Too many Americans, in almost all groups, are dying |
Since it was first introduced by the economists Anne Case and Angus Deaton in 2015, the phrase “deaths of despair” has become a sort of spiritual skeleton key that promised to unlock the whole tragic story of a new American underclass. |
Beginning around the turn of the millennium, Case and Deaton showed, deaths from suicide, opioid overdose and alcohol-related liver disease among less educated, white, middle-aged people began to grow in a pattern that seemed to demonstrate how the country’s white working class was being — or at least feeling — left behind. Last month, the economists presented their updated data with a new paper showing a growing divergence in life expectancy between those with college degrees and those without. |
But over the past few years, the “deaths of despair” story has come to seem thinner to many of those reading the literature most closely. And in response to the new findings, pointed critiques were published by Dylan Matthews in Voxand by Matthew Yglesias in Slow Boring, arguing that the deaths of despair narrative had been overhyped, creating a just-so story about postindustrial decline that had seemed too good to scrutinize. |
Eight years on, the central claim from Case and Deaton holds up relatively well: Deaths by suicide, overdose and liver disease have been on the rise among the white working class and the middle class. But so have gun deaths across the country, deaths among the young and suicides, which puts the data on white middle-aged men and women in a different light. Among other questions about that data, it turns out that deaths of despair increased pretty uniformly across all demographic groups and that the rise in such deaths among white middle-aged people was, while real and concerning, not all that exceptional. |
What does that imply, though? In their critiques, both Yglesias and Matthews argue that the data tells a narrower story than Case and Deaton do — and that rather than invoking national malaise we should focus on the role of opioids among the country’s worst off in the first case, or high school dropouts and heart disease in the second. |
But it seems to me that the opposite is true: The American mortality crisis is much larger than deaths of despair, in fact too broad and diffuse to be stuffed into one demographic box or characterized as a failure of one policy area. You can see it almost anywhere you care to look and any way you slice the data. |
Unless they’re in the top 1 percent, Americans are dying at higher rates than their British counterparts, and if you’re part of the bottom half of income earners, simply being American can cut as much as five years off your life expectancy. At every age below 80, Americans are dying more often than people in their peer nations: Infant mortality is up to three times as high as it is in comparison countries; one in 25 kindergartners can’t expect to see 40, a rate nearly four times as high as in other countries; and Americans between 15 and 24 are twice as likely to die as those in France, Germany, Japan and other wealthy nations. For every ethnic group but Asian Americans, prepandemic mortality rates in the United States were higher than those of economic peer countries: In 2019, Black Americans were 3.8 times as likely to die as the residents of other wealthy countries, white Americans were 2.5 times as likely to die, and Hispanic Americans 1.8 times as likely to die. Americans with college degrees do substantially better than those without, but that second group represents almost two-thirds of the country. And while mortality rates show a clear geographic divergence, with life expectancy gaps as large as 20 years between the country’s richest and poorest places, just a fraction of American counties even reach the European Union average. |
When looking at American trend lines alone, anomalies like overdose spikes or mortality increases among high-school dropouts can jump out, and the divergence between, say, those with bachelor’s degrees and those without is quite striking. But in comparing the overall health of Americans to those in other wealthy countries, almost everyone looks to be suffering, and even those remarkable anomalies turn out to be quite small, contributing only somewhat trivially to the widening gap between how many Americans are dying each year and how many of our peers elsewhere are. |
Overdose deaths involving synthetic opioids, for instance, have grown from less than 10,000 in 2015 to 70,000 in 2021. Add heroin and other overdoses and the total grows to more than 100,000 — a public health horror story, and a much graver problem than in any of our peer countries. But that barely explains a fraction of the exceptional American mortality pattern identified by the researchers Jacob Bor and Andrew Stokes, who found that a million more Americans died each year than would have if the country’s overall mortality rates matched those of peer countries in Europe. |
Those million extra deaths exceed even the nearly 700,000 who die each year from cardiovascular disease, the country’s biggest killer. But of course many residents of other rich countries die from it, too. And though, as Matthews emphasizes, American progress against heart disease has stalled in recent years, the gap between our cardiovascular mortality and those of our peers turns out to be relatively small, accounting for just another fraction of Bor and Stokes’s “missing Americans.” Which tells you something about how large that number of extra deaths really is: If American mortality rates simply matched those of peers overall, the country’s total number of deaths would have fallen 22 percent on the eve of the pandemic in 2019. In 2021, the researchers found, extra mortality accounted for nearly one in every three American deaths. |
