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The Keckley Report

Three Events likely to Frame Future Priorities for the U.S. Healthcare System

By October 5, 2020March 1st, 2023No Comments

In the midst of the pandemic and Campaign 2020, three events last week may punctuate the unique prominence of healthcare in our government and politics:

Last Saturday, the White House introduced Supreme Court nominee Amy Coney Barrett as its nominee to replace Ruth Bader Ginsburg. Republican Senate Judiciary Chair Lindsey Graham and Majority Leader McConnell assured partisan Republicans they have votes necessary to assure the conservative jurist confirmation this month. To opponents of Roe v. Wade and the Affordable Care Act (ACA), it’s a crucial vote that’s seen as bolstering a conservative majority on the high court that might rule against the ACA  as it hears arguments in California v. Texas November 10.

Last Tuesday, in the first of three Presidential debates, healthcare was prominent: in his opening salvo, President Trump argued the Democratic Party was pushing a radical socialist agenda to take over healthcare and, in reply challenger Biden asked the President where his long-promised replacement plan for the Affordable Care Act was. It went downhill from there as the petulant President persisted in interruptions that debate moderator Chris Wallace could not control. CNN’s Dana Bash called the debate a “s…show”. The New York Times called it a “mess”. The New York Post labelled it “Nasty.” And polls showed the majority of viewers were disappointed or disgusted and undecided voters unswayed by the spectacle.

Then Thursday, the President was admitted to Walter Reed National Military Medical Center having tested positive to the Covid-19 virus along with at least 8 other attendees at the Rose Garden announcement of Barrett. Press coverage about his condition and treatment dominated weekend headlines as journalists pressed the President’s medical team for answers that were less than forthcoming. Then yesterday, it was confirmed that the President had had two episodes of low oxygen saturation levels that required supplemental oxygen and was administered dexamethasone therapy for COVID-19 treatment.

What a week!

The major financial markets were unsettled closing down Friday: the S&P lost .96% to 3,348, NASDAQ lost 2.22% closing at 11,075 and the Dow dropped .48% closing at 27,682.

Political polls showed Vice President’s lead widened over President Trump as a result of the debate debacle while conservative voters rallied behind the Barrett nomination to secure a conservative leaning high court.

And anxiety about the pandemic heightened as positive cases reached at an alarming rate of 52,000 daily and 23 states saw increases.


Disinformation about healthcare is rampant and the political climate is toxic: that’s a volatile combination for thoughtful discussion about health policy and the system’s future.

What’s obvious is this: the President’s misfortune is forcing COVID-deniers to rethink their opposition to social distancing and masking and speculation is high the President might also change his tune. The race for vaccines and therapies has exposed tension between clinical researchers who depend on science and politicians who depend on votes. A second surge of the coronavirus and sobering forecast of more than 360,000 deaths by year end are accepted as fait accompli. There’s growing apprehension among the 17 million in the healthcare workforce about what might replace the ACA if set aside by the court even as hospital capacity is stretched due to the virus.  That’s where we are.

The three events last week illustrate healthcare’s unique power and influence in our politics, our communities and in our economy. Assuming more attention to public health and preventive care, the aftermath of these events will likely re-order other priorities in our system to make it more accessible and affordable. 


P.S. This Wednesday, the candidates for Vice President will debate: pundits believe decorum in this debate will be civil and healthcare plans a prominent focus of questions.  Curious viewers will gauge whether Vice President Pence or Senator Harris seems capable of stepping into the Commander-in-Chief role if their 74 and 77-year-old bosses are unable to perform the duties. Hopefully, we’ll learn more about their plans for the health system’s future should they become President.


CDC: Median Age of Covid-19 Infections Drops

Between May and the end of August 2020, the median age of COVID-19 infection has shifted downward declining from 46 in May to 37 in July and 38 years in August. From June through August, incidence was highest in persons aged 20−29 years accounting for >20% of all confirmed cases. Positive test results in this age group preceded those in adults aged ≥60 years by an average of 8.7 days, suggesting that the younger group contributed to transmission to the older group.

Stephen G. Baum “COVID-19 Population Getting Younger” Stephen G. Baum New England Journal of Medicine September 29, 2020

Study: Covid-19 has Increased Alcohol Consumption Frequency, Especially Among Women

This study examined individual-level changes in alcohol use and consequences associated with alcohol use in US adults, as well as demographic disparities, from before to during the COVID-19 pandemic. Highlights:

  • Frequency of alcohol consumption increased overall, 0.74 days representing an increase of 14% over the baseline of 5.48 days in 2019 (for women, 17% increase over the 2019 baseline, for adults age 30 to 59 years a 19% increase and for non-Hispanic White individuals an increase of 10%.

