What would it take to ‘Make America healthy again?’ Part 2 of 2

How improving our healthcare system can support a healthier country

This piece was co-written with Dr Nason Maani.

In last week’s piece, we started to address the question of “What would it take to Make America healthy again?”— discussing what it would mean to hold a new administration accountable to its word to do just that, and offering some specific ideas building on its stated goals toward this aspiration. We started by outlining the scope of the challenge of poor health in this country and then discussed how we might center prevention to improve health. Here we will talk about addressing how we might tackle the challenges and shortcomings of treatment, and specifically of the healthcare industry itself, to the end of improving health.

When considering how we might improve healthcare, an industry that accounts for more than 17% of the country’s GDP, it might be worth recognizing that there is much about healthcare that is not working well. For example, there is the sheer opacity of the system. In his first term, President Trump called for more transparency in healthcare. That seems worthwhile and we could start by honestly acknowledging the long-term challenges that have plagued how we deliver healthcare in the U.S. Although the U.S. spends more on healthcare than any other country in the world, it has been by many metrics the sickest high-income country for many decades. While this is, in large part, because of a lack of focus on preventing disease in this country, it also reflects the need to improve our healthcare system to secure a better return on our massive investment in it.

It is therefore reasonable to say that we do indeed need to improve how we deliver healthcare, and that, to date, successive administrations have failed to do so, at great fiscal and human cost, and this is far from a recent consequence of COVID-19 alone but reflects both acute and chronic failures. How, then, might we go about improving the healthcare industry?

Improving U.S. healthcare

There is a vast literature about how we might improve healthcare delivery in the U.S., and recent writing about how we might cut healthcare costs, a central priority for creating a better healthcare system. It is no secret that U.S. healthcare, while world-leading in its ability to train physicians, lead biomedical research and offer cutting-edge diagnoses and treatments, suffers from ballooning costs, fragmentation, and challenges with access and affordability for a large proportion of the population. Efforts to address such fundamental failings are complicated by vested interests in the form of private insurance companies, private healthcare, and pharmaceutical companies, which wield disproportionate influence over policy as compared to their influence in peer countries, and which continue to extract uniquely high profit margins from the U.S. In the 2023-2024 election cycle alone, it is estimated that the pharmaceutical/health products industry spent $384,507,360 on lobbying. An Axios report based on an analysis of company financial filings by Public Citizen noted that in 2021 Americans were paying more for 20 blockbuster drugs than the rest of the world combined.

Payments in the form of inpatient or outpatient care average around $7,500 per person in the U.S., as compared to just under $3,000 on average among peer countries. This cost places burdens on American citizens of a nature and scale so unique and challenging that they are almost hard to describe to those in peer countries. As Berwick and colleagues note in a recent commentary, around half of all families struggle to afford healthcare, a third have to choose between food and healthcare, and 25 million Americans remain uninsured. In the self-proclaimed land of opportunity, medical debt is the largest contributor to individual bankruptcy.

There is, in other words, a fundamental problem of power asymmetry, cost-effectiveness, and fitness for purpose, in the U.S. healthcare industry. Any administration seeking to improve efficiency should look to U.S. healthcare as an example of a uniquely expensive yet underperforming area, dominated by powerful vested interests, and underserving a large swath of the population.

For example, focusing narrowly on an area that has increased salience in the moment, it is worth looking at the intersection of drug and vaccine development and undue corporate influence on this process. While there is no question that public proposals to revoke polio or hepatitis vaccines demonstrated to be safe pose substantial threats to health, there have been long-articulated, legitimate, evidence-based arguments regarding corporate influence over pricing, availability, patent protections, and transparency of decision-making.

For example, as Kesselheim and Sharfstein propose, funding the FDA in such a way that it is no longer reliant on industry funding for 40% of its funding and 80% of its drug review budget would help dispel notions of influence (and bring such arrangements more in line with other countries’ approaches), particularly if combined with increasing the transparency of decision-making processes to match that of regulators in Europe.

Drug pricing, another uniquely prevalent U.S. policy problem, is driven to a large degree by government-protected market exclusivity and business and legal strategies to oppose effective improvements in affordability such as biosimilars or generic medications, compounded by a lack of bargaining power by payers. The U.S. experiences uniquely steep increases in the price of many medicines (not just novel or uniquely effective ones) with cost on average doubling over a seven-year period for branded medication from 2010-2016.

While individual policy proposals have sought to address different elements of this affordability matrix (and it appears some may be unwound by the new administration), upstream of these lies a fundamental and uniquely skewed power imbalance between commercial elements of the health system and the U.S. public, through which transparency is sorely lacking across the complex chain between U.S. drug manufacturers and patients’ drug pricing decisions and negotiations, which includes wholesalers, prescribers, retailers, insurers and pharmacy benefit managers. A key priority for any administration seeking to make American health better again would be to use its mandate to seek to fundamentally shift this power asymmetry in ways that better reflect drug approval, conflict of interest management, transparency, and pricing negotiations in high-income countries, which enjoy far lower costs, greater transparency, and lower inequalities in access in their dealings with the same set of products and companies.

Reframing health as a prerequisite for freedom and prosperity

We take, in this piece, the administration at face value when it claims it wants to make Americans healthier. That goal would be a very good thing indeed. Population health can be regarded as a cornerstone of a vibrant and robust economy, and high levels of preventable ill-health as a form of taxation from which no party benefits. Economic modelling indicates that when considering rising treatment costs, and the cost to economic productivity from preventable illness, the economic burden of NCDs in the U.S. in 2015-2050 alone will reach over 90 trillion USD, or 265,000 USD per capita, or an annual tax rate of around 10.8% on aggregate income. These costs are particularly high because of the high levels of preventable ill-health in younger Americans. In 2021, obesity rates in the U.S. were over 40% in 39 U.S. states, and over 45% in 14 among adults, including 41.8% of females and 33.9% of males under the age of 25.

However, beyond the potential direct and indirect economic costs, improving health at all ages helps increase freedom to choose how to live, to take risks in other aspects of life, to extend the window for one to enjoy the fruit of one’s labor as a result, and to see the next generation flourish. These are fundamental, nonpartisan aspirations for many Americans, and yet a willingness to take bold action, or even to have the open-eyed acknowledgement that health in the U.S. is uniquely failing compared to its peers and demands action on economic grounds alone, remains lacking.

We suggest therefore that it is possible to reframe U.S. health as a cornerstone of wider U.S. economic security, well-being, freedom and prosperity, aligning well with the goals of the new administration, indeed, of any administration, looking to make the country better. The goal of better health is too important to be either politicized in the current moment or ignored amidst the pace of proposed reforms in nonhealthcare arenas of government action. While there is much that remains unknown about the course the U.S. will take over the next four years, it is worth stressing that the path that got us here is not one that led to a healthy America. It is fair to say that America should be healthier again, and that transparency, a rebalancing of interests toward the American people, and a reframing of health as a cornerstone of future prosperity and freedom should form key parts of that goal.

__ __ __

Also this week

Thoughts with colleagues in JAMA on the importance of scientific freedom to the work of public health, and an affirmation of JAMA and JAMA Network’s commitment to the principles and practices that support this freedom.

On the value of academic health research, with Kirsten Bibbins-Domingo in JAMA Health Forum.

New in Observing Science, with Michael Stein, on the workings of science, its limitations, and its promise for a healthier world.