“The United States is failing at a fundamental mission — keeping people alive,” The Washington Post recently concluded, in a remarkable series on the country’s mortality crisis. “This erosion in life spans is deeper and broader than widely recognized, afflicting a far-reaching swath of the United States.” In a quarter of American counties, The Post found, death rates among working-age adults are not just failing to improve but are also higher than they were 40 years ago. “The trail of death is so prevalent that a person could go from Virginia to Louisiana, and then up to Kansas, by traveling entirely within counties where death rates are higher than they were when Jimmy Carter was president.” If death rates just among the country’s 55-to-69-year-olds improved to match the rates of peer countries, The Post calculated, 200,000 fewer of them would have died in 2019. That is more than the number of them who died of Covid in 2020. |
There are a few things that Americans do as well or better than other countries (cancer treatment, where outcomes have been steadily improving now for decades, and keeping old people alive), so chances that a 75-year-old makes it to 90 or 100 are about the same as in other wealthy countries — though that stat is somewhat distorted by the fact that many fewer Americans make it to 60 in the first place, with those who do likelier in better health. |
But by almost every other measure the United States is lagging its peers, often catastrophically. The rate of homicides involving a firearm are 22 times higherin the United States as in the European Union, for instance, a worsening trend that has given rise to research suggesting that the country’s mortality crisis is primarily about gun violence. Another set of researchers emphasize exceptional mortality rates among the young, with rates of death among American children growing more than 15 percent between just 2019 and 2021, with little of that increase attributable to Covid. Americans also die much more often in car crashes, workplace accidents and fires. Our maternal mortality rate is more than three times as high as that of other wealthy countries, and our newborns have the highest infant mortality rate in the rich world. We are almost twice as likely to suffer from obesity as are our counterparts in countries of the Organization for Economic Cooperation and Development, and the downstream consequences — from hypertension to heart disease and stroke — mean that obesity could explain more than 40 percent of the U.S. life expectancy shortfall for women, and over 60 percent for men. The life expectancy among America’s poorest men may be 20 years shorter than that of their counterparts in the Netherlands and Sweden. Overall, among 18 high-income countries, America’s life expectancy ranks dead last. |
It’s not quite right to call all this simply “despair,” even if social anomie plays a role. Doing so places too much weight on the suffering of individuals and not enough on what epidemiologists call the social and environmental determinants of health: community support, education and, perhaps most important, health care access. (Since 2015, Case and Deaton have acknowledged these factors; their 2020 book on the subject emphasizes health care inequalities, and Deaton’s new book “Economics in America” focuses squarely on inequality.) |
But the bigger problem seems to me to be that talking narrowly about despair localizes the American mortality dysfunction in a small demographic, when almost the entire country is dying at alarming rates. The burden does not fall equally, and the disparities matter. But looking globally, our mortality crisis appears, effectively, national. |
https://www.nytimes.com/2023/10/18/opinion/beyond-deaths-of-despair.html?searchResultPosition=1
Editor's Note -
The following article from the Washington Post about the effects of an unequal and challenging society on individual health (including life expectancy and maternal and fetal morbidity and mortality) is explained in their excellent book "The Inner Level" by British epidemiologists Richard Wilkinson and Kate Pickett. It is a sequel to their book "The Spirit Level", that explores the effects of inequality on populations.
- SPC
How stress weathers out bodies, causing illness and premature aging
Physicians and public health experts have pointed to one culprit time and again when asked why Americans live shorter lives than peers in nations with similar resources, especially people felled by chronic diseases in the prime of life: stress.
A cardiologist, endocrinologist, obesity specialist, health economist and social epidemiologists all said versions of the same thing: Striving to get ahead in an unequal society contributes to people in the United States aging quicker, becoming sicker and dying younger.
Recent polls show adults are stressed by factors beyond their control, including inflation, violence, politics and race relations. A spring Washington Post-Ipsos poll found 50 percent of Americans said not having enough income was a source of financial stress; 55 percent said not having enough savings was also a source of stress.
“We should take a step back and look at the society we’re living in and how that is actually determining our stress levels, our fatigue levels, our despair levels,” said Elizabeth H. Bradley, president of Vassar College and co-author of the book “The American Health Care Paradox.” “That’s for everybody. Health is influenced very much by these factors, so that’s why we were talking about a reconceptualization of health.”
The Washington Post’s efforts to gain a deeper understanding of how stress can cause illness, disability and shorter lives led to a once derided body of research that has become part of the mainstream discussion about improving America’s health: the Weathering Hypothesis.
Stress is a physiological reaction that is part of the body’s innate programming to protect against external threats.
When danger appears, an alarm goes off in the brain, activating the body’s sympathetic nervous system — the fight-or-flight system. The hypothalamic-pituitary-adrenal axis is activated. Hormones, such as epinephrine and cortisol, flood the bloodstream from the adrenal glands.
The heart beats faster. Breathing quickens. Blood vessels dilate. More oxygen reaches large muscles. Blood pressure and glucose levels rise. The immune system’s inflammatory response activates, promoting quick healing.
Once the threat passes, hormone levels return to normal, blood glucose recedes, and heart rate and blood pressure return to baseline. That’s how the human body should work.
