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What Will Shape Joe Biden’s Health Care Agenda?

I’m thrilled to have health futurist Jeff Goldsmith back on THCB, and given Biden was only confirmed as President-elect this morning, his article on what to expect is extremely timely!–Matthew Holt

By  JEFF GOLDSMITH

The Trump administration’s health care journey began with a trillion dollar near miss–the failed Repeal and Replacement of ObamaCare- and ended with a full-on train wreck, the catastrophically mismanaged COVID epidemic that will have claimed 300,000 lives by the time he leaves office. After four years of posturing and lethal incompetence, it will be a relief to see caring and professionalism return to the White House health policy under President-Elect Joe Biden.   

Like Inheriting a Badly Managed World War

Like Barack Obama, Joe Biden will be saddled at the beginning of his regime with a damaged national economy. He will also walk in the door to the immediate need to manage the greatest public health catastrophe in a century as well as its economic consequences–a deep and enduring recession. Biden will be inheriting the equivalent of a badly managed World War we are presently losing.

Public health professionals who were marginalized by Trump will be challenged not only to craft coherent policy to contain and extinguish COVID  but also to sell it to a frightened and polarized general public, many of whom reject the need for basic public safety measures.    

Controlling COVID and rebuilding the critical public health agencies–CDC and FDA–that have damaged by political meddling will consume the lion’s share of the administration’s health policy bandwidth in its first year. It will be pressed to address a huge readiness gap–from critical PPE supplies to the development and deployment of testing and tracing capability to public health co-ordination and messaging–for the next pandemic. Increasing the presently inadequate level of public health funding (less than $100 billion a year in a $21 trillion economy) seems inevitable.

The inability of Congress to produce a fall round of COVID relief will create pressure on Biden to take immediate action to help struggling sectors of the economy, like airlines, restaurants and hospitals, as well as further help for the long term unemployed. Only a little more than half of the 22 million jobs lost in the spring have returned by November. Twenty million Americans were stranded by the July expiration of supplemental unemployment benefits as well as countless millions more “free agents” and contractors not eligible for traditional unemployment that are losing coverage at the end of the year. Mortgage, credit card and consumer loan forbearance are ending, and unless Congress acts, acres of rotten credit will turn rapidly into a banking and bond market crisis which the Federal Reserve cannot fix by itself.   

State governments face FY21 deficits equaling $500 billion over the next two years , against a current annual spending base of about $900 billion.  Further assistance to state and local governments will almost certainly include an additional increase in the federal match for Medicaid (FMAP), beyond the 6.2% temporary increase passed in March). Medicaid enrollment will likely top 80 million by mid 2021, almost one-quarter of the US population. Some states will have upwards of 40% of their population on Medicaid by mid-2021.

States laboring under severe revenue shortfalls will be unable to afford the expanded Medicaid program that was part of ObamaCare without a further increase in the FMAP rate.  President Trump and Senate Republicans blamed the state and local government fiscal crisis on profligate Democratic mismanagement, and blocked aid to them during 2020. But Texas, Florida, Georgia and other red states have the same problems New York and California do. 

Serious Fiscal Limitations Push the Health Policy Agenda Away from Coverage Expansion

Barack Obama entered office with a FY08 federal deficit of $420 billion. Joe Biden enters with a FY20 deficit of $3.1 trillion and a baseline FY21 deficit of $1.8 trillion, before adding the cost of the likely additional trillion dollar-plus stimulus package early next year. It will be passed over the dead bodies of Republican Congressional leadership suddenly recommitted to deficit reduction after racking up $8 trillion in deficit spending during the four years they controlled the federal government.

Coverage Expansion via Medicare and Public Option Unlikely

That deficit will significantly constrain a further expansion of health coverage. Not only will “Medicare for All” be off the table. Severe fiscal pressures will cause the new administration to “slow walk” a public option (which would require federal subsidies to implement) and Medicare expansion to people over age 60. These expansions were going to be  controversial and politically costly because they would be fiercely contested by hospitals and other care providers concerned about the erosion of their commercial insured customer base (the source of perhaps 130% of their bottom lines) as well as the use of Medicare as a de facto price control lever. 

By the time Biden addresses the first two problems–COVID and the economic crisis–he will probably have expended his limited stock of political capital and be weakened enough to be unable to take on the large messy issues of health coverage expansion and cost control. The Affordable Care Act exhausted Obama’s store of political capital, by early 2010. His administration’s failure to turn the economy cost the Democrats control of the House of Representatives and 20 (!) state legislatures in 2010.

What Can Biden Do in Health that Does Not Require Federal Spending?

Thus, the focus of Biden health policy is likely to be on items not requiring fresh spending.

Continue reading…

The THCB Book Club!

By JESSICA DAMASSA & MATTHEW HOLT

We are launching a new THCB program! The THCB Book Club (TM) is going to be a discussion with leading health care authors, which will be released on the third Wednesday of every month.