  • On average, alcohol was consumed 1 day more per month by 3 of 4 adults.

  • For women, there was a significant increase of 0.18 days of heavy drinking from a 2019 baseline of 0.44 days–an increase of 41% over baseline.

Pollard et al “Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US” JAMA Network; September 29, 2020

Study: Primary Care Office Visits Down 21% in Pandemic, Televisits did not Offset

In this cross-sectional analysis of the US National Disease and Therapeutic Index audit of 125.8 million primary care visits in the 10 calendar quarters between quarter 1 of 2018 and quarter 2 of 2020:

  • Primary care visits decreased by 21.4% during the second quarter of 2020 compared with the average quarterly visit volume of the second quarters of 2018 and 2019. Evaluations of blood pressure and cholesterol levels decreased owing to fewer total visits and less frequent assessment during telemedicine encounters.

  • In the 8 calendar quarters between January 1, 2018, and December 31, 2019, between 122.4 million and 130.3 million quarterly primary care visits occurred in the US most of which were office-based (92.9%).

  • Office-based visits decreased 50.2% (59.1 million visits) in Q2 of 2020 compared with Q2 2018-2019, while telemedicine visits increased from 1.1% of total Q2 2018-2019 visits (1.4 million quarterly visits) to 4.1% in Q1 of 2020 (4.8 million visits) and 35.3% in Q2 of 2020 (35.0 million visits).

Alexander et al “Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US”JAMA Network; October 2, 2020

Survey: Primary Care Finances Remain Pressured

489 primary care clinicians responded to the week 20 survey fielded September 4-8, 2020. Practice settings included 32% self-owned, 12% independent/large group, 37% health system owned, 4% government owned, 7% were convenience/retail settings and 4% were membership-based. Highlights:

  • 35% say revenue and pay are still significantly lower than pre-pandemic levels and net losses threaten current and future viability.

  • 1 in 5 practices report they have clinicians who have chosen early retirement or left their jobs as a direct result of the pandemic. Some say that primary care has rebounded –97% of clinicians disagree

  • 1 in 3 clinicians report FFS volume is 30-50% below pre-pandemic levels and likely to be for a while

  • 81% disagreed emphatically with the notion that primary care has rebounded

  • 33% work longer hours to make up for losses but still are not near pre-pandemic levels

  • 49% report mental exhaustion from work at an all-time high

  • 48% report in-person volume 30-50% below normal and will be for a while

“Primary Care & COVID-19: Week 20 Survey” Primary Care Collaborative; September 22, 2020

Survey: Americans Want their Physicians to Recommend Vaccines

The latest installment of the Axios/Ipsos Coronavirus Index:

  • The biggest determinants of whether Americans are likely to get the COVID-19 vaccine as soon as it’s available: if your doctor said it was safe (62%), if the FDA said it was safe (54%), and if the cost were completely covered by insurance (56%).

  • More Americans said the vaccine being covered by insurance would make them likely to get it than if they were paid $100 as an incentive (44%). Furthermore, less than half (46%) believe the government should take on more debt to pay Americans to get the vaccine.

  • 37% say the actual number of Americans dying from the virus is more than what has been reported, and 36% say it’s less. The number saying “about the same” has dropped to 27%, down five percentage points from last week.

  • Two-thirds of Democrats (64%) believe the actual number is higher than reported, while 70% of Republicans believe the death toll is being overstated.

“Americans most likely to wait for their doctor before getting COVID vaccine” Axios-Ipsos Coronavirus Index; September 29, 2020

HHS Relief Funds Update: Phase 3 Applications Begin Today

The federal government has distributed $106 billion of the $175 billion authorized relief payments to hospitals, doctors, and other providers since the signing of the Coronavirus Aid, Relief, and Economic Security Act.

More than 525,000 individual providers have received some form of payment from the CARES Act funds.  343,000 have attested that they met the terms and conditions for receiving the money. Disbursements to individual providers ranged from slightly more than $1 to $300,000 per person, according to records released by HHS.

Last Thursday, HHS announced that it is sending $20 billion in Phase 3 CARES Act Relief Funding to healthcare providers to help offset financial strain linked to the COVID-19 pandemic. Providers who have already received payments of about 2% of annual revenue from patient care will need to submit more information to become eligible for additional payments. Those who have not yet received relief payments of 2% of patient revenue will receive a payment that, when combined with prior payments, equals 2% of patient care revenue. The remaining balance of the $20 billion will be used to provide add-on payments to providers based on several factors, including changes in patient care revenues and expenses incurred related to the pandemic.  Healthcare providers can apply for funds from Oct. 5 through Nov. 6.

