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Dr. Monteiro and his colleagues developed a food classification system called Nova, named after the Portuguese and Latin words for “new.” It has since been adopted by researchers across the world.

Unprocessed or minimally processed foods, like fresh or frozen fruits and vegetables, beans, lentils, meat, poultry, fish, eggs, milk, plain yogurt, rice, pasta, corn meal, flour, coffee, tea and herbs and spices.

Processed culinary ingredients, such as cooking oils, butter, sugar, honey, vinegar and salt.

If you look at the ingredient list and you see things that you wouldn’t use in home cooking, then that’s probably an ultraprocessed food,”

his group includes freshly baked bread, most cheeses and canned vegetables, beans and fish. These foods may contain preservatives that extend shelf life.

Ultraprocessed foods made using industrial methods and ingredients you wouldn’t typically find in grocery stores — like high-fructose corn syrup, hydrogenated oils and concentrated proteins like soy isolate.

They often contain additives like flavorings, colorings or emulsifiers to make them appear more attractive and palatable.

Think sodas and energy drinks, chips, candies, flavored yogurts, margarine, chicken nuggets, hot dogs, sausages, lunch meats, boxed macaroni and cheese, infant formulas and most packaged breads, plant milks, meat substitutes and breakfast cereals.

Processed foods made by combining foods from Category 1 with the ingredients of Category 2 and preserving or modifying them with relatively simple methods like canning, bottling, fermentation and baking

That has led to debate among nutrition experts about whether it’s useful for describing the healthfulness of a food, partly since many UPFs — like whole grain breads, flavored yogurts and infant formulas — can provide valuable nutrients

Most research linking UPFs to poor health is based on observational studies, in which researchers ask people about their diets and then track their health over many years.

Why might UPFs be harmful?

In a large review of studies that was published in 2024, scientists reported that consuming UPFs was associated with 32 health problems, with the most convincing evidence for heart disease-related deaths, Type 2 diabetes and common mental health issues like anxiety and depression.

Such studies are valuable, because they can look at large groups of people — the 2024 review included results from nearly 10 million — over the many years it can take for chronic health conditions to develop

She added that the consistency of the link between UPFs and health issues increased her confidence that there was a real problem with the foods.

But the observational studies also have limitations,

It’s true that there is a correlation between these foods and chronic diseases, she said, but that doesn’t mean that UPFs directly cause poor health.

Dr. O’Connor questioned whether it’s helpful to group such “starkly different” foods — like Twinkies and breakfast cereals — into one category. Certain types of ultraprocessed foods, like sodas and processed meats, are more clearly harmful than others

UPFs like flavored yogurts and whole grain breads, on the other hand, have been associated with a reduced risk of developing Type 2 diabetes.

Clinical trials are needed to test if UPFs directly cause health problems, Dr. O’Connor said. Only one such study, which was small and had some limitations, has been done, s

In that study, published in 2019, 20 adults with a range of body sizes lived in a research hospital at the National Institutes of Health for four weeks. For two weeks, they ate mainly unprocessed or minimally processed foods, and for another two weeks, they ate mainly UPFs. The diets had similar amounts of calories and nutrients, and the participants could eat as much as they wanted at each meal.

During their two weeks on the ultraprocessed diet, participants gained an average of two pounds and consumed about 500 calories more per day than they did on the unprocessed diet

During their time on the unprocessed diet, they lost about two pounds.

That finding might help explain the link between UPFs, obesity and other metabolic conditions

The Nova system notably doesn’t classify foods based on nutrients like fat, fiber, vitamins or minerals. It’s “agnostic to nutrition,”

There are many “strong opinions” about why ultraprocessed foods are unhealthy, Dr. Hall said. “But there’s actually not a lot of rigorous science” on what those mechanisms are

Because UPFs are often cheap, convenient and accessible, they’re probably displacing healthier foods from our diets

the foods could be having more direct effects on health. They can be easy to overeat — maybe because they contain hard-to-resist combinations of carbohydrates, sugars, fats and salt, are high-calorie and easy to chew

It’s also possible that resulting blood sugar spikes may damage arteries or ramp up inflammation, or that certain food additives or chemicals may interfere with hormones, cause a “leaky” intestine or disrupt the gut microbiome.

Researchers, including Dr. Hall and Dr. Davy, are beginning to conduct small clinical trials that will test some of these theories.

most researchers think there are various ways the foods are causing harm. “Rarely in nutrition is there a single factor that fully explains the relationship between foods and some health outcome,”

In 2014, Dr. Monteiro helped write new dietary guidelines for Brazil that advised people to avoid ultraprocessed foods.

Other countries like Mexico, Israel and Canada have also explicitly recommended avoiding or limiting UPFs or “highly processed foods.”

The U.S. dietary guidelines contain no such advice, but an advisory committee is currently looking into the evidence on how UPFs may affect weight gain, which could influence the 2025 guidelines.

It’s difficult to know what to do about UPFs in the United States, where so much food is already ultraprocessed and people with lower incomes can be especially dependent on them,

“At the end of the day, they are an important source of food, and food is food,” Dr. Mattei added. “We really cannot vilify them,”

While research continues, expert opinions differ on how people should approach UPFs.

the safest course is to avoid them altogether

to swap flavored yogurt for plain yogurt with fruit, for example, or to buy a fresh loaf from a local bakery instead of packaged bread, if you can afford to do so

Dr. Vadiveloo suggested a more moderate strategy, focusing on limiting UPFs that don’t provide valuable nutrients, like soda and cookies

She also recommended eating more fruits, vegetables, whole grains (ultraprocessed or not), legumes, nuts and seeds.

Cook at home as much as you can, using minimally processed foods

nearly five million Americans fall into what’s called the “Medicaid gap”

In Germany, employees' premiums are a percentage of their incomes, so low-wage workers simply pay rock-bottom insurance rates.

Germany actually pioneered this type of insurance—it all started when Otto von Bismarck signed his Health Insurance Bill of 1883 into law. (It’s still known as the “Bismarck model” because of his legacy, and other parts of Europe and Asia have adopted it over the years.)

You can think of this setup as the Goldilocks option among all of the possible ways governments can insure health. It's not as radical as single-payer models like the U.K.’s, where the government covers everyone. And it's also not as brutal as the less-regulated version of the insurance market we had before the ACA.

Since there are no provider networks in Germany, doctors don’t know what other providers patients have seen, so there are few ways to limit repeat procedures.

All things considered, it’s good to be a sick German. There are no network limitations, so people can see any doctor they want. There are no deductibles, so Germans have no fear of spending hundreds before their insurance ever kicks in.

There’s also no money that changes hands during a medical appointment. Patients show their insurance card at the doctor’s office, and the doctors' association pays the doctor using money from the sickness funds. "You don’t have to sit at home and sort through invoices or wonder if you overlooked fine print,”

That insurance card, by the way, is good for hospital visits anywhere in Europe.

of all of the countries studied, Germans were the most likely to be able to get a same-day or next-day appointment and to hear back from a doctor quickly if they had a question. They rarely use emergency rooms, and they can access doctors after-hours with ease.

