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The Fantastic Fungi — Biohybrid Bots Are Mushrooming

By KIM BELLARD

I hadn’t expected to write about a biology-related topic anytime soon after doing so last week, but, gosh darn it, then I saw a press release from Cornell about biohybrid robots – powered by mushrooms (aka fungi)! They had me at “biohybrid.”  

The release talks about a new paper — Sensorimotor Control of Robots Mediated by Electrophysiological Measurements of Fungal Mycelia – from the Cornell’s Organic Robotics Lab, led by Professor Rob Shepherd. As the release describes the work:

By harnessing mycelia’s innate electrical signals, the researchers discovered a new way of controlling “biohybrid” robots that can potentially react to their environment better than their purely synthetic counterparts.  

Or, in the researchers’ own words:

The paper highlights two key innovations: first, a vibration- and electromagnetic interference–shielded mycelium electrical interface that allows for stable, long-term electrophysiological bioelectric recordings during untethered, mobile operation; second, a control architecture for robots inspired by neural central pattern generators, incorporating rhythmic patterns of positive and negative spikes from the living mycelia.

Let’s simplify that: “This paper is the first of many that will use the fungal kingdom to provide environmental sensing and command signals to robots to improve their levels of autonomy,” Professor Shepherd said. “By growing mycelium into the electronics of a robot, we were able to allow the biohybrid machine to sense and respond to the environment.”

Lead author Anand Mishra, a research associate in the lab, explained: “If you think about a synthetic system – let’s say, any passive sensor – we just use it for one purpose. But living systems respond to touch, they respond to light, they respond to heat, they respond to even some unknowns, like signals. That’s why we think, OK, if you wanted to build future robots, how can they work in an unexpected environment? We can leverage these living systems, and any unknown input comes in, the robot will respond to that.”

The team build two robots: a soft one shaped like a spider, and a wheeled one. The researchers first used the natural spike in the mycelia to make them walk and roll, respectively, using the natural signals from the mycelia. Then researchers exposed them to ultraviolet light, which caused the mycelia to react and changed the robots’ gaits. Finally, the researchers were able to override the mycelia signals entirely.

“This kind of project is not just about controlling a robot,” Dr. Mishra said. “It is also about creating a true connection with the living system. Because once you hear the signal, you also understand what’s going on. Maybe that signal is coming from some kind of stresses. So you’re seeing the physical response, because those signals we can’t visualize, but the robot is making a visualization.”

Dr. Shepherd believes that instead of using light as the signal, they will use chemical signals. For example: “The potential for future robots could be to sense soil chemistry in row crops and decide when to add more fertilizer, for example, perhaps mitigating downstream effects of agriculture like harmful algal blooms.”

It turns out that biohybrid robots in general and fungal computing in particular are a thing. In last week’s article I quoted Professor Andrew Adamatzky, of the University of the West of England about his preference for fungal computing. He not only is the Professor in Unconventional Computing there, and is the founder and Editor-in-Chief of the International Journal for Unconventional Computing, but also literally wrote the book about fungal computing.  He’s been working on fungal computing since 2018 (and before that on slime mold computing).

Professor Adamatzky notes that fungi have a wide array of sensory inputs: “They sense light, chemicals, gases, gravity, and electric fields,” which opens the door to a wide variety of inputs (and outputs). Accordingly, Ugnius Bajarunas, a member of Professor Adamatzy’s team, told an audience last year: “Our goal is real-time dialog between natural and artificial systems.”

With fungal computing, TechHQ predicts: “The future of computing could turn out to be one where we care for our devices in a way that’s closer to looking after a houseplant than it is to plugging in and switching on a laptop.”

But how would we reboot them?

Continue reading…

Convention Invisibility Teaches A Crucial Health Policy Lesson

By MICHAEL MILLENSON

It’s close to an iron rule: Politics drives policy. In that context, the health policy issues that were largely invisible at the Republican and Democratic conventions taught a crucial political lesson.

Start with access. According to KFF (formerly the Kaiser Family Foundation), more than 25 million Americans have been disenrolled from Medicaid as of Aug. 23. Ten states, all dominated by Republican legislatures and/or governors, have declined to expand the program, leaving 2.8 million Americans unnecessarily uninsured.

