Those of us of a certain age remember the Timex slogan that bragged about its watches’ durability: “It takes a licking and keeps on ticking.” A recent article about our military, of all things, made me wish we had a healthcare system that prized that kind of durability.
I can never resist analogies between the U.S. healthcare system and the U.S. military system. They’re both huge, they’re both wildly expensive, they both rely on a combination of high tech and front-line people, and they both protect us from threats. In some ways, both are the best in the world, and, in other ways, both have weaknesses that are embarrassing. And, as I wrote last year, both are often still fighting the wrong wars.
Ms. Herz notes how Americans love innovation, but:
This mythos informs a narrative that what is valuable is The New—the upgrade to something bigger, badder, and sexier…What the United States needs to reinvigorate its defense base, compete with China, and win the global economy must be more innovation.
Except the United States does not suffer from a lack of innovation; it suffers from a lack of resilience.
But these systems can be tuned to reflect and address key concerns.
What follows is a list of ten separable concerns, and responsive design strategies. The concept of separation of concerns in technology design offers a path to better health policy. Because each concern hardly interacts with the others, any of them can be left out of the design in order to prioritize more important outcomes. Together, all of them can maximize scientific benefit while enhancing social trust.
An inspector should be assured that a vaccine certificate was not tampered with and that it was issued to the presenter. This need not imply any privacy risk, or even need a network connection. One such method for authenticating vaccine credentials adds a human-recognizable and machine-readable face photo to a standard 2D barcode. It works with paper as well as mobile phone presentations.
The digital divide
For this concern, paper credentials have equity and privacy advantages. Equity, because paper is cheap and well understood. Privacy, because there is no expectation that a person must unlock and show a mobile phone. Digitally signed certificates that also include a photo, like #1 above, can be copied for convenience without risk of fraud.
Mothers deserve more than a day of recognition this year—they deserve the whole month, and more. The pandemic has been particularly hard on women, especially poor women and women of color.
To demonstrate the appreciation mothers deserve this Mother’s Day, we should get them something they really need: health care. To improve maternal health, we should look to the Medicaid program, long a pathway to accessible, quality health care for low-income Americans. Medicaid is especially important for mothers; it covers close to half of all births in the U.S.
Now, states have the opportunity to do even more for moms.
The American Rescue Plan signed into law in March gives every state the option to extend Medicaid maternity coverage for up to 12 months postpartum, a significant increase from the current limit of just 60 days. Illinois has already announced it will extend postpartum coverage; other states should follow. Extending the guaranteed coverage period will increase access to postnatal care during this ‘fourth trimester’ to ensure that women can access treatment for common conditions like postpartum depression as well as preventing organ prolapse or hemorrhage. Not only mothers will benefit. Parental insurance is associated with better health for children, including a lower risk of adverse childhood experiences.
In addition, the American Rescue Plan offers an opening to expand Medicaid with even more federal funding than is currently available through the Affordable Care Act. The 12 states, mostly in the South, that have not expanded their Medicaid programs are leaving hundreds of thousands of women without the support they deserve.
Expanding Medicaid programs will provide robust access to health care to more women and reduce maternal morbidity and mortality, which has reached crisis proportions among many women of color. Black and Indigenous women are more likely than other women to die during pregnancy, childbirth, and the postpartum period. According to the CDC, the maternal mortality rate is 2.5 times higher for Black women than white women. Disparate access and uneven quality of care, higher rates of chronic illness, and racism all play a part in that grim statistic.
The disproportionate burden of maternal mortality and adverse outcomes from childbirth has long-lasting effects on mothers and their children. Black newborns have an increased risk for long-term complications resulting from pre-birth complications. They may also face generational poverty and trauma in the long run if they are born to a mother who dies during childbirth.
In the second half of the 19th century, Emily Dickinson wrote a short poem that could easily have been a forward looking tribute to two American Presidents – one from the 20th, the other the 21st century.
