services that are covered one year can cease to be covered the following year. For example, the US Preventive Services Task Force (USPSTF), which is not an official US government body but an advisory group whose views carry a great deal of weight, switches back and forth on its recommendations for breast cancer and prostate cancer screening, such that patients may not know whether their insurance will pay for the screening until the bill comes. That uncertainty can dissuade some individuals from seeking treatment.

Medicare is a puzzle. There is Medicare Part A, B, and D. Part A is the hospital care plan, and mostly it works reasonably well. Part B is meant to cover non-hospital care, and Part D is the drug plan. And then there are supplemental plans called Medigap, with designations that take up half the alphabet.

Medicare Advantage is a misnomer. These plans are also sometimes referred to as Medicare Part C. These are private plans, approved by the Medicare system, but individuals who sign up for Medicare Advantage can only use healthcare providers that are approved by their specific private plan. There are several types of Medicare Advantage plans, including plans set up by Health Maintenance Organizations (HMOs), by Preferred Provider Organization (PPO) Plans, and by Private Fee-for-Service (PFFS) Plans. As I see it, limiting a person’s choice of healthcare providers to the physicians in a private plan is a limitation, not an advantage.

To call the drug plans complicated is a colossal understatement. Drug costs depend on a range of factors and players. Pharmaceutical companies, the drug’s manufacturers, set a so-called “market price,” which is usually much higher than most patients will ever pay. That price is manipulated by pharmacy benefit managers and insurers and also by Medicare. A patient’s assumption that the drug prescribed by his/her physician will be covered by insurance/Medicare is not always well-founded. It’s of course possible to check whether a particular drug is covered by checking on the Medicare website.

But more often than one would like to think, drugs are not covered. This is especially the case with new drugs, but some long-established drugs are also omitted from coverage. There is an assumption that once a drug receives FDA approval, Medicare will cover the cost. That is incorrect. Medicare “reserves the right” not to approve drugs that are not, in Medicare’s view, “necessary and appropriate” for the specific medical condition. And Medicare also has a limit on how many drugs it approves. Medicare’s costs are part of the Federal budget, and the Centers for Medicare and Medicaid Services, like all Federal agencies, need to watch their bottom line.

Where does all this come out? My unfortunate conclusion is that there is a large and concerning disparity between the outstanding treatment innovations that have emerged in the past few years and the present complicated and unnecessarily restricted delivery of those innovations – and, indeed, of healthcare treatment in general – to the population.

If we assess current healthcare based on the treatment options that have been developed, we can conclude that the overall picture is very rosy. Superb treatment options have emerged for a great many diseases for which effective treatment did not exist. But if we look at it from the perspective of patients, the picture changes considerably. To get these excellent treatment options, patients may have to go through something like an obstacle course. Whether a patient will succeed in getting a particular treatment covered is by no means certain.

My conclusion is that we need to keep front of mind the reality that excellent treatment options are out there in the healthcare system, and more excellent treatment options are emerging. And we also need to keep front of mind that other reality, that accessing good healthcare treatment may require navigating a series of vexing obstacles. But to maintain our health, we need to keep navigating those obstacles and not getting stuck in the quagmire of the system. Push the system and stay healthy!

* * * * * * * *
I’ll try to get back to you on any comments you may have about this not entirely positive piece. We’re taking some vacation time in mid-to-late August, so my responses may be delayed a bit. Be well and enjoy the rest of the summer! Best to all, Michael Jorrin (aka Doc Gumshoe)

[ed note: Michael Jorrin, who I dubbed “Doc Gumshoe” many years ago, is a longtime medical writer (not a doctor) and shares his commentary with Gumshoe readers once or twice a month. He does not generally write about the investment prospects of topics he covers, but has agreed to our trading restrictions.  Past Doc Gumshoe columns are available here.]