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The Silicon Curtain Descends on SB 1047

By MIKE MAGEE

Whether you’re talking health, environment, technology or politics, the common denominator these days appears to be information.  And the injection of AI, not surprisingly, has managed to reinforce our worst fears about information overload and misinformation. As the “godfather of AI”, Geoffrey Hinton, confessed as he left Google after a decade of leading their AI effort, “It is hard to see how you can prevent the bad actors from using AI for bad things.”

Hinton is a 75-year-old British expatriate who has been around the world. In 1972 he began to work with neural networks that are today the foundation of AI. Back then he was a graduate student at the University of Edinburgh. Mathematics and computer science were his life. but they co-existed alongside a well evolved social conscience, which caused him to abandon a 1980’s post at Carnegie Mellon rather that accept Pentagon funding with a possible endpoint that included “robotic soldiers.” 

Four years later in 2013, he was comfortably resettled at the University of Toronto where he managed to create a computer neural network able to teach itself image identification by analyzing data over and over again. That caught Google’s eye and made Hinton $44 million dollars richer overnight. It also won Hinton the Turing Award, the “Nobel Prize of Computing” in 2018. But on May 1 2023, he unceremoniously quit over a range of safety concerns.

He didn’t go quietly. At the time, Hinton took the lead in signing on to a public statement by scientists that read, “We believe that the most powerful AI models may soon pose severe risks, such as expanded access to biological weapons and cyberattacks on critical infrastructure.” This was part of an effort to encourage Governor Newsom of California to sign SB 1047 which the California Legislature passed to codify regulations that the industry had already pledged to pursue voluntarily. They failed, but more on that in a moment.

At the time of his resignation from Google, Hinton didn’t mix words. In an interview with the BBC, he described the generative AI as “quite scary…This is just a kind of worst-case scenario, kind of a nightmare scenario.”

Hinton has a knack for explaining complex mathematical and computer concepts in simple terms.

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Red Alert about Red Buttons

By KIM BELLARD

In a week where, say, the iconic brand Tupperware declared bankruptcy and University of Michigan researchers unveiled a squid-inspired screen that doesn’t use electronics, the most startling stories have been about, of all things, pagers and walkie-talkies.

Now, most of us don’t think much about either pagers or walkie-talkies these days, and when we do, we definitely don’t think about them exploding. But that’s what happened in Lebanon this week, in ones carried by members of Hezbollah. Scores of people were killed and thousands injured, many of them innocent bystanders. The suspicion, not officially confirmed, is that Israel engineered the explosions.

I don’t want to get into a discussion about the Middle East quagmire, and I condemn the killing of innocent civilians on either side, but what I can’t get my mind around is the tradecraft of the whole thing. This was not a casual weekend cyberattack by some guys sitting in their basements; this was a years-in-the-making, deeply embedded, carefully planned move.

A former Israeli intelligence official told WaPo that, first, intelligence agencies had to determine “what Hezbollah needs, what are its gaps, which shell companies it works with, where they are, who are the contacts,” then “you need to create an infrastructure of companies, in which one sells to another who sells to another.”  It’s not clear, for example, if Israel someone planted the devices during the manufacturing process or during the shipping, or, indeed, if its shell companies actually were the manufacturer or shipping company. 

Either way, this is some James Bond kind of shit.

The Washington Post reports that this is what Israeli officials call a “red-button” capability, “meaning a potentially devastating penetration of an adversary that can remain dormant for months if not years before being activated.” One has to wonder what other red buttons are out there.

Many have attributed the attacks to Israel’s Unit 8200, which is roughly equivalent to the NSA.  An article in Reuters described the unit as “famous for a work culture that emphasizes out-of-the-box thinking to tackle issues previously not encountered or imagined.”  Making pagers explode upon command certainly falls in that category.

