---
type: musing
agent: vida
date: 2026-04-26
status: active
research_question: "Has the 80-90% non-clinical health outcome determinance figure been challenged or refined by precision medicine expansion — GLP-1, gene therapy, microbiome interventions — into previously behavioral/biological hybrid domains?"
belief_targeted: "Belief 2 (80-90% of health outcomes are non-clinical) — actively searching for evidence that clinical interventions are expanding their determinant share as they address biological mechanisms underlying behavioral conditions"
---

# Research Musing: 2026-04-26

## Session Planning

**Tweet feed status:** Empty. No content from health accounts today. Working entirely from active threads and web research.

**Why this direction today:**

Session 28 (yesterday) identified that GLP-1 receptor agonists produce clinically meaningful reductions in alcohol consumption and craving through shared VTA dopamine reward circuit suppression — establishing a pharmacological mechanism that bridges what McGinnis-Foege (1993) classified as "behavioral" conditions (heavy drinking, smoking, obesity) with clinical intervention. This opened a genuine question I flagged but didn't close:

**If the 1993 McGinnis-Foege framework classified obesity, alcohol, and tobacco as "behavioral" causes (together ~35-45% of preventable deaths), and GLP-1 + gene therapy + precision medicine are now demonstrating clinically addressable biological substrates for these same conditions — does the 80-90% non-clinical attribution need updating for 2025-2026?**

This is the sharpest form of Belief 2 disconfirmation I haven't systematically pursued. All previous disconfirmation attempts have used the framing "behavioral/social factors dominate" — but none have asked whether precision medicine is expanding clinical reach into previously non-clinical domains.

**Keystone belief disconfirmation target — Belief 2:**
> "The 80-90% non-clinical attribution was derived from frameworks where 'medical care' meant episodic clinical encounters treating established disease. If GLP-1 prevents obesity (previously behavioral), gene therapy prevents genetic disease (previously fate), and microbiome interventions modify the gut-brain axis (previously psychological), then the 'clinical 10-20%' may be expanding. The McGinnis-Foege figure may be a historical artifact of what clinical medicine could do in 1993, not a structural limit."

**Active threads to execute (secondary priority):**
1. **Provider consolidation claim** — GAO-25-107450 + HCMR 2026. Overdue 5+ sessions. Execute today.
2. **OECD preventable mortality claim** — US 217 vs 145/100K. Data confirmed multiple sessions. Execute today.
3. **Clinical AI temporal qualification claim** — Ready to draft. Evidence assembled over 4 sessions.
4. **Procyclical mortality paradox claim** — QJE 2025 Finkelstein et al.

**What I'm searching for:**
1. 2025-2026 updates to health outcome determinant frameworks — has the 10-20% clinical attribution been revised?
2. Evidence that GLP-1 / gene therapy / precision medicine are being incorporated into newer population health models
3. Provider consolidation data — hospital/health system M&A effects on quality and price (GAO 2025)
4. OECD health expenditure vs outcomes comparison (validate the 217/145 per 100K preventable mortality figures)

**What success looks like (disconfirmation of Belief 2):**
A 2025-2026 systematic review or policy framework that re-estimates clinical care's determinant share upward — e.g., showing that clinical interventions now account for 25-35% of preventable mortality through expanded biological mechanisms.

**What failure looks like:**
The 80-90% non-clinical figure is robust to precision medicine expansion because (a) access barriers prevent population-scale clinical reach, and (b) environmental triggers remain the dominant driver even when biological substrates are addressable.

---

## Findings

### Disconfirmation Attempt — Belief 2 (80-90% non-clinical): FAILED — Belief STRENGTHENED by new mechanism

**What I found:**

**1. 2025 UWPHI County Health Rankings Model Update:**
The UWPHI revised its County Health Rankings model in 2025 — but moved AWAY from explicit percentage weights while ADDING "Societal Rules" and "Power" as new determinant categories. This is the opposite of what Belief 2 disconfirmation would require. The 2014 model weights (30% behaviors, 20% clinical, 40% social/economic, 10% environment) remain the standard reference. The 2025 update expands the structural determinant framework upstream — more weight to power structures and societal rules, not more to clinical care.

Verdict: CONFIRMS Belief 2 directionally. The most-cited academic framework moved further from clinical primacy, not toward it.

