Better Health? Think Different...

The principal problem with our American healthcare system, with its foundation in the ‘medical model’, is that it is not primarily purposed to improve health.

I want to make myself very clear here; I have proudly spent forty years working in the American healthcare system as a physician and a leader, with the majority of that time spent in acute care. I am incredibly proud of the work that I have done over the years both in the direct care of patients, and in improving the quality, safety, and equity of the care we deliver. I now lead a team of over 800 caregivers who strive daily to deliver compassionate care to improve the lives of those we serve and to continually improve the quality and safety of that care. I could not be more proud of what this skilled and dedicated team accomplishes each and every day—their contributions cannot be overstated.

We will always need a robust, effective, and safe care delivery system—truly, so many lives depend on it. But it is in many ways a misnomer to refer to this as a healthcare system. It IS a system that is increasingly effective at managing chronic illness (for those with full access to care), it is a system that excels at treating acute illnesses (such as sepsis and trauma), but it is a system that falls far short of what could be achieved to improve the healthy lifespans of those we serve in an equitable way.

Consider that the US saw approximately $125 billion in investment in new biopharma development by pharmaceutical companies and venture capital (excluding federal government funding of drug development), $38 billion combined industry and VC investment in medical device development, and approximately $5 billion investment in AI directed at medical use in 2023. This investment will undoubtedly eventually result in treatments that will improve and even save the lives of many individuals, and will almost certainly in aggregate result in a return for investors. But it is quite safe to say that this massive investment in the development of new treatments and knowledge will NOT improve overall measures of health or life expectancy in the United States—nor will the trillions of dollars that fill health insurance coffers; pay for the training and salaries of doctors, nurses and other healthcare workers; and fund the construction and operation of healthcare facilities across the country—unless we change what we are doing now.

I can make this statement with such confidence because changes in measures of population health in the United States: life expectancy, chronic disease incidence, and infant and maternal mortality, have been flat or negative during the past decade, significantly trailing the rest of the developed world (accounting for the COVID pandemic), despite unprecedented investment in the healthcare industry and expenditures on healthcare delivery. Life expectancy in the Unites States is a solid five years lower than in other developed economies, and ‘healthspan’, the portion of our lives that we live free of debilitating chronic disease or disability is actually decreasing in the US.

The questions as to WHY this is true would fill textbooks rather than a brief article, and should fascinate all of us. How does the most advanced scientific and medical complex in recorded history preside over the deterioration of the health of the people it supposedly exists to serve?

I want to humbly propose that the widening disconnect between health outcomes and our ever advancing abilities to treat disease arises in large part because our healthcare system is principally a ‘sick-care’ system that has yet to robustly support wellness as a goal. As a result, the most important opportunities we have to improve health and wellness lie in the areas of cognitive and behavioral sciences and health equity rather than in pharmaceutical or other therapeutic developments. A “Cancer Moonshot” is a galvanizing aspiration, but the thing that would help more of us in the developed world to live longer and healthier lives than any other change would be the ability to make better decisions and exert some willpower over our behavior.

A statement like this may seem almost banal—our minds are far more attracted to a major pharmaceutical advance such as the advent of GLP-1 inhibitors like Wegovy and Ozempic than to the inconvenient fact that making our many thousands upon thousands of mundane day to day decisions about what we do with our minds and bodies in a manner more beneficial to our health would more effectively lengthen and improve our lives than any combination of new drugs and treatments ever will.

Banality aside, this is actually VERY exciting stuff, and there is good news here. The United States has seen a 50% reduction in the incidence of smoking among adults and a 60% reduction in the packs of cigarettes consumed per capita during the last twenty years. The health benefits from this enormous behavioral change (fewer heart attacks and strokes, less chronic obstructive lung disease, fewer cases of cancer...to name a few) are only beginning to be realized, and will continue to be experienced for many years to come. But sadly, the improvements in health outcomes related to the reduction in smoking in the US have been counteracted to a significant extent by the combined impacts of rising obesity rates, worsening nutrition, and trauma and toxic stress among children as well as adults, leading to large increases in the incidence of chronic disease in the United States. Nonetheless, the smoking story powerfully informs us that beneficial behavior change is possible when supported by education, changes in social norms, public policy, and tax policy.

US healthcare spending reached nearly $5 trillion in 2023, over $14 thousand for every American. Spending within the wellness industry, driven largely by discretionary consumer spending, was $1.8 trillion in 2023. We spend more on healthcare and wellness products than any country on earth, and are receiving poor value for our money. Ironically, the most revealing research on longevity and wellness suggests that low tech, inexpensive practices readily available to many of us are the most effective tools for promoting long and high quality lives: promoting healthy relationships, plant-based or low animal protein diets, stress reduction, avoiding excessive alcohol and opiates, sleep hygiene, healthy activity, living with purpose…in other words the best available data suggests that the path towards longer and healthier lives is remarkably simple, if not easy.

None of this refutes the very real needs to expand access to primary care for all Americans, to continue our focus on improving the poor outcomes for pregnant women and children in the US, and particularly to improve health equity in the United States. But a straight forward analysis easily reveals a profound disconnect between how we as Americans spend and invest on healthcare and wellness and what would actually improve our health and our lives. We have a profound need to align incentives for investment with what actually works. The alternative is continued unsustainable increases in the cost of healthcare, continued deterioration of health services in rural and other areas largely dependent on government payers, stagnate or worsening health outcomes, and the increasing human and economic consequences of poor health and declining productivity.

We are an extraordinarily industrious and creative species and society, albeit one with some self-destructive tendencies. There is an amazing and fruitful path towards better health in this country, but to embrace this path we will need to break out that 1997 Apple Inc. slogan, and “Think Different.”