Yet if you were looking to either convention to find protestors telling heart-rending personal stories to humanize those statistics, you’d search in vain. There were none.

The Poor People’s Army, a group advocating for economic justice, did invite reporters covering both conventions to focus on one of the most urgent issues facing the poor and near-poor – not medical care access, but the lack of basic housing.

Homelessness set a record in 2023, according to the National Alliance to End Homelessness, affecting one in 500 Americans, while the number of renters forced to pay more than 50 percent of their income has surged since 2015. The former is apparent on the streets of every big city, while the latter is felt by millions in every paycheck.

The political lesson is clear. While support for Medicaid expansion was buried deep in the Democratic platform, at the grassroots level there’s no sign of the kind of passionate involvement that could drive votes in a close election. Medicare, of course, is a separate issue, with both parties promising to protect the program dear to the hearts of the nation’s elderly, who have the highest percentage voting turnout of any age group.

Of course, even those with good health insurance often have to worry about medical costs, with KFF polling finding that a shocking 41% of U.S. adults have medical debt. However, although the phrase, “It’s the prices, stupid!” has become a bipartisan policy refrain, there are no swing state votes to be swung by harping on the alleged cupidity of the local hospital. So while denouncing “medical debt,” no one did.

On the other hand, Democrats spoke repeatedly about the depredations of “Big Pharma.” The GOP platform satisfied itself with a vague promise to “expand access to new…prescription drug options” to address prescription drug costs that “are out of control.” The responsibility for those prices was unspecified.

As for health insurers, articles about questionable denials of medical claims by giant insurers like United Healthcare and Humana have garnered headlines and expressions of outrage. Once again, however, the grassroots reaction is the key. There has been no outpouring of public indignation remotely comparable to the HMO backlash of the 1990s. As a result, health insurers have largely vacated the role of politically visible corporate villain.

Continue reading…

How’s Human Evolution Going? The Harris-Walz Health Policy team wants to know.

By MIKE MAGEE

Clearly the Harris-Walz ticket has been doing their homework. Last week, the book above was spotted on one prominent thought-leader’s pile: “Human Evolutionary Demography.” It’s a 780 page academic Tour de force read by veteran scientist Oskar Burger, leader of the Max Planck Institute for Demographic Research and the Laboratory of Evolutionary Biodemography.

That’s the Institute founded in 1917 in Berlin whose first director was Albert Einstein. These days, its researchers work (in an age of “alternate facts”) to separate justified belief from opinion. Their major focus is on “categories of thought, proof, and experience” at the crossroads of “science and ambient cultures.”

This is the field of Human Evolutionary Demography, a blending of natural science with social science. Demographers study populations and explore how humans behave, organize and thrive focusing heavily on birth, migration, and aging.

This has been a year of just that in American politics. First, the fallout of the Dobbs decision caught Republicans with their electoral pants down in reproductive freedom referendums in Kansas, Michigan, Kentucky and Vermont. Southern migration of Democrats to former red states like Michigan, Arizona, Georgia, and North Carolina have turned them various shades of purple. And this summer, octogenarian candidates from both parties have been all the rage, literally.

Up until July 21, 2024, the race for the Presidency was between two aging candidates with visible mental and physical disabilities. The victor was destined to a term of office that would extend into his 80’s.

The emergence of Kamala Harris as the Democratic nominee was a reflection of the electorates growing discomfort with turning a blind eye to the realities of aging. It also suggested that Americans, especially Gen X’ers, have grown tired of Boomer dominance in the lives of an increasingly multi-cultural America – tired as well of growing income disparity, attacks on reproductive freedom, and declining life expectancy in America.

But why the sudden interest in “Human Evolutionary Demography?” The answer lies in the numbers. Back in 2012 Oskar Burger studied Swedes and noted that in 1800 their life expectancy was 32 years. They gained an additional 20 years in the century that followed, and 30 more years by 2000.

What stumped Burger was not the gains over these two hundred years. Instead he focused on the question, “Why did it take the human race so long to progress?” The bottom line is this, we left chimpanzees behind in the evolutionary dust some 6.6 million years ago. We limped along, not faring very well, for all but the last 200 years. In the past century, a moment in time spanning just 4 of our historic 8000 plus human generations, we took off.

