For decades, most doctors, me included, focused on the usual suspects when assessing heart disease risk: LDL cholesterol, HDL cholesterol, triglycerides, blood pressure, and lifestyle factors like smoking, activity, and diet. But lurking in the background was another player that most of us didn’t routinely check and most patients had never heard of—lipoprotein(a), abbreviated as Lp(a) and pronounced “L-P-little-A.”
Here’s the sobering reality: about one in five people worldwide have elevated Lp(a) levels, and if you’re among them, your risk of heart attack or stroke roughly doubles or triples. Yet until recently, most clinical guidelines didn’t even recommend testing for it. Why? Because there wasn’t much doctors could do about it even if we found it. That’s changing now, and the story of Lp(a) offers a window into how medicine sometimes waits for treatment options before fully embracing a diagnostic test.
What Exactly Is Lipoprotein(a)?
Lp(a) is structurally similar to LDL cholesterol—both are cholesterol-carrying particles—but Lp(a) has an extra protein component called apolipoprotein(a), or apo(a), that makes it particularly troublesome. The structure of this protein varies dramatically between individuals due to differences in genetic sequences, and the specific variant you inherit from your parents determines your Lp(a) level for life.
Unlike LDL cholesterol, which rises with age and responds to diet and exercise, your Lp(a) level remains largely constant throughout your lifetime. Eating better, exercising more, losing weight—none of the lifestyle interventions that work wonders for other cardiovascular risk factors will budge your Lp(a). It’s entirely genetic. There’s also significant variation across populations, with individuals of African descent tending to have higher average Lp(a) levels compared to people of White or Asian backgrounds, though the clinical implications of these differences are still not well understood.
Getting Tested: Who Should Do It and How Does It Works
The blood test for Lp(a) isn’t part of a routine cholesterol panel—your doctor has to specifically order it. So, who should be tested? Current recommendations focus on people with a family history of high Lp(a), those with a personal or family history of premature heart disease (cardiovascular events before age 55 in men or 65 in women), and anyone diagnosed with familial hypercholesterolemia, a genetic condition where the body poorly recycles LDL cholesterol. About a third of people with familial hypercholesterolemia also have high Lp(a), compounding their cardiovascular risk significantly.
Because Lp(a) levels don’t change over time, a single test is all you need. Results can be reported in two different units—milligrams per deciliter (mg/dL) or nanomoles per liter (nmol/L)—and there’s no universal agreement on what constitutes a risky level. Most American guidelines use a threshold of ≥50 mg/dL or ≥125 nmol/L as indicating increased cardiovascular risk, with levels below 30 mg/dL generally considered normal.
What High Lp(a) Means for Your Health
The evidence linking elevated Lp(a) to cardiovascular disease has become increasingly compelling over the past two decades. People with high Lp(a) face a two to threefold increased risk of heart attack and aortic valve disease. For those with extremely elevated levels above 180 mg/dL, the cardiovascular risk approaches that of people with untreated familial hypercholesterolemia (genetic extremely high cholesterol), which is notoriously dangerous.
Beyond heart attacks and valve problems, elevated Lp(a) has been linked to peripheral arterial disease (clogged arteries) and aortic aneurysms. What makes it particularly insidious is that it contributes to what researchers call “residual cardiovascular risk”—meaning it raises your chances of a cardiovascular event even when your LDL cholesterol is well controlled. You could be doing everything right by traditional measures and still be at elevated risk if your Lp(a) is high.
A large multi-ethnic study following nearly 28,000 people for an average of 21 years found that higher Lp(a) levels were consistently associated with greater cardiovascular disease risk across different ethnic groups and in both men and women. The mechanism involves both promoting arterial plaque buildup and increasing blood clot formation—a double threat to cardiovascular health.
Current Management Options: Limited but Important
This is where the story gets frustrating. For years, the honest answer to “what can I do about my high Lp(a)?” has been: not much directly, but a few things indirectly.
While lifestyle changes won’t affect your Lp(a) numbers, people with high levels should still follow all standard heart-healthy practices—physical activity, good nutrition, adequate sleep, avoiding smoking, and maintaining a healthy weight. The logic is straightforward: if you can’t eliminate one major risk factor, be more diligent about controlling all the others.
People with high Lp(a) may also benefit from more aggressive LDL cholesterol treatment, even if their LDL is already in a normal range. Some injectable cholesterol medications can lower Lp(a) by about 20% in some patients in addition to their primary effect on LDL. This helps overall cardiovascular risk even if it doesn’t fully address the Lp(a) problem.
