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Matthew Holt is the founder and publisher of The Health Care Blog and still writes regularly for the site and hosts the #THCBGang and #HealthInTwoPoint00 video shows/podcasts. He was co-founder of the Health 2.0 Conference and now also does advisory work mostly for health tech startups at his consulting firm SMACK.health.

Health Insurance Cancel Culture

By MATTHEW HOLT

Strap in for a dramatic tale in which our hero battles bureaucracy and logic to try to get his health insurance back.

About 20 years ago lots of Americans, especially Californians who bought health insurance from Blue Shield of California, found that their coverage was cancelled without them knowing about it. That practice called “recission” got lots of attention during the run up to the ACA, and was banned by it. Now if you want to buy insurance and you pay for it, the insurance company has to sell it to you and can’t cancel it after the fact.

Or so I thought.

Post ACA most people who don’t get their insurance through an employer, or Medicare or Medicaid, now buy it via a very regulated “individual market” on a state-based or Federal exchange. Generally, the insurance they buy is heavily standardized (with bronze, silver or gold levels) and what they pay for insurance is heavily subsidized based on income. It’s those subsidies that were increased in the pandemic and extended in the Inflation Reduction Act (IRA) during the Biden administration. The subsidies were the topic–still unresolved–of the latest government shutdown. (Yes, yes, I know the shutdown is over—for now).

It’s pretty much impossible to buy individual insurance outside the exchange, although if you have Scott Galloway levels of wealth you can avoid buying insurance altogether and pay cash and you might be better off, or you can join some quasi-religious health share organization and take your chance. But for most people you are way better off buying on the exchange because that’s the only way you can get those subsidies.

I live in California and remain an under-employed blogger, and a few times in my recent life I have not been married to someone with health insurance provided by their employer. It happened in 2016-17 and again two years ago. No, not what you’re thinking. I didn’t get kicked to the curb by my wife, but in 2022 she got laid off by her employer and decided not to get another job. For the first year of that period (2023) we did not buy via the exchange, but used COBRA. That means we bought into her previous company’s insurance using our own money because it was cheaper than buying on the exchange. Two reasons for this. First, she got a severance package that made our combined incomes too high to get a subsidy and secondly, the ACA plans charge by age, whereas employers pay a flat fee for all employees. That made the exchange plan more expensive than the employer plan. (No prizes for guessing who in our family is old and expensive!)

But COBRA only lasts a year, and then it was time to head back to Covered California.

This starts a process where you try to figure out which plan offered is the cheapest, yet includes your and your family’s doctors, and which one has the lowest associated fees for the stuff you use the most (usually pediatric visits in our case). Turns out that in our case is the Blue Shield Trio 73 HMO. My inability to understand why it’s called Trio 73 reveals why no one calls me a marketing genius.

The other thing you have to figure out is what level of subsidy you get. As mentioned, the IRA passed in 2022 extended the pandemic emergency increase in subsidies for people with higher incomes. But then again, you have to figure out what your income will be when you sign up. Like the audience laughing at an obvious punch line a comedian hasn’t gotten to yet, those of you running ahead of me will have worked out a slight problem here.

I was signing up for a 2024 health plan in 2023. But I had to guess what my 2024 taxable income would be. Like many self-employed people with extremely variable income I had no idea what that final income would be until I filed my 2024 taxes in October 2025 (given I take the IRS extension). In other words, almost two years after I chose the plan. It turns out that in California, the people who track your income are not your health plan, nor the exchange but instead your local county health department. So in November 2023 I guessed my 2024 income and had to tell the local county what that guess is via some affidavit. The county health department actually called me to check that my estimate was correct. Or at least was what I told them it was.  Remember this for later.

Meanwhile I sign up on what I regard to be a very complex web site run by Covered California, and select the aforementioned Blue Shield HMO. It covers One Medical and UCSF theoretically via the Brown & Toland IPA, and leads to lots of fun and games in terms generating much content for me on this blog and Linkedin.

As it turns out, I was sent for an echocardiogram by my primary care doctor this past summer to check if I had a heart. While many of you were surprised at the answer (yes, I do), apparently it’s got a congenital disorder that needs a little help.

