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The Keckley Report

The Great Debate: How Healthcare will be Framed

By September 28, 2020March 1st, 2023No Comments

The tradition dating back to 1960 of televised Presidential debates continues tomorrow night from Cleveland as Fox News Anchor Chris Wallace moderates.

This debate comes at an unprecedented time in our country: social unrest, public anxiety about the coronavirus, and economic recovery worry voters. Early voting is underway in 8 states already and will commence in 34 others in coming days.  And the nomination Saturday of conservative jurist Amy Coney Barrett to replace liberal justice icon Ruth Bader Ginsburg on the Supreme Court adds suspense to the role courts will play in our democratic experiment.

Debate organizers have allocated the 90-minute exchange to cover six broad topics including the coronavirus. The Trump campaign will assert the ‘China virus’ has been well-managed; the Biden campaign will challenge the veracity of that assertion. Both will decry the loss of 205,000 American lives, thank frontline caregivers for their heroics and promise vaccines and therapies to mitigate its impact.

Polls about the pandemic by Kaiser Family Foundation, Pew and others reflect consensus among the majority who consider Covid-19 a serious public health challenge that could have been handled by elected officials better. They’re anxious about its impact, hopeful for a vaccine and worried about a second surge. There’s consensus on the gravity of the issue but division about how to deal with it. As a result, ‘pandemic politics’ about masking, social distancing, lockdowns et al will be a reality for the next President well into 2021.

Regrettably, the debate will not feature discussion about each candidate’s vision for the future of the U.S. health system. Their guiding principles are known but specifics about their policies, structural changes and funding for their programs is unavailable:

Trump Guiding Principles:

The states are the focus for innovation and reforms. Private solutions are better than government programs. Price transparency will spark competition and consumerism. Healthcare is an individual responsibility in which government policy plays a role.

Biden Guiding Principles:

Healthcare is a fundamental right. Access must be equitable and universal. Spending should be constrained but adequate. The Affordable Care Act (ACA) is a suitable starting point for needed reforms to the efficiency and effectiveness of the system.

President Trump will call the ACA a disaster while promising to continue its popular protections like guaranteed issue, lifetime coverage limits and others.

Vice President Biden will call the ACA sound policy noting 20 million gained insurance coverage through Medicaid expansion and the marketplaces and reproductive rights for women protected.

And opinions about the ACA are unlikely to change: In the September 2020 Kaiser Foundation Tracking Poll, 49% held a favorable opinion of the ACA while 42% held a negative opinion of the law. Across partisans, about eight in ten Democrats (82%) have a favorable view of the ACA compared to roughly half of independents (48%) and a much smaller share of Republicans (16%). Thus, 10 years after passage, the Affordable Care Act remains a lightning rod for public discord.

Beyond the ACA and pandemic, the candidates’ plans for healthcare in other key areas will probably not surface in the debate i.e. how to integrate the labyrinth of federal, state and local health programs to eliminate waste and align policies, how to increase personal accountability for the health habits that account for 75% of health costs and soaring incident rates for chronic diseases, how to encourage innovation and competition that’s fair and many others. Thoughtful comments about these don’t lend to soundbites.

The debate tomorrow night is consequential because healthcare will be framed in the spotlight. Neither candidate will paint a flattering picture of the status quo. Both will decry corporate profits while lauding its frontline caregivers, scientists and first responders. But it’s unlikely voter opinions will change: fewer than 15% of voters say they are undecided about their Presidential pick today and only 29% think the debate will be consequential in this election.

Over the course of the next 36 days, voters will pick a President. The debate tomorrow night will frame healthcare and influence the vote for many. 



National Conference of State Legislatures

Kaiser Family Foundation Health Tracking Poll September 2020

Julie Rovner “Without Ginsburg, Judicial Threats to the ACA, Reproductive Rights Heighten” September 21, 2020; Kaiser Health News

Liu et al “Catastrophic Health Expenditures Across Insurance Types and Incomes Before and After the Patient Protection and Affordable Care Act” September 24, 2020; JAMA Network


CDC: Young Adults are Now the Largest Group of Americans Getting COVID-19

A new study from the Centers for Disease Control and Prevention reports that the median age of people with COVID-19 in the U.S. has declined over the spring and summer, with Americans in their 20s now accounting for more cases than people in any other age group:

  • In May, the median age of U.S. residents with COVID-19 was 46. By July, it had dropped to 37, then rose slightly to 38 in August.

