Month: March 2022

Take a long enough lens — say, 25 years — and it seems as though health care in America is inarguably getting better.

People are living longer than they did a quarter century ago. The burden of disease, a metric that includes premature deaths and disability, has dropped. The number of avoidable hospitalizations and hospital errors is lower.

But below those rosy numbers is the truth: American health care has been falling behind other countries in the developed world for decades.

Life expectancy has increased, but by less in the US than in the wealthy nations of Europe and Asia. The improvement in disease burden has likewise been less impressive than that of comparable countries. Meanwhile, to achieve those mediocre results, the United States continues to spend more money on medical care than any other country in the world; while health spending in the US isn’t going up faster than in other countries, it was higher to begin with and continues to increase. We’ve maintained a sizable lead in health care spending while getting outcomes that are worse than countries that spend less.

And all of that was true even before the United States experienced one of the worst Covid-19 outbreaks in the world.

Kaiser Family Foundation researchers recently warned of a “further widening of the gap” between the US and other countries as a result of the pandemic. Life expectancy in the US had already stagnated in the last few years, driven by a rise in drug overdoses and suicides; now Covid-19 will shorten it further. Disease burden had been trending upward in the US while dropping elsewhere; the Covid-19 pandemic is likely to widen that disparity too.

“This pandemic has been a fast pandemic, fueled by a slower pandemic of chronic illness,” Howard Koh, a Harvard public health professor who worked in the Obama administration, told me. “All those streams have converged to cause the public health catastrophe we’ve endured.”

You could say the trajectory of American health care before, during, and after the pandemic is like that of an individual vulnerable patient: It was sicker to begin with, hit hard by Covid-19, and will be dealing with the lingering effects for a long time.

The US was already falling behind the rest of the world on health care

When it comes to getting value for money in health care, America slowly but perceptibly fell behind other developed countries over the last 25 years.

It starts with life expectancy, the bluntest measure of how well people are served by their health system. Life expectancy in the developed world has steadily improved over the past few decades, driven primarily by major breakthroughs in the treatment of heart disease and other cardiovascular problems, which rank near the top among causes of deaths in wealthy nations.

But not as much in the United States as in other countries. According to a KFF analysis of health care trends from 1991 to 2016, Americans saw their life expectancy rise by 3.1 years during that period — a meaningful improvement, to be sure, but substantially less than the 5.2 years gained in comparable countries.

And in the US specifically, that progress has stagnated in recent years. With tens of thousands of people dying of opioid overdoses every year and a sustained increase in the number of suicides, American life expectancy actually started tailing off in 2014, according to a 2019 analysis published in JAMA. The gap between the US and other wealthy countries was already growing before Covid-19 struck.

Likewise, disease burden had steadily improved until a recent downturn separated the US from other countries. The reasons for the improvement were the same: better medical treatment for chronic diseases. But once again, America did not improve to the degree that comparable countries did, seeing a 12 percent improvement versus an average of 22 percent elsewhere. In the United States, the burdens from disease of the heart, lung, kidney, and liver — as well as from diabetes — remain stubbornly high compared with the rest of the developed world.

And the reasons for America’s recent stagnation are the same, too: Suicides and drug overdoses, plus a rise in the number of young people with chronic health conditions, are robbing people of years of healthy living.

The same pattern holds for medical errors. They have been declining in the US over the last 25 years but are still more common in America than in comparable countries. Avoidable hospitalizations and adverse drug events are down, but not as much as in wealthy European or Asian nations. Americans are roughly twice as likely to experience an error in their medical care as their counterparts the world over.

One metric — known as mortality amenable to health care — combines all of these characteristics and grades a country’s health system on how well it prevents deaths from conditions that should be treatable with timely access to health care. The US ranked behind the biggest countries in Europe, as well as Japan, as of 2016.

A country like Taiwan, which performed much worse than the US on the same metric 30 years ago, is now nearly its equal.

And for those middling outcomes, the US still spends more on health care than other countries: nearly 18 percent of its GDP versus about 11 percent, on average, in comparable nations. Health spending has been rising at the same rate in the US and its peers over the last few decades, and yet those other countries have seen more improvement in their health outcomes.

They are, in other words, getting more value out of their health systems than the US.