Life brings an accumulation of unremitting stress, especially for those subjected to inequity — and not just from immediate and chronic threats. Even the anticipation of those menaces causes persistent damage.
The body produces too much cortisol and other stress hormones, straining to bring itself back to normal. Eventually, the body’s machinery malfunctions.
Like tree rings, the body remembers.
The constant strain — the chronic sources of stress — resets what is “normal,” and the body begins to change.
It is the repeated triggering of this process year after year — the persistence of striving to overcome barriers — that leads to poor health.
Blood pressure remains high. Inflammation turns chronic. In the arteries, plaque forms, causing the linings of blood vessels to thicken and stiffen. That forces the heart to work harder. It doesn’t stop there. Other organs begin to fail.
Struggling and striving
It’s part of the weathering process, a theory first suggested by Arline T. Geronimus, a professor and population health equity researcher at the University of Michigan.
Geronimus, whose book “Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society” published in March, started out studying the health of women and babies as a graduate student in the 1980s, having been influenced by two distinctly different jobs she had as an undergraduate: one as an on-campus research assistant, the other as a peer companion at an off-campus school for teen mothers.
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At the time, she said, conventional wisdom held that the Black community had higher rates of infant mortality because teen mothers were physically and psychosocially too immature to have healthy babies. But her research showed younger Black women had better pregnancy and birth outcomes than Black mothers in their mid- to late 20s and 30s.
For this, she was criticized as someone arguing in favor of teen pregnancy, even though she was not. Shaken but undeterred, she continued trying to understand the phenomenon, which meant better understanding the overall health of the community these teens depended on for help. As she studied those networks, she recognized “people’s life expectancies were shorter, and they were getting all these chronic diseases at young ages,” she said.
But she hadn’t come up with a name yet for what she was witnessing. That happened in the early 1990s while sitting in her office: “‘Weathering’ struck me as the perfect word.”
She said she was trying to capture two things. First, that people’s varied life experiences affect their health by wearing down their bodies. And second, she said: “People are not just passive victims of these horrible exposures. They withstand them. They struggle against them. These are people who weather storms.”
People seem to instinctively understand the first, but she said they often overlook the second. It isn’t just living in an unequal society that makes people sick. It’s the day-in, day-out effort of trying to be equal that wears bodies down.
Weathering, she said, helps explain the double-edged sword of “high-effort coping.”
Over the years, Geronimus widened the aperture of her research to include immigrants, Latinos, the LGBTQIA community, poor White people from Appalachia. She found that while weathering is a universal human physiological process, it happens more often in marginalized populations.
Regulation of cortisol — what we think of as the body’s main stress hormone — is disrupted. Optimally, it should work like a wave with a steep morning rise followed by a rapid decline, which slows until reaching baseline at bedtime.
But existing research suggests that is blunted by repeated exposure to psychosocial and environmental stressors, such as perceived racial discrimination, which flatten this rhythm.
Stress-induced high cortisol levels stimulate appetite by triggering the release of ghrelin, a peptide that stimulates hunger.
The interplay between elevated cortisol and glucose is especially complex and insidious, eventually leading to obesity, fatigue, cardiovascular disease, poor immune and inflammatory functions, higher breast cancer mortality rates and other metabolic disorders. Dysregulated cortisol also increases depression and anxiety and interferes with sleep.
Weathering doesn’t start in middle age.
It begins in the womb. Cortisol released into a pregnant person’s bloodstream crosses the placenta, which helps explain why a disproportionate number of babies born to parents who live in impoverished communities or who experience the constant scorn of discrimination are preterm and too small.
During the coronavirus pandemic, pregnant women experiencing stress endured changes in the structure and texture of their placentas, according to a study published this year in Scientific Reports.
The toxic stream can persist into childhood fueled by exposure to abuse, neglect, poverty, hunger. Too much exposure to cortisol can reset the neurological system’s fight-or-flight response, essentially causing the brain’s stress switch to go haywire.
Too much stress in children and adolescents can trigger academic, behavioral and health problems, including depression and obesity.
Stress can change the body at a cellular level.
The effects of relentless stress can be seen at the chromosomal level, in telomeres, which are repeated sequences of DNA found in just about every cell.
Telomeres are the active tips of chromosomes, and they protect the cell’s genetic stability by “capping” the ends of the chromosomes to prevent degeneration. (Think of the plastic tips of shoelaces.)
Researchers have discovered that in people with chronically high levels of cortisol, telomeres become shortened at a faster rate, a sign of premature aging.
The shorter the telomeres, the older the cell’s biological age.
Shortened telomeres cause a disconnect between biological and chronological age.
‘A societal project’
“I don’t think most people understand weathering stress. Stress is such a vague term,” Geronimus said. “But it still gives us a leverage point to get in there and see a more complex and more frightening picture of what it does to people’s bodies and whose bodies it does it to.”