  • In May, people in their 20s made up 15.5% of confirmed COVID-19 cases nationwide. At the time, they trailed people in their 30s (who accounted for 16.9% of total cases) as well as people in their 40s and 50s (both of those age groups accounted for another 16.4% of cases). By June, 20-somethings had taken over the top spot, making up 20.2% of all cases. That figure rose to 23.2% in July, then dropped back to 21% in August. The proportion of cases among Americans in their 30s also increased in June and July. But by August, it had fallen slightly below the level seen in May.

“Morbidity and Mortality Weekly Report” CDC September 23, 2020; CDC

Study finds 5 Criteria Necessary to Ease Lockdowns Successfully

A study of 9 high income countries found solutions range from effective surveillance to gauge exactly how many people are infected to more challenging needs including a health system that can handle surges in infections. The other successful strategies include strict border control measures and quarantine requirements for any visitors; a robust public health system that has the capacity to do large-scale testing; and engagement from local communities to do their part to fend off the virus. They also advised that four public-health principles should be considered in each country’s exit strategy: infection status, community acceptance, public-health capacity, and health-system capacity Nations analyzed were Japan, Hong Kong, Germany, New Zealand, Norway, South Korea, United Kingdom, Singapore and Spain.

Han et al “Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe” September 24, 2020; The Lancet

Medicare Inability to Cover Vaccines Approved Under Emergency Authorization Gets Attention

Under the Coronavirus Aid, Relief, and Economic Security Act, or Cares Act, which ensures free coronavirus vaccine coverage, including no out-of-pocket costs for people on Medicare. But Medicare doesn’t cover costs for drugs approved under emergency-use designations.

Administering the vaccine can require office visits and fees ranging from $20-$46 for providing a shot and additional cost for a booster shot. The government would cover those costs under the Cares Act, but Medicare wouldn’t cover those administrative costs.

A new federal fund created by the Cares Act will provide the shots free of charge to people who don’t have health insurance. The government has been working with commercial insurers to make sure their members don’t face copays.

Stephanie Armour “Medicare Wouldn’t Cover Costs of Administering Coronavirus Vaccine Approved Under Emergency-Use Authorization” September 21, 2020; Wall Street Journal


Announcements From Big Name Disruptors Last Week:

  • Amazon announced it new virtual care app that facilitates e-visits (in partnership with Care Medical) and script refills

  • Walmart is testing drones to deliver home-based COVID-19 tests in a partnership with Quest Diagnostics, and DroneUp. It’s warehouse operating company, Sam’s Club is partnering with 98point6 to offer a telehealth subscription plan to Sam’s Club members that starts at $20 for the first three months which features $1 telehealth offerings where physicians can diagnose and treat around 400 conditions that include diabetes, heart disease, and behavioral health issues.

  • Microsoft is partnering with Epic to integrate electronic health records for provider telehealth services facilitating virtual visits directly from the EHR.

March of Dimes: 2 million U.S. Women Live in Maternity Care Deserts

According to a new March of Dimes report released last week, maternity care deserts — areas without hospitals that offer obstetric care, birth centers, or a specialized provider — continue to be a problem in the U.S. More than 2.2 million women of childbearing age live in such deserts and 4.8 million live in areas with limited access to maternity care. Women in the rural U.S. are especially at risk: there are four times as many rural counties that are maternity care deserts than urban counties, and 8% of obstetrics providers report working in rural areas. At the same time, 1 in 3 women of childbearing age in a maternity care desert lives in an urban setting. 

CMMI: Alternative Payment Models Get Mixed Results

At last week’s National Association of Accountable Care Organizations’ fall conference conducted virtually, Brad Smith, the head of the Center for Medicare & Medicaid Innovation (CMMI) that oversees value-based care payment models said results from value-based payment models reviewed by the agency were mixed: Models that focused on a global budget (i.e. Maryland’s Total Cost of Care, home health value-based purchasing model) were successful but bundled payment results and oncology bundles had disappointing results.

