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Evaluating President-Elect Biden’s Healthcare Plan | Part 2

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By TAYLOR J. CHRISTENSEN

In Part 1 of this series, I reviewed the relevant context of our post-ACA healthcare system to show why President-Elect Joe Biden’s healthcare plan is perfectly reasonable. In this part, I will critically evaluate that plan to show what he got right and what he got wrong or missed altogether.

Joe Biden plans to get rid of the current limit (400% of the federal poverty level) on who qualifies for health insurance premium subsidies and instead convert it to a flat percentage of income (8.5%), which means anyone whose health insurance is going to cost more than 8.5% of their annual income would qualify for a subsidy. And those subsidies would be more generous, being based on a gold-level insurance plan’s price rather than a silver-level insurance plan. He also plans to create a new government-run health insurance company to offer an insurance plan—a “public option”—on the private market, which would be available to private market health insurance shoppers and some other groups as well.

Ok, now for some evaluation of all that.

First, let me frame how I am going to evaluate Joe Biden’s plan.

There are three problems healthcare reformers are usually trying to solve. They want to (1) increase access to care, (2) decrease healthcare prices, and (3) improve the quality of care.

But if we merge the last two goals into one, we can say they want to (1) increase access, and (2) improve the value of care (Value = Quality / Price). We will take these one by one.

Goal 1: Increase Access

How will Joe Biden’s plan do at increasing access?

There are three things to consider when evaluating access-increasing policies. The first is how many people will be covered. The second is how much it will cost. And the third, almost universally forgotten, is how much it will interfere with efforts to accomplish the second goal to improve the value of care.

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Evaluating President-Elect Biden’s Healthcare Plan | Part 1

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By TAYLOR J. CHRISTENSEN

Without the full support of congress behind him, President-Elect Joe Biden will probably not have an opportunity to sign any major system-altering healthcare legislation. But, if Democrats can gain a majority in the senate–either this election cycle or next—healthcare reform will be high on the agenda. Let’s take a critical look at what Joe Biden would push to accomplish.

For this evaluation, I am relying solely on information that Joe Biden has committed to on his official campaign website. He has many pages talking about a variety healthcare issues, such as the pandemic, gun violence, and the opioid epidemic. But the main page that reviews his plans for the healthcare system as a whole is here. Consider giving it a read through first, because what follows will only be summarizing and evaluating the key big-picture components of his plan.

Joe Biden is not pushing for Medicare for All. He instead wants to keep the Affordable Care Act (i.e., the ACA, or “Obamacare”) and fix the parts of it that are not working so well. To understand the rationale of his proposed changes, we first need to review where we are at now with the ACA.

There are many parts to the ACA, but its main thrust was to increase insurance coverage. What kind of numbers are we working with? Below are some 2019 data, rounded for simplicity. And note that I am excluding the 60,000,000 people who are over age 65 and therefore on Medicare.

The under-age-65 people fall into one of four insurance groups . . .

Employer-sponsored insurance (160,000,000 people) if they are lucky enough to work for an employer that provides benefits.

Medicaid (70,000,000 people) if their income is low enough to qualify.

Private insurance from the “private market” (10,000,000 people) if they make too much money to qualify for Medicaid and do not have an employer that provides benefits.

Uninsured (30,000,000 people) if they do not get insurance from their employer, their income is too high to qualify for Medicaid, and they do not want to pay for insurance from the private market.

Remember, those are from 2019, so they are post-ACA numbers. Prior to the implementation of the ACA, the uninsured number hovered around 45,000,000 people. What did it do to reduce the number of uninsured people? There were many ways, but here are the two biggest ways:

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No Names, Please

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By KIM BELLARD

Feeling good about your holiday spending?  You’ve made it through most of this mostly horrible 2020, maybe lost a job or even a loved one, but still probably found a way to buy presents for your loved ones and maybe even to give some money to charity.  Indeed, charitable giving was up 7.5% for the first half of 2020, despite the economic headwinds.

Then there’s MacKenzie Scott.

Ms. Scott, as you may recall, is the former wife of Amazon founder/CEO Jeff Bezos.  She got Amazon stock worth some $38b in their 2019 divorce, which is now estimated to be worth around $62b.  She just gave away $4.2b – and that’s on top of $1.7b she gave away in July. 

