Progress Without Access to Its Fruits: The Paradox of Degrading Medicine

Introduction

Vadim Yanshin

Despite explosive scientific progress, most people never touch its fruits. Behind this triumph lies a disturbing reality: access to new treatments remains the privilege of the few. A paradox emerges—medicine develops, but the social structure in which it is embedded shows signs of degradation.

Scientific Progress as an Empty Shell

Each decade brings breakthroughs that were recently considered fantasy. In 2019, the drug Zolgensma (for treating spinal muscular atrophy) became the most expensive in history—one dose costs over $2.1 million [1]. CAR-T cell therapies for leukemia treatment cost $400-500 thousand. In 2023, the FDA approved the first CRISPR gene therapy Casgevy costing around $2 million [2]. But against the backdrop of growing treatment possibilities comes their systematic alienation from the patient. The boundaries of possibilities expand—but not the framework of accessibility. The effect of a "future showcase" emerges, where technologies exist but only for the chosen few.

Behind the glass of this showcase lie perfect medicines, personalized genetic therapy, organs grown in laboratories, and neural implants capable of restoring lost functions. All of this exists, but "not for everyone." This situation increasingly resembles medical apartheid: the boundary of access runs not along biology or necessity, but along wealth, place of residence, and social status. Some have the right to life and innovation, others face MRI queues and inaccessible quotas. This is not simply inequality, this is a system-entrenched division between those who can live longer and better, and those who can only observe through the glass.

Why is everything so expensive? The reason lies not only in technological complexity, but in the very structure of the pharmaceutical market. Most innovative drugs are developed within a patent monopoly system, where companies receive exclusive sales rights for 15-20 years. This allows them to set prices that don't reflect real costs, but are based on the "value" of therapy for the patient or insurer. Meanwhile, a significant portion of R&D is funded from government and academic sources, but results are commercialized by private corporations. This model leads to life-saving drugs becoming objects of financial speculation rather than public goods. Progress turns into a commodity available in the market, not by necessity.

Paradoxically, the brighter this "future showcase" sparkles, the higher the entry price. It is precisely the rising cost of innovation that exposes the weakness of existing healthcare financing models and leads us to the next question—why even wealthy countries cannot ensure real access to advanced treatment methods.

Financial Insolvency of Healthcare Systems

The most complex technologies require not only laboratories, but sustainable financing models. Today's government and insurance models prove powerless. In the US, according to Kaiser Family Foundation data, only 12% of cancer patients have access to innovative treatment outside clinical trials [3]. In Canada, patients with rare diseases may wait years for therapy. In 2021, a child with SMA in Ontario was denied Zolgensma due to its cost, despite federal approval [4].

The situation in Russia has its peculiarities. Despite having a mandatory medical insurance (OMI) system, access to high-tech medical care (HTC) is limited. According to Ministry of Health data, in 2022, 1.3 million people were treated under HTC, which constitutes less than 1% of the population [9]. Most such interventions are performed in federal clinics, which are difficult to access. Funding for rare disease treatment is unstable, fundraising through charitable platforms has become commonplace. Example: in 2022 alone, the "Circle of Good" fund raised over 20 billion rubles for therapy for children with rare diseases [10]. In regions, shortages of personnel, equipment, and modern drugs make medical care uneven and unfair.

Insurance Models and Access Barriers

According to fresh Commonwealth Fund estimates (2024 survey), 17% of insured American adults received denial from insurers for payment of doctor-prescribed treatment, and 45% faced unexpected bills for services they considered covered [19]. Analysis by the HHS Inspector General, summarized by MACPAC in August 2024, showed that in some Medicaid-MCOs, the share of rejected prior authorization requests reaches 41%, with a median of 13% [22]. These indicators are particularly high for expensive cellular and gene therapies, directly strengthening the access barrier.