And Germany manages to put its health-care dollars to relatively good use: For each $100 it spends on healthcare, it extends life by about four months, according to a recent analysis in the American Journal of Public Health. In the U.S., one of the worst-performing nations in the ranking, each $100 spent on healthcare resulted in only a couple of extra weeks of longevity.

those differences aside, it’s fair to say the U.S. is moving in the direction of systems like Germany’s—multi-payer, compulsory, employer-based, highly regulated, and fee-for-service.

The German government is similarly trying to push more people into “family physician” programs, in which just one doctor would serve as a gatekeeper.

like the U.S., Germany may see a shortage of primary-care doctors in the near future, both because primary-care doctors there don’t get paid as much as specialists, and because entrenched norms have prevented physician assistants from shouldering more responsibility

With limitations on how much they can charge, German doctors and hospitals instead try to pump up their earnings by performing as many procedures as possible, just like American providers do.

Similarly, “In Germany, it will always be an operation,” Göpffarth said. “Meanwhile, France and the U.K. tend to try drugs first and operations later.”

With few resource constraints, healthcare systems like America's and Germany's tend to go with the most expensive treatment option possible. An American might find himself in an MRI machine for a headache that a British doctor would have treated with an aspirin and a smile.

Perhaps the biggest difference between our two approaches is the extent to which Germany has managed to rein in the cost of healthcare for consumers. Prices for procedures there are lower and more uniform because doctors’ associations negotiate their fees directly with all of the sickness funds in each state. That's part of the reason why an appendectomy costs $3,093 in Germany, but $13,000 in the U.S.

Now, Maryland is going a step further still, having just launched a plan to cap the amount each hospital can spend, total, each year. The state's hospital spending growth will be limited to 3.58 percent for the next five years. “We know that right now, the more [doctors] do, the more they get paid,” John Colmers, executive director of Maryland’s Health Services Cost Review Commission, told me. “We want to say, ‘The better you do, the better you get paid.’”

certain U.S. states have tried a more German strategy, attempting to keep costs low by setting prices across the board. Maryland, for example, has been regulating how much all of the state’s hospitals can charge since 1977. A 2009 study published in Health Affairs found that we would have saved $2 trillion if the entire country’s health costs had grown at the same rate as Maryland’s over the past three decades.

“In Germany, there is a uniform fee schedule for all physicians that work under the social code,” Schlette said. “There’s a huge catalogue where they determine meticulously how much is billed for each procedure. That’s like the Bible.”

“The red states are unlikely to follow their lead. The notion that government may be a big part of the solution, instead of the problem, is anathema, and Republican controlled legislatures, and their governors, would find it too substantial a conflict to pursue with any vigor.”

no other state has Maryland’s uniform, German-style payment system in place, “so Maryland starts the race nine paces ahead of the other 46 states,” McDonough said.

the unique spirit of each country is what ultimately gets in its way. Germany’s more orderly system can be too rigid for experimentation. And America’s free-for-all, where hospitals and doctors all charge different amounts, is great for innovation but too chaotic to make payment reforms stick.

rising health costs will continue to be the main problem for Americans as we launch into our more Bismarckian system. “The main challenge you’ll have is price control,” he said. “You have subsidies in health exchanges now, so for the first time, the federal budget is really involved in health expenditure increases in the commercial market. In order to keep your federal budget under control, you’ll have to control prices.”

Even in better times, this arrangement was a bad idea from a health perspective. Most Americans whose families depend on their employers for coverage are just a layoff away from being uninsured.

Many will sadly lose their jobs over the coming weeks – with one estimate projecting as many as 30%. And as they do, Americans are about to learn something horrifying: how irrational and irresponsible it is for so many to be dependent on employers for health insurance.

Take it from me. I’m a former health insurance executive who once profited from this system. It’s time for it to stop.

the cost of treatment for Covid-19 can run around $35,000. As the patient in the report exclaimed: “I was pretty sticker-shocked. I personally don’t know anybody who has that kind of money.”

During the last big recession, researchers at Cornell University found that 9.3 million Americans lost their health insurance between 2007 and 2009

During this time, roughly six in 10 Americans who lost their jobs became uninsured.

this problem compounds itself. If the reason you lost your health insurance is that you no longer have steady employment, how are you now going to be able to afford monthly premiums for some other private health care plan?

even in good times, the employer-based model fails to cover enough of us, with the number of Americans covered through an employer steadily dropping in general. Since 1999, the percentage of those with job-based coverage has declined by nine points.

at a time in our nation’s history where more will need quality care than ever before, the human cost will simply be too much to bear.

what the administration should have been doing in January to prepare us for today.

She cites the delay on tests, without which “cases go undetected and people continue to circulate” as a leading issue along with other missed federal government responses—many of which are still not fully operational

The prescient recommendations from experts across disciplines in the period before COVID-19 reached American shores—about testing, equipment, and distancing—make clear that more than any single factor, it was Trump’s squandering of out lead-time which should have been used to prepare for the pandemic that has exacerbated this crisis.

What follows is an annotated timeline revealing the warning signs the administration received and showing how slow the administration was to act on these recommendations.

The Early Years: Warnings Ignored

2017: Trump administrations officials are briefed on an intelligence document titled “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.” That’s right. The administration literally had an actual playbook for what to do in the early stages of a pandemic

February 2018: The Washington Post writes “CDC to cut by 80 percent efforts to prevent global disease outbreak.” The meat of the story is “Countries where the CDC is planning to scale back include some of the world’s hot spots for emerging infectious disease, such as China, Pakistan, Haiti, Rwanda and Congo.”

May 2018: At an event marking the 100 year anniversary of the 1918 pandemic, Borio says “pandemic flu” is the “number 1 health security issue” and that the U.S. is not ready to respond.

One day later her boss, Rear Adm. Timothy Ziemer is pushed out of the administration and the global health security team is disbanded

Beth Cameron, former senior director for global health security on the National Security Council adds: “It is unclear in his absence who at the White House would be in charge of a pandemic,” Cameron said, calling it “a situation that should be immediately rectified.” Note: It was not

January 2019: The director of National Intelligence issues the U.S. Intelligence Community’s assessment of threats to national security. Among its findings:

A novel strain of a virulent microbe that is easily transmissible between humans continues to be a major threat, with pathogens such as H5N1 and H7N9 influenza and Middle East Respiratory Syndrome Coronavirus having pandemic potential if they were to acquire efficient human-to-human transmissibility.”

Page 21: “We assess that the United States and the world will remain vulnerable to the next flu pandemic or large scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.”

September, 2019: The Trump Administration ended the pandemic early warning program, PREDICT, which trained scientists in China and other countries to identify viruses that had the potential to turn into pandemics. According to the Los Angeles Times, “field work ceased when funding ran out in September,” two months before COVID-19 emerged in Wuhan Province, China.

2020: COVID-19 Arrives

anuary 3, 2020: The CDC is first alerted to a public health event in Wuhan, China

January 6, 2020: The CDC issues a travel notice for Wuhan due to the spreading coronavirus

Note: The Trump campaign claims that this marks the beginning of the federal government disease control experts becoming aware of the virus. It was 10 weeks from this point until the week of March 16 when Trump began to change his tone on the threat.

