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The Keckley Report

Health Literacy Needs a Fresh Look

By September 14, 2020March 1st, 2023No Comments

Last week, the news cycle included coverage about the release of Bob Woodward’s “Rage”, continued volatility in the U.S. stock market, the California fires, and the Presidential Campaign. Relatively speaking, news about the pandemic garnered its share of coverage about vaccines, drugs, testing, and deaths but it’s now just part of the news tapestry.

An analysis last week by NewsWhip found coronavirus fatigue setting in. Polling by the Kaiser Family Foundation found that the majority of Americans don’t expect a Covid-19 vaccine this year. An Ipsos poll found possible side effects of a vaccine and political pressure on scientists in the CDC a growing concern to voters.  And in tandem, polls show the relative importance of healthcare as an issue in Campaign 2020 has slipped, even among Democratic voters keen to see healthcare policy at the top of the domestic policy agenda.

Public fatigue about Covid-19 news is problematic. Mixed messaging from elected officials about masks, social distancing and testing has confused the public. News coverage has been equally inconsistent: Pew Research Center found Fox News had emerged as the ‘single source of truth’ to conservative Republicans in key areas of the country often at odds with scientists and public health experts.

Ideally, consumers depend on their physicians for the information they need, but practically it’s impossible. The public’s low level of health literacy is the issue.

My Take

Health literacy is defined as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (Title V, the Patient Protection and Affordable Care Act, 2010). It’s about how individuals make decisions about their own health and the sources of information and accuracy of information provided.

Attention to and investment in health literacy is woefully inadequate in the U.S. system. Though 9 of 10 adults say they have difficulty using everyday health information routinely available in clinics, hospitals, retail outlets, social media, and communities, little progress has been made. The HHS’ National Action Plan to Improve Health Literacy (2010) has been a victim of budget cuts. The investment of $30 billion in ‘meaningful use’ of electronic health records by hospitals and physicians has not improved health literacy.  And physicians and frontline caregivers who own the public’s trust are frustrated by the enormity of patient ignorance and their lack of tools to improve their engagement. It’s a major source of burnout.

Our inclination to trust only the sources with whom we agree (selective attention and selective retention) lend to divisiveness and social disorder.  That’s why questions about the credibility of the CDC’s vaccine development process, or reports from drug companies about their progress toward effective coronavirus therapeutics is so problematic. When the medium—a scientist, a media personality or an elected official—becomes the message and other sources are tuned out, health literacy fails, and misinformation abounds.

An informed electorate about the healthcare system—how it works, how it’s funded, what it does well, where it falls short and how to use it effectively—is necessary to its future. Improved health literacy lowers costs, improves outcomes and lends to improvements in how healthcare services are provided. That includes pandemic preparedness and how the system of the future should be organized.

Health literacy is not a major element in either Presidential campaign platform but should be. It’s rare that a hospital, medical practice, or insurer invests in health literacy as a strategic investment, but they should. And the education system pays minimal attention in its curricula despite the significance of the system to the future.

It’s time health literacy got a fresh look!



Healthy People 2020 CDC Office of Disease Prevention and Health Promotion

“National Action Plan to Improve Health Literacy” US Department of Health and Human Services May 2010;


KFF’s Health Tracking Poll: The Role of Misinformation on COVID-19

According to the poll:

  • The economy has now secured a spot as the top issue in the 2020 election with one-third of registered voters (32%) saying it will be the most important issue in deciding their vote for president, followed by the coronavirus outbreak (20%), criminal justice and policing (16%), and race relations (14%).

  • The share of voters who say health care will be the most important issue in deciding their vote has dropped 16% since February (from 26% to 10%), and outside of coronavirus, health care now ranks 5th as an issue for voters (and ranks 3rd for Democrats).

  • Most adults (81%), including majorities across partisans, do not think a vaccine for coronavirus will be widely available in the U.S. before the presidential election in November.

“KFF Health Tracking Poll – September 2020: Top Issues in 2020 Election, The Role of Misinformation, and Views on A Potential Coronavirus Vaccine” Kaiser Family Foundation September 10, 2020

Gallup: Americans’ Trust in Mass Media Down Substantially

  • 13% trust the media “a great deal,” and 28% “a fair amount”—up from all-time low of 32% in 2016 and 4% below 2018. Note: in 1997, trust in media stood at 53%.