“Trump Administration Announces $20 Billion in New Phase 3 Provider Relief Funding” HHS Provider Relief Funds


Medicare Advantage Premiums Drop, Insurers Expand MA Plans

Last week, CMS announced updates for 2021 Medicare Advantage plans:

  • The average monthly plan premium is expected to decrease 11% to $21.00 in 2021 down from $23.63 in 2020– the lowest average monthly premium since 2007. The number of plans offering $0 premiums will increase by 26% from 1,743 plans in 2020 to 2,189 plans in 2021. Over 50% of MA enrollees enrolled in $0 premium plans in 2020.

  • The number of MA plans will increase, from 3,997 in 2020 to 4,520 in 2021, largely driven by growth in local HMOs and local PPOs. Among these, 92% will offer Part D coverage.

In response, private health insurers like United, Cigna, and Humana announced expansion of their MA plans and while provider sponsored plans like Braven Health (Hackensack-Meridian JV with Blue Cross-NJ) announced their entrance to the MA market this month.

Center for Medicare and Medicaid Services

Kaufman Hall Hospital Flash Report for 2020 YTD: Revenues Down, Expenses Up

Kaufman Halls latest hospital flash report for 2020 through August:

  • Margin: -7.9% before relief funds, -2.3% after relief funds (-12% from July to August)

  • Adjusted Discharges: -13% (-2% from July to August)

  • ED Visits: -16%

  • Gross revenue: inpatient -4%, outpatient -10%

  • Expenses per adjusted discharges: +17%

September 2020 National Hospital Flash Report- Kaufman Hall

Study: U.S. Costs Twice as High as Other Wealthy Countries due to Unit Costs for Drugs, Hospitals, Specialists

The Peterson-KFF Health System Tracker compared the drivers of health spending in the U.S. to other large, wealthy nations. In 2018, U.S. per capita spending was $10,637 per capita vs. $5,527 per capita for comparable countries. Big differences: U.S. vs. comparable countries:

  • % of GDP spent on healthcare: 17.7% vs. 8.3%

  • Inpatient, Outpatient Care: $6624 vs. $2718

  • Prescription drugs & devices: $1397 vs. $884

  • Administrative: $937 vs. $201

  • Long term care: $516 vs. $1,111

  • Preventive: $309 vs.$175

  • Other: $854 vs. $439

Peterson-KFF Health System Tracker

Cigna: Resilience is Lowest Among Young Adults

Resilience — the ability to quickly recover from challenges — is lowest among young adults, according to a new report based on a sample of 16,500 U.S. adults. Highlights:

22% of those ages 18-23 were deemed highly resilient, compared to 42% of their parents. Full-time workers were more likely than furloughed or part-time employees to demonstrate resilience, but most were still deemed to have low or moderate levels of the quality.

Cigna Resilience Index; September 29, 2020

Study: 27% of Health Spending Could be Reduced if Modifiable Risks

The research team examined estimates of US health-care spending by condition, age, and sex from the Institute for Health Metrics and Evaluation’s Disease Expenditure Study 2016 and merged these estimates with population attributable fraction estimates for 84 modifiable risk factors from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 to produce estimates of spending by condition attributable to these risk factors. Findings:

  • In 2016, US healthcare spending attributable to modifiable risk factors was US $730·4 billion corresponding to 27·0% of total health-care spending.

  • Attributable spending was largely due to five risk factors: high body-mass index ($238·5 billion, 178·2–291·6), high systolic blood pressure ($179·9 billion, 164·5–196·0), high fasting plasma glucose ($171·9 billion, 154·8–191·9), dietary risks ($143·6 billion, 130·3–156·1), and tobacco smoke ($130·0 billion, 116·8–143·5).

  • Spending attributable to risk factor varied by age and sex, with the fraction of attributable spending largest for those aged 65 years and older (45·5%, 44·2–46·8).

Bolnick et al “Health-care spending attributable to modifiable risk factors in the USA: an economic attribution analysis” The Lancet; October 1, 2020

Study: Medicaid Expansion Reduced Churn in Medicaid Population

This study compared the claims of low income pregnant women in 14 expansion states to 6 non expansion states: Medicaid expansion resulted in a 10.1% decrease in churning between insurance and un-insurance, representing a 28% decrease from the pre-policy baseline in expansion states  driven by a 5.8% increase in the proportion of women who were continuously insured and a 4.2% increase in churning between Medicaid and private insurance.

Daw et al “Medicaid Expansion Improved Perinatal Insurance Continuity For Low-Income Women” Health Affairs; September 2020

Guth et al “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review” Kaiser Family Foundation; March 17, 2020