“One could conclude that the comparable … countries’ value improvement was greater,” the KFF researchers wrote in 2018, “even though they started at a higher threshold in terms of better outcomes and a lower percentage of GDP consumed to achieve it.”

One possible explanation for America’s poor performance: We underinvest in social spending and overspend on medical care compared with other developed countries. If you combine social services spending and health spending, the US and its peers actually spend about the same amount of money, a little more than 30 percent of their GDPs. But spending in those other countries is more slanted toward social services, while America spends more on medical care.

America’s underinvestment exacerbates disparities between haves and have-nots: 18 percent of Americans live in poverty versus 10 percent in other wealthy countries. We know that people with lower incomes have structural challenges — access to healthy food, clean water, and fresh air, for starters — that lead to worse health outcomes. When they get sick, they have a harder time finding a doctor and affording their medical care.

“Economic inequality is increasingly linked to disparities in life expectancy across the income distribution, and these disparities seem to be growing over time,” wrote the authors of a 2018 review of relevant research in Health Affairs. Poor health also tends to lead to lower incomes, creating a feedback loop known as the “health-poverty trap.”

And those disparities — between rich and poor, white and Black — only worsened during the Covid-19 pandemic.

Covid-19 will have long-term consequences for American health

The gap between the US and other wealthy nations is expected to grow because of the pandemic. America has lost more than 600,000 people to Covid-19, the highest confirmed death toll in the world. Adjusting for population, the US has lost more people on a per-capita basis than most of the European and Asian countries to which it is compared.

Official death counts can be somewhat arbitrary because they depend on testing to identify cases. Excess deaths — the number of deaths from all causes above what would be expected in an ordinary year — are considered by experts to be a more reliable gauge. On that metric, too, and adjusting for population, the United States is one of the worst performers among wealthy nations.

“The outsized effect of the pandemic on the U.S. will likely widen the existing gap in mortality rates between the U.S. and peer countries,” wrote the authors of an October 2020 analysis on Covid-19 death rates and life expectancy.

America is also likely to experience a higher disease burden (that’s the years of quality life lost to premature death and disability) as a result of its pandemic failures. People under 65 in the US have died from Covid-19 at higher rates than their peers elsewhere.

A prolonged mental health crisis may linger after a year of disrupted social lives and isolation. More than 4 in 10 Americans reported experiencing symptoms of anxiety or depression in 2020, according to US census surveys.

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Health spending actually slowed down in 2020, a historic aberration, as people postponed medical care during the pandemic. But medical spending did not slow down as much as the rest of the economy: As of October 2020, it had fallen 0.5 percent versus a 1.8 percent contraction overall. So even as spending dropped, health care likely consumed an even greater share of America’s GDP than in years prior.

And the short-term drop in spending could have long-term consequences. Last year, 24 percent of Americans said in a census survey that they did not get needed medical care during the pandemic, with 33 percent saying they delayed care. To give one example, cervical cancer screenings dropped about 80 percent from normal levels in spring 2020, and while they rebounded later in the year, they were still 25 percent down by the end of September.

While patient volume generally has recovered, we still don’t know what the long-term effects of people missing care or receiving belated diagnoses will be. And there are tens of millions of people recovering from a Covid-19 infection; as many as 15 million of them may struggle with “long Covid” for the foreseeable future, according to a new analysis in the New England Journal of Medicine that called long Covid-19 “our next public health disaster in the making.” Those direct health aftershocks from the pandemic will be yet another burden on the US health system long after the coronavirus itself starts to subside.

Long-term spending trends were already prompting health plans to push more of the cost of health care onto patients. Deductibles and worker premiums have been increasing for years.

Post-Covid-19, at least as a relative share of the economy, health care is eating up even more of the country’s resources. America’s health outcomes have been set back by the pandemic, and the spending crunch is intensifying.

UL 0-12
UCC 0-11

UL CAPTAIN FIADHNA Tangney scored 0-4 as her side were crowned Yoplait O’Connor Cup champions again after a thrilling win over UCC.

The holders held a 0-10 to 0-4 lead at half-time and they went on to make it five titles since 2014 at a wet and windy DCU Dóchas Éireann.

But it was not without a scare, UCC came with a late fightback and they almost got level before the end only for the equaliser to evade them.