In case your math skills are impaired, that’s $6b in six months, which Melissa Berman, chief executive officer of Rockefeller Philanthropy Advisors told Bloomberg: “has to be one of the biggest annual distributions by a living individual.”   Ms. Scott has vowed: “I will keep at it until the safe is empty.”

Kenzie Bryant, writing in Vanity Fair, marveled: “It gives a whole new meaning to “fuck-you money.” 

Private foundations are required to distribute at least 5% of their endowments each year; Ms. Scott not only has given away 10% of her net worth this year alone, but she hasn’t even used a foundation to do so.  As The New York Times reported: “Ms. Scott’s operation has no known address — or even website. She refers to a “team of advisers” rather than a large dedicated staff.”

She doesn’t make recipients plead for money through grant applications.  She doesn’t specify how the money is to be used, or require reports on how it is spent.  She doesn’t expect her name on anything.  She doesn’t even make public how much she is giving each recipient (although some choose to do so).

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3 Patient Lessons: What Cancer Patients Teach Me

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By YASMIN ASVAT

An estimated 1.8 million people in this country may face a cancer diagnosis this year, in what has already been a bleak year of isolation and loss.  

While news of the COVID-19 vaccine rolling out across the U.S. offers hope in a year of 311,000 deaths,  11 million  people face the financial pressure of unemployment, and, approximately 43 percent of the nation reports some symptoms of anxiety or depression.  

It is understandable that a cancer diagnosis now may be too much to bear. And yet, somehow, many patients cope with the diagnosis and the associated uncertainty, fragility, and the threat of mortality with remarkable resilience.  

As a clinical psychologist in the Supportive Oncology program at a major Midwestern cancer center, I witness these quiet heroics every day. 

Since the beginning of the pandemic earlier this year, I have been striving to listen, empathize, support, and help cancer patients cope as their lives have been disrupted by both a cancer diagnosis and COVID-19. These are lessons these patients have taught me. 

Courage is being faced with doing something that utterly terrifies you, and you do it anyway. One of my patients described that leading up to the day of chemotherapy treatment, she is highly anxious, has racing thoughts and worries, and has trouble concentrating and sleeping. The morning of treatment, she vents to her partner about how she doesn’t want to go to the clinic. During the drive, she braces herself repeating, “I don’t want to do this” over and over again. 

Once in the clinic, she tells some of her nurses that she doesn’t want to be there because she worries about COVID-19 exposure, despite all the precautions the clinics have in place. She tells another set of nurses that she is scared of the side-effects of treatment – the disabling fatigue, the nausea, the suppressed immune system. 

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A Christmas Message to All Physicians From a Swedish-American Country Doctor in Maine

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By HANS DUVEFELT, MD

Growing up in Sweden without a Thanksgiving holiday, Christmas has been a time for me to reflect on where I am and where I have been and New Year’s is when I look forward.

I have written different kinds of Christmas reflections before: sometimes in jest, asking Santa for a better EMR; sometimes filled with compassion for physicians or patients who struggle during the holidays. I have also borrowed original sentences from Osler’s writings to imagine how he would address physicians in the present time.

This year, with the pandemic changing both medicine and so many aspects of life in general, and with a gut wrenching political battle that threatens to erupt in anarchy or civil war within the next few weeks or months, my thoughts run deep toward the soul of medicine, the purpose of being a good doctor, even being a good human being.

We live in ideological silos, protected from dissenting opinions. News is not news if it is unpopular. Fake news and fake science are concepts that seemed marginal before but have now entered the mainstream.

As a physician, I serve whoever comes to see me to the best of my ability. But this year I have had to pay extra attention to the fact that so many people have already made up their minds about the nature and severity of the pandemic we are living with. If they don’t believe the country’s top experts, they are not likely to believe in me. Still, I try to gently state that we are still trying to figure this thing out and until we do, it’s better to be cautious.

I am starting to read about what some are now calling the Fourth Wave of the pandemic, the mental health crisis this winter may see in the wake of the physical illness we are surrounded by.

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Two Surgeons—a Veteran and a Newcomer—Talk Fighting COVID Burnout

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By MICHAEL E. LIPKIN and RUSSELL S. TERRY, JR.