This period coincided with rapid scientific and technologic advances, cleaner air and water, greater nutritional support, improved education and housing, expanded public health related governmental policy, and establishment of a safety net for our most vulnerable citizens.

But in the past decade, growth in U.S. life expectancy has all but stalled. For the first time, we actually saw declines each year from 2014 to 2019. For the decade just past, the numbers improved overall by less than 1/2 of 1 %. When first studied, declines were blamed on losses in working age adults due to trauma, addiction, suicide or “deaths of despair.”

But recent studies reveal losses due to poor maternal/fetal care, especially in red states, and made worse by fallout of the Dobbs decision. A second complicator has been losses starting at age 65 from complications of cardiovascular disease and diabetes, made worse by obesity and poor health care follow-up.

This has led the Max Planck Institute to issue an alert to U.S. health experts: “Our findings suggest that the U.S. faces a ‘double jeopardy’ from both midlife and old-age mortality trends, with the latter being more severe.”

Women’s reproductive advocates say it’s really a “triple jeopardy” demanding grass roots advocacy focused on access today, and political victory up and down the ballot in November. In their words, “Today, and every day, we work to ensure that every patient who seeks sexual and reproductive health care can access it, and to build a just world that includes nationwide access to abortion for all — no matter what.”

If this is true, a careful read of “Human Evolutionary Demography” could direct a 3-prong approach for the health policy leaders in the Harris-Walz campaign:

  1. Expanded safety net to address “deaths of despair.”
  2. Expansion of the ACA toward Universal Health Insurance to address the chronic disease burden of older Americans.
  3. Federal guarantees of reproductive freedom and open access to reproductive care.

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

“Moral Distress” Has Arrived On Health Care’s Stoop

By MIKE MAGEE

When Andrew Jameton, a Nursing Professor at the Department of Mental Health and Community Nursing at UCSF in 1984 published “Nursing Practice: The Ethical Issues”, the term “Moral Distress” was a novel term in clinical health care. It focused primarily on “care that they were expected to provide but ethically opposed.”

Over the past four decades, the definition has expanded and now encompasses the “inability to provide the care that one feels morally compelled to provide.” Beyond its’ impact on individual health professionals, it has growing health policy implications, explosively reverberating in the wake of the recent Dobbs decision.

There are approximately 1600 health care facilities nationwide that provide abortion care in the U.S. In the wake of the Dobbs decision overturning Roe v. Wade, 14 states have near complete bans on all abortions and this reproductive care is severely restricted in an additional 11 states “with few or no exceptions for maternal health or life endangerment.”

The impact of these rulings has created not only a moral dilemma for health professionals, but also intense legal jeopardy. As one Tennessee Obstetrician recently put it, “There are weeks when I commit multiple felonies.”

There now exists a validated psychometric tool to measure the mental health impact of the Supreme Court’s actions called the Moral Distress Thermometer(MDT). Experts recently surveyed 310 practicing clinicians involved in women’s reproductive health care, with a focus on comparing moral distress in those from restricted versus unrestricted states. What they reported in JAMA was that those in restricted vs. protected states had scores on the MDT that were more than double their comparators.

As one might expect, high scores on the MDT also correlate with higher rates of job burnout and attrition. This means lower rates of abortion care, but also a smaller maternal health workforce overall. This is in states that had already been lagging behind in access to obstetrical and reproductive health care in general. Clinical shortages are expected to rise in the months approaching an historic Presidential election.

Project 2025’s agenda for future women in America is much more expansive and aggressive than restriction of abortion alone. Trump’s denials aside, his selection of JD Vance as a running mate signals an intent to thoroughly engage in restriction of women’s reproductive rights in allegiance with a Supreme Court that appears equally committed.

With that in mind, the massive response to the Harris-Walz ticket appears to be offering a response that appears to be go well beyond simple “weird” labeling. Those words are a promise to each other, “We’re not going back.”

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

Fake News from MedPac on Medicare Advantage Needs to Be Corrected, Part 2

By GEORGE HALVORSON

Special Needs Plans Change Lives for The Lowest Income and Highest Need Patients

The people who benefit the most from Medicare Advantage are clearly the very low-income and high health-need people who are eligible for both Medicare and Medicaid as programs and who enroll as members in the Medicare Advantage Special Needs Plan programs.