We are kicking off with the new book from Hemant Teneja (VC at General Catalyst who has been writing many big checks lately) and Stephen Klasko (CEO at Jefferson Health System and one of the most unusual hospital system bosses in America). Their book is called UnHealthcare: A Manifesto for Health Assurance which is a how-to for creating a platform for a revolutionary future for healthcare, Taneja said. “Health assurance is an emerging category of consumer-centric, data-driven healthcare services that are designed to bend the cost curve of care and help us stay well.” Sitting in on the interview because we can’t get rid of him we will also have Glen Tullman from Livongo (Just kidding, Glen!). He will weigh in on how this connects with his new idea of Consumer Directed Virtual Care. Matthew may say something about the Continuous Clinic too, and Jessica will keep score of all the crises, Tsunamis, the many ways the health care is broken, and how many zingers Glen & Matthew get in on each other!

We want YOU to read the book in advance and email us questions or comments for us to ask the author(s) before the show. (We record a day or two in advance so please email us or put question in the comments here or on Twitter by the 17th). 

Please go buy the book here (eVersion only $6!)

It should be a lot of fun and very educational! This will be up on THCB on August 19.

In September the author will be Jane Metcalfe with her 2020 book NEO.LIFE

THCB Gang, Episode 19, July 23, 2020

This episode of the THCB Gang included regulars Grace Cordavano (@GraceCordovano) , Deven McGraw (@HealthPrivacy), Ian Morrison (@seccurve), and special guest patient entrepreneur Robin Farmanfarmaian (@Robinff3). We talked about patient experiences, the state of play in health care business, and about new technologies and more. And after tomorrow it gets preserved as a podcast on Itunes & Spotify Enjoy! – Matthew Holt

THCB Gang, Episode 12

Episode 12 of “The THCB Gang” was live-streamed on Friday, June 5th from 1PM PT to 4PM ET. If you didn’t have a chance to tune in, you can watch it below or on our YouTube Channel.

Editor-in-Chief, Zoya Khan (@zoyak1594), ran the show! She spoke to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation focused on health disparities seen in POC communities across the nation and ideas on how the system can make impactful changes across the industry, starting with executive leadership and new hires. It was an informative and action-oriented conversation packed with bursts of great facts and figures.

If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt

How to Manage Patients in Quarantine, Smartly

By MATTHEW HOLT

Smart Quarantine as the next step to combat COVID-19

As the nation and the world grapple with the impact of the COVID-19 pandemic, there is growing consensus among experts that we need a sustainable system of specific lockdowns, social distancing, and extreme resource provision in terms of labor, ventilators and PPE to arm hospitals and health providers as they deal with the onslaught of patients. Even while some American states start to slowly open up, we need a system that can manage COVID-19 over the coming months and years–especially if this Fall brings a second wave.

Writing in the NY Times on April 7, Harvey Fineberg and colleagues summarized an as yet overlooked issue. There are many patients who may or do have COVID-19, but are not sick enough to need hospital care, or who have been discharged from hospitals. We need to keep these patients away from hospitals but if they shelter in place in their household there is a high risk they will infect their families or housemates. This likelihood is even higher if they are homeless,  incarcerated, or living in other group arrangements.

Instead of sheltering in place at home Fineberg and colleagues suggest those patients enter “smart quarantine” in temporary isolated accommodation, such as hotels or college dormitories, where they can be looked after by medical teams and tested semi-regularly. But whether they are at home or in temporary accommodation, leaving those patients with minimal support to be tested at the end of 14 days is not enough. A significant proportion of them will develop COVID-19 and some of those are going to be admitted to hospital. In addition several patients have been discharged from hospital, but still need to be monitored. We are going to need to be able to closely monitor a significant number of people even while the majority of them will need relatively limited amounts of care.

The good news is that we have had a couple of decades of development of the technologies and services required to both care for and monitor these patients, while keeping the main resources such as ventilators for those in hospitals. Pulling together available technologies and services, we will be able to quickly and accurately manage these patients, ensure their best outcomes, and spare scarce hospital resources. There are seven main components of this process, which I am calling “smart care in quarantine.”

The Process

Upon either a positive test for COVID-19 or a suspicion of those symptoms awaiting testing, patients can be admitted to isolation at home or in, say, empty hotels. 

1. Monitoring equipment. Patients can be given FDA regulated monitoring devices which will work using bluetooth and WiFi (or 4G cellular). The main monitoring tools required are:

  • Pulse Oximeters
  • Thermometers
  • Stethoscopes (with acoustic recording)
  • Weight Scales
  • Video & audio via iPad, phone or computer
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The THCB Gang, Today at 1pm PT/4pm ET

Starting today we are going to create a new live show on THCB that will be preserved as a weekly podcast. I’m calling it The THCB Gang. Each week 4-6 semi regular guests drawn from THCB authors and other assorted old friends of mine will shoot the shit about health care business, politics and tech. It should be fun but serious and informative!