For the most severe cases, the only FDA-approved treatment specifically targeting Lp(a) lipoprotein is apheresis which filters apolipoprotein-containing particles from the blood, achieving over 50% reduction. But the reductions are temporary, the procedure is similar to dialysis in its time demands, and it’s expensive and reserved for only the most extreme situations. It’s not a practical solution for the millions of people with moderately elevated levels.
The Treatment Revolution: New Therapies on the Horizon
Here’s where things get genuinely exciting. After decades of essentially no targeted treatment, five promising new therapies are now in advanced clinical development.
Four are RNA-based therapies that work by silencing the gene responsible for producing apolipoprotein(a) in the liver thereby preventing Lp(a) formation at its source. All are engineered to be taken up specifically by liver cells, where Lp(a) is made to minimize side effects elsewhere.
Early trial results have been remarkable. One drug, given as a monthly injection under the skin, has reduced Lp(a) levels by about 80%, with 98% of participants achieving levels below the risk threshold of 50 mg/dL. A phase 3 trial enrolling over 8,300 patients is expected to report results sometime in 2026, potentially leading to regulatory approval shortly after.
Other drugs have shown even more dramatic results, with one achieving a 93.9% reduction in Lp(a) with a single dose, with the effect persisting above 90% even at 360 days after just one injection.
There’s also an oral medication in development which works by preventing the apo(a) protein from assembling into Lp(a) particles in the first place. Taken daily as a pill, it has shown reductions of 63-65%—less dramatic than the RNA-based therapies, but potentially preferable for patients who want to avoid injections entirely.
The Critical Caveat
While these medications dramatically lower Lp(a) levels, we don’t yet have definitive proof that lowering Lp(a) will prevent heart attacks and strokes. That sounds counterintuitive—if high Lp(a) causes cardiovascular disease, then lowering it should help—but medicine requires rigorous evidence from randomized controlled trials. The FDA won’t approve these drugs based solely on their ability to improve a lab value; they need to demonstrate actual clinical benefit. Large outcome trials are underway and we should have answers within the next few years.
Where Things Stand Now
The story of Lp(a) reflects a broader tension in medicine: when should we test for something we can’t yet treat? For decades, many argued against routine screening precisely because no targeted therapies existed. That calculus has shifted. Recent reviews have concluded that the benefits of early detection now outweigh the risks, even though specific Lp(a)-lowering drugs are not yet approved, because early knowledge allows for more aggressive management of other risk factors.
For the roughly 20-25% of people with elevated Lp(a), the next few years could bring transformative options. If you fall into one of the higher-risk groups and have never been tested, it’s worth asking your doctor whether screening makes sense. The treatment landscape for Lp(a) is changing faster than it has in decades, and knowing your number today puts you in a much better position to act when those new options arrive.
Illustration generated by the author using ChatGPT.
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America’s Healthcare Paradox: Why We Pay Double and Get Less
By John Turley
On January 5, 2026
In Commentary, Medicine
The healthcare debate in America often circles back to a fundamental question: should we move toward a single-payer system, or is our current mixed public-private model the better path forward? It’s a conversation that gets heated quickly, but when you strip away the politics and look at how different systems actually function around the world, some interesting patterns emerge.
What We Mean by Single-Payer
A single-payer healthcare system means that one entity—usually the government or a government-related organization—pays for all covered healthcare services. Doctors and hospitals can still be private (and usually are), but instead of dealing with dozens of different insurance companies, they bill one source. It’s a lot like Medicare, which is why proponents often call it “Medicare-for-all”.
The key thing to understand is that single-payer isn’t necessarily the same as socialized medicine. In Canada’s system, for instance, the government pays the bills, but doctors are largely in the private sector and hospitals are controlled by private boards or regional health authorities rather than being part of the national government. Compare that to the UK’s National Health Service, where many hospitals and clinics are government-owned and many doctors are government employees.
America’s Current Patchwork
The United States operates what might charitably be called a “creative” approach to healthcare—a complex mix of employer-sponsored private insurance, government programs like Medicare, Medicaid and the VA system, individual marketplace plans, and direct out-of-pocket payments. Government already pays roughly half of total US health spending, but benefits, cost-sharing, and networks vary widely between plans, with little overall coordination. In 2023, private health insurance spending accounted for 30 percent of total national health expenditures, Medicare covered 21 percent, and Medicaid covered 18 percent. Most of the remainder was either paid out of pocket by private citizens or was written off by providers as uncollectible.
Here’s where it gets expensive. U.S. health care spending grew 7.5 percent in 2023, reaching $4.9 trillion or $14,570 per person, accounting for 17.6 percent of the nation’s GDP, and national health spending for 2024 is expected to have exceeded $5.3 trillion or 18% of GDP, and health spending is expected to grow to 20.3 percent of GDP by 2033.