January 10, 2020: Former Trump Homeland Security Advisor Tom Bossert warns that we shouldn’t “jerk around with ego politics” because “we face a global health threat…Coordinate!”

January 18, 2020: After two weeks of attempts, HHS Secretary Alex Azar finally gets the chance to speak to Trump about the virus. The president redirects the conversation to vaping, according to the Washington Post. 

January 21, 2020: Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Disease at the CDC tells reporters, “We do expect additional cases in the United States.”

January 27, 2020: Top White House aides meet with Chief of Staff Mick Mulvaney to encourage greater focus on the threat from the virus. Joe Grogan, head of the White House Domestic Policy Council warns that “dealing with the virus was likely to dominate life in the United States for many months.”

January 28, 2020: Two former Trump administration officials—Gottlieb and Borio—publish an op-ed in the Wall Street Journal imploring the president to “Act Now to Prevent an American Epidemic.” They advocate a 4-point plan to address the coming crisis:

(1) Expand testing to identify and isolate cases. Note: This did not happen for many weeks. The first time more than 2,000 tests were deployed in a single day was not until almost six weeks later, on March 11.

(3) Prepare hospital units for isolation with more gowns and masks. Note: There was no dramatic ramp-up in the production of critical supplies undertaken. As a result, many hospitals quickly experienced shortages of critical PPE materials. Federal agencies waited until Mid-March to begin bulk orders of N95 masks.

January 29, 2020: Trump trade advisor Peter Navarro circulates an internal memo warning that America is “defenseless” in the face of an outbreak which “elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”

January 30, 2020: Dr. James Hamblin publishes another warning about critical PPE materials in the Atlantic, titled “We Don’t Have Enough Masks.”

January 29, 2020: Republican Senator Tom Cotton reaches out to President Trump in private to encourage him to take the virus seriously.

Late January, 2020:  HHS sends a letter asking to use its transfer authority to shift $136 million of department funds into pools that could be tapped for combating the coronavirus. White House budget hawks argued that appropriating too much money at once when there were only a few U.S. cases would be viewed as alarmist.

Trump’s Chinese travel ban only banned “foreign nationals who had been in China in the last 14 days.” This wording did not—at all—stop people from arriving in America from China. In fact, for much of the crisis, flights from China landed in America almost daily filled with people who had been in China, but did not fit the category as Trump’s “travel ban” defined it.

January 31, 2020: On the same day Trump was enacting his fake travel ban, Foreign Policy reports that face masks and latex gloves are sold out on Amazon and at leading stores in New York City and suggests the surge in masks being sold to other countries needs “refereeing” in the face of the coming crisis.

February 4, 2020: Gottlieb and Borio take to the WSJ again, this time to warn the president that “a pandemic seems inevitable” and call on the administration to dramatically expand testing, expand the number of labs for reviewing tests, and change the rules to allow for tests of people even if they don’t have a clear known risk factor.

Note: Some of these recommendations were eventually implemented—25 days later.

February 5, 2020: HHS Secretary Alex Azar requests $2 billion to “buy respirator masks and other supplies for a depleted federal stockpile of emergency medical equipment.” He is rebuffed by Trump and the White House OMB who eventually send Congress a $500 million request weeks later.

February 4 or 5, 2020: Robert Kadlec, the assistant secretary for preparedness and response, and other intelligence officials brief the Senate Intelligence Committee that the virus poses a “serious” threat and that “Americans would need to take actions that could disrupt their daily lives.”

February 5, 2020: Senator Chris Murphy tweets: Just left the Administration briefing on Coronavirus. Bottom line: they aren't taking this seriously enough. Notably, no request for ANY emergency funding, which is a big mistake. Local health systems need supplies, training, screening staff etc. And they need it now.

February 9, 2020: The Washington Post reports that a group of governors participated in a jarring meeting with Dr. Anthony Fauci and Dr. Robert Redfield that was much more alarmist than what they were hearing from Trump. “The doctors and the scientists, they were telling us then exactly what they are saying now,” Maryland Gov. Larry Hogan (R) said.

the administration lifted CDC restrictions on tests. This is a factually true statement. But it elides that fact that they did so on March 3—two critical weeks after the third Borio/Gottlieb op-ed on the topic, during which time the window for intervention had shrunk to a pinhole.

February 20, 2020: Borio and Gottlieb write in the Wall Street Journal that tests must be ramped up immediately “while we can intervene to stop spread.”

February 23, 2020: Harvard School of Public Health professor issues warning on lack of test capability: “As of today, the US remains extremely limited in#COVID19 testing. Only 3 of ~100 public health labs haveCDC test kits working and CDC is not sharing what went wrong with the kits. How to know if COVID19 is spreading here if we are not looking for it.

February 24, 2020: The Trump administration sends a letter to Congress requesting a small dollar amount—between $1.8 billion and $2.5 billion—to help combat the spread of the coronavirus. This is, of course, a pittance

February 25, 2020: Messonier says she expects “community spread” of the virus in the United States and that “disruption to everyday life might be severe.” Trump is reportedly furious and Messonier’s warnings are curtailed in the ensuing weeks.

Trump mocks Congress in a White House briefing, saying “If Congress wants to give us the money so easy—it wasn’t very easy for the wall, but we got that one done. If they want to give us the money, we’ll take the money.”

February 26, 2020: Congress, recognizing the coming threat, offers to give the administration $6 billion more than Trump asked for in order to prepare for the virus.

February 27, 2020: In a leaked audio recording Sen. Richard Burr, chairman of the Intelligence Committee and author of the Pandemic and All-Hazards Preparedness Act (PAHPA) and the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (reauthorization of PAHPA), was telling people that COVID-19 “is probably more akin to the 1918 pandemic.”

March 4, 2020: HHS says they only have 1 percent of respirator masks needed if the virus became a “full-blown pandemic.”

March 3, 2020: Vice President Pence is asked about legislation encouraging companies to produce more masks. He says the Trump administration is “looking at it.”

March 7, 2020: Fox News host Tucker Carlson, flies to Mar-a-Lago to implore Trump to take the virus seriously in private rather than embarrass him on TV. Even after the private meeting, Trump continued to downplay the crisis

March 9, 2020: Tom Bossert, Trump’s former Homeland Security adviser, publishes an op-ed saying it is “now or never” to act. He advocates for social distancing and school closures to slow the spread of the contagion.

Trump says that developments are “good for the consumer” and compares COVID-19 favorably to the common flu.

March 17, 2020: Facing continued shortages of the PPE equipment needed to prevent healthcare providers from succumbing to the virus, Oregon Senators Jeff Merkeley and Ron Wyden call on Trump to use the Defense Production Act to expand supply of medical equipment

March 18, 2020: Trump signs the executive order to activate the Defense Production Act, but declines to use it

At the White House briefing he is asked about Senator Chuck Schumer’s call to urgently produce medical supplies and ventilators. Trump responds: “Well we’re going to know whether or not it’s urgent.” Note: At this point 118 Americans had died from COVID-19.