If you’re thinking, well, I don’t carry either a pager or a walkie-talkie, and, in any event, I’m not a member of Hezbollah, don’t be so quick to think you are off the hook. If you use a device that is connected to the internet – be it a phone, a TV, a car, even a toaster – you might want to be wondering if it comes with a red button. And who might be in control of that button.

Just today, for example, the Biden Administration proposed a ban on Chinese software used in cars.

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A Baby Step Backwards

Bringing the Tools of Accountable Care to Maternity Care is a Great Idea – But This Sure Ain’t It

By VICTORIA ADEWALE & J.D. KLEINKE

How desperate are we to find some kind of good news about the sorry state of maternity care in America? To find out, look no further than the current cover of no less venerable a health policy journal than Health Affairs.

With the headline “Medicaid ACO Improves Maternity Care” jumping off the cover of its September issue, we were expecting great things from the article “Massachusetts Medicaid ACO Program May Have Improved Care Quality for Pregnant and Postpartum Enrollees” (Megan B. Cole, et al.). The headline certainly promises some rare good news for all of us working to fix the national embarrassment that is maternity care in the US in general, and the maternal mortality crisis in particular.

But alas, the article itself is one more reminder that process improvements are not outcomes improvements. It is also a classic case of earnest researchers’ tendency to torture retrospective data — because it happens to be available for study — into something that might be useful. While it would be easy to dismiss out of hand the listless findings of this study of data-convenience, the danger here is they may well provide yet more ammunition for skeptical payers not to pay for more care that numerous studies have shown patients desperately need.

The authors make a valiant effort with an elegant study design to glean what they can from the “natural experiment” of analyzing pre- and post-natal care delivered to pregnant patients before and after the implementation of Accountable Care Organizations in Massachusetts. But as another old saw goes: when you have a hammer, everything looks like a nail; and patient enrollment in a primary care ACO, as with this dataset, hardly counts as an independent variable with much power to predict the care utilization and outcomes of maternity care for covered enrollees.

It is well established in the literature – not to mention an accepted truism among providers and patients – that when most women become pregnant, the bulk of their care shifts from the primary care setting to obstetrician/gynecologists (OB/GYNs) and certified nurse-midwives (CNMs). Many researchers and clinicians believe that much of this shift occurs even before a confirmed pregnancy, as a consequence of fertility challenges and pregnancy planning.

The authors did find that pregnant patients newly enrolled in ACOs had a small increase in the number of pre- and post-natal visits.

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THCB Gang Special! Women Healthcare Leaders for Progress talk about health care & the election

THCB Gang is back! (I know you’ve all missed it) and we started with a bang. I met with five powerhouse women leaders in health care who’ve just issued a public statement signed by another 500+ women leaders in support of the Harris/Walz campaign.

On the Gang are Missy Krasner, digital health veteran most recently at Amazon and Redesign Health but wayback on the founder team at ONC; Molly Coye, who ran Medicaid in NJ and CA and has had every role in health innovation know to womankind; Miriam Paramore, investor board member and operator at many, many health tech companies; (Lori Evans Bernstein, founder of Caraway, Health Reveal & many more but also at ONC back in the day, who actually couldn’t make the call); Laurie McGraw, EVP at Transcarent, formerly at AMA, Allscripts, etc; and Audrey Mann Cronin, communication advisor to CEOs and Founder, Say it Media.

Despite my obvious political leanings, this wasn’t be a push over. Do we need this group? What does Harris want to do about health care? What can she do? I am on record as saying “not much”. This was great discussion, and I was (virtually) ducking alot! — Matthew Holt

Miscarriage or Abortion? The Crisis in 14 States Post Dobbs.

By MIKE MAGEE

“What did they know, and when did they know it?”

These are the questions Americans have become accustomed to asking of their leaders, dating back to Nixon and extending to Trump, and all Presidents in between. But now the same questions have surfaced, to the extreme discomfort of conservative Justices, as death and destruction of lives begins to mount in the wake of the Dobbs decision.