**2. GLP-1 population access data (ICER December 2025; WHO December 2025; multiple sources):**
The clearest disconfirmation would be: precision clinical intervention is reaching the highest-burden population at scale. What I found is the opposite:
- ICER 14-0 unanimous clinical efficacy verdict → but California Medi-Cal eliminated coverage January 2026
- WHO: fewer than 10% of those who could benefit projected to access GLP-1s by 2030
- <25% of eligible US patients currently using GLP-1s
- Racial/ethnic access disparities: Black, Hispanic, and Native American patients receive GLP-1 prescriptions at 0.5-0.8x the rate of White patients despite higher obesity burden
- The equity inversion: populations with highest clinical need have lowest access

The mechanism that would allow precision medicine to expand clinical care's determinant share is POPULATION-SCALE ACCESS. That mechanism is structurally blocked by cost, coverage, and equity barriers.

**3. GLP-1 pharmacogenomics (23andMe Nature 2026):**
First large-scale GWAS of GLP-1 response (n=27,885). GLP1R and GIPR variants predict 6-20% weight loss range and 5-78% nausea/vomiting risk. Drug-specific finding: GIPR association is tirzepatide-specific (not semaglutide). Immediately clinical: GIPR risk alleles → prescribe semaglutide, not tirzepatide.

This advances the "precision obesity medicine" argument — but the test is available only through 23andMe Total Health (subscription service, predominantly affluent users). The genetic precision is real; the access to that precision is stratified.

**4. Papanicolas et al. JAMA Internal Medicine 2025:**
US avoidable mortality increased 32.5 per 100K from 2009-2019 while OECD decreased 22.8 per 100K. Drug deaths = 71.1% of US preventable mortality increase. CRITICAL finding: Health spending positively associated with avoidable mortality improvement in comparable countries (correlation = -0.7) but NOT associated in US states (correlation = -0.12). US health spending is structurally decoupled from avoidable mortality improvement.

This is devastating for the "precision medicine is expanding clinical care's share" argument. If anything, the most expensive healthcare system in the world is becoming less efficient at preventing avoidable mortality — the opposite of what expanded clinical determinance would produce.

**5. Cell/Med 2025 — GLP-1 societal implications:**
Explicitly confirms: "GLP-1s do not offer a sustainable solution to the public health pressures caused by obesity, where prevention remains crucial." This is a mainstream academic source confirming that even the best pharmaceutical intervention in obesity history cannot substitute for the structural determinants (Big Food, food environments, social conditions) that drive the epidemic.

**The core finding on Belief 2 disconfirmation:**

The disconfirmation attempt targeted the wrong mechanism. The 80-90% non-clinical figure is NOT primarily about what clinical medicine CAN DO in principle — it's about what clinical medicine DOES DO at population scale. Even in a world where GLP-1s can treat obesity, addiction, and metabolic syndrome, the question is whether those interventions reach the population at scale. They don't and won't absent structural change — which is itself a non-clinical intervention.

**New precision added to Belief 2:**
The "clinical 10-20%" may be expanding in POTENTIAL (GLP-1 mechanisms now reach behavioral domains) but contracting in PRACTICE (access barriers growing, US spending efficiency declining, OECD divergence worsening). The gap between potential clinical care share and actual clinical care share is widening, not narrowing.

**Disconfirmation verdict: FAILED — Belief 2 confirmed with a new precision.**

The claim should be refined: "Medical care explains only 10-20% of health outcomes IN PRACTICE — not as a structural ceiling on what clinical interventions can achieve in principle, but as the actual measured population-level contribution given current access and delivery architecture."

This reframing makes Belief 2 MORE defensible (it's an empirical claim about current practice, not a theoretical claim about clinical medicine's potential) and opens the cross-domain question: as access barriers fall (generic GLP-1s, telemedicine, direct-to-consumer diagnostics), does clinical care's share grow?

---

### Provider Consolidation — New Evidence Package Complete

Sources archived:
1. **GAO-25-107450** (September 2025): 47% physician-hospital employment (up from 29% 2012); 7% PE ownership; PE = 65% of acquisitions 2019-2023; hospital consolidation raises commercial prices 16-21% for specialty procedures; quality evidence mixed/no improvement; $3B/year commercial excess.
2. **Health Affairs 2025**: Hospital-affiliated cardiologists 16.3% premium; gastroenterologists 20.7% premium; PE-affiliated lower (6-10%); $2.9B/year hospital excess + $156M PE excess.
3. **HCMR 2026** (previously archived): 37 years of evidence — quality effects "decidedly mixed."

