systemic time bomb

Obesity, chronic illness, and health care

Quartz reported this morning that by 2050, more than half of all adults worldwide are likely to be overweight, if not obese. This glum news matters despite the advent of wildly exciting (and expensive) therapies such as weight-loss drugs, surgeries, and anything else that seems effortless in the face of the human body. These numbers are astonishing if you consider how many places around the world still regularly confront hunger.

About twenty-five years ago, my brother noted with exasperation my fixation with weight. Well, um, yes. When one was a hefty child, one dieted, then regained, then dieted, then regained (you get the pathetic picture) over half a century, one does tend to fixate on weight. I have a ceasefire with food, but I doubt weight will ever leave my priorities.

As I have noted, my father passed at 65, increasing my vigilance about various conditions. I watch stories on links between obesity and heart disease (still the number one killer in the United States), diabetes, cancer, and joint replacement, among other things. I find it hard enough to watch a woman in her mid-fifties struggling to walk across a room unaided because of a sprained ankle, much less recognizing she has decades to face a debilitating illness. As a result, I am health conscious, with weight at the top of my list.

I raise the point today, however, following a story on the front page of Monday's New York Times. Eli Saslow penned "House by House, She Steels for Grim Battle with Chronic Illness," a detailed exploration of a traveling nurse in West Virginia daily confronting the growing scourge of America's declining health. The subtext refers to Sam Runyon, the nurse who visits shut-ins to ensure what little she can about their daily health choices, as "a weary rural nurse, and a Nation on a Perilous Path [emphasis mine—cw]."

Seventy-two million, or 72,000,000 if you prefer digits, Americans live on Medicaid today, and few likely have a Sam Runyon visiting. That number indicates a perilous trajectory for a country, significantly slashing Medicaid. That sixty-year-old initiative, subsidizing health care for the poorest among us, is the largest source of public insurance in the United States. Medicaid provides resources for 40% (four in ten) births nationwide. To put it another way, Medicaid supports one in five Americans, hardly an inconsequential portion of our population.

It is easy to make generalizations, driven by ignorance and/or political biases, about where these recipients are. An article by Sarah Kliff and Marti'n Gonza'lez Go'mez, however, destroys the partisan attacks by illustrating graphically how vast and diverse the areas are where Medicaid recipients live. While a substantial number are along the country's periphery, one can hardly call downstate Illinois along the Indiana border the edge of our geographic expanse, nor is inner-city New York. In many places—electing both Democrats and Republicans—more than half of the population relies on the government program to pay their mounting health care costs.

However, the real canary in the coal mine might be Maine, where more than 40% of the population needs Medicaid to ensure coverage (assuming they have doctors willing to accept its lower benefits than private caregivers) for medical needs. Maine is not a bunch of radicals on the left (represented for decades by former Senator Olympia Snowe, who was anything other than a firebrand) or right-wing zealots. I find it not the least surprising that the state's senior senator is Republican, perpetually "concerned" Senator Susan Collins, while avowed political Independent Angus King holds the other seat. Mainers are skeptics of both parties, often self-reliant because they only escape their snowed-in homes three or four weeks annually (I exaggerate slightly, but not much). Many down-to-earth Mainers need this program, indicative of its centrality to healthcare in America in 2025.

Politics aside, too many Americans increasingly confront a painful and expensive reality as we age: our accumulating chronic illnesses sap our adult years while breaking the bank, whether individually or collectively, under public assistance. Those long-term health conditions most notable in the twenty-first century include diabetes (causing an additional 25% increase in deaths over the past twenty years), liver disease (40% increase), kidney disease (60% growth), hypertension (up 80%) on obesity (95% of higher than merely twenty-five years ago). These are debilitating, sustained conditions for millions of Americans; accumulating costs lead us to pay more for health care than citizens of 183 other countries in the World Health Organization (a body we are departing).

The nurse above, Sam Runyon, asks Cora Perkins a revealing question: are you worse today "than your generally painful conditions"? Perkins, a survivor of two forms of cancer by the age of 64, has trouble even arising from a chair. Runyon visits Perkins regularly, but the cruel, interwoven nature of deteriorating health seems endless. Perkins shed 40 pounds while ameliorating both blood pressure and diabetes levels as a result of Runyon's regular visits but is far from healthy, not the least, because her diet is appalling along with her blood pressure. Perkins lives on public assistance such as food stamps, insufficient for "healthier" options when salt-laden chips and other ultra-processed foods fit her monthly allocation. Perkins lives in a cycle of ever-declining health as increased damage to the body occurs over the years.

The body demands food. It's easy to blame the consumer for overeating or choosing less-than-optimal items, but the problem is multifaceted. What grocery options are available to someone immobile? Some of Perkins' issues may be self-induced, but many are systemic. Ultra-processed foods suck fewer dollars from her monthly check but at a cost far lower than "whole" foods, which are counterintuitive but true. The pre-packaged options are also easier to procure and prepare, complicating Perkins' likelihood of turning around conditions.

Additionally, this is America in the twenty-first century, where our demand for "freedom" to do as we please is hard to overstate. I doubt Perkins asserts a right to be ill (or she likely would not accept Runyon's visits at all) but makes choices, in conjunction with her boyfriend, on how to spend her precious pennies. Those choices may not include oranges, beets, broccoli, or six-mile hikes on a snowy West Virginia morning.