March 20, 2020: At an April 2nd White House Press Conference, President Trump’s son-in-law Jared Kushner who was made ad hoc point man for the coronavirus response said that on this date he began working with Rear Admiral John Polowczyk to “build a team” that would handle the logistics and supply chain for providing medical supplies to the states. This suggestion was first made by former Trump Administration officials January 28th

March 22, 2020: Six days after calling for a 15-day period of distancing, Trump tweets that this approach “may be worse than the problem itself.”

March 24, 2020: Trump tells Fox News that he wants the country opened up by Easter Sunday (April 12)

As Trump was speaking to Fox, there were 52,145 confirmed cases in the United States and the doubling time for daily new cases was roughly four days.

"They don't have a massive eraser pen. They've got to go through the rule-making process," said Allison Orris, a former Obama administration official and counsel with Manatt Health, a professional services firm. "They are going to have to think about what comes first, second and third and be realistic about timing."

Plus, the Biden administration may opt to keep and continue several Trump administration efforts, including shifting to value-based care, rather than paying doctors for every visit and procedure, and increasing access to telehealth,

The two administrations also share common views on some measures to lower drug pricing, including basing Medicare payments on the cost of prescription medications in other countries and importing drugs from abroad. But Trump officials have not actually put these proposals in place.

While Trump focused on dismantling the Affordable Care Act, Biden will emphasize expanding the law and access to health coverage.

The Trump administration took the historic step in early 2018 of allowing states to require certain Medicaid recipients to work in order to receive benefits. Eight states have received approval, seven have pending requests and four had their waivers set aside in court, according to the Kaiser Family Foundation.

Biden's Health and Human Services secretary would be able to unwind the approvals, but it is a complicated task, said Joan Alker, executive director of the Center for Children and Families at Georgetown University. The secretary would have to determine whether to withdraw permission for the entire waiver or just certain features.

Several of these waivers included other provisions that could make it harder for low-income Americans to retain Medicaid coverage, such as lockouts for non-payment of premiums.

One executive order Trump repeatedly points to is expanding short-term health plans, which typically have lower premiums, but provide less comprehensive coverage and don't have to adhere to the Affordable Care Act's protections for people with pre-existing conditions.

"The short-term plans have important symbolic significance because they restrict coverage to people with pre-existing conditions, which was a prominent political issue in the campaign," said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation.

In its first year in office, the Trump administration slashed funds to promote Obamacare open enrollment and to assist consumers with selecting plans by 90% and 84%, respectively.

The Biden administration is expected to reverse all these measures to curtail Obamacare.

Biden has promised to revoke the Trump administration rule barring federally funded health care providers in the Title X family planning program from referring patients for abortions.

Biden has vowed to reverse the so-called Mexico City Policy, a ban on funding for foreign nonprofits that perform or promote abortions, which Trump reinstated and expanded during his tenure.

The Trump administration reinstated the measure -- which had previously impacted only family planning assistance -- in 2017 by presidential memorandum and extended it to all applicable US global health funding under the "Protecting Life in Global Health Assistance."

The Biden administration is also expected to reinstitute a directive that states cannot bar Medicaid funds from going to qualified providers that separately provide abortions, such as Planned Parenthood.

Trump also signed a bill in 2017 allowing states to withhold federal money from organizations that provide abortion services, including Planned Parenthood.

The Trump administration has been particularly hostile toward transgender Americans. Among its most criticized moves was an effort earlier this year to rollback an Obama-era regulation prohibiting discrimination in health care against patients who are transgender.

Biden's LGBTQ policy plan also says he will work to expand funding for mental health services for LGBTQ Americans and that his administration plans to automatically enroll low-income LGBTQ people in the public option, once it's created, if they live in rural areas in states that didn't expand Medicaid.

In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices.

I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.

If you can’t afford it, not buying it is hardly a choice.

in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.

And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.

And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd

According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.

In fact, the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries.

When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world — but that’s barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries.

the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care.

Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.

It’s true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.

Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that’s not necessarily the case either.

A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better

When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.

in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power

It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care

And the point of having the government manage this complicated service is not to take freedom away from the individual

The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone

What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.

As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.

So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.

According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.

in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.

Last year, a Chinese scientist he worked with published a specific forecast: “It is highly likely that future SARS- or MERS-like coronavirus outbreaks will originate from bats, and there is an increased probability that this will occur in China.”

Humans today are exposed to more deadly new pathogens than ever. They typically come from animals, as global travel, trade and economic development, such as meat production and deforestation, push people, livestock and wildlife closer together

Scientists knew infectious disease outbreaks were becoming more common, with 2010 having more than six times the outbreaks of pathogens from animal origins than in 1980, according to data in a study by Brown University researchers.

Yet plenty was left undone, in areas including funding, early-warning systems, the role of the WHO and coordination with China. A big chunk of U.S. funding went toward protecting Americans against a bioterror attack. Government funding for pandemics has come largely in emergency, one-time packages to stop an ongoing outbreak.

She said a better solution would be to fund public health more like national defense, with much more guaranteed money, year in, year out.

“Will there be another human influenza pandemic?” Dr. Webster asked in a paper presented at an NIH meeting in 1995. “The certainty is that there will be.”

Experts including Dr. Webster were particularly concerned about the potential for spillover in southern China, where large, densely populated cities were expanding rapidly into forests and agricultural lands, bringing people into closer contact with animals. Two of the three influenza pandemics of the 20th century are thought to have originated in China.

Dr. Webster and others warned it could re-emerge or mutate into something more contagious. With U.S. funding, he set up an animal influenza surveillance center in Hong Kong. The WHO, which hadn’t planned for pandemics before, started compiling protocols for a large-scale outbreak, including contingency plans for vaccines.

At a dinner back in the U.S., he remembers one guest saying, “Oh, you really needed to have someone in the U.S. to be impacted to really galvanize the government.”

That “drove home the reality in my own mind of globalization,” said Dr. Fukuda. SARS showed that viruses can crisscross the globe by plane in hours, making a local epidemic much more dangerous.

The WHO’s director-general, Gro Harlem Brundtland, publicly criticized China. The government under new leaders reversed course. It implemented draconian quarantines and sanitized cities, including a reported 80 million people enlisted to clean streets in Guangdong.

By May 2003, the number of new SARS cases was dwindling. It infected around 8,000 people world-wide, killing nearly 10%.

After SARS, China expanded epidemiologist training and increased budgets for new laboratories. It started working more closely in public health with the U.S., the world’s leader. The U.S. CDC opened an office in Beijing to share expertise and make sure coverups never happened again. U.S. CDC officials visiting a new China CDC campus planted a friendship tree.

In Washington in 2005, a powerful player started driving U.S. efforts to become more prepared. President George W. Bush had read author John M. Barry’s “The Great Influenza,” a history of the 1918 flu pandemic

Mr. Bush leaned toward the group of 10 or so officials and said, “I want to see a plan,” according to Dr. Venkayya. “He had been asking questions and not getting answers,” recalled Dr. Venkayya, now president of Takeda Pharmaceutical Co. ’s global vaccine business unit. “He wanted people to see this as a national threat.”