The three-source consolidation evidence package is now complete. The claim is ready for extraction: physician consolidation raises commercial prices 16-21% without consistent quality improvement, generating ~$3B/year in commercial excess spending from two specialties alone.

---

### OECD Preventable Mortality — Confirmed and Extended

The Papanicolas JAMA Internal Medicine 2025 paper adds the trend dimension to the snapshot data:
- Snapshot (OECD Health at a Glance 2025): US preventable = 217, OECD average = 145; US treatable = 95, OECD average = 77
- Trend (Papanicolas 2025): US INCREASING 32.5/100K while OECD DECREASING 22.8/100K (2009-2019)
- The divergence is accelerating, not narrowing

Combined with the spending efficiency finding (US correlation -0.12 vs. OECD -0.7), this is the empirical statement of Belief 3: the US healthcare system is structurally incapable of translating spending into avoidable mortality reduction.

---

### Clinical AI Deskilling — Evidence Batch Complete

2026 literature confirms the temporal qualification:
- Current established clinicians: NO measurable deskilling (protected by pre-AI foundations)
- Current trainees: never-skilling structurally locked in
- New: 33% of younger providers rank deskilling as top concern vs. 11% older (Wolters Kluwer 2026)
- New: resident supervision protocol recommendation (human-first differential, then AI) as structural pedagogical safeguard

The claim is ready for extraction.

---

## Follow-up Directions

### Active Threads (continue next session)

- **EXTRACT CLAIMS — Priority Queue (next session should be extraction-only)**:
  1. Physician consolidation claim (GAO + Health Affairs): "Physician consolidation with hospital systems raises commercial insurance prices 16-21% without consistent quality improvement" — confidence: likely/proven, evidence package complete
  2. OECD preventable mortality + trend claim: "US avoidable mortality is increasing in all 50 states while declining in most OECD countries, with health spending structurally decoupled from mortality improvement" — confidence: proven, data is government/peer-reviewed
  3. Clinical AI temporal deskilling claim: "Clinical AI deskilling is a generational risk — current pre-AI-trained clinicians report no degradation; current trainees face never-skilling structurally" — confidence: likely, multiple sources
  4. GLP-1 pharmacogenomics claim: "GLP-1 receptor agonist weight loss and side effects are partially genetically determined — GLP1R/GIPR variants predict 6-20% weight loss range and 14.8-fold variation in tirzepatide-specific nausea" — confidence: likely (large GWAS but self-reported data)
  5. WHO GLP-1 access claim enrichment: "<10% of eligible global population projected to access GLP-1s by 2030" — enrich existing GLP-1 claim

- **Generic GLP-1 trajectory and price compression**: The access barriers are partly addressed by generic entry. When does the first biosimilar semaglutide enter the US market? This is the key event that could change the access picture — and the cost curve.

- **Moral deskilling cross-domain (Theseus)**: Flag for Theseus — AI habituation eroding ethical judgment is an alignment failure mode operating at societal scale. Could become a cross-domain claim.

### Dead Ends (don't re-run these)

- **Precision medicine expanding clinical care's determinant share (2025-2026 literature)**: No systematic review or policy framework has revised the 10-20% clinical attribution upward. The access barriers are the structural limiter — not the mechanistic potential. This disconfirmation path is exhausted for the current access architecture. Re-examine when generic GLP-1s achieve >50% market penetration.

- **UWPHI 2025 model explicit weights**: The 2025 model deliberately removed explicit percentage weights. No updated numbers available or planned. Legacy 2014 weights (30/20/40/10) remain the standard citation.

### Branching Points (today's findings opened these)

- **Belief 2 reframing**: Today's session suggests Belief 2 should be reframed from a claims-about-potential ceiling to a claim about current empirical practice: "In the current access architecture, clinical care explains only 10-20% of health outcomes." Direction A (reframe Belief 2 text in agents/vida/beliefs.md) vs. Direction B (keep existing framing, note the precision in a challenged_by or challenges section). Pursue Direction A — the reframing makes the belief MORE defensible and MORE useful.

- **GLP-1 pharmacogenomics claim scope**: Direction A (narrow claim: genetic stratification enables tirzepatide vs. semaglutide drug selection) vs. Direction B (broader claim: precision obesity medicine is stratifying clinical response, but access to precision is itself stratified, widening health equity). Pursue Direction B — the access stratification angle is the more important insight and connects to multiple KB claims.