As predicted, graphic cases of young women bleeding out in parking lots after being refused life-saving acute care for miscarriage in 14 states across the nation are being documented and described. These stories are not only affecting the lives of couples across the land, but also threatening the “political lives” of downstream Republicans facing an upcoming election.

The responsible Supreme Court Justices (Alito, Thomas, Gorsuch, Kavanaugh, and Barrett) and their legions of Ivy League clerks had scoured the literature far and wide before making the decision to eliminate women’s reproductive freedom in the U.S. and inflict lasting harm to their life-saving relationships with their local doctors.

Their review had to include Blue Cross & Blue Shield’s timely publication, “Trends in Pregnancy and Childbirth Complications in the U.S.” That report, surveying over 1000 pregnant women ages 18 to 44 in April, 2020, was, in part, designed to understand the impact the Covid epidemic had had on prenatal care nationwide. But what it revealed was that pregnancy complications were up 16% over prior years, in part due to “social barriers such as availability of appointments, lack of transportation or nearby providers.”

A comparison of 1.8 million pregnancies in 2014 versus 2018 demonstrated a severely compromised women’s health support system. 14% did not receive prenatal care in their first trimester, and 34% missed scheduled prenatal visits with 1 in 4 of these suffering complications in pregnancy. The BC/BS summary “underscores the importance of focusing on the health of pregnant women in America, especially as health conditions increase in this population…”

The Conservative Justices were forewarned. Yet they still elected to throw fuel on a maternal health system which was already in flames. They were also aware of a 2021 study that confirmed that miscarriage was 43% more likely in Black women than in their white counterparts.

On May 2, 2022, Justice Alito and his allies engineered the release of a draft of a majority opinion in part to freeze attempts by Chief Justice Roberts to secure a compromise. The leaked document labeled Roe v. Wade “egregiously wrong from the start.”  As predicted, the ruling spawned chaos.  When 14 Red states established total bans on all abortions, miscarrying women seeking help in ER’s literally had to fight for their lives. Their doctors were criminalized. Was this an abortion gone bad?

A miscarriage, or pregnancy loss before 20 completed weeks, is not an uncommon affair. Approximately 15% of pregnancies end in miscarriage, mainly the result of chromosomal or genetic abnormalities. That amounts to some 540,000 women in crisis, which most believe is under-counted. 80% of miscarriages occur in the first 13 weeks of pregnancy.

25% of pregnant women experience some vaginal bleeding in the first trimester. For most (6 in 10) this is self-limiting and they go on to deliver a healthy baby. But for 4 in 10 (or 10% who present with bleeding) they go on to miscarry. All pregnant women who experience vaginal bleeding in early pregnancy need to have a medical examination. Doctors and midwifes check blood work, perform a physical examination, and do an ultrasound examination.

Most pregnancy loss (95%+) occurs before 20 weeks gestation. If miscarriage occurs before 13 weeks, there is a good chance of clearing the blood clots and uterine tissue with medication and no surgical intervention. But if bleeding is severe, or the loss is occurring beyond 13 weeks, dilation and curettage (D&C) is both necessary and at times life-saving. Under anesthesia, the cervix is dilated and any remaining pregnancy-related tissue is gently scraped and suctioned from inside the uterus. Patients are then closely monitored for several weeks for any evidence of continued bleeding or infection.

What did the Justices know, and when did they know it?

  1. They knew that Miscarriages were a medical emergency and exceedingly common.
  2. They knew that 80% occur during the first trimester, and that existing state abortion laws on the books would restrict access to acute life-saving treatments in 14 states.
  3. They knew that pregnancy loss was far more common in non-whites and in rural underserved communities.
  4. They knew that the medical community opposed overturning Roe v. Wade in overwhelming majorities, and predicted maternal loss of life if the Justices proceeded.
  5. They read, two years after their deadly decision, the Commonwealth Report which stated that “The United States continues to have the highest rate of maternal deaths of any high-income nation, despite a decline since the COVID-19 pandemic. And within the U.S., the rate is by far the highest for Black women. Most of these deaths — over 80 percent — are likely preventable.”