Mr. Bush launched the strategy in November, and Congress approved $6.1 billion in one-time funding.

The CDC began exercises enacting pandemic scenarios and expanded research. The government created the Biomedical Advanced Research and Development Authority to fund companies to develop diagnostics, drugs and vaccines.

A team of researchers also dug into archives of the 1918 pandemic to develop guidelines for mitigating the spread when vaccines aren’t available. The tactics included social distancing, canceling large public gatherings and closing schools—steps adopted this year when Covid-19 struck, though at the time they didn’t include wide-scale lockdowns.

A year after the plan was released, a progress report called for more real-time disease surveillance and preparations for a medical surge to care for large numbers of patients, and stressed strong, coordinated federal planning.

A European vaccine makers’ association said its members had spent around $4 billion on pandemic vaccine research and manufacturing adjustments by 2008.

The $6.1 billion Congress appropriated for Mr. Bush’s pandemic plan was spent mostly to make and stockpile medicines and flu vaccines and to train public-health department staff. The money wasn’t renewed. “The reality is that for any leader it’s really hard to maintain a focus on low-probability high-consequence events, particularly in the health arena,” Dr. Venkayya said.

In the U.S., President Barack Obama’s administration put Mr. Bush’s new plan into action for the first time. By mid-June, swine flu, as it was dubbed, had jumped to 74 countries. The WHO officially labeled it a pandemic, despite some evidence suggesting the sickness was pretty mild in most people.

That put in motion a host of measures, including some “sleeping” contracts with pharmaceutical companies to begin vaccine manufacturing—contracts that countries like the United Kingdom had negotiated ahead of time so they wouldn’t have to scramble during an outbreak.

In August, a panel of scientific advisers to Mr. Obama published a scenario in which as many as 120 million Americans, 40% of the population, could be infected that year, and up to 90,000 people could die.

H1N1 turned out to be much milder. Although it eventually infected more than 60 million Americans, it killed less than 13,000. In Europe, fewer than 5,000 deaths were reported.

The WHO came under fire for labeling the outbreak a pandemic too soon. European lawmakers, health professionals and others suggested the organization may have been pressured by the pharmaceutical industry.

France ordered 94 million doses, but had logged only 1,334 serious cases and 312 deaths as of April 2010. It managed to cancel 50 million doses and sell some to other countries, but it was still stuck with a €365 million tab, or about $520 million at the time, and 25 million extra doses.

The WHO had raised scares for SARS, mad-cow disease, bird flu and now swine flu, and it had been wrong each time, said Paul Flynn, a member of the Council of Europe’s Parliamentary Assembly and a British lawmaker, at a 2010 health committee hearing in Strasbourg.

Ultimately, an investigation by the council’s committee accused the WHO and public-health officials of jumping the gun, wasting money, provoking “unjustified fear” among Europeans and creating risks through vaccines and medications that might not have been sufficiently tested.

“I thought you might have uttered a word of regret or an apology,” Mr. Flynn told Dr. Fukuda, who as a representative of the WHO had been called to testify.

Back in Washington, scientist Dennis Carroll, at the U.S. Agency for International Development, was also convinced that flu wasn’t the only major pandemic threat. In early 2008, Dr. Carroll was intrigued by Dr. Daszak’s newly published research that said viruses from wildlife were a growing threat, and would emerge most frequently where development was bringing people closer to animals.

If most of these viruses spilled over to humans in just a few places, including southern China, USAID could more easily fund an early warning system.

“You didn’t have to look everywhere,” he said he realized. “You could target certain places.” He launched a new USAID effort focused on emerging pandemic threats. One program called Predict had funding of about $20 million a year to identify pathogens in wildlife that have the potential to infect people.

Drs. Daszak, Shi and Wang, supported by funds from Predict, the NIH and China, shifted their focus to Yunnan, a relatively wild and mountainous province that borders Myanmar, Laos and Vietnam.

One key discovery: a coronavirus resembling SARS that lab tests showed could infect human cells. It was the first proof that SARS-like coronaviruses circulating in southern China could hop from bats to people. The scientists warned of their findings in a study published in the journal Nature in 2013.

Evidence grew that showed people in the area were being exposed to coronaviruses. One survey turned up hundreds of villagers who said they recently showed symptoms such as trouble breathing and a fever, suggesting a possible viral infection.

Over the next several years, governments in the U.S. and elsewhere found themselves constantly on the defensive from global viral outbreaks. Time and again, preparedness plans proved insufficient. One, which started sickening people in Saudi Arabia and nearby

On a weekend morning in January 2013, more than a dozen senior Obama administration officials met in a basement family room in the suburban home of a senior National Security Council official. They were brainstorming how to help other countries upgrade their epidemic response capabilities, fueled by bagels and coffee. Emerging disease threats were growing, yet more than 80% of the world’s countries hadn’t met a 2012 International Health Regulations deadline to be able to detect and respond to epidemics.

The session led to the Global Health Security Agenda, launched by the U.S., the WHO and about 30 partners in early 2014, to help nations improve their capabilities within five years.

Money was tight. The U.S. was recovering from the 2008-09 financial crisis, and federal funding to help U.S. states and cities prepare and train for health emergencies was declining. Public-health departments had cut thousands of jobs, and outdated data systems weren’t replaced.

“It was a Hail Mary pass,” said Tom Frieden, who was director of the CDC from 2009 to 2017 and a force behind the creation of the GHSA. “We didn’t have any money.”

At the WHO, Dr. Fukuda was in charge of health security. When the Ebola outbreak was found in March 2014, he and his colleagues were already stretched, after budget cuts and amid other crises.

The United Nations created a special Ebola response mission that assumed the role normally played by the WHO. Mr. Obama sent the U.S. military to Liberia, underscoring the inability of international organizations to fully handle the problem.

It took the WHO until August to raise an international alarm about Ebola. By then, the epidemic was raging. It would become the largest Ebola epidemic in history, with at least 28,600 people infected, and more than 11,300 dead in 10 countries. The largest outbreak before that, in Uganda, had involved 425 cases.

Congress passed a $5.4 billion package in supplemental funds over five years, with about $1 billion going to the GHSA. The flood of money, along with aggressive contact tracing and other steps, helped bring the epidemic to a halt, though it took until mid-2016.

Global health experts and authorities called for changes at the WHO to strengthen epidemic response, and it created an emergencies program. The National Security Council warned that globalization and population growth “will lead to more pandemics,” and called for the U.S. to do more.

r. Carroll of USAID, who had visited West Africa during the crisis, and saw some health workers wrap themselves in garbage bags for protection, started conceiving of a Global Virome Project, to detect and sequence all the unknown viral species in mammals and avian populations on the planet.

Billionaire Bill Gates warned in a TED talk that an infectious disease pandemic posed a greater threat to the world than nuclear war, and urged world leaders to invest more in preparing for one. The Bill & Melinda Gates Foundation helped form a new initiative to finance vaccines for emerging infections, the Coalition for Epidemic Preparedness Innovations.