Changes in seven biomarkers in cardiac patients during a 30-year period showed Black patients weathering about six years faster than White people, a 2019 study published in SSM-Population Health found.
Research also found that Black people experience hypertension, diabetes and strokes 10 years earlier than White people, according to a study published in the Journal of Urban Health.
The impact of repeatedly activating the body’s stress response is called allostatic load.
Research has shown that Mexican immigrants living in the United States for more than 10 years have elevated allostatic load scores compared with those who have lived here for less than a decade, and a study of Ohio breast cancer patients published in May in JAMA Network Open found that women with higher allostatic loads — who tended to be older, Black, single and publicly insured — were more likely to experience postoperative complications than those with lower allostatic loads.
“The argument weathering is trying to make is these are things we can change, but we have to understand them in their complexity,” Geronimus said. “This has to be a societal project, not the new app on your phone that will remind you to take deep breaths when you’re feeling stress.”
So, in short, social inequality causes stress, leading to shortened telomeres and, in turn, premature aging, disease and early death.
About this story
Reporting by Akilah Johnson. Illustration by Charlotte Gomez.
Design and development by Stephanie Hays, Agnes Lee and Carson TerBush. Design editing by Christian Font.
Editing by Kainaz Amaria, Stephen Smith and Wendy Galietta. Additional editing by Martha Murdock, Frances Moody and Phil Lueck.
Additional support by Matt Clough, Kyley Schultz, Brandon Carter and Jordan Melendrez.
Originally published in
Castine Patriot, October 5, 2023
Penobscot voters to consider universal health care referendum on Election Day
In addition to the eight state ballot questions this November,
residents of Penobscot will have their own referendum to consider:
“Shall the citizens of Penobscot call on the Maine Legislature to create
a publicly funded healthcare plan that provides every Maine resident
with comprehensive medical care?”
David Jolly, a Penobscot resident and board member for Maine
AllCare, asked the town’s select board to put the referendum on the
November ballot, and the three select board members agreed to do so.
Maine AllCare is a statewide nonprofit that advocates for universal
health care in Maine and across the U.S.
“The Penobscot select board understands that there are many in our
community who are concerned about the future of our health care
system,” said select board member Sara Leighton in a press release. “We
feel it’s important for our citizens to make their voices heard. We are
very proud that Penobscot is the first town in Maine to have this type
of ballot initiative on universal health care, and it is our hope that
voters come out in droves to weigh in on this important issue.”
Maine AllCare volunteers have presented similar measures to town
select boards and city councils and 12 have passed, including one in
Penobscot in 2020. The current effort in Penobscot is the first time the
question is being put directly to voters on the November ballot.
(Voters in Trenton and Woolwich passed similar resolutions at their
annual town meetings in 2021.)
If the Penobscot referendum succeeds, Maine AllCare intends to
launch similar initiatives in towns and cities across the state, with
the goal of demonstrating that there is widespread support for a
publicly funded universal health care system in Maine.
Maine AllCare held an informational session on the referendum
October 4 at Penobscot Community School to provide information about the
referendum and the state of health care in Maine and to talk with
attendees about their views, experiences and concerns.
The Penobscot select board will conduct a public hearing about the
referendum on Tuesday, October 17, from 6 to 7 p.m. at the school,
giving residents another opportunity to discuss issues related to the
referendum.
“Comprehensive health care reform is unlikely at the federal level
any time soon,” David Jolly said in the release. “But change is
possible at the state level and Maine AllCare wants to put pressure on
our legislators to make that happen. That’s why we’re asking the people
of Penobscot to vote yes on this referendum.”
Ozempic Can’t Fix What Our Culture Has Broken
by Tressie McMillan Cottom - NYT - October 9, 2023
We have become fluent in the new language of pharmacology, diabetes, and weight loss. Ozempic, Wegovy and Mounjaro are part of our public lexicon. Glucagon-like peptide-1 (GLP-1) receptor agonists are lifesaving drugs, created to help the hundreds of millions of people with Type 2 diabetes and clinical obesity. They promise to rid the United States of obesity, if our country can figure out how to make the pricey fix affordable.
But these wonder drugs are also a shorthand for our coded language of shame, stigma, status and bias around fatness. Untangling those two functions is a social problem that one miracle drug cannot fix.
It is hard to recall the last time a drug so excited the general public. Fen-phen in the 1990s, maybe? Viagra or Botox in the 2000s? Each had amazing hype cycles but none as explosive as Ozempic. Market watchers have flagged Novo Nordisk, the Danish pharmaceutical giant that makes Ozempic and Wegovy, as a contender for most valuable company in Europe. With better drugs still in various stages of development, the anti-obesity gold rush has just begun.
If GLP-1 drugs only treated diabetes and did not promote weight loss, they would still be medically groundbreaking. But Ozempic, Wegovy and Mounjaro probably would not have social media hashtags. These drugs are blockbusters because they promise to solve a medical problem that is also a cultural problem — how to cure the moral crisis of fat bodies that refuse to get and stay thin.