They knew all this, and they did it anyway.

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

Streamlining Public Benefits Access is a Must to Address Poverty

By ALISTER MARTIN and TARA MENON

If a friend were to ask you which state, Massachusetts or Texas, has a more streamlined federal benefits enrollment program, what would your guess be?

Having screened over 17,000 families and helped them obtain more than $1.8M in federal and state aid through our work in both Massachusetts and Texas, our experiences doing federal benefit enrollment have led us to a surprising conclusion: Texas is leading the way. While Massachusetts has room for improvement, this issue extends beyond a single state—many other states face similar challenges with complex and fragmented benefits systems.

At Link Health, where our work spans the bustling neighborhoods of Boston and Houston, this revelation has been both a surprise and a call to action. In many underserved communities, through partnerships with Federally Qualified Health Centers, our organization seeks to assist eligible people in the navigation and enrollment in benefit programs that address crucial needs like access to affordable internet, food access, healthcare support, and housing resources.

One of the main obstacles we’ve encountered is that people are often unaware of the benefits they qualify for or find the process overwhelming. In states like Massachusetts, separate applications are required for each benefit program, making it harder for families to get the help they need. Programs such as LIHEAP, which offers heating subsidies, Lifeline, which provides internet access for telehealth, and SNAP, which helps with food assistance, all come with different paperwork and requirements. This fragmentation creates unnecessary barriers.

This is not unique to Massachusetts. Across the U.S., many states have similarly disjointed systems, leaving millions of dollars in federal aid unclaimed. It’s estimated that around $140 billion in federal aid goes unclaimed each year due to these inefficiencies.

In contrast, we have found that Texas’s “Your Texas Benefits” platform is efficient and user-friendly. This centralized, comprehensive application process covers a wide range of state benefit programs, including SNAP, TANF, Medicaid, and CHIP, as well as other services like WIC, family violence support, adult education, and substance abuse prevention programs. This unified system allows users to apply for multiple programs through a single portal, streamlining the process considerably. Plus, this common application system allows groups like ours to efficiently connect patients with the help they need without the usual bureaucratic entanglements — it benefits us both.

Although Massachusetts made some progress with its limited common application for MassHealth and SNAP in 2021, it still doesn’t offer a fully unified system for all its programs. This means that many residents must continue navigating multiple applications and processes. During the recent Medicaid “unwinding,” people across the U.S. lost coverage because they couldn’t manage the renewal process. It’s estimated that between 8 million and 24 million people are at risk of losing Medicaid benefits nationwide(Center For Children and Families), not because they no longer qualify, but because of these application challenges.

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David Dyke demos Relatient scheduling

David Dyke is the Chief Product Officer of Relatient, which is one of the biggest players in the up and coming area of direct patient scheduling. As anyone who has been stuck in a phone tree or tried to reach a live human just to get an appointment at a doctor’s office knows, scheduling in health care is way behind the eight ball compared to booking a restaurant, massage, or basically anything else online. Why is it so hard? David explained that and then demos how Relatient allows provider organizations to let both new and returning patients self-schedule. There is a ton of complexity behind this including what David says is an average of infinity minus one API calls to the practice management system and EMR of all of its clients. But speaking as someone who has literally left a message and hoped that someone called me back “within 4 business days” for my last specialty appointment, I’m glad to see one company at least is taking on this challenge–Matthew Holt

Software Living in an Enterprise World: Why Digital Behavioral Health Can’t Gain Traction

By TREVOR VAN MIERLO

Let’s face it: for the past 25 years, digital behavioral health has struggled. Yet, we keep reinventing (and funding) the same models over and over again.

How It All Started

In the beginning (mid-1990s), a handful of developers, researchers, and investors envisioned high reach, lower-cost, highly tailored, anonymous interventions reaching millions of people with limited healthcare access.

