Robert Wack

This is a difficult time to be a health care professional dedicated to improving our systems. Along with all the problems inherent to the peculiar American way of providing care, we now have an Administration openly promoting health disinformation from the MAHA movement through the actions of the Secretary Health and Human Services, Robert F. Kennedy Jr. 

Trump’s alliance with RFK Jr. is one of political expediency to maintain MAHA support. The MAHA movement has so much allure with some people because some of their central beliefs aren’t wrong. We do need to focus more on nutrition. We do need to ensure clean water and food supplies. We do need to make better decisions about healthier lifestyles. There ARE problems with corruption and too much influence of money on the healthcare system.

The challenge with MAHA is that for the most part, the good intentions of those truly focused on improving health are influenced, controlled, and manipulated by bad actors seeking financial gain, the very thing they accuse the medical establishment of doing. In addition, Trump’s support for MAHA is purely transactional and doesn’t involve any sincere agreement on specific policy priorities. Despite their fervent wishes, MAHA priorities are not Trump’s.

This post will not be a list of specific policy prescriptions. Rather, these are some observations of larger structural problems that should inform future attempts at reform, knowing both the existing challenges and our new burden of disinformation. To the extent any attempt at reform ignores these issues, they will be at best incomplete and will most likely fail to produce meaningful change.

There are three large issues plaguing American healthcare: 1) the distortions that free market incentives create in the delivery of quality health care; 2) the inability of healthcare consumers (all of us) to confront the reality that we don’t really control most of the things that affect health as we age, such as our genetics; we can influence some of them, but at the end of the day, we mostly react to health changes caused by normal processes of aging that result in the deterioration of healthy systems;  3) the inability (or refusal?) to confront the small handful of factors that healthcare consumers CAN control: diet, activity levels, and lifestyle choices.

It is these structural issues that create the environment that MAHA disinformation feeds on. Our healthcare finance system incentivizes behaviors that are counter to quality care and positive patient experiences. Because we can’t/won’t admit that some aspects of life changes can’t be reversed, and maybe only slightly influenced, there is a never-ending quest for magic solutions. At the same time, because of our inability to confront the consequences of our lifestyle choices, and the pressures from social norms and our capitalist system to perpetuate many of them (consumer culture, unhealthy social behaviors, convenience) we continue behaving in ways that are directly counter to long healthy lives. All the while, the profit motive lurks in the background, creating opportunities to exploit consumer information deficits or unrealistic/mismanaged expectations.

Healthcare financing is very complex and transitioning the U.S. healthcare system further away from private insurance is both economically and politically fraught. Vested interests operating within deeply entrenched systems have powerful incentives to maintain the status quo, making any change extremely difficult. However, that can’t distract from the centrality of misaligned financial incentives in the degradation of clinical decisions, outcomes, quality of care, and patient experience. When physicians are compensated on the number and complexity of procedures they do, that influences their decision making. When a third party is positioned between a provider and a patient and benefits financially by interfering in the provision of services, only bad things can happen. That misalignment is behind many, perhaps most, of the inefficiencies of the U.S. system.

Fraud, waste, and abuse are also inherent in any system humans are involved in, no matter how it is structured. The solutions are oversight, inspections, regulations, and sanctions. In a political environment that deprioritizes regulatory oversight and enforcement, as well as elevates self-dealing, graft, and corruption, reform will be a long time coming, but needs come it must, and the financing of health services has to be a central priority.

The human body, under the best circumstances, has certain features determined by genetic information that are better or worse suited for a particular environment. Our success in modifying our environment and freeing ourselves from the constraints of local resources for providing sustenance, inadvertently creates a mismatch between individual genetic attributes and our new, manmade environment. Very few people are genetically suited for the high calorie, low activity, high stress lifestyles of the modern world. Many chronic diseases arise from this mismatch between our genetic endowments and the pressures of modern living. 

Our metabolism, the enzymes and pathways determined by our unique genetics, are optimized for a world we left behind tens of thousands of years ago. Our bodies are designed for scarcity punctuated by episodes of plenty: the successful hunt, the serendipity of discovered food, the seasonal variations in the availability of edible plant life. Today in the U.S., we have universal access to unlimited calories, and we no longer spend the day walking, gathering, and stalking.

We also have industries geared toward producing those unlimited calories and driving consumption through media and marketing. Those marketing methods have become increasingly effective and almost irresistible. In addition, powerful cultural norms around sharing food communally, and all the emotional attachments that creates, are also powerful factors that can conflict with our genetics. In fact, sharing nourishment and the emotional investments in certain food behaviors are part of why we outcompeted other hominid species.

This mismatch between our genetics and modern lifestyles creates the conflicting tensions described above. On the one hand, our bodies are not eternal, and the toll of time and chance inevitably causes problems. This cannot be avoided, only mitigated. We’ve made miraculous progress dealing with wear and tear on the body, and that work continues, but at the end of the day, sooner or later all bodies fail, some gradually, some suddenly.

At the same time, we have the power to modify the adverse influences and effects the modern world has on our health. These are choices, and once we recognize the maleficent influences of our lifestyle, we have the power to minimize or eliminate them. Smoking is a choice. Alcohol consumption is a choice. Activity level is a choice.

Of course, those choices are constrained by social determinants of health. Income and the imperatives of participating in a capitalist system create demands on time and attention. Education and employment are major drivers of health status due to availability of nutrition, recreational time, a healthy living environment, and access to health care. In a wealthy country like the U.S., poverty is a major adverse health factor, and it is the result of policy choices of our political and economic system imposed on the population. This is an uncomfortable truth we all have difficultly facing.

This is where the three factors intersect. Capitalism creates adverse determinants of health, as well as perverts the incentives of providers and the middlemen of health finance. Our unrealistic expectations about what is normal and what should be fixable create opportunities for frustration due to unmet expectations. Unscrupulous providers, seeking only profit maximization, don’t discourage those unrealistic expectations, perfectly willing to sell us the next test or procedure for problems that will never be solved. At the same time, the food, beverage, and entertainment industries use every lever available to them to influence behaviors that feed into unhealthy lifestyles and chronic disease.

These are the challenges which MAHA grifters exploit for financial gain. It’s obvious the system doesn’t work well for many people, which leads to frustration and anger. Whether it’s onerous insurance bills, poor customer service, unpleasant interactions with healthcare providers, or bad outcomes deriving from mismatched or unrealistic expectations, the MAHA grifter has a simple solution for sale to exploit those emotions and distract from the real causes.

Physicians, public health professionals, and other providers face a three front war: caring for, educating, and protecting our patients; reforming an imperfect system; and combatting the relentless disinformation seeking to profit off people’s understandable anger by undermining the mainstream health system.

We have a lot of work to do.