To kick off this week, joining me I’ll have Saurabh Jha (@roguerad), Jane Sarasohn Kahn (@healthythinker), Deven McGraw (@healthprivacy) & Kim Bellard (@kimbbellard). Join us at 1pm PT and 4pm ET right here! Hopefully if I don’t screw up too badly we will repeat this every week at the same time with a variety of guests! — Matthew Holt

Update, just added Ian Morrison (@seccurve) to the gang!

Understanding #Medicare4All & the Democratic Primaries

By MATTHEW HOLT

Since Saturday’s Nevada primaries, confusion seems to be reigning about how Bernie Sanders seems to be winning. Time (and not a lot more of it) will tell who actually ends up as the Democratic nominee. But the progressive side (Bernie + Warren) is doing much better than the moderate side (Biden/Butt-edge-edge/Klobuchar) expected, while we wait to see how the  Republican side of the Democratic primary (Bloomberg) does in an actual vote. The key here is the main policy differential between the two sides, Medicare For All.

Don’t get too hung up in the details of the individual plans, especially as revealing said details may have hurt Elizabeth Warren. But do remember that there is one big difference between Sanders/Warren and the moderates. It comes down to whether everyone is in the same state-run single payer system (a modified and expanded version of Medicare) or whether the private employer system is left as it is, with expanded access to something that looks like Medicare (the public option) for everyone else. Note that no Democrat wants to stand pat on Obamacare “as is”. Everyone is way to the left of what Obama ran on in 2008 (or at least what he settled for in early 2009).

Why has this changed? Well there’s been a decade of horror stories. I’m not talking about the BS anti-Obamacare stories from people forced to give up their junk insurance, I’m talking about people with insurance being bankrupted or put through horrendous experiences, like this mother who was put through the ringer by various insurers when her 1 year old son was killed and husband injured in a road accident. Or this health tech CEO, who was an MD & JD and had to put $62,000 on his American Express card to get surgery

About 3 years ago as the dust was clearing from the Obamacare implementation, the impact of this started showing up in the polls.Continue reading…

THCB Spotlights: Lightbeam Health Solutions

By ZOYA KHAN

Today, THCB is spotlighting Lightbeam Health Solutions. Lightbeam is an end-to-end population health management solution, which means they build everything from the ground up (i.e. no acquisitions or 3rd party interfaces are used). “Interface to innovation” as Jorge Miranda, CRO of Lightbeam, states, allows Lightbeam to build a health system’s value-based contracts relatively quickly. Their main focus is to generate data insights for ACOs and other provider systems, to engage care teams in the coordination of patient care. This is Lightbeam’s 6th year in the health care field, and with 100 customers and over 20 million patients in their enterprise data warehouse (EDW), they have no signs of slowing down.

Lightbeam has 4 main focuses: data ingestion, data insights, the engagement of the team with the data gathered, and the patient outcomes that result from that data. Lightbeam seeks to use their insights to empower care teams by giving the information back to the caregivers, physicians, and patients. According to them, this creates more transparency in the entire process as well as allows the patient and caregivers to play an active role in their health care process.

The ultimate value that clients (health systems or providers) receive from Lightbeam’s system is cutting costs and improving quality. Lightbeam does this by monitoring engagement numbers and patient outcomes based on the data and insights they gathered, ensuring costs savings for clients as well as an effective approach to cutting the high cost of care today. Lightbeam’s ultimate goal is to replace a manual process that is currently being done by multiple people and using multiple resources, to refocus the target on improving care for everyone involved in the health care system.

Zoya Khan is the Editor-in-Chief of THCB as well as an Associate at SMACK.health, a health-tech advisory service for early-stage startups.

Welcome to the New & Improved THCB!

Welcome back–and thank you for bearing with us while we figured out all the technical stuff transitioning the old THCB site to the new one! Hopefully this all looks familiar, but while the content is the same, under the hood everything is actually brand new.

We’ve made some simplifications, particularly having the “big 4” categories listed at the top of the page: Health Tech, Health Policy, Medical Practice & Health Care Business. The left margin has Videos (THCB Spotlight, WTF Health and Health in 2 Point 00), and our latest tweets from @THCBstaff below them. The right margin has room for our soon-to-come podcast “HardCore Health”, as well as 15 years worth of Archives and a place to sign up for our email newsletter, the THCB Reader.

If you want to comment and were previously registered, your registration should have carried over — login is on the top right. Of course you can still register in the same place (and yes, to stop spammers, you do need to do so in order to comment).

We will be adding new features and changing stuff around a little as we stretch our new technical legs! I hope you enjoy the new and improved THCB site — Matthew Holt

New THCB site coming MONDAY! (It’ll be down this weekend)

I’m thrilled to tell you that after a lot of work by Zoya Khan, Dan Kogan and his tech whizzes, there’ll be a new THCB site up on Monday. Hopefully you’ll notice the changes and think it’s an improvement!

But while we do the switch (to a new server, template, host, et al) the site will be down this weekend starting Friday night PT.  So go outside and enjoy some fresh air and we’ll be back Monday morning!  Thanks!  — Matthew Holt

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