The US is a "Fee for Service" model, the more sickness, the more fees, the more profits for the medical system. In a "Value Based Model" you would get paid to keep people healthy.
maybe one of the reasons, but imo, not even close to the biggest reason - look at the diet and weight and sedentary lifestyle of the average american - that is likey a HUGE reason that people are not healthier - not because they didn't get go to a doctor enough.
and doctors don't even try to solve that problem anymore - they just push pills to counter the bad diet and bad lifestyle.
Built environment causing sedentary (and socially atomizing) life and cost of care seem like the two biggest issues. I think we should just start solving both instead of debating which is 1 and which is 2.
According to the research it’s mostly diet (what we eat) and the sedentary lifestyle. Less than 10% of people eat healthy. Most people I know daily eat food’s causing them harm (not neutral)
The US isn’t the only place people eat like shit, though.
The french and Aussies and English and Germans and Italians all have some unhealthy food habits, or excessive butter/cheese, or elevated alcohol consumption levels, etc.
You can point to activity levels, but weight is about food consumption, not activity levels, and (eg) Aussies are a pretty car-reliant culture too. Pretty much any way you can argue that the US is "unique" - it's not, we are a culture exporter and some other place has inevitably picked up some of our habits.
Americans aren't even uniquely fat anymore. There are other populations (like aussies) that are getting close to our obesity levels and they still don't 5x their healthcare spending. And the idea that obesity makes up even a simple majority of total healthcare costs (as it would need to be for this to be the factor that 2-5x's healthcare spending) is generally ridiculous.
(also, paradoxically, a lot of things that we think of as unhealthy actually reduce total life healthcare spending, because US care is heavily weighted towards end-of-life care. It's cheaper to die of lung cancer at 40 than to have three knee replacements and spend a month in the ICU at 80, and US health care is heavily weighted towards the latter because of medicare, everyone else struggles to get affordable access to the system.)
Like it would be interesting to see an attribution of what specifically americans are eating so differently vs everyone else, and the caloric/macronutrient balance and total inflow/outflow, and total life expectancy (and total spending) changes. I suspect it's just a "how much of it" more than anything, but the "gosh americans just eat like shit, that's why!" really doesn't justify 5x per-capita expenditures on the face of it, in the way people try to use it. The rest of the world drives cars and eats like shit, and eats too much too, in varying proportions.
But to go back to spending - it's really hard to argue that it's any one thing. It's everything. Everyone at every layer is bleeding everyone else. Americans are a bit unhealthier, but we also have for-profit hospitals (even non-profits make a "profit", it just goes into real estate investments), for-profit insurance, doctors who make $400k because they need to pay off $300k of loans from for-profit education, drug and device manufacturers who have no cost containment before approvals, a political system that tolerates evergreening and similar practices, an "access problem" for delivering basic care before it escalates into expensive problems (even "preventative care" often still ends up costing), etc etc.
That is really the problem and why the system cannot be reformed. Medical care is at the nexus of every single "unsolvable problem" of the US political system, from patents to education to farm-lobby and environmental regulation, and it involves a million taking hands that after a true reform will no longer be able to take. There is a lot of people who have become reliant on the revenue streams from this rent-seeking/unproductive activity, and they will lobby heavily to make sure they can keep taking.
The point can be made that interventions into these types of lifestyle's would have to come from somewhere. Probably a doctors visit could make a big difference in this type of lifestyle for some portion of the population. Maybe we need an Auxiliary location that's just full of dieticians and lifestyle coaches or something. Get people involved in a community, know their neighbors. These problems are systemic and the system is intractably large, but it's gotta start somewhere.
People wake up, go to an incredibly stressful workplace and use up all possible productive hours of the day, come home extremely tired, pop on the incredibly stressful news cycle and get permanently angry as they eat their TV dinners, then fall asleep in their chair as the news continues to unsettle and disturb them even in their most peaceful moments. I've seen this over and over again, it's how a lot of people live here.
There's a million places a resolution to this type of issue could start, but damn it's gotta start somewhere!
> Probably a doctors visit could make a big difference in this type of lifestyle for some portion of the population.
Most doctors are never taught to deal with lifestyle. It’s sick care with things like medications and surgery. Doctors office visit won’t address this for most.
Most people live lifestyles that lead to conditions. For example, most high cholesterol that cause people to use statins is caused by diet. Less than 10% of Americans eat a healthy diet. Doctors almost never deal with that and usually aren’t even taught that in school.
What if people just never had most of those issues that require treatment?
As far as I know, the link between diet and cholesterol was a myth that caused many of the bad diet choices people make today, such as replacing animal fats with (bad) plant-based fats like palm oil.
In a healthy individual, cholesterol intake is not related to blood cholesterol levels (beyond some reasonable threshold, like not eating a tub of lard in one sitting).
Americans visit the dr about as often as other oecd countries, it's just that every interaction costs about 5x in comparison due to crazy tangled insurance/regulatory overhead.
>> Holy cow, really? Is this a case of over-diagnosing things, or are virtually half of Americans legitimately struggling with multiple health issues?
There isnt much incentive in the US to prevent disease, doctors make their money from visits fees, procedures, etc. Not saying they purposefully make people sick, but I think there is some Darwinism in a system like this -- a hospital system that keeps people healthy would wither and go bankrupt because hospital systems dont get paid to keep people healhty, they make most of their money when people get very ill.
Over 1/3 of US adults have cholesterol levels that cause them to use or qualify for a statin. High cholesterol which leads to cardiovascular disease (leading cause of death in the US).
what usually causes this also causes a bunch of other chronic issues. So, yeah.
