How do we Fix our Broken Healthcare System?

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Americans experience a starkly different healthcare landscape compared to many other countries, especially those with universal healthcare systems. Here's an overview of key comparisons:

Costs

• U.S. Spending: The U.S. spends more on healthcare per capita than any other nation—about $12,914 per person annually (2021), accounting for nearly 20% of GDP.

• Other Countries: Most developed nations spend significantly less, with average per capita costs around $5,000–$6,000 annually, and healthcare typically accounts for 8–12% of GDP.

 Access

• U.S.: Access to healthcare depends heavily on insurance. Many Americans remain uninsured or underinsured, leading to delays in care. Emergency care is guaranteed, but costs can be crippling.

• Other Countries: Most developed nations offer universal healthcare, ensuring all residents can access necessary care regardless of income or employment status.

 Health Outcomes

• Life Expectancy: Americans have a lower life expectancy (~77 years) than residents of most other high-income countries (~82 years in OECD countries).

• Chronic Conditions: The U.S. has higher rates of chronic diseases like diabetes, obesity, and heart disease compared to many peers.

• Infant Mortality: The U.S. has one of the highest infant mortality rates among developed nations, reflecting disparities in prenatal and postnatal care.

Administrative Complexity

• U.S.: The healthcare system is fragmented, with a mix of public (Medicare, Medicaid) and private insurance, creating high administrative costs and inefficiencies.

• Other Countries: Countries with single-payer systems or nationalized healthcare (e.g., Canada, UK) have simpler and more centralized administration, reducing costs.

 Patient Experience

• U.S.: Americans often face high out-of-pocket expenses, surprise bills, and limited transparency in pricing. Many must navigate complex insurance rules, including prior authorizations.

• Other Countries: Out-of-pocket costs are typically low in countries with universal coverage, and surprise billing is rare.

Innovations and Technology

• U.S.: The U.S. excels in medical innovation, offering access to cutting-edge treatments and technology. However, this is often limited to those who can afford it.

• Other Countries: While they are slightly slower in adopting new technologies, universal systems prioritize equitable access to proven treatments.

Public Satisfaction

• U.S.: Many Americans are dissatisfied with their healthcare system, particularly due to costs and inequities.

• Other Countries: Public satisfaction is higher in countries with universal systems, though some report longer waiting times for non-urgent care.

Conclusion

The U.S. stands out for its high healthcare spending and innovative treatments but lags behind in access, affordability, and health outcomes compared to other developed nations. Achieving better outcomes would likely require systemic reforms to improve equity, reduce costs, and simplify administration.

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The Coverage Crisis

Rising health insurance coverage denials in the U.S., often driven by AI-powered algorithms, have prompted the development of new AI tools to automate appeals. However, experts argue that systemic reforms are needed to address excessive costs and ensure access to care. Insurers like UnitedHealth, Humana, and Cigna face lawsuits alleging reliance on flawed algorithms to deny claims, sometimes in mere seconds, with some tools reportedly having error rates as high as 90%.

Despite the ability to appeal, less than 0.2% of patients do so, often due to a confusing and time-intensive process. These practices have led to financial burdens, delayed care, and worsened health for many Americans. Some states are passing laws to mitigate these issues, while scrutiny of automated denials grows at federal and state levels.

A U.S. Senate report reveals that UnitedHealthcare, CVS, and Humana, which together provide nearly 60% of Medicare Advantage coverage, reject prior authorization claims at high rates using automated systems. These denials cost providers over $7.2 billion annually in administrative expenses for appeals. The Centers for Medicare and Medicaid Services (CMS) have introduced new rules to regulate prior authorization in Medicare Advantage plans.

Generative AI tools have emerged to assist hospitals and patients in drafting appeal letters, offering a "battle of the bots" to challenge denials. However, experts emphasize the need for human oversight in automated processes to address frequent errors. UnitedHealth's CEO, Andrew Witty, stated that 85% of denials could be avoided through standardized industry processes and technology.

California has banned AI from making coverage decisions without physician oversight, but broader issues persist, such as high medical costs and inefficiencies in the healthcare system. Experts argue that a systemic overhaul is necessary, as healthcare spending constitutes one-fifth of the U.S. GDP.