There clearly aren’t any other programs existing in our country that do more good for large numbers of needing people than the Medicare Advantage Special Needs Plans do for those members.

Those people with that dual eligibility are in major need for care.

We have millions of retirees who are eligible for both programs who have gone through years of inequities, inadequacies, and deficiencies relative to our care systems for a number of reasons, and who are now in need of care and support at multiple levels in their lives.

The plans do extremely good things for those high-need patients.

Medicare Advantage Special Needs Plan programs now help and provide services to millions of people who’ve actually never had good or adequate care in their entire lives.

The Special Needs Plan programs for Medicare Advantage reach into people’s homes and provide layers of service and support that are life changing, badly needed, and the Special Needs Plans are much appreciated, with very high satisfaction levels from the patients they serve for that better care and far better life support levels.

We tend, as a country, to abandon and under serve people in too many settings and communities who are old and who have no money and who are in significant need of care. The Medicare Advantage programs do wonderful and badly needed things for many of those patients that we need to understand, appreciate, and then protect as we look at Medicare Advantage plans and the overall Medicare Advantage programs and approaches.

The people at MedPac who are trying so hard to reduce the benefit levels for Medicare Advantage members and who do shamelessly inaccurate, distorted, and clearly intentionally fake news pieces on the cost of Medicare Advantage plans are trying to undermine and weaken the Special Needs Plan program in order to somehow create a level playing field with higher income patients for Medicare for the patients who get the most benefits from those programs.

That’s a very bad practice, and protecting those high-income people is a very wrong functional priority for MedPac to have. But they have it year after year in uncaring, insensitive, and cold ways relative to those patients and they seem impervious to data and information from all of the plans about those patients and that care, and their need for those benefits and services in their lives.

We need MedPac to clean up their act relative to their lowest income people, and we need them to start telling the truth about the actual relative cost of Medicare Advantage.

And we very much need them to understand how much the lowest income members need those benefits.

We need them to stop saying that the plans are overpaid when they know better from having more than 6 million people enrolled as Special Needs Plan members and benefit levels, and when they know that two out of three of the lowest income Members are in plans, and it should be painfully obvious to even the most cold-hearted observer, that those people clearly need the care and benefits that they get there from the plans.

The Medicare Advantage attacks from MedPac in their current report now say that the total cost of Medicare Advantage is 22% higher than those members would have cost as normal Medicare members.

They actually say in their most recent report that if all of the Medicare Advantage enrollees were now actually enrolled in fee-for-service Medicare, those enrollees who are currently in the plans would cost 22% less money for the overall Medicare program.

That’s obviously impossible and it’s a complete fabrication that they do not support in their document with even a wisp of data.

They use that false information, and they use a very skillful and intentional fake news context to attack the plans with that information.

Continue reading…

Biology to the Rescue?

By KIM BELLARD

I feel much about synthetic biology as I do AI: I don’t really understand it from a technical point of view, but I sure am excited about its potential. Sometimes they even overlap, as I’ll discuss later. But I’ll start with some recent developments with bioplastics, a topic I have somehow never really covered.

Let’s start with some work at Washington University (St. Louis) involving, of all things, purple bacteria. In case you didn’t know it – I certainly didn’t – purple bacteria “are a special group of aquatic microbes renowned for their adaptability and ability to create useful compounds from simple ingredients,” according to the press release. The researchers are turning the bacteria into bioplastic factories.

One study, led by graduate student Eric Connors, showed that two “obscure” species of purple bacteria can produce polyhydroxyalkanoates (PHAs), a natural polymer that can be purified to make plastics.  Another study, led by research lab supervisor Tahina Ranaivoarisoa, took another “well studied but notoriously stubborn” species of purple bacteria to dramatically ramp up its production of PHAs, by inserting a gene that helped turn them into “relative PHA powerhouses.” The researchers are optimistic they could use other bacteria to produce even higher levels of bioplastics.

The work was done in the lab of associate professor Aripta Bose, who said: “There’s a huge global demand for bioplastics. They can be produced without adding CO2 to the atmosphere and are completely biodegradable. These two studies show the importance of taking multiple approaches to finding new ways to produce this valuable material.”