Dickinson’s poem “A WORD is dead” is hardly longer than its title.
“A WORD is dead
When it is said,
I say it just
Begins to live
She certainly was on the mark when it came to President Franklin Delano Roosevelt’s signature legislation. FDR’s New Deal, extending from 1933 to 1939, ultimately came down to just three words – the 3R’s – Relief , Recovery, and Reform.
He promised “Action, and action now!” This included a series of programs, infrastructure projects, financial reforms, a national health care program and industry regulations, protecting those he saw as particularly vulnerable including farmers, unemployed, children and the elderly. And he wasn’t afraid to make enemies. Of Big Business, he said in a 1936 speech in Madison Square Garden, “They are unanimous in their hate for me – and I welcome their hatred.”
But he was also a political realist. And by his second term of office Justice Hughes and his Conservative dominated Supreme Court had begun to undermine his legislative successes and were threatening his signature bill- the Social Security Act. So FDR compromised, and in the face of withering criticism from the AMA, postponed his plans for national health care.
Unlike medical meetings, rendering Beethoven’s Ninth Symphony isn’t easy on Zoom, so the local orchestra has been furloughed and their members work for Uber. The opera house wants to reopen, preferably before we reach the elusive herd immunity threshold. They mandate vaccinations for their artists, not least because the performers can keep their masks off. Should they extend this requirement to their patrons?
Vaccine passports, proof of immunity against SARS-CoV-2, to work, dine, fly or watch shows, are controversial. Opponents say they blithely disregard decency, are operationally onerous, and hurt liberty. Worryingly, they create a caste system, which wouldn’t be as concerning if based on just immunology. Such a two-tiered system could sadly mirror societal inequities because it’s the poor who may disproportionately be left unvaccinated. Supporters of vaccine passports further the very structural disadvantages they seek to end.
When arguments are too compelling they likely betray an obvious simplicity. Too often arguments against mandates assume they’d be a government fiat. The opponents recline on the country’s inherently liberal streak conjuring visions of rugged individuals fighting unelected bureaucrats. They say with undisguised pride “this isn’t who we are. We’re the US, not New Zealand. We can’t be controlled.”
This narrative is so tightly embedded in right-of-center discourse that it’s now folklore bordering on an Ayn Rand fairy tale. The narrative is nonsense. The state is too incompetent to either govern adeptly or tyrannize efficiently. Case-in-point: CDC’s easily forgeable paper vaccine certificate. If the state were serious about prying on people’s antibodies, it’d have made the immunosurveillance digital.
The obsession with big government should be antiquated. By censoring content, Facebook and Twitter showed that freedom can more efficiently be curtailed by the private sector. Bottom-up censorship is arguably more powerful than top-down censorship because it has buy-in from a segment of the market. It may very well be the private sector which demands vaccine passports, which begs two questions – why and why not?
Since I first heard about them, I have been fascinated, and dismayed, by the concept of “million dollar blocks.” For those of you unfamiliar with the term, it doesn’t refer to, say, Beverly Hills, Chicago’s Gold Coast, or Manhattan’s Hudson Yards — areas where the wealthy congregate. No, it refers to city blocks for which society spends over a million dollars annually to incarcerate residents of that block.
I, of course, have to think about the healthcare parallels.
The concept dates back many years, credited to Eric Cadora, now at Justice Mapping, and Laura Kurgan, a professor of architecture at Columbia University, where she is the Director of the Center for Spatial Research (CSR). The power of the concept is to use data visualization to illustrate the problem.
Here, for example, is CSR’s map of Brooklyn for prison spending:
CSR describes the findings as follows:
The maps suggest that the criminal justice system has become the predominant government institution in these communities and that public investment in this system has resulted in significant costs to other elements of our civic infrastructure — education, housing, health, and family. Prisons and jails form the distant exostructure of many American cities today.
