The April Fools joining me on THCB Gang today will be policy expert consultant/author Rosemarie Day (@Rosemarie_Day1), futurist Jeff Goldsmith, policy & tech expert Vince Kuraitis (@VinceKuraitis), and patient safety expert & all around wit Michael Millenson (@MLMillenson). There’s vaccines, a 4th wave, Texas reopening, Florida never having closed, and a whole mess of health policy. It’ll be fun — so come join us
Joining me , Matthew Holt (@boltyboy), on THCB Gang this week were fierce patient activist Casey Quinlan (@MightyCasey), consumer advocate & CTO of Carium, Lygeia Ricciardi (@Lygeia), THCB regular authors radiologist Saurabh Jha (@roguerad) & cardiologist Anish Koka (@anish_koka), with futurist Jeff Goldsmith on hand to keep us all honest. We started with Casey’s current health journey and Anish’s inability to get vaccines for his clinic — and this moved to a really fun and raucous discussion about whether the public sector can work in health care, whether we need to mandate the vaccine and if America is becoming a failed state! Great stuff!
Joining me, Matthew Holt (@boltyboy), on this week’s THCB Gang were consultant/author Rosemarie Day @Rosemarie_Day1), Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune), and health futurist Jeff Goldsmith (@JeffcGoldsmith) and a late add Ian Morrison (@seccurve).
We will also had a special guest who is possibly the most successful corporate venture capitalist in health tech–Merck’s Bill Taranto. He had a decent run last decade– you may have heard of Livongo which he was a big investor in! We talked with Bill about the future of investing, what role investing in digital health has for drug business and what he’s expecting in the big health care realignment. Apparently Merck treasury took all the cash he made with Livongo so he couldn’t give it to us, but he has $500m+ top spend and as he said, “you want a Billion Dollar exit? Put me on the board”
Episode 39 of “The THCB Gang” will live-streamed on Thursday, Jan 21. You can see it below!
Matthew Holt (@boltyboy) was joined by regulars: futurists Ian Morrison (@seccurve) & Jeff Goldsmith, surgeon and now digital health entrepreneur Raj Aggarwal (@docaggarwal), radiologist Saurabh Jha (@roguerad), and patient advocate Robin Farmanfarmaian (@Robinff3).
Like the nation we took a big collective sigh of relief. We then talked a lot about COVID vaccinations, what the newly (sort of) Dem-led Senate is going to do on stimulus and health care , and we fnished on all that money pouring into digital health, while the stock market goes crazy. It was all good grist for the #THCBGang’s mill.
Episode 35 of “The THCB Gang” was live-streamed Thursday, Dec 10. You can watch it below.
Matthew Holt (@boltyboy) was joined by not one but two of America’s leading health futurists Ian Morrison (@seccurve) and Jeff Goldsmith; Patient advocate Grace Cordovano (@GraceCordovano); health writer Kim Bellard (@kimbbellard); employer health expert Jennifer Benz (@jenbenz); and surgeon and innovation dude Raj Aggarwal (@docaggarwal).
There was lots of conversation about who is going to pay for what health care. What are big employers going to do. How is the vaccine going to roll out and are we ready? What does it all mean for the future of hospitals, doctors, employers, innovation and more.
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…
William Tecumseh Sherman, who laid waste to the South at the end of the Civil War, famously said, “War is Hell”. So, too, is health reform. And like Sherman’s infamous March to the Sea, where he burned town after Confederate town, the Republican War on Obamacare entered its attrition phase with the introduction on Monday in the House legislation to repeal and replace ObamaCare. Except that Ryan is marching in the wrong direction; his troops are marching “north” and burning towns behind their own lines.
Ryan’s bill released Monday was greeted with a chorus of derision from the newly empowered Republican base; some conservative wags dubbed the bill “RINOCare”. Thoughtful conservative analysts savaged it. Michael Cannon, the hard core libertarian Cato Institute health analyst, called it “a trainwreck waiting to happen” and suggested that “ it will create the potential for the sort of wave election Democrats experienced in 2008” In Reason.com, Peter Sunderman wrote, “it’s not clear what problems this particular bill would actually solve.”