That many people don’t even question that eliminating fat people is an objectively good idea is why it is such a powerful idea. Thinness is a way to perform moral discipline, even if one pursues it through morally ambiguous means. Subconsciously, consciously, politically, economically and culturally, obesity signals moral laxity.
Any decent cleric will tell you that there is no price too high for salvation, so an entire class of people — the roughly three in four adult Americans who are overweight — is a target for profit-seeking. Medical weight loss interventions have, over the years, led to heart damage, strokes, nerve damage, psychosis and death. But under this moral code, it’s the social policies that promote, subsidize and profit from obesity that are cleansed of their extractive sins. It’s as if fat bodies, by housing slovenly people, do not deserve the protections of good regulations and healthy communities.
There’s something seductive about a weekly shot that fixes the body, while skipping right past the messiness of improving the way people have to live. Both diabetes and obesity are conditions that are as much about social policy as they are about what people eat. Studies show that the crops the U.S. government subsidizes are linked to the high-sugar, high-calorie diets that put Americans at risk for abdominal fat, weight gain and high cholesterol. Sprawling communities, car-centered lives and desk jobs make it hard for many Americans to move as much as medical guidance thinks that we should. Under these conditions, telling people to change their lifestyle to lose weight or prevent diabetes is cruel.
It should be no surprise that near-guaranteed weight loss — big, rapid weight loss in many cases — drives millions of people to take the drugs off label, creating consumer demand like the gold nugget that lured miners out West.
The cultural conversation around Ozempic is as obsessed with celebrities as the celebrities are obsessed with themselves. Rumors of which A-list star was on Ozempic peaked with the pejorative “Ozempic face,” a sign that someone was taking a shortcut right to skinny’s spoils. Social media users became adept at finding clues that a celebrity cheated, purchasing obesity absolution through pharma indulgence.
At the top of the status hierarchy, the rich, famous and near famous were getting skinnier. But in the same span of years Ozempic took hold of those buzzy sets, I began noticing that regular people like my friends were being reclassified as insulin-sensitive, insulin-resistant, and the utterly terrifying “prediabetic.”
Most of them are highly educated, self-made successes, with no family wealth or other cultural endowments. They handle their health with the same ferocity they brought to college admissions and career planning. One friend began blowing into a device that told her if she had reached a “fasting” state; another was prescribed metformin, a diabetes medication. So many of them seemed to be on a crash course with a medical liminal state that associated them with diabetes even though none of them were diabetic.
Although it was unknown to me at the time, my friends were swimming with a public health tide that would mark them for medicalization, even though nothing about their physiology, behavior or medical profile had changed. They may have needed drugs, they may not have, but “prediabetes” is not a precise enough predictor of whether anyone will become diabetic to warrant the fear the term provokes.
The American Diabetes Association developed the term “prediabetes” to bring attention to slightly elevated blood sugar levels in some Americans in 2001. Over the next two decades, the organization expanded the definition of the condition, so that by 2019, as Charles Piller reported for Science magazine, 84 million Americans had prediabetes, “the most common chronic disease after obesity.”
There were no drugs specifically designed for prediabetes, so doctors often relied on off-label treatments, a common medical practice. But because off-label drug interventions coincided with the wholesale expanded classification of millions of people with a novel condition, a new market boomed.
This shift broadened the consumer language for medicalizing weight loss as a preventive strategy to treat not only diabetes, but also supposed — though not always proven — diabetes risk. It armed a wellness machine with the medical terminology of “insulin resistance” and “insulin sensitivity,” without the medical expertise to screen for diabetes risk indicators. People could soon buy an astonishing array of apps and devices to self-diagnose insulin efficiency. Enter Ozempic and Wegovy, perfectly designed for our highly developed consumer palates.
Given all these changes, I wondered what Dr. Richard Kahn, the former chief scientific and medical officer at the American Diabetes Association, who helped establish “prediabetes” as a term, now thought about the phenomenon.
When we talked, Dr. Kahn told me that he regrets his role in developing “prediabetes” and its associated grift, but his giddiness about GLP-1 drugs was palpable. He said that encouraging weight loss through lifestyle changes was an “abject failure.” Now, Ozempic offers patients light and hope.
The problem with these drugs, he said, “is that they cost an enormous amount of money.”
Ozempic and all similar formulations are administered by injection, via a pen that lasts about 30 days and costs from about $900 to $1,300. A year of pens can run between $10,000 and $16,000; the median household income in the United States is around $75,000. How in the world can regular people afford it?