Taken as a whole, these denials, coupled with the ongoing reduction in benefits across all coverage levels, are creating significant financial challenges for individuals in their late 70s and 80s. Many are outliving their retirement savings, leaving them particularly vulnerable to rising out-of-pocket and denied healthcare expenses.

 Possible Solutions

Fixing the American healthcare system is complex and requires both immediate and long-term strategies. Below are some immediate actions that could significantly improve access, affordability, and efficiency.

Since Donald Trump took office, it’s become clear that he isn’t afraid to “shake things up.” His nomination of JFK Jr. to lead the Department of Health and Human Services is a prime example. While I personally admire the man, I’m deeply concerned about his lack of medical expertise and the potential consequences of his radical—and possibly harmful—proposals for our healthcare system. His confirmation hearing is set for this week.

As I’ve highlighted in previous newsletters, the changes he’s advocating for are monumental in scope. Realistically, implementing them within the remaining time of the Trump administration seems improbable, raising questions about both feasibility and long-term impact.

Alternatively, I believe he offers valuable insights into addressing the growing prevalence of chronic diseases. In my view, the primary driver behind this alarming rise across all age groups is our Western diet and many of the practices adopted by Big Food.

Rather than the complete destruction and recreation of our existing health infrastructure, I advocate focusing on a smaller spectrum concerning diet. If we were able to significantly improve the overall health of our nation, it would save us billions if not trillions of dollars reducing healthcare costs for Americans. In addition, I offer the following changes to our overall healthcare system:

Implementing even a small percentage of these proposed changes could significantly improve our healthcare system. However, transformative change of this scale will inevitably require substantial time, particularly to address the financial implications of restructuring the industries involved.

Addressing Cost Transparency and Control

Mandate Price Transparency: Enforce and expand rules requiring hospitals, insurers, and drug companies to disclose prices for services, procedures, and medications.

• Cap Out-of-Pocket Costs: Set limits on copays and deductibles for essential services and medications, especially for chronic conditions.

• Negotiate Drug Prices: Allow Medicare to negotiate drug prices directly with pharmaceutical companies to lower prescription costs.

Expand Coverage

• Expand Medicaid: Incentivize states to adopt Medicaid expansion under the Affordable Care Act (ACA), covering millions of low-income individuals.

• Public Option: Introduce a public insurance option that provides affordable coverage for people without employer-provided insurance.

• Automatic Enrollment: Automatically enroll uninsured individuals in a basic public plan, with an option to opt-out or upgrade.

Reduce Administrative Burden

• Standardize Billing: Implement a standardized billing and claims process across insurers to reduce complexity for patients and providers.

• Simplify Prior Authorization: Streamline or eliminate prior authorization requirements for routine care and treatments.

• Leverage Technology: Use AI and automation to improve efficiency in claims processing and reduce administrative costs.

Invest in Primary and Preventive Care

• Increase Access: Provide incentives for healthcare providers to work in underserved areas and expand telehealth services.

• Preventive Services: Mandate coverage for preventive services like screenings, vaccinations, and chronic disease management at no cost to patients.

• Community Health Programs: Fund local health initiatives that address social determinants of health, such as housing, nutrition, and transportation.

Regulate Insurance Practices

• Ban Surprise Billing: Prohibit surprise medical bills from out-of-network providers for emergency and non-emergency care.

• Enforce Essential Benefits: Require all insurance plans to cover essential health benefits, including mental health, maternity care, and prescription drugs.

• Cap Insurance Premiums: Set limits on the percentage of income that households can spend on insurance premiums.

Strengthen Workforce and Provider Support

• Support Healthcare Workers: Provide immediate financial and mental health support for healthcare professionals to combat burnout and shortages.

• Increase Medicare Reimbursement Rates: Ensure fair payment rates for providers, especially those in rural or underserved areas, to maintain access.

Promote Equity

• Expand Access in Underserved Areas: Invest in rural health clinics, urban health centers, and telemedicine to reach marginalized populations.

• Cultural Competency Training: Improve healthcare providers’ understanding of diverse populations to reduce disparities in treatment outcomes.

• Address Bias in AI: Regulate the use of healthcare algorithms to ensure they do not perpetuate systemic biases.