Related: CMS finalized two specialty alternative payment models (APMs) around kidney care and oncology initially proposed in 2019. The models, ESRD Treatment Choices (ETC) and Radiation Oncology (RO), will both begin January 2021 and will be mandatory.

Related: Last week, a group of ACO advocates sent a letter to CMS requesting changes in how ACOs are assessed on quality in the Medicare Shared Savings Program (MSSP) and Merit-Based Incentive Payment System (MIPS). Among targets for 2021 that appear problematic for most ACOs: the requirement that 75% of a practitioner’s patients participate in the ACO to qualify for a 5% bonus. Signers include American College of Physicians, American Medical Association, America’s Essential Hospitals, America’s Physician Groups, AMGA, Association of American Medical Colleges, Federation of American Hospitals, Medical Group Management Association, National Association of ACOs, and Premier.

Robert King “CMMI director finds mixed results for bundled payments, gives high marks to global budgets” September 22, 2020; Fierce Healthcare  

“Ten Groups Ask CMS to Not Finalize Proposed ACO Quality Changes”; NAACOS

Joyce Frieden “ACOs Saved Medicare $$ in 2019 — But What Will Happen to Them Now?” September 22, 2020; MedPage Today

CDC Reports on the Mental Health of U.S. Adults

Three new reports from the CDC outline the state of mental health among U.S. adults in 2019. More than 1 in 7 U.S. adults experienced some level of anxiety during 2019 — before the pandemic — while nearly 1 in 5 reported depression:

  • Anxiety: When asked about their anxiety symptoms in the two weeks prior to being surveyed, nearly 10% of adults reported mild anxiety, while around 3% reported severe forms of anxiety. Women and those aged 18-29 were most likely to report being anxious.

  • Depression: Nearly 12% of respondents reported mild depression symptoms in the two weeks prior to being surveyed, while nearly 3% reported severe depression. White and Black adults were most likely to report depression than other racial groups.

  • Treatment: Around 1 in 5 U.S. adults reported getting any mental health treatment last year. Around 16% said they had taken some medication, while around 10% reporting getting counseling.

National Center for Health Statistics

Bright Health Raises $500M, Plans Expansion into Employer-Based Insurance

After raising $635 million last year, Minneapolis-based insurance startup Bright Health formed by ex-United Healthcare execs in 2015, raised another $500 million led by three private equity firms. Starting next year, the company said it will offer small-group plans and services for self-insured companies in addition to its individual and Medicare Advantage offerings.  A notable feature of its business strategy is its use of a narrow-network model that involves partnering closely with one health system in each market. The company currently operates in 43 markets across 13 states, a significant expansion from December, when it was in 22 markets and 12 states.

“Bright Health Inc. Announces $500 Million Series E Funding Including Significant Investments by Tiger Global Management, T. Rowe Price Associates, Blackstone, NEA and Bessemer Venture Partners” Bright Health September 22, 2020; Bright Health

Study: System Affiliated Physicians Outperform Independents in MIPS

Focus: The Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS). In this cross-sectional study of 636,552 clinicians with MIPS data for 2019 (based on clinician performance in 2017), those with health system affiliations were compared with clinicians without such affiliations. Key findings:

  • System affiliated clinicians had a mean MIPS statistically significant performance score of 79.0 vs 60.3 on a scale of 0 to 100.

  • The percentage receiving a negative (penalty) payment adjustment was 2.8% for system-affiliated clinicians vs 13.7% for unaffiliated clinicians, 97.1% vs 82.6%, respectively, for those receiving a positive payment adjustment (absolute difference, 14.5% and 73.9% vs 55.1% for those receiving a bonus payment adjustment.

  • The percentage of clinicians who received a positive payment adjustment was 97.1% for clinicians affiliated with a health system vs. 82.6% for independent clinicians. The percentage of clinicians who received a bonus payment adjustment was 73.9% for clinicians affiliated with a health system vs. 55.1% for independent clinicians.