This gets us to November 2025 (last month!) with your brave hero going back onto the Covered California exchange trying to figure out whether the cardiologist recommended by my primary care doc is covered by the 2026 version of the Blue Shield plan I am on, or whether I need to switch. I could now digress and tell you the late Ian Morrison’s formula for choosing a health plan but I will hold that for the next telenovela article as of course that process is a fricking mess too!

In order to try to do that I login to the Covered California site and see I have a notice that I am not eligible for health insurance. I am confused.

Continue reading…

Katie D’Amico, Carequest–Integrating Oral Health into Medical Care

Katie D‘Amico is the VP of Innovation at Carequest, a non-profit that supports oral health–she’s a big proponent on its integration with medical care. At HLTH in October 2025 she took me on a brief tour of innovation in dental care and oral health. We had a quick look at the ability to test collagen breakdown and how to use the dental office to refer to lab tests. I also had a brief chat with Dr Ashley Lerman from Firstgrin, which is helping kids take care of their teeth, and distributing her kits and apps via health plans and hospitals–Matthew Holt

Nabla — It’s been a rocketship

I met the Nabla management team two years ago. Two years later they have ridden the wave of AI scribing to be one of the leaders in the field. At HLTH this year, I caught up with CEO Alex Lebrun and COO Delphine Groll to check in on their growth (150 customers and 100K users) what the next little bit of ambient AI scribing will look like (more specialties, more integration) and whether they’re scared of Epic (no!).–Matthew Holt

Sachin Jain–How do we do better?

What are the practices that we have normalized that future generations will criticize us for? Sachin Jain, CEO of SCAN Health Plan, is perhaps the leading truth teller in health care who also runs a real health care organization. I had a really fun but serious interview with Sachin about what health care people are doing, what are the bad things that happen. How are good people letting this happen? How we should be changing what we are doing?–Matthew Holt

Kai Romero, Evidently

Kai Romero is Head of Clinical Success at Evidently. The company is one of many that are using AI to dive into the EMR and extract data to deliver it to clinicians. It works to get really great information from the EMR to various flavors of clinicians in a fast and innovative way. Kai leads me on a detailed exploration of how the technology gets used as a layer over the EMR. And Kai shows me the new version that allows and LLM to deliver immediate answers from the data. This is a demo you really need to see to understand how AI is changing, and improving, that clinical experience. Meanwhile Kai is fascinating. She was an ER doc who became a specialist in hospice. We didn’t get into that too much, but you can tell about her input into Evidently’s design — Matthew Holt

Justin Schrager demos Vital.io

Justin Schrager is the CMO of Vital.io. Their technology sits in the hospital telling patients what is going on with their care while they are in the hospital, particularly in the ER. Justin showed a deep demo about the patient experience of using Vital.io which includes what the patient can expect and guides them through the confusing workflow. It allows the patient to make requests, and also lots of guidance about what is happening to them, or for example what lab results might mean. It goes as far as helping people book appointments for follow up with the right doctor. We had a great chat about the product and also about the realities of running a tech company that has to integrate with Epic and many other EMRs.–Matthew Holt

Greg Whisman, CareMore Health

Greg Whisman is the Chief Medical Officer of CareMore Health, a venerable prepaid medical group caring for seniors. It’s been part of Anthem/Elevance for many years but this year spun off as part of a larger PE backed group called Millennium. We really got into the what and the how of primary care for seniors and, yes, we delved deep into the future of primary care. This is a topic that will never die on THCB and getting a real expert to opine on it was really valuable. This is a great conversation–Matthew Holt

Sami Inkinen, Virta Health

Virta Health is in the diabetes reversal business. It’s a medical group that for a decade has been aggressively coaching people with diabetes and cardiometabolic disease to radically change their eating habits–basically to eat the right things for them, to saity. Some how in a nation obsessed with processed food and carbs they have succeeded for a lot of people. And the business is growing fast, with over $160m in annual run rate. Ten years in since it started I spoke with CEO Sami Inkinen about how and why it works, and what the future for this approach is in a world of GLP1s (and no there’s no GLP sales in that revenue number!)–Matthew Holt

Concierge Care for all: What would it look like?