Insurance systems—private and government—become filters through which the patient-consumer of innovations passes (or doesn't pass). In the US, high premiums for commercial plans are often accompanied by "exclusions" for the newest gene and cell therapies: the insurer pays only part of the cost or requires the patient to exhaust "traditional" options entirely. Government programs (Medicare/Medicaid) include innovations more slowly due to complex "value" assessment processes (cost-effectiveness). In European countries with universal insurance schemes, access to innovations depends on whether the national HTA agency (health technology assessment) has managed to recognize them as economically justified. Even where assessment is positive, insurance coverage may be limited by age or disease severity. As a result, insurance premiums grow faster than inflation, and middle-income patients find themselves "between layers": too wealthy for subsidies, but too poor to pay co-payments [19].

The Role of Government Regulation

Government can influence prices through direct regulation (reference pricing, strict price limits, centralized procurement) or indirectly—through patent policy and co-financing programs. Price containment succeeds in countries with a single government purchaser (Canada, Australia) or active patent control (India, Brazil—compulsory licenses for HIV drugs). In the US, attempts to establish price ceilings on insulin and cancer drugs met resistance from pharmaceutical lobbies. In the EU, the "Joint Procurement" program operates, but it covers only vaccines and emergency drugs. The Russian government regulation model (ЖНВЛП) limits retail prices, but companies compensate by creating supply shortages or withdrawing products from the market [20].

Economic Consequences of Inequality

Uneven access hits not only health but also the economy. According to World Bank calculations, every 10% increase in universal health coverage (UHC) increases per capita GDP by 0.6% in the long term. The reverse relationship also works: undertreated chronic diseases reduce labor productivity and increase absenteeism. OECD research showed that countries with high healthcare inequality spend up to 1.5% of GDP additionally on disability benefits and early pensions. In Russia, costs for temporary disability due to cardiovascular diseases increased by 28% over the past five years, while mortality rates could have been reduced by applying modern therapies [21].

Centralization of Technologies as a Factor of Territorial Inequality

High-tech medicine naturally gravitates toward centralization. Equipment for PET-CT, proton therapy, genetic cell modification, or surgery using the Da Vinci robot requires special infrastructure, highly qualified personnel, and constant technical support. All this is available only in a limited number of federal or private clinics. As a result, for residents of remote and rural territories, even formally guaranteed care becomes practically unattainable. The problem is particularly acute for outpatient therapy courses—for example, radiotherapy or chemotherapy. Patients are forced to independently find and pay for housing, food, and transport if treatment occurs outside hospitalization. Thus, the right to care is not realized—and medical progress only strengthens territorial inequality.

For example, in Russia, proton therapy is available only in several centers—in Obninsk, St. Petersburg, and Dimitrovgrad (Ulyanovsk region). For most cancer patients from other regions, getting there is difficult: quotas are limited, and logistics and accommodation require significant funds. A similar situation is observed in Canada: proton therapy centers exist only in several provinces (for example, in Ontario and Alberta), and patients from remote regions are often forced to pay for their own relocation and accommodation if they don't receive subsidies. Treatment can last 3-6 weeks, making it virtually inaccessible to socially vulnerable groups.

Infrastructure centralization pulls human resources along: specialists in proton therapy, radiation physics, and robotic surgery concentrate in capital or federal centers. According to Rosstat data (2024), the number of oncologists in Moscow exceeds the average regional indicator by four times, and in the Far Eastern Federal District, the shortage of radiologists reaches 45%. Regional clinics, deprived of personnel, are forced to reduce high-tech care volumes or send patients thousands of kilometers away. Thus, territorial inequality is strengthened not only by equipment but also by specialist brain drain, turning the periphery into a personnel "desert."

Alternatives like telemedicine and mobile clinics [12][13] are intended to compensate for the accessibility gap but have serious limitations. Telemedicine is effective in consultative tasks but cannot replace diagnostics and treatment requiring patient presence (for example, biopsy, surgery, radiation therapy). Mobile clinics are useful for screening and prevention but don't ensure continuity of specialized treatment. Moreover, both solutions require sustainable financing and staffing—precisely what peripheral areas lack. Thus, these tools remain temporary solutions rather than structural alternatives.