Congress established a permanent Infectious Diseases Rapid Response Fund for the CDC in fiscal 2019, with $50 million for that year and $85 million in fiscal 2020.

In May 2018, John Bolton, then President Trump’s national security adviser, dismantled an NSC unit that had focused on global health security and biodefense, with staff going to other units. The senior director of the unit left.

It pushed emerging disease threats down one level in the NSC hierarchy, making pandemics compete for attention with issues such as North Korea, said Beth Cameron, a previous senior director of the unit. She is now vice president for global biological policy and programs at the Nuclear Threat Initiative.

Deteriorating relations with China reduced Washington’s activities there just as researchers were becoming more certain of the threat from coronaviruses.

Dr. Carroll had earlier been ordered to suspend his emerging pandemic threats program in China.

Dr. Carroll pitched to USAID his Global Virome Project. USAID wasn’t interested, he said. He left USAID last year. A meeting that Dr. Carroll planned for last August with the Chinese CDC and Chinese Academy of Sciences to form a Chinese National Virome Project was postponed due to a bureaucratic hang-up. Plans to meet are now on hold, due to Covid-19.

Unfortunately, epinephrine is inherently unstable. Research shows that it degrades pretty quickly over time, and it’s recommended that EpiPens be replaced every year.

Mylan stopped selling individual EpiPens and began to sell only twin-packs.It also raised the price.

Kids need them in many places. They need them at home. They need them at school. They need them at camp. They may even want to stash one at Grandma’s house. So people often need to buy quite a few.More revenue for Mylan. And it raised the price.

Then in 2010, federal guidelines changed to recommend that two EpiPens be sold in a package instead of one

People in anaphylaxis need a full dose every time. They therefore need to replace all their EpiPens every year, again and again.

In 2013, the government went further. It passed a law that gave funding preferences for asthma treatment grants to states that maintained an emergency supply of EpiPens. As the near sole supplier of the devices, Mylan stood to make even more money. Advertisement Continue reading the main story That year, Mylan raised the price again.

Of course, competition would bring the price down. But it’s very hard to bring such a device to market.

setbacks, all in the last year, have once again left Mylan with a veritable run of the market. It raised the price of EpiPens again. As of this May, they cost more than $600 a pack. Since 2004, after adjusting for inflation, the price of EpiPens has risen more than 450 percent.

An alternative still exists. The Adrenaclick, while still not cheap, is back and less expensive than the EpiPen. Some think it’s harder to use, though. It’s not on the accepted list for many health insurance plans. More important, few physicians think of it. Because of that, they write prescriptions for EpiPens. Since the Adrenaclick is not a generic version of the EpiPen, pharmacists can’t substitute one for the other. A prescription for an EpiPen must be filled with an EpiPen, regardless of what consumers might want.

you could argue that they’re an alternative when the “Cadillac” EpiPens are financially out of reach. Write A Comment But those are unsatisfactory arguments. Epinephrine isn’t an elective medication. It doesn’t last, so people need to purchase the drug repeatedly. There’s little competition, but there are huge hurdles to enter the market, so a company can raise the price again and again with little pushback. The government encourages the product’s use, but makes no effort to control its cost. Insurance coverage shields some from the expense, allowing higher prices, but leaves those most at-risk most exposed to extreme out-of-pocket outlays. The poor are the most likely to consider going without because they can’t afford it.

EpiPens are a perfect example of a health care nightmare. They’re also just a typical example of the dysfunction of the American health care system.

This narrative – that "others," often from far-flung places, are to blame for epidemics – is a dramatic example of a long tradition of hatred. In 14th-century Europe, Jewish communities were wrongfully accused of poisoning wells to spread the Black Death. In 1900, Chinese people were unfairly vilified for an outbreak of the plague in San Francisco's Chinatown. And in the '80s, Haitians were blamed for bringing HIV/AIDS to the U.S., a theory that's considered unsubstantiated by many global health experts.

Some public health practitioners say the global health system is partially responsible for perpetuating these ideas.According to Abraar Karan, a doctor at the Brigham and Women's Hospital and Harvard Medical School, the notion persists in global health that "the West is the best." This led to an assumption early on in the pandemic that COVID-19 spread to the rest of the world because China wasn't able to control it.

China's response was not without fault. The government's decision to silence doctors and not warn the public about a likely pandemic for six days in mid-January caused more than 3,000 people to become infected within a week, according to a report by the Associated Press, and created ripe conditions for global spread. Some of the aggressive measures China took to control the epidemic – confining people to their homes, for example — have been described as "draconian" and a violation of civil rights, even if they ultimately proved effective.

But it soon became clear that assumptions about the superiority of Western health systems were false when China and other Asian countries, along with many African countries, controlled outbreaks far more effectively and faster than Western countries did, says Karan.

Some politicians, including former President Donald Trump publicly blamed China for the pandemic, calling this novel coronavirus the "Chinese Virus" or the "Wuhan Virus." They consistently pushed that narrative even after the World Health Organization (WHO) warned as early as March 2020, when the pandemic was declared, that such language would encourage racial profiling and stigmatization against Asians. Trump has continued to use stigmatizing language in the wake of the Atlanta shooting, using the phrase "China virus" during a March 16 call to Fox News.

A report by researchers at the University of California at San Francisco (UCSF), released this month, directly linked Trump's first tweet about a "Chinese virus" to a significant increase in anti-Asian hashtags. According to a separate report by the Center for the Study of Hate and Extremism, anti-Asian hate crimes in 16 U.S. cities increased 149 percent in 2020, from 49 to 122.

Suspicion tends to manifest more during times of vulnerability, like in wartime or during a pandemic, says ElsaMarie D'Silva, an Aspen Institute New Voices fellow from India who studies violence and harassment issues. It just so happened that COVID-19 was originally identified in China, but, as NPR's Jason Beaubien has reported, some of the early clusters of cases elsewhere came from jet setters who traveled to Europe and ski destinations.

Karan says we also need to shift our approach to epidemics. In the case of COVID-19 and other outbreaks, Western countries often think of them as a national security issue, closing borders and blaming the countries where the disease was first reported. This approach encourages stigmatization, he says.

In the early days of COVID-19, skepticism by Western public health officials about the efficacy of Asian mask protocols hindered the U.S.'s ability to control the pandemic. Additionally, stereotypes about who was and wasn't at risk had significant consequences, says Nancy Kass, deputy director for public health at the Johns Hopkins Berman Institute of Bioethics.

According to Kass, doctors initially only considered a possible COVID-19 diagnosis among people who had recently flown back from China. That narrow focus caused the U.S. to misdiagnose patients who presented with what we now call classic COVID symptoms simply because they hadn't traveled from China.

It's reminiscent of the HIV/AIDS epidemic in the 1980s, Kass says. Because itwas so widely billed as a "gay disease," there are many documented cases of heterosexual women who presented with symptoms but weren't diagnosed until they were on their deathbeds.

That's not to say that we should ignore facts and patterns about new diseases. For example, Kass says it's appropriate to warn pregnant women about the risks of traveling to countries where the Zika virus, which is linked to birth and developmental defects, is present.