“It’s worth taking a look at bacteria that we haven’t looked at before,” Mr. Conners said. “We haven’t come close to realizing their potential.” Professor Bose agrees: “We hope these bioplastics will produce real solutions down the road.”

Meanwhile, researchers at Korea Advanced Institute of Science and Technology, led by Sang Yup Lee, have manipulated bacteria to produce polymers that contain “ring-like structures,” which apparently make the plastics more rigid and thermally stable.  Normally those structures would be toxic to the bacteria, but the researchers managed to enable E. coli bacteria to both tolerate and produce them.  The researchers believe that the polymer would be especially useful in biomedical applications, such as drug delivery.

As with the Washington University work, this research is not producing output at scale, but the researchers have good confidence that it can. “If we put more effort into increasing the yield, then this method might be able to be commercialized at a larger scale,” says Professor Lee. “We’re working to improve the efficiency of our production process as well as the recovery process, so that we can economically purify the polymers we produce.”

Because the polymer is produced using biological instead of chemical processes, and is biodegradable, the researchers believe it can be important for the environment. “I think biomanufacturing will be a key to the success of mitigating climate change and the global plastic crisis,” says Professor Lee. “We need to collaborate internationally to promote bio-based manufacturing so that we can ensure a better environment for our future.”

Environmental impact is also very much on the minds of researchers at the University of Virginia. They are working on creating biodegradable bioplastics from food waste. “By creating cost-effective bioplastics that naturally decompose, we can reduce plastic pollution on land and in oceans and address significant issues such as greenhouse gas emissions and economic losses associated with food waste,” said lead researcher Zhiwu “Drew” Wang.

The team is developing microorganisms that convert food waste into fats, which are then processed into bioplastics. Those bioplastics then should easily be composed. “Our first step is to make single-layer film to see if it can be utilized as an actual product,” said Chenxi Cao, a senior in packaging and system design. “If it has good oxygen and water vapor barriers and other properties, we can move to the next step. We aim to replace traditional coated paper products with PHA. Current paper products are often coated with polyethylene or polyactic acid, which are not fully degradable. PHA is fully biodegradable in nature, even in a backyard environment.”

The approach is currently still in the pilot project stage.

If all that isn’t cool enough, our own bodies may become biofactories, such as to deliver drugs or vaccines. Earlier this year researchers at UT Southwestern reported on “in situ production and secretion of proteins,” which in this case targeted psoriasis and two types of cancer.

The researchers say: “Through this engineering approach, the body can be utilized as a bioreactor to produce and systemically secrete virtually any encodable protein that would otherwise be confined to the intracellular space of the transfected cell, thus opening up new therapeutic opportunities.”

“Instead of going to the hospital or outpatient clinic frequently for infusions, this technology may someday allow a patient to receive a treatment at a pharmacy or even at home once a month, which would be a significant boost to their quality of life,” said study leader Daniel Siegwart, Ph.D. Professor Siegwart believes this type of in situ production could eventually improve health and quality of life for patients with inflammatory diseases, cancers, clotting disorders, diabetes, and a range of genetic disorders.  

I promised I’d touch on an example of synthetic biology and AI overlapping. Last year I wrote about how “organoid intelligence” was a new approach to biocomputing and AI. Earlier this year Swiss firm FinalSpark launched its Neuroplatform, which uses 16 human brain organoids as the computing platform, claiming it was: “The next evolutionary leap for AI.”   

“Our principal goal is artificial intelligence for 100,000 times less energy,” FinalSpark co-founder Fred Jordan says. 

Now FinalSpark is renting its biocomputers to AI researchers at several top universities…for only $500 a month. “As far as I know, we are the only ones in the world doing this” on a publicly rentable platform, Dr. Jordan told Scientific American. Reportedly, around 34 universities requested access, but FinalSpark so far has limited use to 9 institutions, including the University of Michigan, the Free University of Berlin, and the Lancaster University in Germany.

Scientific America reports related work at Spain’s National Center for Biotechnology, using cellular computing, and at the University of the West of England, using – I’m serious! – fungal networks. “Fungal computing offers several advantages over brain-organoid-based computing,” Andrew Adamatzky says, “particularly in terms of ethical simplicity, ease of cultivation, environmental resilience, cost-effectiveness and integration with existing technologies.”