Degradation as a Social Symptom

The gap in access to medical innovations is a sign of erosion of public institutions, not lack of scientific knowledge; and trust in these institutions is rapidly falling: according to a 2024 Gallup poll, only 34% of respondents stated they "completely" or "significantly" trust the healthcare system [23]. According to a 2022 WHO report, 133 countries worldwide violate universal health coverage principles [5]. A society unable to distribute the fruits of progress in everyone's interests demonstrates organizational and ethical weakness. We see expensive check-up centers with expanded, often excessive screening packages (full-body MRI scanning, preventive PET-CT without indications, extensive genetic panels "for everything") in private clinics, while millions cannot buy insulin or see an endocrinologist. Progress without access is phantom progress.

Brain Drain and the Dunning-Kruger Effect

Loss of human resources becomes an additional threat. In the US, burnout among doctors reached 63% [6], in Canada 50% of family doctors declared intention to leave the profession within five years [7]. According to American Foundation for Suicide Prevention data, over 400 doctors commit suicide annually in the US—this is 1.6-2.3 times higher than the population average [8].

In Russia, there is no systematic data on doctor suicides, but according to 2023 surveys, up to 70% of medical workers experience signs of severe burnout, and over 30% consider the possibility of leaving the government healthcare system [11].

When qualified specialists leave, the remaining ones must serve a larger patient flow. Workload indicators per doctor grow—in regional polyclinics up to 25-30 appointments per shift. This leads to increased waiting times, decreased consultation quality, and rising costs: medical institutions are forced to pay overtime, and patients turn to the private sector, where prices are 2-3 times higher. Thus, staff shortage directly increases medical service costs and strengthens access inequality.

Dark Scenario: Medicine 2035 Without Reforms

If structural contradictions remain unresolved, by the mid-2030s we will get the following:

1. Two-circuit healthcare [14]. Premium "longevity centers" for wealthy clients will offer genetic upgrades, neural implants, and complete preventive diagnostics 24/7. The mass system will slide into "patch medicine"—treating acute conditions with minimal means.
2. Geo-medical enclaves [15]. Hub cities with high per capita GDP will be magnets for medical tourism. Surrounding territories will turn into "healthcare deserts" where only telemonitoring and basic care are available.
3. Black market biotechnology [16]. Prohibitive prices and patent barriers will spawn underground CRISPR therapy laboratories and illegal vascular stents. Risks for patients will multiply.
4. Inequality epidemics [17]. Diseases of poverty (tuberculosis, antibiotic-resistant infections) will become chronic background, simultaneously with progress in cancer treatment among the wealthy.
5. Ethical collapse of the profession [18]. The best specialists will go to private capsule clinics or the "eternal youth" bioindustry, leaving government hospitals in staffing agony.
6. Social turbulence. Growing distrust of government and science: conspiracy theories, vaccine refusal, protests against the "genetic elite."

Thus, without reforms, medicine will cease to be a public good and become a catalyst for new class conflict—between those who can afford the future and those forced to live in the past.

Conclusion

Medicine is not only a body of knowledge but also a mirror of social priorities. Today it reflects a paradox: scientific development is not accompanied by development of justice. A society that can cure disease but cannot afford it is not progressing—it is stagnating. It is necessary not only to develop technologies but to reconsider mechanisms for their distribution. Without this, medicine will lose its humanistic essence.

Sources:

1. Novartis: Zolgensma — Pricing and Access.
2. FDA Approves First CRISPR-Based Gene Therapy — Casgevy (Vertex/CRISPR Therapeutics), 2023.
3. Kaiser Family Foundation, Access to Cancer Drugs, 2022.
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