But there's a difference, she says, between making sure people have enough information to understand a disease and attaching a label, like "Chinese virus," that is inaccurate and that leads to stereotyping.

the West is usually regarded as the hub of expertise and knowledge, says Sriram Shamasunder, an associate professor of medicine at UCSF, and there's a sense among Western health workers that epidemics occur in impoverished contexts because the people there engage in primitive behaviors and just don't care as much about health.

Instead, Karan suggests reframing the discussion to focus on global solidarity, which promotes the idea that we are all in this together. One way for wealthy countries to demonstrate solidarity now, Karan says, is by supporting the equitable and speedy distribution of vaccines among countries globally as well as among communities within their own borders.Without such commitments in place, "it prompts the question, whose lives matter most?" says Shamasunder.

Ultimately, the global health community – and Western society as a whole – has to discard its deep-rooted mindset of coloniality and tendency to scapegoat others, says Hswen. The public health community can start by talking more about the historic racism and atrocities that have been tied to diseases.

Additionally, Karan says, leaders should reframe the pandemic for people: Instead of blaming Asians for the virus, blame the systems that weren't adequately prepared to respond to a pandemic.

Although WHO has had specific guidance since 2015 about not naming diseases after places, Hswen says the public health community at large should have spoken out earlier and stronger last year against racialized language and the ensuing violence. She says they should have anticipated the backlash against Asians and preempted it with public messaging and education about why neutral terms like "COVID-19" should be used instead of "Chinese virus."

But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.

by next year, more than half of Medicare recipients will be in a private plan.

a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers

Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete

Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist

Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.

Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

few analysts expect major legislative or regulatory changes to the program.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

Comprehensive data about those who have gotten sick could help inform more effective responses to the crisis. But public health researchers say that when governments such as the United States either don't collect, or don't publish their data, it's impossible for experts to gain an accurate sense of what's going on.

While necessarily partial and incomplete, the results highlight what public health experts have been warning for some time, theorizing that it is not only biology but also gendered behaviors -- the different ways in which men and women conduct their lives -- which may play a significant role in the different mortality rate for respiratory diseases.

"If I was designing clinical guidelines, I would very much want to understand why some people seem to have a much higher risk of mortality than others. It might for example lead to a difference in the way in which we administer clinical guidelines amongst people who have pre-existing health conditions that lead to risk of death along with those with chronic lung disease, who are more likely to be men."Hawkes also noted that reporting sex-disaggregated data on epidemics has been requested by the World Health Organization since 2007, but many countries fail to do so.

"I am fairly sure that down to the smallest districts across the US, people have the data. What we've not seeing happening it seems is a collation, a collection of that data at state and national level with the speed which one might hope to see from the perspective of global health research."

From an evolutionary perspective, some research suggests that women have a stronger immune response against viral infections than men because they spend part of their lives with a foreign body inside -- their offspring -- thus granting them a survival advantage."It might have to do with hormonal changes," Ostrosky-Zeichner said. "There is actual research in animals that has shown there may be a biological basis for the sort of increasing susceptibility in the male gender and not only that but also an increased severity and response to the virus."

Initial reports of people with severe Covid-19 disease have found that they were likely to have underlying health conditions such as hypertension, cardiovascular disease and chronic lung disease, according to Global Health 50/50. These conditions tend to be more common among men in the six countries analyzed as well as globally, the institute said, possibly because of riskier lifestyle choices.

China has the largest smoking population in the world, with around 316 million adult smokers. But while over 50% of Chinese men smoke, less than 3% of women do, according to the Chinese Center for Disease Control and Prevention. In Italy, 7 million men smoke as opposed to the 4.5 million women, according to 2020 data released by the National Health Institute (ISS)The institute reported that, upon admission to hospital, "a third more Covid-19-positive smokers had a more serious clinical situation than non-smokers."

But the lack of data on how many men died of novel coronavirus as opposed to women, Global Health 50/50 researchers say, feels like a missed opportunity for governments to implement public health policies that target certain groups of people who are significantly more vulnerable than the rest of the population.

"What Covid-19 reveals is a classic case of failing to use data for decision making. For every patient there is a record of their sex. But that data is not collated and analyzed with a gender lens," Dr. Kent Buse, co-founder of GH5050 and chief of strategic policy directions at UNAIDS told CNN.

“It’s supposed to be going down, as it is in other countries,” said the lead author of the report, Steven H. Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University. “The fact that that number is climbing, there’s something terribly wrong.”

The opioid epidemic is a major driver of the worrisome numbers, but far from the sole cause. The study found that improvements in life expectancy, largely because of lower rates of infant mortality, began to slow in the 1980s, long before the opioid epidemic became a national tragedy

Some of it may be due to obesity, some of it may be due to drug addiction, some of it may be due to distracted driving from cellphones

Given the breadth and pervasiveness of the trend, “it suggests that the cause has to be systemic, that there’s some root cause that’s causing adverse health across many different dimensions for working-age adults.”

The risk of death from drug overdoses increased 486 percent for midlife women between 1999 and 2017; the risk increased 351 percent for men in that same period. Women also experienced a bigger relative increase in risk of suicide and alcohol-related liver disease.

The all-cause death rate — meaning deaths per 100,000 people — rose 6 percent from 2010 to 2017 among working-age people in the United States

There’s something more fundamental about how people are feeling at some level — whether it’s economic, whether it’s stress, whether it’s deterioration of family,” she said. “People are feeling worse about themselves and their futures, and that’s leading them to do things that are self-destructive and not promoting health.”

. The general trend: Life expectancy improved a great deal for several decades, particularly in the 1970s, then slowed down, leveled off, and finally reversed course after 2014, decreasing three years in a row.

Obesity is a significant part of the story. The average woman in America today weighs as much as the average man half a century ago, and men now weigh about 30 pounds more

Princeton professors Anne Case and Angus Deaton, whose much-publicized report in 2015 highlighted the death rates in middle-aged whites, published a paper in 2017 pointing to a widening gap in health associated with levels of education, a trend dating to the 1970s. Case told reporters their research showed a “sea of despair” in the United States among people with only a high school diploma or less. She declined to comment on the new report.

“When they get up into their 20s, 30s and 40s, they’re carrying the risk factors of obesity that were acquired when they were children. We didn’t see that in previous generations.”

Most people in the United States are overweight — an estimated 71.6 percent of the population ages 20 and older, according to the CDC. That figure includes the 39.8 percent who are obese, defined as having a body mass index of 30 or higher in adults (18.5 to 25 is the normal range). Obesity is also rising in children; nearly 19 percent of the population ages 2 to 19 is obese.

The average life expectancy in the United States fell behind that of other wealthy countries in 1998 and since then, the gap has grown steadily. Experts refer to this gap as America’s “health disadvantage.”

Death rates from suicide, drug overdoses, liver disease and dozens of other causes have been rising over the past decade for young and middle-aged adults, driving down overall life expectancy in the United States for three consecutive years, according to a strikingly bleak study published Tuesday that looked at the past six decades of mortality data.