Kerry star Tangney won the toss and UL played with a strong wind at their backs in the first half. They scored twice in the opening minute with Erone Fitzpatrick and Tangney on target.

UL went on to take a 0-8 to 0-0 lead into the water break. UCC were struggling to contend with the driving rain into their faces, Tangney brought her tally to 0-4, while Niamh O’Connor, Ailish Morrissey and Hannah O’Donoghue also chipped in, in the opening quarter.

The reigning champions were making the most of their wind advantage but Katie Quirke set up Sadhbh O’Leary and she got UCC’s first point of the game in the 22nd minute.

Ciara McCarthy scored from distance shortly afterwards and Sarah Leahy got forward for another but Morrissey steadied the UL ship, and they were 0-9 to 0-3 in front approaching half-time.

Aisling Reidy and Emma Cleary exchanged points before the interval and Quirke was inches away from a badly needed goal.

Sadhbh O’Leary of UCC in action against Roisin Ambrose of UL.

Source: Eóin Noonan/SPORTSFILE

However, UL went in with a six-point lead and although Cleary scored early in the second half there was no onslaught. Instead, Morrissey scored her third, this time from a free, and almost found the net moments later.

That left the door open for UCC who were still in the game, trailing 0-11 to 0-5, in the 39th minute. Quirke was next to score but Morrissey answered that again and it looked like UL would cruise to the win.

However, UCC caught fire in the closing quarter; Kellyann Hogan scored in the 50th minute and further points from Quirke (two), McCarthy and Laura O’Mahony brought the lead down to just one with time running out.

UCC were on the brink and they had a number of chances late on but Hogan shot wide from a free and they couldn’t find another opening to draw the sides level.

Party time! UL celebrate following today’s victory over UCC in the Yoplait O’Connor Cup Final #AlwaysBelieve 🏆 pic.twitter.com/hSpnCtKWaB

— Ladies Football (@LadiesFootball) March 12, 2022

Scorers for UL: F Tangney 0-4 (2f), A Morrissey 0-4 (2f), N O’Connor 0-1, E Fitzpatrick 0-1, H O’Donoghue 0-1, A Reidy 0-1.

Scorers for UCC: K Quirke 0-3 (2f), E Cleary 0-2 (1f), C McCarthy 0-2, K Hogan 0-1 (1f), S O’Leary 0-1, C S Leahy 0-1, L O’Mahony 0-1.

UL: R Landers; A Molloy, S Ni Chonnaill, C Boyle; C Needham, R Ambrose, E O’Shea; N O’Connor, A Reidy; Z Fay, E Fitzpatrick, D Beirne; A Morrissey, F Tangney, H O’Donoghue.

Subs: L Noone for Boyle (30), S Cunney for Beirne (37), A Sexton for Fitzpatrick (49), A O’Rourke for Morrissey (49).

UCC: C Forde; R Corkery, J O’Gorman, S Leahy; J O’Sullivan, I Sheehan, L O’Mahony; K Horgan, E Mullins; K Hogan, E Cleary, C McCarthy; A Carey, K Quirke, S O’Leary.

Subs: A Fennessy for Carey (45), N Martin for O’Sullivan (57).

Referee: Jonathan Murphy (Carlow).

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After learning that the venom of a Gila monster lizard contained hormones that can regulate blood sugar, Daniel Drucker started wondering why. And could the venom somehow help treat diabetes?

Drucker is a scientist and endocrinologist at the University of Toronto who has dedicated his career to understanding the universe of hormones in the body, which do everything from regulating appetite to helping with digestion. His curiosity about the Gila monster led to a call with a zoo in Utah. In 1995, Drucker had a lizard shipped from Utah to his lab and began experiments on the deadly venom.

Ten years later, a synthetic version of a hormone in the venom became the first medicine of its kind approved to treat type 2 diabetes. Known as a GLP-1 (for glucagon-like peptide-1) receptor agonist, the medicine set off a cascade of additional venom-inspired discoveries.

After doctors noticed mice and humans on the drug for diabetes appeared to lose weight, they began to consider its use in obesity science. In June 2021, another effective treatment, this one for obesity, got Food and Drug Administration approval. Called semaglutide and marketed as Wegovy, it also takes its structure from the lizard’s venom.