Most troubling about this story is the overall national costs it imposes on a society suddenly awakening to the realities of our healthcare debt burden. Health care in 2021 constituted more than 17% of the gross domestic product; that is not merely for patient care, but the associated role health care plays within our economy. There are countless reasons, though Ryan Nunn, Jana Parsons, and Jay Shambaugh tout twelve items in a Brookings Institution article. They mention that public spending increased roughly four times between 1980 and 2017 and that costs vary so greatly across this vast country that it becomes a federal-level expense to ensure equity. I also note that the authors argue that 5 percent of people account for half of the spending in this country, but how will that number change with more cases of obesity and more illness?

Health care will get more expensive in the country, one way or another, because Americans are suffering more health issues. I am unclear how cutting Medicaid spending will address those who get insufficient care as their conditions worsen, which chronic conditions do. One of the primary reasons the Affordable Care Act (a.k.a. ObamaCare) became law a generation ago was the reality that the cost of people heading to an emergency room to confront an unavoidably deteriorating condition was more expensive than seeing a primary care physician along the way. While current cuts don't cite the now-popular ACA, Republicans abhor the program, so ending it has to be an objective. Voters in much of the country absolutely rely on the ACA today, regardless of how they feel about its primary author.

Leaving sick Americans high and dry would be neither popular nor feasible without a substitute for the above reason if nothing else. However, the consistent rise in chronic conditions will require increased availability of care, even in an era of demonizing others' behavior. There is no other option to keep people alive, as the Hippocratic Oath obligates the medical community to do.

Remember the "death panels" supposedly operating years ago when opponents of the ACA initially sought to end it? Without access to care for chronic conditions and deteriorating health, wouldn't we be seeing a de facto form of choosing among our population as if death panels?

Health care can bankrupt any of us should a catastrophic illness devour our savings virtually any of us have. Medical costs in the United States, a function not only of demand but of the fantastic supply of miraculous (often costly) treatment options and specialized health providers, make the industry remarkably costly. Friends in the United Kingdom shake their heads at what we have—good and evil.

With fewer regulations in place, I have a hard time thinking costs can decrease meaningfully for an individual. When multiplied against 350 million, that becomes real money, paraphrasing the late Illinois Republican Everett Dirksen when asked about government spending.

Is there fraud? Yes but I strongly doubt it’s as widespread as touted by the program’s opponents nor vast enough to lower the program’s costs significantly, if rooted out. The government actually does watch its pennies better than people give it credit. Fraud strikes me as likely by the medical community as much as by individual patients but that is my gut.

Some will say I am mixing apples, oranges, and kumquats. Still, my overall message today is that health care is bankrupting us as a nation, regardless of what the federal government does, because the legitimate demand for care (as well, perhaps, as unrealistic expectations) is outstripping the incomes all but the richest of the rich have. Yet we see little indication of hope that the causes for those increased expenditures are under control, whether they are people becoming obese, the effects of obesity on the body, the follow-on effects (actions and consequences), or anything else. It's bloody expensive to be ill with chronic ailments in this country regardless of our demand for freedom to make our own choices or the panoply of high-tech options to address the conditions.

We could raise taxes, which is a definite step toward addressing the challenge, but that option fell off the table under George H.W. Bush.

Medicine is a big business rather than a solution to a curable problem. As a big business, it seeks to expand its reach while satisfying its investors. Curing patients—or at least giving them relief from the illnesses they are suffering through—is an added benefit to the trillions invested in the system.

As my theme for this column, I try remembering that getting sick or getting too heavy (or being fearful of that) has consequences. Finding easy, cheap, enduring solutions would be nice, but that appears ever less likely in the intricately woven world where Americans live in 2025. Some challenges are of our own making, while others are actions and consequences beyond our control, such as genetics. But we should stop thinking there are easy solutions to addressing the health costs increasingly bedeviling us in the modern world. Whatever actions we take will create other effects.

We can all exercise gentle tolerance of each other's challenges, but that doesn't seem as likely today as in the past, as Americans talk past each other for various reasons on virtually every major public policy question.

I welcome your thoughts on this wicked problem. I hardly know the best response for any aspect other than to recognize the range of difficulties and unintended consequences we confront. You may have incisive thoughts on these specific challenges.

Thank you for taking time to read Actions this afternoon or any day. I appreciate you, the readers, for the feedback and motivation. I also thank those who subscribe to the newsletter.

It was a burst of pink this morning before the heavy rains I am seeing clear out this afternoon over the Chesapeake. The wind is en route.

Be well, be healthy, and safe. FIN

Center for Medicare and Medicaid Services, “There are Many Types of Medicaid Fraud”, cms.gov, retrieved at https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/downloads/infograph-there-are-many-types-medicaid-fraud-%5Bmay-2016%5D.pdf

Bruce Gil, “Over hald of adults could be overweight by 2050. Why weight loss drugs aren’t a cure”, quartz.com, 4 March 2025, retrieved at

Sarah Kliff and Marti’n Gonza’lez Go’mez, “More than 70 Million Americans Live on Medicaid. This is Where they Live”, NewYorkTimes.com, 27 February 2025, retrieved at https://www.nytimes.com/interactive/2025/02/27/us/politics/medicaid-enrollment.html

Ryan Nunn, Jana Parsons, and Jay Shambaugh, “A dozen facts about the economics of the US health-care system”, Brookings.edu, 10 March 2020, retrieved at https://www.brookings.edu/articles/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/

Eli Saslow, “She’s a Foot Soldier in America’s Losing War with Chronic Disease”, NewYorkTimes.com, 3 March 2025, retrieved athttps://www.nytimes.com/2025/03/02/us/chronic-disease-us-americans.html