Johnston et al “Association of Clinician Health System Affiliation with Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System” September 8, 2020; JAMA Network

Trump Announces Health Plan: Importation, Transparency Key Themes

Late Thursday, President Trump announced his health plan “America First Healthcare Plan” at a rally in North Carolina. “On June 24, 2019, I signed Executive Order 13877 (Improving Price and Quality Transparency in American Healthcare to Put Patients First), directing certain agencies — for the first time ever — to make sure patients have access to meaningful price and quality information prior to the delivery of care.” Key elements of the plan:

•             Drug importation from Canada authorization for states
•             Protections against pre-existing condition coverage restrictions
•             Increased price transparency for consumers
•             Improvements in the Veteran’s Choice program

My take: the EO essentially recap’s previous Executive Orders and includes no new provisions. It requires HHS and other agencies to implement provisions within 3-6 month in most cases, and does not include details about funding, measures of performance et al.

The President also announced that the government will be sending $200 rebate cards to 33 million seniors to help them pay for their drugs. The $7 billion cost would be covered through savings from index pricing whereby the U.S. government will pay less for drugs sold in other countries at lower prices. 

“Executive Order on An America-First Healthcare Plan” September 24, 2020; White House

Study: ACA Expanded Financial Protection Against “Catastrophic” Medical Expenses for 2M Annually

Researchers analyzed insurance coverage and medical claims for adults under 65 from 2010-2017. Highlights:

  • The number of uninsured nonelderly adults declined from 42.9 million (23.5%) in 2010 to 27.9 million (14.8%) in 2017, whereas those with Medicaid coverage increased from 11.0 million (6.0%) to 18.3 million (9.7%)

  • Coverage gains were concentrated in the 2 lower income quartiles, in which the uninsured rate decreased from 44.1% to 28.6% (lowest quartile) and 27.0% to 18.7%).

  • The number of adults experiencing catastrophic expenditures yearly declined from 13.6 million (7.4%) in 2010 to 11.2 million (5.9%) in 2017.Privately insured adults composed 46.4% of catastrophic expenditure cases in 2010 and 53.6% in 2017.

Conclusion: “The Affordable Care Act implementation was associated with 2 million fewer US adults with catastrophic expenditures each year. Financial protection improved for the lowest income quartile, which was one of the ACA’s principal aims. However, improvements were not observed in higher income quartiles or among the privately insured, who represent an increasing share of those experiencing catastrophic expenditures… Despite large coverage gains, 11 million US adults, including 6 million with private insurance, continue to experience catastrophic health expenditures annually. “

Liu et al “Catastrophic Health Expenditures Across Insurance Types and Incomes Before and After the Patient Protection and Affordable Care Act” September 24, 2020; JAMA Network

Blue Health Plans Reach Tentative Antitrust Settlement for $2.7 Billion

Last week, Blue Cross Blue Shield announced a tentative settlement in an antitrust suit filed in 2012 on behalf of customers that requires a payout of $2.7 billion and curtailment of practices that allegedly limited competition.

Under the draft settlement, the 36 Blue insurers would drop a rule requiring two-thirds of each company’s national net revenue from health plans and related services to come from Blue-branded business. The other major change negotiated in the draft settlement would relax rules requiring a national employer seeking Blue Cross Blue Shield coverage to work through the Blue insurer that covers the location of its headquarters.

The settlement isn’t final: it requires approval by each Blue Cross Blue Shield board.

Anna Wilde Mathews, Brent Kendall “Blue Health Insurers Reach Tentative Antitrust Settlement for $2.7 Billion” September 24th, 2020; Wall Street Journal

CMS: 2021 Medicare Advantage Premium Decrease

CMS said Thursday that average Medicare Advantage premiums will decrease 11% to an estimated $21 from $23.63 this year. CMS estimates enrollment will increase 10% to 26.9 million in 2021, a rate that’s on par with growth in 2020, to 40% of all Medicare enrollees. There will be 4,800 plans in the Medicare Advantage market, with an average of 47 plans per county–up from 39 plans this year.  Medicare Advantage open enrollment starts Oct. 15 and ends Dec. 7 for coverage that begins Jan. 1, 2021.

“Trump Administration Announces Historically Low Medicare Advantage Premiums and New Payment Model to Make Insulin Affordable Again for Seniors” September 24, 2020; CMS