Burnout has always been a concern in medicine, and that concern has been amplified by the added stress of COVID-19. Many months into an unpredictable and distressing situation, we have both hung on to our mental health and professional passion by seeking out strategies that work for us. We offer them in two perspectives: veteran and relative newcomer.  

Dr. Lipkin: A Veteran’s Perspective

When lockdown began in March, we slowed down my practice for about 6 to 8 weeks, and then returned to full pre-COVID levels. It feels like the uncertainty has affected me most, since it has not been clear if and when things will get substantially better. Everyone is both experiencing and projecting persistent anxiety, stress and uncertainty. Isolation is a problem as well. I no longer have the time or ability to sit down with colleagues and vent over a beer, which was an outlet I counted on to mitigate burnout. At the same time, on a more concrete level, the pandemic has made everything we do incrementally more difficult, which is grindingly stressful. These tips are helping me cope and avoid burnout.

There are so many changes—just accept them. As COVID affects so many areas of practice, there’s a kind of low-grade stress that fluctuates with events. It seems like everything is a little bit harder. We have to shift some patient visits to telehealth and make sure they get COVID tests before surgery. We’re all looking over our shoulders, wondering who’s going to get us sick. There’s always the specter of more shutdowns and how they might affect our livelihoods. Budgets have been cut back, so hiring is frozen and there’s virtually no incremental spending. Everything will stay this way for now, so the best thing to do is accept that we’re going through a tough period and focus on the big picture, rather than the list of irritations.

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COVID-19 Symptom Data Challenge Showcase Event — WEDNESDAY 4pm ET!

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After receiving applications from 115 people (across every continent except Antarctica!) and 50 organizations, including 35 academic institutions, the judges have declared DeepOutbreak, a team with members from Georgia Tech, the University of Iowa, and Virginia Tech as the winner of COVID-19 Symptom Data Challenge.

Second place was awarded to K&A, a Russia-based team working with the World Bank and the Higher School of Economics. $75,000 in prizes will be awarded to the winners.

The winners and the other three finalists will present their prototypes at the COVID-19 Symptom Data Challenge Showcase on Wednesday, December 16th, from 4-5:30pm ET. Register here!

The program’s distinguished speakers include

  • Dr. Tom Frieden, President & CEO of Resolve to Save Lives, an initiative of Vital Strategies & former director of the CDC
  • Dr. Mark McClellan, director of the Duke Margolis Center for Health Policy
  • Dr. Farzad Mostashari, CEO of Aledade & former National Coordinator for Health IT at the Department of Health and Human Services, and
  • Kang-Xing Jin, Facebook’s Head of Health.

Chrissy Farr, Principal and Health-Tech Lead at OMERS Ventures and former technology and health reporter for CNBC.com, will serve as emcee.

Register for the COVID-19 Symptom Data Challenge Showcase on Wednesday, December 16th, from 4-5:30pm ET here

The Year When Everything Changed: Covid, Self Care and High Tech Innovation In Medicine

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By HANS DUVEFELT

Life as we knew it and medicine as we had viewed it shapeshifted so dramatically in the past year that it is still hard to believe.

Medicine has started to move from an in-person only profession to one that finally recognizes that clinical assessment and treatment have fewer boundaries than people assumed. A patient of mine with newly diagnosed mastocytosis had a productive first consultation with an immunologist hundreds of miles away right from her own living room.

Efficiency increased when we could handle straightforward clinical issues electronically, even over the telephone, and still get paid. We were liberated from the perverted and miserly view by insurers that services not delivered in person should be free, as if fast food restaurants couldn’t charge for food at the drive through.

We delivered more virtual services to allow patients the safety of staying at home and avoiding lobbies, waiting rooms and exam rooms where airborne particles might linger.

Yet, when a primary care or mental health patient is in crisis or a person with new symptoms needs to be evaluated, a video visit is sometimes not enough. Step by step, we improvised screening protocols, not knowing which would be efficient or relevant as we didn’t know quite how the coronavirus behaved and transmitted.

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The “Right” to Health Care in America

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By MIKE MAGEE

I’ve been working on a Spring lecture for President’s College at the University of Hartford titled, “The Constitution and Your ‘Right to Health Care’ in America.” 