By MATTHEW HOLT

A few weeks back I wrote an article on what’s wrong with primary care and how we should fix it. The tl:dr version was to give every American a concierge primary care physician paid for by the government. We would give everyone a $2k voucher (on average, dependent on age, medical status, location, etc) and have an average panel of 600 people per PCP.

My argument was that a) this would be cheaper than health care now – due to cutting back on Emergency Department visits and inpatient admissions and that b) it would enable us to pay PCPs the same as specialists (roughly $500K a year). This would mean that many current ED docs, internists, hospitalists etc would convert to being PCPs. I also think that we could and would make better use of the now 400,000 nurse practitioners in the US. We would only need about 600,000 PCPs to make this work. Although it would double spending on primary care, it would reduce health care costs overall. (OK there’s some debate about this but the Milliman study linked above and common sense suggests it would save money).

There are obviously two huge issues with my proposal. First we would have to go through the conversion process. Second, we would have to do something big with the three major players who are sucking at the teat of health care $$ right now—those being big hospital systems and their associated specialists, health insurers, and pharma and device companies.

I don’t think that there will be any problem selling this to most doctors or to the American people.

The doctors know that they are trapped in the current system. This would free them to practice as they want to practice, and to remember why they got into medicine in the first place—to care for their patients holistically.

People know all too well that accessing primary care is both good for them and also very difficult. Wait lists are way too long. In this system primary care would be abundant. And I and many others have only horror stories of how big hospital systems, insurers and big pharma treat them badly. They would much rather have an empowered PCP on their side.

The only concern about primary care for patients is if the PCP is incented to not refer them to needed specialty care. In my system there would be no global capitation or risk to the PCP, and thus no incentive not to refer out. But no reason to refer out unnecessarily. They would do the right thing because it is the right thing. (It has taken Jeff Goldsmith 30 years to convince me of this). So there would be no need for insurance companies to manage primary care at all. No claims, no bills, no utilization management. Instead we should have 600,000 primary care docs paid well and able to manage their practices to do the right thing.

And this would probably involve a ton of variation. There would be PCPs who work in groups. There would be solo. There would be those specializing in specific types of patients (think kids or people with serious diseases or geriatricians). They would all make the same amount of salary but their practice’s revenue and number of patients would be adjusted in a similar way to how we do risk adjustment for Medicare Advantage now, but without the games, and with no profit motive.

This system would create a lot of innovation. PCPs would be responsible for those with chronic conditions. They would have budget from the $2,000 per head (of which they would get roughly $800 as income) to build remote monitoring programs, to use AI, to build teams of assistants and nurses et al.

So can it be done in the US? Yes it already has. I urge you to take the time to read this ingenious ChatGPT summary of the Nuka system in Alaska. (I believe created by Steve Schutzer MD). Nuka went from being a hidebound bureaucratic expensive system–that its patients hated–to being a system with culturally appropriate care that its “consumer-owners” love today. And its costs are lower and outcomes better. There are lots of other examples of similar approaches across the US.  Just ask Dave Chase. They just haven’t scaled because the current incumbents have killed them.  (One great example is this case in Texas where a hospital chain bought and killed a big primary care group led by Scott Conard because it was costing them $100m a year in reduced hospital FFS admissions).

What we need is to set up the incentives, prod doctors and patients hard to get into these arrangements and let American ingenuity and medical professionalism go at it.

The other side of the equation is the need to reign in the costs of specialty and hospital care. How this would happen is up for debate.

Continue reading…

Avasure: Tech for helpful watching & remote care in hospitals

Lisbeth Votruba, the Chief Clinical Officer and Dana Peco, the AVP of Clinical Informatics from Avasure came on THCB to explain how their AI enabled surveillance system improves the care team experience in hospitals and health care facilities. Their technology enables remote nurses and clinical staff to monitor patients, and manage their care in a tight virtual nursing relationship with the staff at the facility, and also deliver remote specialty consults. They showed their tools and services which are now present in thousands of facilities and are helping with the nursing shortage. A demo and great discussion about how technology is improving the quality of care and the staff experience–Matthew Holt

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