Life expectancy rates in the US were going down before COVID. Chronic illness.
The numbers aren’t looking good. Unless you’re trying to make money on healthcare. Healthcare income goes up when health goes down. Capitalism.
Far more than a super majority of those with high cholesterol are due to lifestyle. At my least yearly doctors appointment I asked about the genetic case. My doctor, in his mid-40s, said he had only had a few patients with that in his career. I've listened to lipid PhDs lecture and they talk about it being rare but present.
We cannot change the genetic case. But everyone else can be affected.
I was talking with someone recently who changed her diet. In a matter of weeks her LDL cholesterol dropped 50 points.
Oh wow, it sounds like my understanding is off considerably. I was under the impression only 15% decrease is possible with lifestyle changes!
Can you provide any basic literature on how large of an effect can be achieved through lifestyle alone? It sounds like my vaguely recalled ~15% is way, way off.
(I do wonder how statins are so easily justified if lifestyle is so effective, but pharma profits/lobbying may explain that.)
So 25%, which is well above the 15% effect I’ve seen, but you could just be an outlier. Also possible that such research suffers from self reporting problems, and many who claim they’ve made lifestyle changes are not reliable in those self reports. Fwiw, my experience is similar to yours. Lifestyle changes (weight loss moreso than diet) improved my “bad” cholesterol and glucose.
It's probably worth noting that I went from fatass to healthyish (about 50 pounds lost) so that's fairly drastic as well. We are certainly each unique medically speaking, but I'd still think that the single biggest change for the better you can make in your health is to try and kick the obesity. While BMI might be far from a perfect measure, I'd still like to get to at least the top end of the normal range.
not to mention the varying obesity rates - USA is almost double that in France - solve that problem and a lot of the health problems and costs will be solved as well.
Instead we as a country are glamorizing obesity, which has become a bizarre and deadly trend in the USA, we should attack it like we did smoking.
Even my local doctors office is advertising how you can be 'healthy at any weight' - talk about gaslighting, no you cannot.
Without a doubt the 'healthy at any weight' campaign is directly or indirectly funded by food companies and drug companies - neither of them which want thin and health populice.
Huge parts of the money are going to middlemen who do nothing productive at all (gigantic health insurance companies hiring armies of paper pushers that cause a need for more paper pushers in hospitals and pharmacies etc). Another large chunk is the enormous profits of drug manufacturers, who, entirely uniquely in the world, can set prices however they want with no government negotiation - ending up in madness like insulin being an expensive drug in the USA.
While obesity is a huge issue and a huge cost factor, there are more obese countries with nevertheless a tiny sliver of the US medical budget - even after adjusting for life expectancy.
Careful with “without a doubt” thinking when presenting a strong argument without facts to back them up. BMI is the foundation of a lot of health studies and it is increasingly called out as a bogus standard to base people’s healthfulness on. Science changes.
The body positivity movement, plus sedentary lifestyles, plus the increasing cost of healthful foods, the time it takes out of your day to exercise, almost mandatory amounts of sitting in a car daily… there’s a lot of factors in modern American life that are just bad for our health. It’s not just the money spent on healthcare.
if you follow the money, it is pretty easy to connect the dots - ask yourself - who benefits the most, and makes the most money keeping people fat, and on lots of drugs?
it gets even more paradoxical when you consider total healthcare spending, and how the US system tends to weight this far more towards end-of-life care than other systems.
in many cases, when looking at total life spending, things that kill you earlier actually can reduce total life spending (smokers are a great example) because it means you don't incur the three knee replacements and bouncing in and out of hospital for the last 2 years of your life and spend the last 2 weeks dying in an ICU. Having a heart attack and dying on the surgical table is pretty cheap in terms of total healthcare spending.
Obesity is still cost-positive, but it's a lot less than you think from numbers like "X% of total medical funds spent on obesity" - you are going to substitute around 50-75% of that cost in cancer treatment and knee replacements instead (see table 2).
anyway, one of the problems is that obese people are massively stigmatized and shamed. they are already treated worse (and receive worse medical care, etc) than others, for every moment of their lives, they have constantly-reinforced negative body image, which is psychologically unhealthy to impose on people. And the point of "healthy at any size" (when not taken to an absurd extreme) is to get people to at least feel like they aren't so far gone that it's pointless to make better choices, because starting to make better choices are the foundation of starting to climb out.
This is usually met (even here, in past discussions) by some variety of "good, they should feel bad", and "well, I was fat and it helped me!", but that's basically a riff on "my parents spanked me and I turned out fine". Not only is that probably not a medically-supportable opinion (stress and fear are themselves powerfully negative causative factors that place actual physical damage on the body over time), but not everyone's brains work the same in the first place. What inspires you to improve might just reinforce someone else's depressive spiral, a lot of obese people have very negative body image ("good", says the peanut gallery).
Black Mirror wasn't wrong, people love having an underclass to look down on, and obese people are a very visible and very socially-acceptable underclass to punch down on. A "steelmanned" view of HAES, when not taken to ridiculous extremes (and I'm not saying nobody does!) is that it's simply asking that we not go full Black Mirror on shaming fat people, but frankly I think a lot of people don't even agree on that much, or that it would be a good thing. "It's for their own good" etc.
The whole reaction to the idea of HAES, itself, is a microcosm of the social problems around obesity and self-image - how dare you feel good about yourself? Why aren't you going through every day in a haze of shame like you deserve to? It's for your own good!