Bioplastics, biofactories, biocomputing — pretty cool stuff all around. I’ll admit I don’t know where all of this is leading, but I can’t wait to see where it leads.   

Fake News from MedPac on Medicare Advantage Needs to Be Corrected, Pt 1

By GEORGE HALVORSON

MedPac has just released a report on Medicare Advantage that’s incorrect on multiple key points that need to be corrected.

Medicare Advantage currently enrolls the majority of Medicare members in the country, and it’s now the new basic plan for the Medicare program because of that majority enrollment level.

That’s very good news for Medicare because the average cost for those members is significantly less than those members would’ve cost under fee-for-service Medicare — and we can be comfortable and know that the lower cost is permanent because of the way we pay for the program.

The plans are paid a capitation for each member, and they’re not paid a fee for each piece of care that’s delivered to Medicare patients.

The capitation is an excellent purchasing approach for the program because it limits the amount paid for the enrollees, and when that amount, paid in capitation, is lower than the average cost of care for the traditional Medicare members, it guarantees that those lower costs will be paid for those members for the Medicare program, and that those costs will continue to be lower for Medicare.

The program that’s used to set the bids for the plans annually calculates the average cost of the traditional Medicare program in every county, and then lets the plans bid for the amount they will be paid for their members for the next year.

Those average costs for Medicare members are accurately calculated, and they’re based on consistent information that Medicare records, computes, and then reports on actual spending in every county by fee-for-service Medicare for the members every year.

The plans look at the information from the fee-for-service Medicare program in every county each year and then they each bid a capitation that’s always lower than that average cost, because those average Medicare costs are actually higher than the Plans need to provide the full set of required care for their members.

That bidding process guarantees that the plans will cost less than fee-for-service Medicare because it’s legitimately, appropriately and accurately based on the actual costs of that program in every county as the starting points for the bids each year.

We know that’s how much Medicare costs in every county using those numbers — and when the plans submit bids that are lower than that average cost, we know that the lower amount in those bids represents actual savings to the Medicare program.

In the world of insurance, having a bid that sets and determines the payment level for the coverage from every plan is a competent, appropriate, intellectually sound, financially legitimate, accurate, and fully functional payment approach and price for Medicare to spend on that coverage as a buyer.

Medicare is a buyer for Medicare Advantage and not just a payer as it is for the rest of the fee-for-service Medicare program.

Once the bid is set, all of the concerns, worries, risks, and uncertainties of the payment process that people used to have about the payments disappear, because that bid amount is exactly how much the plans will be paid for their members and it can’t be modified or changed in any way by the plans.

There are no possible upcoding approaches or risk pool manipulation processes or any possible subsequent plan fudging on the right cost for payments based on the risk levels of the patients that can happen for those payments because the capitation payment is the only one that Medicare will give to the plans, and that locks the cost in place.

That protection against future up coding problems is clear and true because the bids are the final payment to the plans, and there’s no way of doing any kind of risk-pool manipulation after the fact to create any level of overpayment after that capitation payment is made to each plan.

CMS Uses Good Encounter Data to Get that Risk-Level Information

CMS now has very good information about the actual risk levels of the members because they competently, appropriately, effectively and completely eliminated all of the old coding systems that were using estimates from the plans that they previously used to get the patient risk-level information to create the payments.

They replaced that old data flow from the plans with actual encounter data from the care delivered to each patient with information about each actual encounter, and that encounter data at the point of care ties back to the actual medical records that exist and that are used in the care settings for each patient.

The risk levels of the members in the plans are now determined and set by an extremely accurate process that uses the actual care encounter reports for each patient that are filed with the Medicare program to get each diagnosis for each piece of care.

There were some earlier systems for paying the plans that were built on plans filing data about the risk levels of the members, and there were some instances where some plans did filings in ways that upcoded and increased their payment levels, but CMS has actually completely eliminated and cancelled those old processes and reports, and now gets the needed diagnosis data for the payment system from the actual encounters that are filed by the providers for each piece of care.

We now have very current data about the patients, and the reporting process is extremely accurate in its information flow.

Continue reading…

What will Harris mean for Health Care? – Not much

By MATTHEW HOLT

The Democratic convention wrapped with a fine speech from Kamala Harris, star power from the Obamas and Clintons, and a bunch of Republicans telling their ideological brethren that it was better to be a Democrat than a Trumper. More importantly no Beyonce/Taylor Swift duet–as we were promised by Mitt Romney.