If this origin story sounds outlandish, consider the history of obesity treatments. Over the years, people have turned to extreme and unlikely interventions to try to lose weight, from jaw wiring, laxatives, and vagotomies to lap band operations and fen-phen, a “miracle” diet drug that was ultimately recalled.

The new treatment — a once-weekly injectable from Novo Nordisk, a Danish pharmaceutical company that has hired many leading diabetes and obesity scientists as consultants — is poised to safely help many people with health-threatening obesity, physicians and researchers say. It may even illuminate some of the mysteries around how appetite works in the first place.

“It’s phenomenal,” says Michael Krashes, a diabetes and obesity investigator at the National Institutes of Health. Semaglutide is “a big step forward — we finally have something that’s reliable and able to produce sustained effects over time,” adds Ivan de Araujo, a neuroscientist who studies brain-gut interactions at Mount Sinai’s Icahn School of Medicine. Neither scientist is affiliated with Novo Nordisk.

Doctors who treat obesity patients told Vox they wished they had a treatment option like semaglutide years ago, and patients described the drug as life-altering.

Yet many people with obesity may not seek out semaglutide, and doctors may not prescribe it to them — not only because of the dangerous history of weight loss medications, but also because of a persistent bias and stigma around a disease that now afflicts nearly half of Americans. Obesity is still widely viewed as a personal responsibility problem, despite scientific evidence to the contrary. And history has shown that the most effective medical interventions, such as bariatric surgery — currently the gold standard for treating obesity — often go unused in favor of dieting and exercise, which for many don’t work.

There’s also a practical challenge: Health insurers don’t typically cover obesity medications, says Scott Kahan, an obesity doctor and professor at Johns Hopkins Bloomberg School of Public Health and the George Washington University School of Medicine. “Medicare explicitly excludes weight medications,” Kahan, who consults with Novo Nordisk, says. “And most insurers follow what Medicare does.”

The new drug certainly won’t be a cure-all for obesity, Krashes adds. “You are not taking a 280-pound person and making them 130,” he points out, though reductions that are enough to improve health outcomes are typical. Drucker, who began consulting with Novo Nordisk and other drug companies after his reptilian discovery, agrees that it’s a starting point for obesity: “It will only scratch the surface of the problem in the population that needs to be healthier.”

But semaglutide is the most powerful obesity drug ever approved, he adds. “Drugs that will produce 15 percent body weight loss — we did not have that before in the medical therapy of obesity.” With additional, potentially more effective GLP-1 receptor agonists coming online in the future, we’re at the beginning of a promising new chapter of obesity therapeutics. A look at the fascinating science of how the medication works could also go a long way to changing how Americans think about this disease.

“We have to thank the lizard for that,” Drucker says.

What semaglutide reveals about weight problems

To understand how semaglutide causes some people to eat less, it’s helpful to understand what hormones do. They’re the body’s traveling messengers: Manufactured in one area, they move to another to deliver messages through receptors — molecules that bind to specific hormones — in distant organs and cells.

The gut makes dozens of hormones, and many of them travel to the brain receptors that either curb appetite or stimulate it, Drucker explains. GLP-1 is one such gut hormone. It’s unleashed in the gut in response to food and stimulates the pancreas to make more insulin after a meal, which lowers blood sugar. (GLP-1 is also made in the brain stem, where it may modify appetite.)

“It sends a signal to our brain that says, ‘You know, we’ve had enough to eat,’” says Drucker.

Enter semaglutide, one of a class of medicines — the GLP-1-receptor agonists — that imitate GLP-1, helping the body lower glucose (in the case of people with diabetes) and, researchers suspect, curb appetite (in the case of people living with obesity who may also have diabetes).

The precise way the drug works on obesity is still unknown, in part because scientists don’t understand exactly how appetite works. But researchers generally agree that the drug harnesses the brain’s GLP-1 receptors to curb food intake. When researchers delete the GLP-1 receptors from the brains of mice, the drug loses its appetite-suppressing effects, says Krashes.

Obesity is “primarily an issue of our brain biology, and the way it’s processing info about the environment we live in,” says Randy Seeley, a University of Michigan researcher focused on obesity treatments, who also consults with Novo Nordisk.