For a typical American family, the costs are real and rising. In 2024, the estimated cost of healthcare for a family of four in an employer-sponsored health plan was $32,066.
The European Landscape
Europe doesn’t have one healthcare model—it has several, and they’re all quite different from what we have in the States. Most of the 35 countries in the European Union have single-payer healthcare systems, but the details vary considerably.
Countries like the UK, Sweden, and Norway operate what are essentially single-payer systems where it is solely the government who pays for and provides healthcare services and directly owns most facilities and employs most clinical and related staff with funds from tax contributions. Then you have countries like Germany, and Belgium that use “sickness funds”—these are non-profit funds that don’t market, cherry pick patients, set premiums or rates paid to providers, determine benefits, earn profits or have investors. They’re quasi-public institutions, not private insurance companies like we know them in America. Some systems, such as the Netherlands or Switzerland, rely on mandatory individually purchased private insurance with tight regulation and subsidies, achieving universal coverage with a structured, competitive market.
The French System
France is particularly noted for a successful universal, government-run health insurance system usually described as a single-payer with supplements. All legal residents are automatically covered through the national health insurance program, which is funded by payroll taxes and general taxation.
Most physicians and hospitals are private or nonprofit, not government employees or facilities. Patients generally have free choice of doctors and specialists, though coordinating through a primary care physician improves access and reimbursement. The national insurer pays a large portion of medical costs (often 70–80%), while voluntary private supplemental insurance covers most remaining out-of-pocket expenses such as copays and deductibles.
France is known for spending significantly less per capita than the United States. Cost controls come from nationally negotiated fee schedules and drug pricing rather than limits on access.
What’s striking is that in 2019, US healthcare spending reached $11,072 per person—over double the average of $5,505 across wealthy European nations. Yet despite spending roughly twice as much per person, American health outcomes often lag behind.
The Outcomes Question
This is where the comparison gets uncomfortable for American exceptionalism. The U.S. has the lowest life expectancy at birth among comparable wealthy nations, the highest death rates for avoidable or treatable conditions, and the highest maternal and infant mortality.
In 2023, life expectancy in comparable countries was 82.5 years, which is 4.1 years longer than in the U.S. Japan manages this with healthcare spending at just $5,300 per capita, while Americans spend more than double that amount.
Now, it’s important to note that healthcare systems don’t operate in a vacuum. Life expectancy is influenced by many factors beyond medical care—diet, exercise, smoking, gun violence, drug overdoses, and social determinants of health all play roles. But when you’re spending twice as much and getting worse results, it suggests the system itself might be part of the problem.
Advantages of Single-Payer Systems
The case for single-payer rests on several compelling points. First, administrative simplicity translates to real cost savings. A study found that the administrative burden of health care in the United States was 27 percent of all national health expenditures, with the excess administrative cost of the private insurer system estimated at about $471 billion in 2012 compared to a single-payer system like Canada’s. That’s over $1 out of every $5 of total healthcare spending just going to paperwork, billing disputes, and insurance company profit and overhead before any patient receives care.
Universal coverage is another major advantage. In a properly functioning single-payer system, nobody goes bankrupt from medical bills, nobody delays care because they can’t afford it, and nobody loses coverage when they lose their job. The peace of mind that comes with knowing you’re covered regardless of employment status or pre-existing conditions is difficult to quantify but enormously valuable.
Single-payer systems also have significant negotiating power. When one entity is buying drugs and services for an entire nation, pharmaceutical companies and medical device manufacturers have much less leverage to charge whatever they want. This helps explain why prescription drug prices in other countries are often a fraction of prices in the U.S.
Disadvantages and Trade-offs
The critics of single-payer systems aren’t wrong about everything. Wait times are a genuine concern in some systems. When prices and overall budgets are tightly controlled, some countries experience longer waits for selected elective surgeries, imaging, or specialty visits, especially if investment lags demand.
In 2024, Canadian patients experienced a median wait time of 30 weeks between specialty referral and first treatment, up from 27.2 weeks in 2023, with rural areas facing even longer delays. For procedures like elective orthopedic surgery, patients wait an average of 39 weeks in Canada.
However, it’s crucial to understand that wait times are not a result of the single-payer system itself but of system management, as wait times vary significantly across different single-payer and social insurance systems. Many European countries with universal coverage don’t experience the same wait time issues that plague Canada.
