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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.

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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

Anmol Madan, RadiantGraph

Anmol Madan is CEO of RadiantGraph. He’s building an end to end solution that goes from data ingestion to applications to consumer connection via text/email and voice in order to let payers quickly roll out patient engagement plans. His idea is that plans/payers don’t need to fix their data, RadiantGraph’s AI can take the messy data and and then add an AI layer, and on that create specific applications–Anmol showed me a comprehensive demo. I also asked him if they are doing too much, or conversely if they need to do more!–Matthew Holt

Matthew Explores the Referral Process

So I thought I would try a little experiment. Following up on a recent primary care visit I got a couple of referrals. I went investigating as to what I could find out about the where to go and what the cost might be. And what the connection if any between my primary care group (One Medical), the facility & specialists I was referred to, and my health plan, Blue Shield. I hope you enjoy my little tour of this part of the online health system–Matthew Holt

How to Fix the Paradox of Primary Care

By MATTHEW HOLT

If health policy wonks believe anything it’s that primary care is a good thing. In theory we should all have strong relationships with our primary care doctors. They should navigate us around the health system and be arriving on our doorsteps like Marcus Welby MD when needed. Wonks like me believe that if you introduce such a relationship patients will receive preventative care, will get on the right meds and take them, will avoid the emergency room, and have fewer hospital admissions—as well as costing a whole lot less. That’s in large the theory behind HMOs and their latter-day descendants, value-based care and ACOs

Of course there are decent examples of primary care-based systems like the UK NHS or even Kaiser Permanente or the Alaskan Artic Slope Native Health Association. But for most Americans that is fantasy land. Instead, we have a system where primary care is the ugly stepchild. It’s being slowly throttled and picked apart. Even the wealth of Walmart couldn’t make it work.

There are at least 3 types of primary care that have emerged over recent decades. And none of them are really successful in making that “primary care as the lynchpin of population health” idea work.

The first is the primary care doctor purchased by and/or working for the big system. The point of these practices is to make sure that referrals for the expensive stuff go into the correct hospital system. For a long time those primary care doctors have been losing their employers money—Bob Kocher said $150-250k a  year per doctor in the late 2000s. So why are they kept around by the bigger systems? Because the patients that they do admit to the hospital are insanely profitable. Consider this NC system which ended up suing the big hospital system Atrium because they only wanted the referrals. As you might expect the “cost saving” benefits of primary care are tough to find among those systems. (If you have time watch Eric Bricker’s video on Atrium & Troyon/Mecklenberg)

The second is urgent care. Urgent care has replaced primary care in much of America. The number of urgent care centers doubled in the last decade or so. While it has taken some pressure off emergency rooms, Urgent care has replaced primary care because it’s convenient and you can easily get appointments. But it’s not doing population health and care management. And often the urgent care centers are owned either by hospital systems that are using them to generate referrals, or private equity pirates that are trying to boost costs not control them.

Thirdly telehealth, especially attached to pharmacies, has enabled lots of people to get access to medications in a cheaper and more convenient fashion. Of course, this isn’t really complete primary care but HIMS & HERS and their many, many competitors are enabling access to common antibiotics for UTIs, contraceptive pills, and also mental health medications, as well as those boner and baldness pills.

That’s not to say that there haven’t been attempts to build new types of primary care

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Matthew on the Inside Medtech Innovation podcast

I was a guest on Shannon Lantzy‘s podcast Inside Medtech Innovation. I went on far too long about my background but we had a very fun chat, including the real origin story of why I am in health technology, and a bit about my fascination with Japan. Plus some more health care stuff. I enjoyed it. Hopefully you will too–Matthew Holt

Medicaid Should be Abolished. But Not Like This!

By MATTHEW HOLT

A long time ago in a different country, there was a landslide election from a population looking for change. And change they got. Americans had been campaigning for national health care since 1917. There had been failures in 1933 and 1946 and 1961. But in 1965 they got it. Sort of.

But a weird thing happened in the Congress. Out of the political sausage making came a plan that “Cared” for those over 65. While another plan came out that “Aid”ed the poor. (Stole that from the wonderful Adimika Arthur). Weirder still, the Medicare program was and is a Federally-funded program. The Medicaid program was a state-administered program, even though it was at least half funded by the Feds. 

That meant that Medicaid was always vulnerable to the whims of states. Of course many states already had demonstrated dismal records in how they treated their poorer and minority populations in the past (think slavery, Jim Crow, KKK, separate schools, drinking fountains, buses…you get the idea).