It’s easy to assume that the non-wealthy use health insurance to pay for these drugs. And yes, if they’re using Ozempic for diabetes, the health insurance claim is straightforward. But for weight loss, getting health insurance to pay for Wegovy (or even Ozempic) can be more difficult. As Dr. Kahn says, “The vast majority of insurance companies refuse to pay for it no matter what the degree of obesity is. ”
Dr. Kahn grasps the big picture of health economics and the insurance cliff we’re standing on. But in the doctor’s office, the cliff is more of a canyon. In 2021, I went to a fancy doctor for my annual checkup. I justify the steep subscription fee for my concierge medical care because I have moderate medical anxiety from years of being talked down to, ignored, dismissed, and victimized by medical malpractice. I consider the concierge fee a convenience tax to be treated like a person.
After two hours of getting to know my new OB-GYN, bloodletting, and internal spelunking, we sat down to talk about my lifestyle and health goals. As an overweight person with high verbal acuity, I was sure to describe my Peloton practice as well as my plan to eat more plants for ethical reasons. The doctor’s face lit up when I finally intimated an interest in, shall we say, size modification.
Glancing at my blood test results she began describing her professional interest in “metabolic medicine.” What followed was a 20-minute presentation on the advancements in weight loss drugs. Ozempic was the star, but there were other drugs, many of them prescribed off label. The seizure medication might curb snacking. Another might slow digestion if it did not ruin your kidneys. And then, of course, there were the “injectables,” the “gold standard” of weight loss medical interventions.
The only problem was that I was not diabetic.
I was not even medically prediabetic.
The doctor said this with great regret.
My A1C, the measurement of average blood sugar levels over the past months, was within the normal range. It was, in fact, bordering on low.
“But these tests malfunction. We can test it again,” she said hopefully.
My doctor was hoping for a higher A1C because it would classify me as prediabetic, as it would increase the odds of getting health insurance to pay for the off-label use of the pricey drugs she recommended to me that day.
I vacillated between wanting to show my doctor that I could afford to pay for Ozempic out of pocket, not even wanting Ozempic and wanting to prove to her that my A1C was no fluke. I took the A1C test again a week later. It was still low. She was still dismayed.
I switched doctors when I realized one of us was rooting for me to be sicker so I could afford to be skinnier. In her defense, that is exactly the equation that GLP-1 drugs present to the millions of Americans who need health insurance to afford them.
Of course, that says nothing of the 27 million Americans who do not have health insurance at all. People without insurance are typically low-income and are overexposed to the social policies that produced the obesity crisis. For them, the best-in-class drugs may as well not exist.
But, just for the sake of argument, if obesity is a public health crisis and it can be solved with one imperfect injectable, it should be possible to make it so that everyone can afford the solution. Right?
But so far we have done the opposite. To prescribe millions of Americans Ozempic at its current price would stress the health care system to its breaking point. Dr. Kahn did some rough math when we spoke. “If 80 percent of the people with obesity would start to take this drug,” he argued, “it would bankrupt the health care system.” He bases that on the Centers for Disease Control and Prevention’s finding that more than 40 percent of Americans are obese. “We’re hurtling quite rapidly to this game of chicken,” Dr. Kahn said, “where you have the manufacturers saying they’re not going to reduce the price. And you have the insurance companies saying it’s too much to pay.”
Making GLP-1 drugs accessible for Type 2 diabetes and weight loss at a cost that regular Americans could afford would be an achievement for our health care system. The Biden administration is rolling out its Medicare Drug Price Negotiation program. For now, none of these drugs are included. The Treat and Reduce Obesity Act would expand Medicare coverage for obesity. These are the kind of policy approaches that could be a game changer for obesity management and diabetes care, while this country continues to work on the bigger problem: our poverty of imagination for the ethical care of all bodies.
For now, cash-strapped American consumers are left to contend with a society in which the price of being fat is so high that there will always be a rational reason to pay an exorbitant amount to be thin.
There is weight loss for health. There is also weight loss for status and avoiding stigma. While both men and women experience greater discrimination if they are fat, women suffer more for failing to be thin enough. Study after study shows that overweight women are more likely to be unemployed than their thinner counterparts. When they are employed, larger women earn less, with smaller penalties for Black and Hispanic women, who already earn less, on average. Overweight white and Asian women experience the labor market discrimination that Black and Hispanic women already do.
Outside of the workplace, the trend of educational and economic elites marrying, befriending and socializing with one another — assortative matching and mating — is also a marked characteristic of our time. Elite homogeneity has a look and the look is thin. So when women say that it is better to be sick and thin than healthy and fat, they are perfectly rational.
Kate Manne, a philosopher, says that the fear of being fat — fatphobia — is structural and intersectional. In her forthcoming book, “Unshrinking,” she questions whether solving obesity is something that can truly be done by eradicating fat people. Ozempic mania is not just a perfect example of how self-defeating our health economics are in this country, as Dr. Kahn points out. It is also an example of how the American penchant for solving structural issues by fixing individual bodies is excellent at creating demand without solving social problems.