The 33,000 excess deaths are an estimate based on the number of all-cause midlife deaths from 2010 to 2017 that would be expected if mortality was unchanged vs. the number of deaths actually recorded by medical examiners.

Outside researchers praised the study for knitting together so much research into a sweeping look at U.S. mortality trends.“This report has universal relevance. It has broad implications for all of society,” said Howard Koh, a professor of public health at Harvard University who was not part of the research team.

The average life expectancy in the United States fell behind that of other wealthy countries in 1998, and since then the gap has grown steadily. Experts refer to this gap as the United States’ “health disadvantage.”

For example, in the late 1960s and early ’70s, cigarette companies aggressively marketed to women, and the health effects of that push may not show up for decades.

Obesity is a significant part of the story. The average woman in the United States today weighs as much as the average man half a century ago, and men now weigh about 30 pounds more. Most people in the United States are overweight — an estimated 71.6 percent of the population age 20 and older, according to the CDC. That figure includes the 39.8 percent who are obese, defined as having a body mass index of 30 or higher in adults (18.5 to 25 is the normal range). Obesity is also rising in children; nearly 19 percent of the population age 2 to 19 is obese.

What that index didn't take into account — and what has compounded months of governmental failures — is that even before COVID-19 arrived on its shores, the U.S. was an unusually sick country for its level of wealth and development.

High blood pressure, obesity and metabolic disorders are all on the rise in the U.S.

Healthy life expectancy — the number of years people can expect to live without disability — is 65.5 years in the U.S., more than two decades fewer than in Japan.

65,700 Americans died of drug overdoses in 2019, more than double the number in 2010. Those deaths account for more than half of all drug overdose fatalities worldwide and held down life expectancy in the U.S.

Mortality for mothers and children under 5 is 6.5 per 1,000 live births in the U.S., compared to 4.9 for other wealthy countries.

Context: Lancet Editor-in-Chief Richard Horton has called COVID-19 a "syndemic" — a synergistic epidemic of a new and deadly infectious disease and numerous underlying health problems. The U.S. is squarely in the heart of that syndemic.

A study published in August found cardiovascular disease can double a patient's risk of dying from COVID-19, while diabetics — who number more than 30 million in the U.S. — are 1.5 times more likely to die.

All in all, more than 40% of American adults have a pre-existing health condition that puts them at higher risk of severe COVID-19.

Those conditions are particularly prevalent in minority communities with unequal health care access that have disproportionately suffered from COVID-19.

A report from McKinsey earlier this month estimated that poor health costs the U.S. economy about $3.2 trillion a year

For every $1 invested in targeting population health, the U.S. stands to gain almost $4 in economic benefit, and altogether health improvements could add up to a 10% boost to U.S. GDP by 2040.

The bottom line: There is no excuse for the way the U.S. has mishandled COVID-19, but the seeds of this catastrophe were planted well before the novel coronavirus arrived on American shores.

2. How movement spread COVID-19

What's happening: Researchers in Germany studied the effect of entry bans and mandatory quarantines on COVID-19 mortality, and found the earlier such measures were implemented, the greater the effect they had on limiting deaths.

Of note: The study found mandatory quarantines for incoming travelers were more effective than outright entry bans, largely because such bans often exempted citizens and permanent residents, while quarantines usually applied to everyone.

The U.S. lost track of at least 1,600 people flying in from China in just the first few days after the ban went into effect, according to reporting from the AP.

Border controls are of little use if governments don't track and quarantine travelers coming from infected areas.

The bottom line: A virus only moves with its host. One lesson we should learn for future pandemics is that restricting that movement is key to controlling a new pathogen, even though the costs of such controls will only grow in a globalized world.

They paint a granular picture of the strain on hospitals across the country that could help local citizens decide when to take extra precautions against COVID-19.

Withholding this information from the public and the research community is a missed opportunity to help prevent outbreaks and even save lives, say public health and data experts who reviewed the documents for NPR.

"At this point, I think it's reckless. It's endangering people," says Ryan Panchadsaram,

The documents show that detailed information hospitals report to HHS every day is reviewed and analyzed — but circulation seems to be limited to a few dozen government staffers from HHS and its agencies,

"The best possible measure of where we are in the pandemic, and the one we would want to anchor modeling to, is daily hospitalizations," he says, which give an early warning of deaths that will likely follow.

For instance, the most recent report obtained by NPR, dated Oct 27, lists cities where hospitals are filling up, including the metro areas of Atlanta, Minneapolis and Baltimore, where in-patient hospital beds are over 80% full. It also lists specific hospitals reaching max capacity, including facilities in Tampa, Birmingham and New York that are at over 95% ICU capacity and at risk of running out of intensive care beds.

Hospitalization data is invaluable in looking ahead to see where and when outbreaks are getting worse, says Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington. "Right now, as we head into the fall and winter surge," Murray says, "we're trying to put more emphasis on predicting where systems will be overwhelmed."

NPR has reviewed several of these reports generated in the past month. They present trends in hospital use, including increases in ventilator usage, along with a growing number of inpatient and ICU beds being occupied by COVID-19 patients. The Oct. 27 report showed that all three measures have increased by 14%-16% in the past month.

About 24% of U.S. hospitals are using more than 80% of their ICU capacity, based on reporting from nearly 5,000 "priority facilities," and more hospitals have joined their ranks in recent weeks.

Researchers say observing these trend lines can help the nation know how to prepare for surge and be ready to intervene before systems become overwhelmed.

Only one member of the White House Coronavirus Task Force, Adm. Brett Giroir, appears to receive the documents directly.

HHS tells NPR that more than 800 state-level employees have access to the daily hospitalization data it gathers, but only for their own state, unless another state grants them permission to view its data.

Without a larger view into national or regional data, some states — like Tennessee, which has eight bordering states — are missing out on valuable regional data, says Melissa McPheeters, who directs the Center for Improving the Public's Health through Informatics at Vanderbilt University.

"It's very challenging for states to get the multistate view of things," she says. "It's just a lot easier when there's a knowledgeable third-party who can pull the data together, make them consistent across states and actually tell the story of what the information shows." Typically, she says, this role would be fulfilled by the CDC, but the agency was stripped of its role in collecting COVID-19 hospital data in July.

McPheeters and colleagues at Vanderbilt put out a report this week that found that Tennessee counties without mask mandates had more rapid increases in hospitalizations.

Experts who reviewed the internal documents for NPR say that even for the limited group of federal employees who get them, the daily reports are not as useful as they could be.

Health data experts NPR consulted had ideas on how to improve the analysis. For instance, Panchadsaram suggested that some of the county-level charts, currently presented as raw numbers, would be more useful if analyzed per capita. "You really need to adjust it to the number of people [in an area] to get a sense of where things are being overwhelmed," he says.

And the quality of the underlying data is a concern. Health experts say the data quality was compromised by a controversial shift in data collection from the CDC to HHS in July, and that the issues with data quality have not been fully resolved.

According to HHS data posted on Monday, just 62% of the nation's hospitals reported all the required information last week.

But greater transparency, even of incomplete data, can be invaluable in a crisis, experts say.