The initial focus was never healthcare providers and insurers. These organizations were seen as too slow to adopt new technologies, and there was a general distrust of integrated care and insurers. Many digital health companies feared these organizations (and pharma) would leverage their power to learn from smaller companies, and then redevelop interventions internally.

Instead, the focus was on partnerships and B2C sales. Funding was easier to obtain from granting agencies, and there was ample development support flowing from sources like the tobacco Master Settlement Agreement (MSA). The primary concern was 1) whether the population could access these revolutionary tools and, 2) who would pay for them.

The Digital Divide

Back then, funders were often short-sightedly obsessed with the digital divide – the gap between people who had access to digital technology (mostly educated, higher-income earners in large cities) and everyone else. The argument was, “Why should we fund digital tools that will only benefit those who already have access to healthcare?”

Data was available, so academics armed themselves with ANOVA and relentlessly examined variables such as hardware costs, processing speed, age, gender, race, ethnicity, geography, income, and education. If you check Google Scholar, you can see the prevailing sentiment was that it would take decades for the digital divide to narrow, and new policy was desperately required to fix the problem (see: here, here, here, and here).

No More Excuses

Fast forward to 2024. According to a recent article in Forbes, there are 5.4 billion internet users worldwide (66% of the global population). In the U.S., 94.6% of Americans have internet access. Most US households have multiple devices, and according to Pew Research Center Research, 97% own a cellphone, of which 90% are smartphones.

As a Gen X’er who used a typewriter in college before upgrading to a Compaq Deskpro 286 from Future Shop (for about $400), my adult life has been a witness to the rapid progression of digital. Now, my 9-year-old daughter is teaching me how to play Fortnite (Epic Games), my 11-year-old is the only kid on his hockey team without a smartphone (this won’t last), and STARLINK allows me to chat face-to-face with my parents in rural Northern Ontario.

All aspects of technology are pervasive and accessible – but if you search Google or Bing for immediate, evidence-based behavioral help, you can’t get it. If you can find access it’s behind a paywall: through your employer (contact HR), health plan (call to see if you’re covered), or subscription ($19.99 per month).

That’s not meeting the original vision – and we have the technology. So, what’s the problem?

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The Art of Political Jiu-Jitsu: Project 2025 and Donald Trump

By MIKE MAGEE

Funny think about that Project 2025’s  “Mandate for Leadership.” Trump declared in this week’s  debate, “I know nothing about it.” But in addition to the vast majority of authors and editors of the document having served in the prior Trump administration, the former President’s name is mentioned in the 887 page document over 300 times.

Described by Pulitzer Prize winning economics columnist, Carlos Lozada, the work itself is an “off-the-shelf governing plan.” It’s packed with conservative fan favorites, not simply “militarizing the southern border” and reversing what they call “climate fanaticism”, but especially placing DEI (diversity, equity, inclusion) efforts in the waste bin, banning abortion nationally, and pushing deregulation and tax cuts for the richy rich.

None of that is surprising if you’ve run into these characters on K street and beyond. This is who they are, and largely who they have always been. Over the years, I’ve bumped elbows with them in Washington and in corporate C-suites galore. What makes this effort a bit unique is, of course, the presence of a cooperative headliner who will clearly endorse “the elevation of religious beliefs in government affairs” and actively diminish “the powers of Congress and the Judiciary.”

This is political jiu-jitsu practiced at its highest level. Rather than dismantling the “deep state,” these operators are fast at work “capturing the administrative state” for their own self-serving purposes.

Understanding jiu-jitsu takes one a long way toward understanding the Heritage Foundation and Freedom Institute’s puppet masters. The word “Jū” means “gentle, soft, supple, flexible, pliable, or yielding.” It’s companion, “jutsu” is the “art or technique.” Combine the two, and you have the ”yielding-art.” The intent in bodily (or political) combat is to harness an opponent’s power against himself, rather that confronting him directly.