So while Medicare became the savior program for anyone who made it to 65, and later for those who were disabled or had kidney disease, Medicaid was a program for poor people that then got treated poorly. (Stole that from Jonathan Cohn). And right now in 2025 it is under severe threat yet again.

Before we get to that threat, it’s worth looking at the program. Medicaid has evolved and now covers most nursing home care (for “poor” seniors), care for the disabled, and even pays Medicare Part B premiums for people too poor to pay their own.  It also covers health insurance for poor people under 65 and in those states that accepted ACA Medicaid expansion, that’s a considerable number. Of course these are people under an imaginary line that makes them too poor to buy on the exchanges set up by the ACA. And usually Medicaid includes the CHIP program, an insurance program that covers poor children set up under Clinton in 1997.

This chart from the venerable KFF shows that while 75% of people on Medicaid are, poor, under 65, and not classified as disabled, 50% of the money goes to those who are not.

This all results in a bizarro world in which there is one Federal government program for people over 65 and the disabled, and then an entirely different state-based one, which spends 1/2 of its money on people who are over 65 and disabled and who are also in the Federal program. This is plain stupid and always has been.

Of course there is more to it than that.

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Sword Health, the Hinge Health S1, and me

By MATTHEW HOLT

The big news in the comeback of digital health is that Hinge Health filed its S1 and is looking to go public soon. I suspect that they’d have preferred to get the IPO done late last year when the AI bubble was expanding rather than deflating, but timing the market is tough! Nonetheless Hinge is almost profitable and at over $350m in revenue at a growth clip of some 75% last year, in terms of a show pony to trot out, it’s about as good as the digital health field has got. The problem is that the last round in 2021 was at a $6bn+ ZIRP-era valuation with Tiger & Coatue paying the idiot price because Teladoc was trading at $15bn market cap then (albeit down from $30bn a year before that!). That is, err, no longer the case. There’s a bunch of weirdness in the IPO structure to pay those guys back, but the main point is that the likely valuation will be in the $1.5-2.5bn range. 

But there’s another problem. And it’s one I have some personal experience with. I must stress that my experience is not with Hinge.

As it happens I did a video interview at Hinge’s booth at HLTH in 2022 when my back collapsed, and I got to try out their Enso device (it helped a bit but not much after the first few minutes using it). I discussed the process with PT Lori Walter and got a quick interview with President Jim Pursely (an old Livongo hand BTW). 

But this past summer I used the services of their main competitor, Sword Health. As far as I can tell the two companies are very similar in their process and services, both with self-service exercises delivered via the smartphone and both moving from remote care from therapists to AI therapists. But I could be wrong. So for this article I am extrapolating from one company to the other to look at the field of MSK digital services overall.

In total, I thought the Sword experience was good as a standalone program. But the problem was that it was standalone.

My problem was with my left knee. I had a lot of knee surgery in 2002-4 as the result of snowboarding into a tree (Hint. If you snowboard, try to make sure you and the board go the same side of the tree). More than 20 years later in 2024 I managed somehow to induce terrible pain in the knee running for a ferry in January, a train in May and an airport shuttle in June. (It seems that travel and my knee disagree). This didn’t stop me strapping up, taking drugs and snowboarding in the 2024 winter season but it certainly slowed me down a whole lot. Around this time there were many reports of people much younger than me getting their knees replaced.

So I thought I should do something about it. My Blue Shield of California plan offers Solera which is an agglomeration marketplace of digital health apps and services. Sword Health is their PT app, so I selected it, enrolled and off I went.

Note that there was zero integration with my PCP, any orthopedic surgeon, any clinical person at the health plan or basically anyone. This was purely patient-driven and managed.

With Sword I had a 15 min intro call on June 6 – then was sent a box containing a generic tablet and six sensors which fit into straps that you attach to your lower and upper legs and arms.

There was a conversation in the app with a PT and then it spat out a selection of exercises for me. The example below is my second exercise session. If you want to check out more, I have put more of the exercise and the chat with the PT here.

Sword suggested, instead of regular 45-60 minute physical PT sessions, that I did four 15 minutes sessions a week. Essentially one every other day.

The end result was that I did eight sessions between June 12 & June 30.

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Jonathan Bush, Zus Health

It’s always fun to chat with Jonathan Bush. You kids today may not remember that he was the first CEO to take a cloud-based (Health 2.0!) company public back in 2007! Athenahealth didn’t end up challenging Epic because a cosmically evil hedge fund took it (and him) down as it was on its way to try to do that, but Jonathan has moved on and is now building a clinical data integration company called Zus Health. We talked Zus, digital health, whether there will ever be value-based care and more. 20 mins of digital health gold right here–Matthew Holt

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