There was a lot of talk about some aspects of health care. But overall if Harris wins, don’t expect much change to the current health care system. 

Why not?

First there’s the pure politics. The Dems need to win back the House (probable but not certain) and hold the Senate to pass legislation. Right now they have a 51-49 edge in the Senate. Most likely that goes to 50-50 as the Republicans will definitely pick up Joe Manchin’s seat in West Virginia. There’s a series of seats the Dems currently hold in close races (Montana, Ohio, MIchigan, Nevada, Arizona) that they’ll need to keep to maintain it at 50-50, and it’s hard to see any pickups from Republicans (perhaps Florida or Texas if you squint really hard). The good news is that Manchin (WV) and Sinema (AZ) will soon both be gone, so the Dems that will be there won’t be as difficult to persuade to follow a Presidential agenda. But that will still leave Walz as VP to do what Harris did and pass a bunch of deciding votes under reconciliation, which massively limits what the legislation can do–it has to be “budget related.”

Which leads us to what we have been hearing from Harris and her campaign about health care? We’ve heard a lot about issues that have impacts on health, specifically creating affordable housing and fighting child poverty, but little that is directly related to health care itself. Really only two issues stand out. Abortion and reproductive rights, and drug prices.

Clearly Harris will take a swing at reversing Dobbs and passing a national right to abortion. This will need either a packing of the Supreme Court (my favorite) or ending the filibuster or both. Either of these will be incredibly tough to pull off constitutionally and politically and will take huge amounts of political oxygen. Of course the cynics would say, the Democrats are better off leaving this as an issue to use to beat up the Republicans on. But if it gets done, womens’ and reproductive rights will only be back where they were in 2022. 

Regarding the cost of drugs, there will continue to be much justified bashing of big pharma, but the extension of insulin price controls is something that (eventually) the market via CivicaRX and others is getting to anyway. Meanwhile the IRA gave Medicare the right to negotiate drug prices and the results are not exactly earth shattering. For example, CMS says it’s negotiated the cost of blood thinner Eliquis from about $6,000 a year to under $3,000 This sounds good until you realize that the price is only that high because of patent games the manufacturer BMS plays in the US, and the price in the rest of the world is under $1,000. We’ll hear more about this as the price cuts come into effect, (although not till 2026!) and more drugs get negotiated, but overall this isn’t exactly an earth-shattering change.

Finally there’s already a guaranteed fight about extending the premium subsidies for ACA plans. These were first in the pandemic American Rescue Act, then extended in the IRA, but they currently are scheduled to end in 2025. It’s hard to imagine them not being extended further whatever the makeup of the Senate, assuming a Democratic House of Representatives. (A Marjorie Taylor Greene speakership does give me pause!). But again there’s nothing new here and the overall flavor of expensive premiums and high deductibles in the current ACA marketplace won’t change.

So what’s not going to happen? Virtually all the interesting stuff we were promised by Harris and for that matter Biden in 2020. You may have missed the one actual “policy-first” speech at the convention which came from Bernie Sanders. To be fair a lot of his agenda was already in the Biden legislation. That was no accident as Biden deliberately reached out to him in 2020 and 2021 and enacted a pretty radical agenda on infrastructure, climate, industrial policy and more. And when I say radical I mean milquetoast social democrat by European standards! But what wasn’t in that agenda? No Medicare for all, which Bernie ran on in 2019/20 and brought up again at the convention. Who else proposed that in 2019? Why, a certain Kamala Harris. That never made it into the Biden agenda. We didn’t even get legislation introduced about lowering the Medicare age to 60, which was a campaign promise. There’s been no conversation about any of this from Harris or from Biden before he withdrew. It’s just a bridge too far.

Which leads to the stuff that gets debated about in THCB and elsewhere as to how the system actually works. There’s been nothing about Medicaid expansion (or its continued contraction). No talk about reining in hospital consolidation. No mention even of insurers gaming Medicare Advantage or private equity buying up physician practices. Nothing about the expansion of value-based care.