Political jiu-jitsu may be deceptive and confusing in the absence of visible weaponry, but it is anything but gentle. In the physical version, you are instructed in joint locks and chokeholds of course, but also biting, hair pulling, and gouging. Kevin Roberts, the President of the Heritage Foundation and editor of Project 2025, is a master of the political version. While he and Trump outwardly employed a “nothing to see here” stance, demographic realities were cued up in the document. The solution to the growing minority status for Republicans? “Voter efficiency” and a rigged census. Or in the Project’s words: “Strong political leadership is needed to increase efficiency and align the Census Bureau’s mission with conservative principles.”

Robert’s language is soft, but its impact hard indeed. In the introduction he suggests that the Declaration of Independence’s words “pursuit of happiness” were better understood to be “the pursuit of blessedness” while providing corporations a market free hand “to flourish.” Career civil servants are recast as “holdovers” without “moral legitimacy.” And the Justice Department suffers this put-down – “a bloated bureaucracy with a critical core of personnel who are infatuated with the perpetuation of a radical liberal agenda.”

Majority rules and demographic changes being what they may, alternative facts and voter suppression have been added to the tools of “political jiu-jitsu” artists. But Kelly Anne Conway was nowhere to be seen this week, and their headliner was long-winded, boring, and tired. As for voter integrity, the Democrats are fully funded and lawyered up. Finally, good Republicans everywhere have begun to recognize that towing the MAGA line much further puts their down-ballot hopes in the direct line of fire.  Those 300 mentions are beginning to look like a liability instead of an asset.

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)

We Should Learn to Have More Fun (or Vice-Versa)

By KIM BELLARD

For several years now, my North Star for thinking about innovation has been Steven Johnson’s great quote (in his delightful Wonderland: How Play Made the Modern World): “You will find the future where people are having the most fun.” No, no, no, naysayers argue, inventing the future is serious business, and certainly fun is not the point of business.  Maybe they’re right, but I’m happier hoping for a future guided by a sense of fun than by one guided by P&Ls.

Well, I think I may have found an equally insightful point of view about fun, espoused by game designer Raph Koster in his 2004 book A Theory of Fun for Game Design: “Fun is just another word for learning.”

Wow.

That’s not how most of us think about learning. Learning is hard, learning is going to school, learning is taking tests, learning is something you have to do when you’re not having fun. So “fun is just another word for learning” is quite a different perspective – and one I’m very much attracted to.

I regret that it took me twenty years to discover Mr. Koster’s insight. I read it in a more current book: Kelly Clancy’s Playing With Reality: How Games Have Shaped Our World. Dr. Clancy is not a game designer; she is a neuroscientist and physicist, but she is all about play. Her book looks at games and game theory, especially how the latter has been misunderstood/misused.

We usually think of play as a waste of time, as something inherently unserious and unimportant, when, in fact, it is how our brains have evolved to learn. The problem is, we’ve turned learning into education, education into a requirement, teaching into a profession, and fun into something entirely separate. We’ve gotten it backwards.

“Play is a tool the brain uses to generate data on which to train itself, a way of building better models of the world to make better predictions,” she writes. “Games are more than an invention; they are an instinct.”  Indeed, she asserts: “Play is to intelligence as mutation is to evolution.”

Mr. Koster’s fuller quote about fun and learning is on target with this:

That’s what games are, in the end. Teachers. Fun is just another word for learning. Games teach you how aspects of reality work, how to understand yourself, how to understand the actions of others, and how to imagine.

We don’t look at our teachers as a source of fun (and many students barely look at them as a source of learning). We don’t look at schools as a place for games, except on the playground, and then only for the youngest students. We drive students to boredom, and, as Mr. Koster says, “boredom is the opposite of learning” (although, ironically, boredom may be important to creativity).  

Learning is actually fun, especially from a physiological standpoint.

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