I was overweight before I entered the concierge medical office. But being overweight was incongruent with a person who could afford concierge medicine. My doctor assumed I would want to be thin. In many ways, she was providing exactly the service I didn’t realize I was paying for — acculturating me to the expectations of the right body for my station. Minimizing weight stigma was a health service, even if my health indicators did not require intervention.
The mere existence of Ozempic and the like encourages millions of people to self-diagnose in a way that stigmatizes. If they walk into doctors’ offices begging to be classified as medically vulnerable, it’s not for some provision from the state like housing or food. They want a drug that can help them manage an environment that works against their aspirations. That is a condemnation of our culture.
Ozempic’s implicit promise is that it can fix what our culture has broken. There aren’t breathless profiles of a pharmaceutical drug because it will help a diabetic manage her blood glucose level. They exist because it promises to democratize access to the holy grail of embodied privilege, that sexy sexism of “nothing tastes as good as skinny feels.”
Whether fatness is a problem for the millions of people whom these drugs are poised to leave behind depends on perspective. It’s perfectly normal to live a happy, full life in a body that is above the medically recommended healthy size. Plenty of people do it and have done it. But being overweight becomes a social problem when it’s a population level statistic with a status hierarchy attached.
When supply chain disruptions made it harder for diabetic patients to get Ozempic last year, wealthy people bought the drug at a premium for weight loss while people who needed it struggled to fill their prescriptions. Then, the grim picture of inequality was clear.
But as the supply rebounds, the inequality may get harder to see. That would be unfortunate.
Inequality of access to Ozempic and Wegovy is not between the deserving sick and undeserving obese. The inequality is in attaching any moral clause to why people use the drugs in the first place. As long as most Americans cannot afford the drug that democratizes weight, the stigma of obesity is still controlled by those who can afford to be thin. GLP-1 drugs — or any miracle drug that cures obesity on label or off — works only if people who need the drug can afford it.
But solving for obesity will require more than drugs. It will require solving for a culture that makes being fat a woman’s burden, a means test for dignity, work, social status, and moral citizenry.
Until we end that stigma, we can create drugs that help people lose weight, but the conditions for making some people undesirable — at a cost — will still be lurking in the shadows.
https://www.nytimes.com/2023/10/09/opinion/ozempic-obesity-fat-diabetes.html
How UnitedHealth became Goliath, Medusa and mythical sirens all wrapped into one
by Wendell Potter - Health Care Uncovered - October 10, 2023
America’s biggest health insurer and I have something in common. Next year, we’ll both be celebrating 40 years in health care. One of us is worth a lot more money.
In 1984, I was a partner in a small PR firm in Atlanta called McKenzie, Gordon and Potter. One of our clients was a small hospital in South Georgia, and I pitched in on the account from time to time. I would go on to lead PR and advertising for the Baptist Health System of East Tennessee — which a few years later would vanish without a trace after being sucked into a much bigger system — and then enter the world of for-profit health care at Humana and Cigna.
Also in 1984, the year George Orwell warned us about, UnitedHealth became a public company. It would go on to become the 10th largest corporation on the Fortune Global 500. As I write this its market capitalization is nearly half a trillion dollars.
A few weeks ago, Krista Brown and Sara Sirota wrote a must-read piece for The American Prospect about UnitedHealth’s ascendancy. It seriously is a must-read if you want to understand how we got to where we are in this country. For me, it was like a trip down memory lane because I was a bit player in many of the events they touched on that helped shape U.S. health care.
Here’s a three-paragraph teaser:
Today, United is the fifth-largest public company in the U.S., bigger than JPMorgan Chase. Its insurance products serve 50 million members, more than the population of Spain, and its $186 billion health services division, Optum, has 103 million patients, more than Vietnam’s population. Earnings came to $28.4 billion last year, putting it in the top 30 of companies worldwide.
We think of United as an insurance company, but it has never really been exactly that. It began as a health management company, and it is now also the largest employer of physicians in the country, with 70,000 doctors across 2,200 locations. Underneath its corporate umbrella are pharmacies, primary care clinics, surgical centers, urgent care centers, home health agencies, hospice agencies, mental health agencies, a pharmacy benefit manager, an IT division, and plenty more. United has so many subsidiaries that 25% of its total revenues come from itself.
United even has a bank. Optum Bank is a way for consumers to manage health savings accounts, but the company’s latest financial service is a payday loan system called Optum Pay Advance for independent physician practices. While they wait for reimbursement from United for their claims but have to make payroll, doctors can get money from United to tide them over … with 35% interest. The other option is to succumb to the pressure and sell out to United, giving it an even greater margin.
Brown and Sirota’s piece is an epic read, but there is much more to learn about UnitedHealth and the handful of other “insurers” that have grown to become what you might get if Goliath had hooked up with Medusa or the sirens that tried to lure Odysseus to his doom. It’s hard to escape their reach and seduction, but we must try.