With semaglutide, the idea is that “we’re changing your brain chemistry for your brain to believe you should be at a lower weight,” Seeley added.

This brain-based pharmacological approach is likely to be more successful than diet and exercise alone, Seeley says, because “the most important underlying part of somebody’s weight has to do with how their brain operates,” not a lack of willpower.

Not quite a “game changer”

Some people with a higher body mass index are perfectly healthy and don’t require any treatment. Semaglutide was only indicated by the FDA for patients who classify as clinically obese — with a body mass index of 30 or greater — or those who are overweight and have at least one weight-related health problem.

For the many people who have used it, it has proved safe and effective, according to the FDA. In weight loss clinical trials, semaglutide helped people lose about 15 percent of their body weight on average — significantly more than the currently available obesity drugs and more than enough to improve health outcomes.

The drug’s most common side effects — nausea, diarrhea, constipation, and vomiting — were mostly short-lived. De Araujo is finding that adverse reactions might be caused by how the drug differs from the naturally occurring peptide hormone: The hormone acts mostly locally and degrades quickly, while the medicine works mainly on the brain and is designed to stick around in the body. “That’s where the nausea, vomiting probably derive from,” De Araujo argues.

Patients who have tried semaglutide told Vox that it helped them manage their weight and relationship to food, and that their side effects were manageable and quickly resolved.

Jim Eggeman, a 911 operator in Ohio, said that before taking semaglutide, “I could sit down and eat a large pizza, and now it’s one to two pieces at the most.” He started on the drug for diabetes after a heart attack in December 2019 and lost 35 pounds, bringing his weight to 220.

Paula Morris-Kaufman, of Cheshire, UK, used the drug to address weight gain following cancer treatments. It helped her bring her weight back to a normal range, she says, and curb her habit of compulsive eating. “If you give me a plate of food, I just eat a small portion of it — and feel full really quickly.”

It’s possible that some of the benefits of treatment come in part from lifestyle changes, which were encouraged by the clinical trials. In many cases, patients on semaglutide also switched to a healthier diet when they started on the drug and added exercise to their routines. But study participants taking the drug still lost significantly more weight than those under the same conditions who received a placebo.

The need for additional interventions — like diet and exercise — is one reason why Kahan stops short of calling this drug a game changer. “It’s an incremental improvement” over existing drugs, he says, and it’s still out of reach for many of the individuals who could benefit from it. “The ‘game changer’ description is not appropriate, because many people don’t have access to these medicines.”

A mindset shift

Only about 1 percent of eligible patients were using FDA-approved medications for obesity in 2019, a study showed. The same is true for bariatric surgery, currently the most effective intervention for obesity, which can also drive type 2 diabetes into remission.

“If someone walks into your office with heart disease and you as a physician don’t try to treat it, that’s malpractice,” Seeley says. “If somebody comes in with a BMI over 30 and you don’t treat it, that’s Tuesday.” He thinks some of the hesitancy for treating patients with obesity medications comes from the history of dangerous weight loss drugs.

Ingrained biases about obesity have also made it harder for patients to get access, Kahan says. “Obesity tends to be categorized as a cosmetic issue in health insurance policies,” he says. “In order to get coverage, employers have to explicitly decide to buy a rider and sign a contract to add weight management services and products to their insurance plans.” He’d like to see obesity treatments covered by insurers in the same way diabetes and hypertension drugs are.

That will require a shift in mindset, Drucker says. “We would never blame other individuals for developing high blood pressure or cardiovascular disease or cancer,” he says. It’s widely known that those conditions are driven by complex biological determinants, including genes, as well as environmental factors. “Obesity is no different.”

When Drucker started in endocrinology in the 1980s, he didn’t have many tools to help patients. With the addition of semaglutide, there are multiple surgical options and drugs for obesity and diabetes. The challenge now is helping those who would benefit gain access.

“I would be delighted if no one needed GLP-1 for diabetes and obesity,” Drucker says. That might be possible in a food landscape that didn’t nudge people toward the overeating and poor diet that leads to these chronic conditions. But for now, “we have new options that are safe, appear to reduce complications, and are very effective. … We shouldn’t just throw up our hands and say there’s nothing we can do.”

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