Emergency Legislation

• Emergency Coverage for All: Pass temporary legislation ensuring all individuals can access COVID-related and other critical care without cost barriers.

• Debt Relief: Offer medical debt forgiveness programs for individuals facing bankruptcy or financial hardship due to medical bills.

Conclusion

These actions could bring immediate relief to patients, improve access, and reduce costs while setting the foundation for broader systemic reforms. Longer-term changes, such as adopting a single-payer system or transitioning to universal healthcare, would require further debate and investment.

A Major Problem

One of our greatest problems without a satisfactory solution is the way we bring drugs and supplements onto the market and how we limit certain traditional medications from public access by requiring a prescription for well-established medications without significant adverse reactions.

Most Americans believe that these restrictions are for our benefit because they prevent potential threats to our health by allowing poor-quality and untested drugs onto the market. While this may be true in some circumstances, I believe the most common reason for this situation is to preserve profits for Big Pharma—and, by extension, the FDA, which relies to a considerable extent on money from Big Pharma to fund its operations.

Not too long ago, American taxpayers fully funded the FDA. However, a shift occurred starting in the late 20th century. In 1992, the Prescription Drug User Fee Act (PDUFA) was passed, allowing the FDA to collect fees from pharmaceutical companies for reviewing their new drug applications. This marked the beginning of a significant change, where a substantial portion of the FDA's budget started to come from industry user fees rather than direct taxpayer funding. Today, user fees account for a large share of the FDA's budget, especially for drug and medical device approvals.

The end result of this change was to make the FDA responsible for policing the activities of Big Pharma—which is a bit like asking the fox to guard the henhouse. Do you see a problem here? Add to this the fact that, because of their financial relationship, a “Revolving Door” employee phenomenon has arisen.

A 2018 study found that approximately 11% of FDA regulators who worked on drug approvals between 2001 and 2010 later worked for the pharmaceutical industry. These transitions often involved high-ranking officials or scientists involved in drug review processes. Similarly, pharmaceutical executives or consultants sometimes move into regulatory roles at the FDA. Watch the following 11-minute video for an eye-opening presentation of the facts concerning this problem.

BIG PHARMA'S Ties to The FDA Should be Questioned (click to view)

It Boils Down to Money

Like so many problems we see in our capitalistic economy, many arise from our motivation to gain wealth. On the one hand, this attribute has made America one of the strongest economies on earth. Conversely, this same philosophy has created significant problems and inequities because profit has become the controlling factor in virtually all businesses. This is especially troublesome when the health and well-being of our citizens suffer as a result…

With respect to the current topic, our profit-driven priorities create significant problems in healthcare. Allow me to provide an anecdote I am very familiar with. You may recall the challenges that arose before the development of a vaccine during the COVID-19 pandemic. Under pressure from Big Pharma, the FDA quashed many potential interim solutions.

Here’s an example: Do you remember the number of NFL players who were unable to play in games due to COVID infections? Beyond its impact on personnel, this problem resulted in the loss of millions of dollars for the National Football League and significant inconvenience for its fans.

I am personally aware of a natural, completely non-toxic substance that has existed since the evolution of the human species. Without it, we may not have survived. This substance, hypochlorous acid (HOCl), is produced by our white blood cells and serves as a first line of defense against infections and skin burns. Recently, science has learned how to manufacture a very stable form of this substance. It has been scientifically demonstrated to kill or deactivate every known virus, bacteria, fungus, or prion—COVID included.

In 2016, a friend and I started a cosmetics company: https://www.curativabay.com/about/our-story/, with its first product line built around HOCl. This substance had been tested by major academic institutions and proven to instantly destroy the COVID virus when used in a nasal spray, thus preventing infection from the virus responsible for millions of deaths. Regrettably, we were prevented by the FDA from making claims about its effectiveness or selling this inexpensive substance for this specific purpose.

You might ask yourself why. Or better yet, ask Pfizer, Moderna, or Johnson & Johnson…

Without realizing it, many fail to see that the structure of our drug approval process results in the incredibly high expense of certain drugs. Let me explain…

For virtually any drug or device produced by big Pharma that requires FDA approval, it is necessary for that product to be patentable. This patent allows the drug company to charge whatever they believe is reasonable for that product. The profit generated is then used to offset the cost of research and development, as well as the enormous expenditure required to achieve FDA approval. According to U.S. patent law, this privilege extends for 17 years. Thereafter, these drugs can be marketed as “generic equivalents,” which typically sell for a fraction of the cost of the name brand.