In the coming weeks, with Brown and Sirota’s help, we’ll be doing deep dives into those companies to give you a better understanding of how they scoop up so much of our pay and taxes and decide whether we’ll get the care and meds many of us must have to see another sunrise.
Doctors Unionize at Big Health Care System
The physicians, at Allina Health in Minnesota and Wisconsin, appear to be the largest group of unionized doctors in the private sector.
bu Naom Scheiber - NYT - October 13, 2023
In the latest sign of growing frustration among professionals, doctors employed by a large nonprofit health care system in Minnesota and Wisconsin have voted to unionize.
The doctors, roughly 400 primary and urgent-care providers across more than 50 clinics operated by the Allina Health System, appear to be the largest group of unionized private-sector physicians in the United States. More than 150 nurse practitioners and physician assistants at the clinics were also eligible to vote and will be members of the union, which will be represented by a local of the Service Employees International Union.
The result was 325 to 200, with 24 other ballots challenged, according to a tally sheet from the National Labor Relations Board, which conducted the vote.
In a statement, Allina said, “While we are disappointed in the decision by some of our providers to be represented by a union, we remain committed to our ongoing work to create a culture where all employees feel supported and valued.”
The doctors complained that chronic understaffing was leading to burnout and compromising patient safety.
“In between patients, your doctor is dealing with prescription refills, phone calls and messages from patients, lab results,” said Dr. Cora Walsh, a family physician involved in the organizing campaign.
“At an adequately staffed clinic, you have enough support to help take some of that workload,” Dr. Walsh added. “When staff levels fall, that work doesn’t go away.”
Dr. Walsh estimated that she and her colleagues often spend an hour or two each night handling “inbox load” and worried that the shortages were increasing backlogs and the risk of mistakes.
The union vote follows recent walkouts by pharmacists in the Kansas City area and elsewhere over similar concerns.
A variety of professionals, including architects and tech workers, have sought to form unions in recent years, while others, like nurses and teachers, have waged strikes and aggressive contract bargaining campaigns.
Some argue that employers have exploited their sense of mission to pay them less than their skills warrant, or to work them around the clock. Others contend that new business models or budget pressures are compromising their independence and interfering with their professional judgment.
Increasingly, doctors appear to be expressing both concerns.
“We feel like we’re not able to advocate for our patients,” said Dr. Matt Hoffman, another doctor involved in the organizing at Allina. Dr. Hoffman, referring to managers, added that “we’re not able to tell them what we need day to day.”
Consolidation in the health care industry over the past two decades appears to underlie much of the frustration among doctors, many of whom now work for large health care systems.
“When a physician ran his or her own practice, they made the decisions about the people and technology they surrounded themselves with,” Dr. Robert Wachter, chair of the department of medicine at the University of California, San Francisco, said in an email. “Now, these decisions are made by administrators.”
Doctors at Allina say that staffing was a concern before the pandemic, that Covid-19 pushed them to the brink and that staffing has never fully recovered to its prepandemic levels.
Relatively low pay for clinical assistants and lab personnel appears to have contributed to the staffing issues, as these workers left for other fields in a tight job market. In some cases, doctors and other clinicians within the Allina system have quit or scaled back their hours, citing so-called moral injury — a sense that they couldn’t perform their jobs in accordance with their values.
“We were promised that when we get through the acute phase of the pandemic, staffing would get better,” Dr. Walsh said. “But staffing never improved.”
Allina, which takes in billions in revenue but has faced financial pressures and recently eliminated hundreds of positions, did not respond to questions about the doctors’ concerns.
Joe Crane, the national organizing director for the Doctors Council of the S.E.I.U., which represents attending physicians, said that before the pandemic, he would receive about 50 inquiries a year from doctors interested in learning more about forming a union. He said he received more than 150 inquiries during the first month of the pandemic. (Mr. Crane was with another physicians’ union at the time.)
Mr. Crane, citing the siloed nature of the medical profession, said that unionization among attending physicians had nonetheless proceeded slowly, but that the victory at Allina could create momentum.
In March, more than 100 doctors voted to unionize at another Allina facility, a hospital with two locations. Dr. Alia Sharif, a physician involved in that union campaign, said doctors were under pressure there not to exceed length-of-stay guidelines for patients, even though many suffer from complex conditions that require more sustained care.
Allina is appealing the outcome of that vote to the National Labor Relations Board in Washington; a board official rejected an earlier appeal.
Even as rates of unionization have languished among attending physicians, they have increased substantially among medical residents. A sister union within the S.E.I.U., the Committee of Interns and Residents, has added thousands of members over the past few years.
Dr. Wachter said this could herald an increase in unionization among doctors outside training programs. “When these physicians finish training and enter practice, they are more comfortable with a world in which unionization doesn’t automatically conflict with their notions of being a professional,” he wrote.
https://www.nytimes.com/2023/10/13/business/economy/doctors-union.html
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