Virtual-first primary care company Firefly Health is becoming a health plan! Backed by a $40M Series B, CEO Fay Rotenberg and Executive Chairman Jonathan Bush stop by to explain how they’re providing “half-price healthcare that’s twice as good.” (Or, as only Jonathan can put it: “we’re a bloat-less Kaiser.”) All kidding aside, some big-name health innovation investors are not only behind this raise (Andreessen Horowitz led, F-Prime Capital and Oak HC/FT dipped back in), but also this idea to wrap a benefit around Firefly’s digitally-driven comprehensive care model. Already in-market, the new benefit-plus-care product is aimed squarely at mid-sized/small, fully-insured employers – shops with 50-500 employees which, right now, have limited options for dramatically changing their healthcare spend or being able to build out their own benefits the same way large self-insured employers can.
Fay and Jonathan get into the details about how they’re extending their “Marie Kondo-ing” of healthcare delivery – which has thus far netted some pretty impressive health outcomes, cost savings, and a 92 Net Promoter Score – into healthcare financing.
BONUS: Tune in around 25:30 and stick around for a few minutes as Jonathan weighs in on the health tech funding boom, how it compares to the EMR arms race days of ole, and whether or not he thinks he can beat Glen Tullman’s $14.5B valuation if/when Firefly goes public. HA!
In the fog of the Covid pandemic, many are wondering what ever happened to prior vocal support for universal coverage and Medicare-for-All. Expect those issues to regain prominence in the coming months. A bit of recent history helps explain why.
The January 6th insurrection, followed by the past weeks two mass shootings, have served to remind our citizens that we must address a range of issues while continuing to confront the pandemic threat.
Modern civilized societies rely on a double-armed approach to maintain order, peace and security. The first arm is laws. But laws are of little value without even and unbiased enforcement.
The second guardrail of civility is culture. MIT professor Edgar Schein described it this way: “Culture has three layers: the artifacts of a culture — our symbols and signs; its espoused values — the things we say we believe; and, most important, its underlying assumptions — the way things really are.”
In the Senate chamber this week, and in Republican controlled state houses across the nation, Americans witnessed a colossal collision of reality and ideals in the form of new Jim Crow laws to suppress minority voting rights, and refusal to address gun violence. In the wake of a constant stream of racial animus and mass shootings, this lethal epidemic demands a response as well.
Were these the only flashing alerts signaling danger ahead, that would be enough to cause sleepless nights. But unenforced or unevenly enforced laws, and value dissonance in America, do not occur in isolation, but are supported by an even more erosive underpinning – greed-induced economic inequality.
Admit it: you’ve been following the story about the huge container ship stuck in the Suez Canal. It’s about the size of the Empire State building laid flat, and somehow ended up blocking one of the busiest waterways in the world.
As serious as this was for global shipping and all of us who depend on it, much hilarity ensued. Memes exploded, using this as a metaphor for almost everything, healthcare included. Once there started to be hope for getting the Ever Given free, people started new memes that it should be “put back.”
Well, I’m a sucker for a funny meme and a good metaphor too. Our healthcare system is that canal, and we’re the unfortunate ship. Only it doesn’t look like we’re getting unstuck anytime soon.
The Ever Given got stuck a week ago. It is one of the world’s largest container ships, but high winds, poor visibility (due to a dust storm), and, perhaps, human error caused things to go sidewise, literally. It got stuck on the banks. Over 300 other ships have been blocked as a result; alternative routes add several thousand miles to the trip, making it a tough choice between waiting/hoping and rerouting.
Kelsey Mellard is CEO of Sitka, one of the emerging companies that’s providing specialty consults online to primary care docs. They’ve been building a specialty care network that can be accessed by asynchronous video, slightly different to some of their competition. Most of their customers are capitated medical groups, like ChenMed, trying to reduce their spend on specialty physician care (as Kelsey calls it the “unmanaged Part B spend bucket”). I asked her how it works, where the company is going (think virtual care integration), and whether it will be needed in the future. (You can guess her answer to the latter!)