  • 69% of Democrats, 15% of Republicans, 36% of independents trust media

Megan Brenan “Americans’ Trust in Mass Media Edges Down to 41%” Gallup September 29, 2019;

YouGov: The Role of Media in COVID-19 Tracking

To summarize:

  • In all markets surveyed bar one, healthcare professionals were the most trusted group, with rates of 79% or higher. Poland is the exception, where friends and family (81%) more trusted than doctors and nurses (72%).

  • In the majority of countries, the level of trust in the media sits between 50% and 70%. Only in four countries is it higher: Vietnam (89%), Malaysia (82%), Singapore (75%) and the Philippines (72%). The U.S. is 43%.

  • The media tends to be the least trusted group, and in no country does it rank first or second. Trust in the media is lowest in France (26%) and Britain (31%). Aside from these two countries, fewer than half of people trust the press in Italy, Poland, Sweden, Mexico, and the US.

Matthew Smith “International Covid-19 tracker update: 18 May 2020” YouGov

Pew: Comparing Trust in News Sources

According to the survey of 12,043 U.S. adults conducted Oct. 29–Nov. 11, 2019, on Pew Research Center’s American Trends Panel comparing trust in 30 sources of news:

  • Partisan polarization in the use and trust of media sources has widened in the past five years.

  • Greater portions of Republicans express distrust than express trust of 20 of the 30 sources asked about. Only 7 outlets generate more trust than distrust among Republicans – including Fox News and the talk radio programs of hosts Sean Hannity and Rush Limbaugh.

  • For Democrats, the numbers are almost reversed. Greater portions of Democrats express trust than express distrust in 22 of the 30 sources asked about. Only 8 generate more distrust than trust – including Fox News, Sean Hannity, and Rush Limbaugh.

  • Another way to look at the diverging partisan views of media credibility: Almost half of the sources included in this report (13) are trusted by at least 33% of Democrats, but only two are trusted by at least 33% of Republicans.

  • Republicans’ lower trust in a variety of measured news sources coincides with their infrequent use. Overall, only one source, Fox News, was used by at least one-third of Republicans for political and election news in the past week. There are five different sources from which at least one-third of Democrats received political or election news in the last week (CNN, NBC News, ABC News, CBS News and MSNBC).

  • None of the 30 sources is trusted by more than 50% of all U.S. adults.

“Americans See Skepticism of News Media as Healthy, Say Public Trust in the Institution Can Improve” Pew Research Center August 31, 2020; Jurkowitz et al

“U.S. Media Polarization and the 2020 Election: A Nation Divided” Pew Research Center January 24, 2020;

Morning Consult: Media Companies Named to Most Divisive Brands List

News outlets make up 12 of the 15 most politically polarizing brands, out of the more than 3,700 brands that Morning Consult tracks daily, according to July 1-Aug. 8 polling that gauged an average of 13,419 survey respondents per brand.

The difference between Republicans’ and Democrats’ net favorability for CNN, for example, stood at 66% last year. It grew 14% to 80 this year, due to a 12% drop in net favorability among Republicans, from minus 13 to minus 25. Republicans held more negative views than Democrats of every media outlet on the list except for Fox News.

“Media Companies Dominate Most Divisive Brands List, and It Keeps Getting Worse” Morning Consult October 1, 2019


Study: Unionization of Staff Associated with Lower Mortality Rate in New York Nursing Homes

Researchers examined the association between the presence of health care worker unions and COVID-19 mortality rates in 355 nursing homes in New York State.  Key finding: health care worker unions were associated with a 1.29% mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions. Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates.

Dean et al “Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes” Health Affairs September 10, 2020;


Study: Inflation Penalties May Slow Drug Price Increases

West Health Policy researcher Sean Dickson analyzed 606 brand-name drugs used annually by more than 5000 individuals with Medicare Part D from 2013 to 2017 to assess increases in the percentage of drug sales subject to inflation penalties were associated with lower drug price increases. Highlights:

Of 2148 brand-name drugs included in the database, 606 drugs were used by more than 5000 beneficiaries annually, with a mean sales percentage subject to inflation penalties of 12.1%. A higher sales percentage subject to inflation penalties was associated with lower annual price increases. Lower price increases owing to inflation penalties were estimated to be associated with a reduction in Medicare Part D pharmacy expenditures of $7.1 billion between 2013 and 2017.

Sean Dickson “Association Between the Percentage of US Drug Sales Subject to Inflation Penalties and the Extent of Drug Price Increases” JAMA Network Open. September 11, 2020;

Pitchbook: Private Equity Deal Volume in Healthcare Down in Second Quarter 2020

According to a new PitchBook report:

  • U.S. private equity deals in healthcare totaled $8.5 billion in the quarter ended June 30, compared with about $24.2 billion in the second quarter of 2019. That follows a 45% dip in PE healthcare investment the first quarter of 2020 year-over-year, from almost $28 billion to $15 billion in the recently ended quarter.