What we can expect in a Harris administration is more of the same from CMS and potentially a slightly more aggressive FTC. That will mean continued efforts to veer slightly away from fee-for-service in Medicare, a few more constraints on the worst behavior in Medicare Advantage, and possibly some warning shots from the FTC about hospital monopolies. But the trends we’ve seen in recent years will largely continue. We’re not getting a primary-care based capitated system emerging from the wreckage of what we have now, and unlike the Clinton and even Obama administrations, there’s not even any rhetoric from Harris or Biden about how that would be a good idea.

So politically I don’t think the Harris administration will be very exciting for health care. And if the other guy wins, as Jeff Goldsmith wrote on THCB last month, expect even less.

Tiny Is Mighty

By KIM BELLARD

I am a fanboy for AI; I don’t really understand the technical aspects, but I sure am excited about its potential. I’m also a sucker for a catchy phrase. So when I (belatedly) learned about TinyAI, I was hooked.  

Now, as it turns out, TinyAI (also know as Tiny AI) has been around for a few years, but with the general surge of interest in AI it is now getting more attention. There is also TinyML and Edge AI, the distinctions between which I won’t attempt to parse. The point is, AI doesn’t have to involve huge datasets run on massive servers somewhere in the cloud; it can happen on about as small a device as you care to imagine. And that’s pretty exciting.

What caught my eye was a overview in Cell by Farid Nakhle, a professor at Temple University, Japan Campus: Shrinking the Giants: Paving the Way for TinyAI.  “Transitioning from the landscape of large artificial intelligence (AI) models to the realm of edge computing, which finds its niche in pocket-sized devices, heralds a remarkable evolution in technological capabilities,” Professor Nakhle begins.

AI’s many successes, he believes, “…are demanding a leap in its capabilities, calling for a paradigm shift in the research landscape, from centralized cloud computing architectures to decentralized and edge-centric frameworks, where data can be processed on edge devices near to where they are being generated.” The demands for real time processing, reduced latency, and enhanced privacy make TinyAI attractive.

Accordingly: “This necessitates TinyAI, here defined as the compression and acceleration of existing AI models or the design of novel, small, yet effective AI architectures and the development of dedicated AI-accelerating hardware to seamlessly ensure their efficient deployment and operation on edge devices.”

Professor Nakhle gives an overview of those compression and acceleration techniques, as well as architecture and hardware designs, all of which I’ll leave as an exercise for the interested reader.  

If all this sounds futuristic, here are some current examples of TinyAI models:

  • This summer Google launched Gemma 2 2B, a 2 billion parameter model that it claims outperforms OpenAI’s GPT 3.5 and Mistral AI’s Mixtral 8X7B. VentureBeat opined: “Gemma 2 2B’s success suggests that sophisticated training techniques, efficient architectures, and high-quality datasets can compensate for raw parameter count.”
  • Also this summer OpenAI introduced GPT-4o mini, “our most cost-efficient small model.” It “supports text and vision in the API, with support for text, image, video and audio inputs and outputs coming in the future.”
  • Salesforce recently introduced its xLAM-1B model, which it likes to call the “Tiny Giant.” It supposedly only has 1b parameters, yet Marc Benoff claims it outperforms modelx 7x its size and boldly says: “On-device agentic AI is here”  
  • This spring Microsoft launched Phi-3 Mini, a 3.8 billion parameter model, which is small enough for a smartphone. It claims to compare well to GPT 3.5 as well as Meta’s Llama 3.
  • H2O.ai offers Danube 2, a 1.8 b parameter model that Alan Simon of Hackernoon calls the most accurate of the open source, tiny LLM models.   

A few billion parameters may not sound so “tiny,” but keep in mind that other AI models may have trillions.

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Phil Fasano, Recuro Health

Phil Fasano is CEO of Recuro Health. Phil was CIO at Kaiser Permanente in the glory years when it rolled out Epic/Health Connect, which was at the time the biggest roll out of an EMR and was instrumental in creating Kaiser’s system of virtual care. A decade+ later the concept of telehealth and virtual care has been battered around, notably in the stock price of Teladoc and others. However, Phil is now leading a smaller organization called Recuro Health which is delivering extensive primary hybrid care to small & medium employers, has more then 1 million lives on the system, and is profitable. Is this the future of digital health? Maybe, and it’s well worth listening to his approach–Matthew Holt

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