The transition costs are also substantial. Moving from our current system to single-payer would disrupt a massive industry. Over fifteen percent of our economy is related to health care, with half spent by the private sector. Around 160 million Americans currently have insurance through their employers, and transitioning all of them to a government-run plan would be an enormous administrative and political challenge.
A large national payer can be slower to change benefit designs or adopt new payment models; shifting political majorities can affect funding levels and benefit generosity.
Taxes would need to increase significantly to fund such a system, though proponents argue this would be offset by the elimination of insurance premiums, deductibles, and co-pays. It’s essentially a question of whether you’d rather pay through taxes or through premiums—the money has to come from somewhere.
Advantages of America’s Mixed System
Our current system does have some genuine strengths. Innovation thrives in the American healthcare market. The profit motive, for all its flaws, does drive pharmaceutical research and medical device development. American medical schools and research institutions lead the world in many areas of medicine. Academic medical centers and specialty hospitals deliver advanced procedures and complex care that attract patients internationally.
The system also offers more choice for those who can afford it. If you have good insurance, you typically face shorter wait times for elective procedures and can often see specialists without lengthy delays. Americans with high-quality employer-sponsored coverage give their plans relatively high ratings.
Competition between providers can theoretically drive quality improvements, though this effect is often undermined by the complexity of the market and the difficulty consumers face in shopping for healthcare.
Disadvantages of the Current U.S. System
The most glaring problem is simple: The United States remains the only developed country without universal healthcare, and 30 million Americans remain uninsured despite gains under the Affordable Care Act, and many of these gains will soon be lost. Being uninsured in America isn’t just an inconvenience—it can be deadly. People delay care, skip medications, and avoid preventive screenings because of cost concerns.
The administrative complexity is staggering. Doctors spend enormous amounts of time dealing with insurance companies, prior authorizations, and billing disputes. Hospitals employ armies of billing specialists just to navigate the maze of different insurance plans, each with its own rules, formularies, and coverage determinations. U.S. administrative costs account for ~25% of all healthcare spending, among the highest in the world.
Medical bankruptcy is uniquely American. Even people with insurance can find themselves financially devastated by serious illness. High deductibles, surprise bills, and out-of-network charges create a minefield of potential financial catastrophe. Studies of U.S. bankruptcy filings over the past two decades have consistently found that medical bills and medical problems are a major factor in a large share of consumer bankruptcies. Recent summaries suggest that roughly two‑thirds of US personal bankruptcies involve medical expenses or illness-related income loss, and around 17% of adults with health care debt report declaring bankruptcy or losing a home because of that debt.
The system is also profoundly inequitable. Quality of care often depends more on your job, your income, and your zip code than on your medical needs. Out-of-pocket costs per capita have increased as compared to previous decades and the burden falls disproportionately on those least able to afford it.
What Europe Shows Us
The European experience demonstrates that there isn’t one “right” way to achieve universal coverage. The UK’s NHS, Germany’s sickness funds, and France’s hybrid system all manage to cover everyone at roughly half the per-capita cost of American healthcare. Universal Health Coverage exists in all European countries, with healthcare financing almost universally government managed, either directly through taxation or semi-directly through mandated and government-subsidized social health insurance.
They’ve accomplished this through various combinations of centralized negotiation of drug prices, global budgets for hospitals, strong primary care systems that serve as gatekeepers to more expensive specialist care, emphasis on preventive services, and regulation that prevents insurance companies from cherry-picking healthy patients.
Are these systems perfect? No. One of the major disadvantages of centralized healthcare systems is long wait lists to access non-urgent care, though Americans often wait as long or longer for routine primary care appointments as do patients in most universal-coverage countries. Many European countries are wrestling with funding challenges as populations age and expensive new treatments become available. But they’ve solved the fundamental problem that America hasn’t: they ensure everyone has access to healthcare without the risk of financial ruin.
The Path Forward?
The debate over healthcare in America often presents false choices. We don’t have to choose between Canadian-style single-payer and our current system—there are multiple models we could adapt. We could move toward a German-style system with heavily regulated non-profit insurers. We could create a robust public option that competes with private insurance. We could expand Medicare gradually by lowering the eligibility age over time.
What’s clear from international comparisons is that the status quo is unusually expensive and produces mediocre results. We’re paying premium prices for economy outcomes. Whether single-payer is the answer depends partly on your priorities. Do you value universal coverage and cost control more than unlimited choice? Are you willing to accept potentially longer wait times for non-urgent care in exchange for lower costs and universal access? How much do you trust government to manage a program this large?
These aren’t easy questions, and reasonable people disagree. But the evidence from Europe suggests that universal coverage at reasonable cost is achievable—it just requires us to make some choices about what we value most in a healthcare system.
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