  • Healthcare deals comprised 9% of PE spending across all industries in the recently ended quarter, down from 11% in the 2019 period.

  • Across all industries, U.S. private equity dealmakers closed 2,173 deals totaling $326.7 billion in the first half of 2020, down 20% from the first half of 2019. Private equity deal value in the second quarter of 2020 was down more than one-third from its value in the second quarter of 2019.

  • Through the first half of 2020, U.S. private equity firms have closed 392 exits valued at a combined $134.8 billion, the report found. Announced global PE exits were down about 70% in May 2020 compared with May 2019.

Tara Bannow “Private equity investment in healthcare slows” Modern Healthcare September 10,2020;

Study: Target Prices Drive Bundled Payment Spending Decreases for Hospitals

The Michigan research team examined the impact of the CMS voluntary Bundled Payments for Care Improvement (BPCI) Advanced Model program implemented in 2018 for 29 episodes of care. Key findings:

  • Using Medicare claims, we estimate that each $1,000 increase in target prices increased the probability of participation by 0.78% across all episodes.

  • Hospitals with spending that was 10% more than target prices at baseline could expect spending to decline by 7.43% in the performance period, hospitals with spending that was 20% more saw spending decline by 9.80%, and hospitals with spending that was 30% more saw spending decline by 11.93%.

“Our findings suggest that CMS will end up paying substantial bonuses to hospitals that resulted from mean reversion rather than from meaningful reductions in costs.”

Berlin et al “Target Prices Influence Hospital Participation And Shared Savings In Medicare Bundled Payment Program” Health Affairs September 2020;

Study: Medicaid Work Requirement Ineffective in Reducing Health Costs

The Harvard research team analyzed the Medicaid work requirement enacted June 2018 in Arkansas.  (Able-body adults ages 30–49 are required to work 20 hours/week, participate in “community engagement” activities, or qualify for an exemption to maintain coverage). Findings:

  • Most of the Medicaid coverage losses in 2018 were reversed in 2019 after the court order.

  • Work requirements did not increase employment over 18 months of follow-up.

  • People in Arkansas ages 30–49 who had lost Medicaid in the prior year experienced adverse consequences: 50% reported serious problems paying off medical debt, 56% delayed care because of cost, and 64%delayed taking medications because of cost. These rates were significantly higher than among Arkansans who remained in Medicaid all year.

  • Finally, awareness of the work requirements remained poor, with more than 70% of Arkansans unsure whether the policy was in effect.

Note: As of July, CMS has allowed 10 states to move forward with Medicaid work requirements, but Arkansas’ policy was the only one to have gone into effect. It cost more than $26 million to implement Arkansas’ Medicaid work requirement: the state paid 17% of the administrative costs, the federal government paid 83%.

Sommers et al “Medicaid Work Requirements In Arkansas: Two-Year Impacts On Coverage, Employment, And Affordability Of Care” Health Affairs September 2020;

Analysis: 9 of 10 teaching Hospitals Accept Industry Funding

The UPMC-Harvard research team examined payments from biomedical companies to teaching hospitals in 2018. Key finding:

  • 91% of teaching hospitals received industry payments totaling $832 million in 2018.

  • Hospital predictors of receiving payments included large bed size, major medical school affiliation, and inclusion on the U.S. News & World Report Best Hospitals Honor Roll.

Anderson et al “Characteristics Of Biomedical Industry Payments To Teaching Hospitals” Health Affairs September 2020;

Moody’s: Pre-Pandemic Financial Stability for Hospitals was Stable

Operating margins in the nonprofit and public healthcare sector remained stable in fiscal year (FY) 2019 prior to the outbreak of coronavirus disease 2019 (COVID-19), according to a Moody’s Investors Service report released last Thursday. Highlights:

  • Expenses outgrew revenues, debt-to-cash flow rose for the second straight year, and median cash-to-debt rose for the fourth consecutive year.

  • Median outpatient surgeries and visits rose 3.4% and 3.8%, respectively, while admissions grew 0.5%.

  • Non-profit hospitals’ median operating cash flow margins remained stable at 8.2%, while the number of hospitals and health systems that generated operating losses held steady at 65, or 23%.

“Research Announcement: Margins in not for profit and public healthcare sector remained stable in fiscal 2019 before coronavirus hit” Moody’s Investors Service September 10, 2020;–PBM_1244974?cid=7QFRKQSZE021