My description reads, “This lecture explores the recent political history and legal controversy surrounding attempts to establish universal health coverage in America. “Is health care a right?” viewed within the context of the Bill of Rights and especially the 9th and 10th Amendments?”

Self-described libertarian-conservative John R. Graham, a health policy analyst in the Trump administration’s HHS, writing on the topic in 2010 stated that, “As a non-lawyer, my understanding is very simple: The Ninth Amendment states that ‘the enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.’ So, if you claim a ‘right to health care,’ there’s nothing in the Constitution that denies your claim. Indeed, libertarians and conservatives should be more willing to concede a ‘right to health care,’ because once it’s defined as a right, the entire weight of the Constitution comes down against federal (and perhaps even state) control.”

This bit of semantics crash-lands with common sense, as it did in my own state in 1965 when the Supreme Court in a 7 to 2 decision (Griswold v. Connecticut) dismantled an 1873 Comstock Law that prohibited married couples from buying and using contraceptives. Writing for the Court, Justice William O. Douglas declared that “specific guarantees in the Bill of Rights have penumbras, formed by emanations from those guarantees that help give them life and substance.” Though marital privacy was not mentioned in the Bill of Rights, legal analysts have suggested that Douglas was asserting that logic dictated that marital privacy “is one of the values served and protected by the First Amendment through its protection of associational rights, and by the Third, the Fourth, and the Fifth Amendments as well.”

Justice Goldberg concurred at the time, writing: “The language and history of the Ninth Amendment reveal that the Framers of the Constitution believed that there are additional fundamental rights, protected from governmental infringement, which exist alongside those fundamental rights specifically mentioned in the first eight constitutional amendments. . . . To hold that a right so basic and fundamental and so deep-rooted in our society as the right of privacy in marriage may be infringed because that right is not guaranteed in so many words by the first eight amendments to the Constitution is to ignore the Ninth Amendment and to give it no effect whatsoever.”

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RWJF Emergency Response Challenges Video

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On November 19, 2020 Catalyst @ Health 2.0 hosted the finals of the RWJF Emergency Response Challenges, one for tools for the General Public and the other for the Health System. The promise of the tools that have been built as part of these challenges is immense in the battle against this COVID-19 pandemic and the ones yet to come. The finalists for the General Public challenge were:

Binformed Covidata– A clinically-driven comprehensive desktop + mobile infectious disease, epidemic + pandemic management tool targeting suppression and containment of diseases such as COVID-19. The presenter was veteran health IT expert Rick Peters.

CovidSMS– A text message-based platform providing city-specific information and resources to help low-income communities endure COVID-19. In contrast to Rick, CovidSMS’ team were undergraduates at Johns Hopkins led by Serena Wang

Fresh EBT by Propel– A technology tool for SNAP families to address food insecurity & economic vulnerability in times of crisis – highlighted by Michael Lewis on his Against the Rules podcast about coaching earlier this year. Stacey Taylor, head of partnerships for Propel presented their solutions for those in desperate need.

The finalists for the Health System challenge were:

PathCheck– A non profit just spun out of MIT. It has a raft of volunteers and well known advisors like John Brownstein and John Halamka among many others, and is already working with several states and countries. Pathcheck provides privacy first, free, open source solutions for public health to supplement manual contact tracing, visualize hot spots, and interface with citizen-facing privacy first apps. MIT Professor Ramesh Raskar was the presenter.

Qventus– A patient flow automation solution that applies AI / ML and behavioral science to help health systems create effective capacity, and reduce frontline burnout. Qventus is a great data analytics startup story. It’s raised over $45m and has lots of health system clients, and they have built a suite of new tools to help them with pandemic preparedness. Anthony Moorman, who won the best facial hair of the day award, showed the demo.

Tiatros – A mental health and social support platform that combines clinical expertise, peer communities and scalable technology to advance mental wellbeing and to sustain meaningful behavioral change. They’ve done a lot of work with soldiers with PTSD and as you’ll see entered this challenge to get their tools to another group of extremely stressed professionals–frontline health care workers. CEO Kimberlie Cerrone and COO Seth Norman jointly presented.

We also presented the Catalyst @ Health 2.0 Covid19 SourceDB between the two competitions. Please enjoy the video

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