When you think about it, can you really blame Big Pharma for operating this way? After all, they are simply playing by the rules. But there’s more to it than what meets the eye. Due to the enormous investment required for the approval process, naturally occurring substances are often unable to obtain FDA approval, regardless of their effectiveness and safety.

One example of this category of drugs is peptides, which are naturally occurring short-chain amino acids discovered in living organisms. Perhaps the best-known example of a peptide is insulin. Although discovered early in the 20th century and initially used by Eli Lilly to treat Type 1 diabetes (with the insulin originally harvested from dogs), it was not widely used until a synthetic manufacturing process was developed, making it patentable.

This type of modification has become popular because the patent process provides the necessary funding to perfect and approve substances. This trend is especially evident in the recent explosion of Type 2 diabetes and weight-loss drugs, such as Ozempic and Mounjaro, which were modified from their naturally occurring forms to generate funding for development, approval, and marketing.

In summary, peptides and other natural substances may be especially useful in addressing a myriad of conditions, particularly those that are associated with aging, because the levels of these amino acids and hormones decrease throughout life. Replacing or augmenting these substances can indeed restore a degree of youthfulness. However, as things currently stand, using these substances without the advice or direction of a qualified medical practitioner can be dangerous. Therefore, even though they may be available through various channels you should always seek advice from qualified professionals who are rarely your typical primary care physicians.

Why Peptides Are the Secret to Better Health and Longevity (click)

Here is an interesting fact: If you start to watch a video and you decide to leave because of its length, you can later return to this link and pick up where you left off.

A Possible Solution

If you understand the situation as I have described it, you will realize that there is no simple solution. This complexity arises from the fact that the FDA and big Pharma are essentially in the private sector, and not entirely controlled or subject to the laws of the states or federal government.

The critical element responsible for achieving success is the approval process, now under the control of the FDA. Realistically, the only way to substantially improve this situation is to bring both the FDA and big Pharma under the control of the federal government. This approach would require a change in funding for the FDA, back to its original configuration.

The United States Food and Drug Administration was first created to enforce the Pure Food and Drug Act of 1906. In this capacity, the FDA is charged with protecting the health of the US public, to ensure the quality of its food, medicine, and cosmetics. The Prescription Drug User Fee Act (PDUFA) of 1992 allowed the Food and Drug Administration to collect fees from drug manufacturers to supplement its funding. This marked a shift from the FDA being primarily funded by taxpayers.

Beyond eliminating the problem of the FDA policing the drug industry, there needs to be a way to fund the necessary research studies to determine the effectiveness and safety of any approved substance, regardless of its potential to produce profits without the need for patents.

Upon reflection, it becomes clear that this funding would likely stem from two primary sources. First, there would be healthcare savings driven by two key factors: an improvement in overall health, which reduces treatment durations, and a decrease in the costs of medications and medical devices. Second, additional contributions would be generated through increased taxation.

At first glance, this may seem problematic, as the prevailing conservative political establishment strongly opposes higher taxes. Moreover, we, as Americans, tend to resist the idea of increased taxation, particularly when it is used to fund larger government programs that may not benefit each of us. However, when examining how other nations tackle this issue, we see that they are largely successful. Their citizens are generally more accepting of these financial burdens, recognizing the tangible benefits they receive in return.

Regardless of your position regarding this type of change, one thing is certain: a major paradigm shift of this magnitude will require something that we as Americans have as an advantage in our democratic system. We must demand this sort of change unanimously. We must unite as a single, collective force to petition our federal and state representatives, demanding meaningful change. While we must acknowledge that such a change will be neither quick nor easy and will undoubtedly face opposition, I firmly believe it is achievable and represents our best path forward. To tackle this formidable challenge, we must collaborate effectively, maintain open lines of communication, and leverage the best available technology to achieve our goals while minimizing costs.

Listen to the Podcast (click)

Until next time, take care and stay POSITIVE…Dr. G

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