Ryan’s draft neither repeals nor replaces ObamaCare. Continue reading…
We all knew how this was going to go, or thought we did. Fee-for-service payment for health services was going to disappear, and be replaced by population health risk-based payment (or as some term it, “capitation”- fixed payment for each enrolled life). Hospitals and care systems invested substantial time and dollars building capacity to manage the health of populations, yet many are discovering a shortage of actual revenues for this complex new activity. Was population health a mirage, or an actual opportunity for hospitals, physicians and health systems?
The historic health reform law passed by Congress and signed by President Obama in March, 2010 was widely expected to catalyze a shift in healthcare payment from “volume to value” through multiple policy changes. The Affordable Care Act’s new health exchanges were going to double or triple the individual health insurance market, channeling tens of millions of new lives into new “narrow network” insurance products expected to evolve rapidly into full risk contracts.
In addition, the Medicare Accountable Care Organization (ACO) program created by ACA would succeed in reducing costs and quickly scale up to cover the entire non-Medicare Advantage population of beneficiaries (currently about 70% of current enrollees) and transition provider payment from one-sided to global/population based risk. Finally, seeking to avoid the looming “Cadillac tax” created by ACA, larger employers would convert their group health plans to defined contribution models to cap their health cost liability, and channel tens of millions of their employees into private exchanges which would, in turn, push them into at-risk narrow networks organized around specific provider systems.
Three Surprising Developments
Well, guess what? It is entirely possible that none of these things may actually come to pass or at least not to the degree and pace predicted. At the end of 2015, a grand total of 8.8 million people had actually paid the premiums for public exchange products, far short of the expected 21 million lives for 2016. As few as half this number may have been previously uninsured. It remains to be seen how many of the 12.7 million who enrolled in 2016’s enrollment cycle will actually pay their premiums, but the likely answer is around ten million. Public exchange enrollment has been a disappointment thus far, largely because the plans have been unattractive to those not eligible for federal subsidy.
That we are experiencing a “consumer revolution” in healthcare is a durable meme in the media and in policy circles just now. When you hear the word “consumer”, it conjures images of someone with a cart and a credit card happily weaving their way through Best Buy. It is, however, a less than useful way of thinking about the patient’s experience in the health system.
A persistent critique of our country’s high cost health system is that because patients are insulated from the cost of care by health insurance, they freely “consume” it without regard to its value, and are absolved of the need to manage their own health. In effect, this view ascribes our very high health costs to moral failure on the part of patients.
Market-oriented policy advocates believe that if we “empower”patients as consumers by asking them to pay more of the bill, market forces will help us tame the ever rising cost of care. If patients have “skin in the game” when they use the health system and also “transparency” of health providers’ prices and performance, patients can deploy their own dollars more sensibly.
This concept played a major role in the otherwise “progressive” Affordable Care Act. The 13 million people who signed up for coverage this year through the Affordable Care Act’s Health Exchanges opted overwhelmingly for subsidized policies with very high deductibles and out-of-pocket cost limits. The “skin in the game” argument has also heavily influenced corporate health benefits decisions. More than 30 million workers and their families receive high deductible plans through employers.
What to do about the seemingly inexorable rise in health spending has been the central health policy challenge for two generations of health economists and policymakers. In 1965, before Medicare and Medicaid, health spending was about 5.8 percent of GDP. In 2013, it was nearly 18 percent. And GDPquadrupled during this same period.
Over the past 30 years, there are been two warring political narratives explaining health spending growth, with two different culprits and indicated remedies. At their cores, these narratives blame the main actors in the health care drama—patients and physicians—for rising costs.
The Conservative Narrative: The Patient As Culprit
The conservative thesis holds that the demand for health care is unlimited because it has been, historically, a free good for many patients. Moreover, the argument runs, much illness is driven by bad personal health choices — for example, smoking and obesity, and the heart disease and diabetes that follows. Thus, much of our cost problem is actually the patient’s fault.