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The Keckley Report

Out of Sight, Out of Mind: The 6 Populations that Lack adequate Voice in the US Health System

By November 28, 2022March 1st, 2023One Comment

As state legislatures reconvene, Governors take their oath and Congress returns for its lame-duck session, the healthcare industry will get scant attention beyond continued debate about abortion rights and spending.

Trade groups and lobbyists for high profile special interests will be active; others less noticed will be under-represented in lawmaking and budgeting. Six groups top this list for healthcare: they share common attributes:

·       They’re not represented by a powerful lobby or trade group

·       Their leaders are not routinely listed in “top 100 most powerful” lists,

·       They’re dependent on government for funding.

·       Their ranks are growing.

·       And the health issues presented in these groups are complicated and unique.

1-College Students: 16 million

College students experience health risks. from living in dormitories or close quarters with other students, through the stress of being away from home and the pressure of academic life, or through the use of drugs and alcohol. As of fall 2021, 39% rated their health as very good, 13% say it’s poor and 54% say their health and well-being are priorities and suicide is the number one cause of death among their peers.

The accessibility of student health services is episodic, inadequate and under-funded by the schools. While average tuition has doubled to $25,281 since 1990, budgeting for student health has been virtually flat. Connectivity to local health providers is rare; use of electronic health records and advanced technologies is missing and the advanced practice nurses who run on-campus programs underappreciated and virtually invisible to college administrators.

2-Undocumented Immigrants: 11.4 million

Of 46.7 million immigrants living in the U,S., 11.4 million (24%) are undocumented with the majority matriculating to four states–CA, TX, NY, FL. Most depend on local and state public health programs and hospital emergency rooms for their care. Most work. Most are younger and more ethnically diverse than populations in the communities where they live and work.

The healthiness of this population is impaired by the politics of U.S. immigration policy. Nonetheless, these individuals are served by the health system though less timely and optimally coordinated. It represents an opportunity for innovation, especially in states most impacted.

3-Incarcerated Populations in State Prisons: 8.7 million

There are 8.7 million in state prisons and another 1.2 million in federal prisons-—the highest incarceration rate in the world. States spend between $14,000 and $70,000 per year per prisoner on their health programs. 51% of the jailed population have a chronic medical condition, 65% reported used illicit drugs before their arrest, 43% have a mental health problem and rates for HIV and Hepatitis C are double the population average. And 61% will be re-incarcerated within 10 years.

In this population, how funding is used and innovation in integrating community resources, mental health and public health services sooner and more effectively is the issue.

4-Home care workers: 3.6 million

88% are women, 47% are Black/Hispanic and median annual pay in 2020 was $27,080 annually/ $13.02 hour—the lowest among all health professions.

Turnover is high, especially for local jobs that offer health benefits. Training is minimal if at all, and regulatory oversight inconsistent across states. Yet, care at home is certain to be the destination of choice for patients including private equity investments in home services and those with insurance that incents settings other than hospitals.

Home care is an afterthought in most healthcare settings, yet it serves patients in the setting with the highest potential for value-based care. It needs fresh attention vis workforce development and technology advancements.

5-Native Americans: 2.7 million

The Indian Health Service (IHS) provides comprehensive primary health care and disease prevention services to 2.7 million American Indians and Alaska Natives in 574 federally recognized tribes in 37 states. It operates a network of over 600 hospitals, clinics, and health stations on or near Indian reservations primarily in rural settings.

They have a life expectancy that is 5.5 years lower than the U.S. all-races population, with some tribes experiencing life expectancy as much as 12 years fewer. They have higher incidence of liver disease and cirrhosis, diabetes, unintentional injuries, assault and homicide, and suicide. And the COVID-19 pandemic compounded the impact of these disparities in tribal communities, with AI/ANs experiencing disproportionate rates of COVID-19 infection, hospitalization, and death.

Healthcare for native Americans is inadequately integrated with broader efforts in rural and preventive health, and in technologies that enable self-care.

6-NAS Children: 400,000-500,000

The numbers of newborns exposed to opioids in utero has skyrocketed in recent years: from 1.5/1000 hospital births to 11.9/1000 in 2019.  According to the U.S. Center for Disease Control and Prevention, between 313,048 to 366,426 children NAS children were born between 2001 and 2019, which does not include those born in non-hospital settings estimated to be an additional 15-20%.   

As a direct result of sudden withdrawal of prenatal opioid exposure, NAS children face cognitive and behavioral disabilities for life. NAS expert Kanwaljeet S. Anand at Stanford University School of Medicine observed that “their brain development has been altered by repeated exposures to opioid drugs in the prenatal period…. These changes in brain development are permanent and will affect these children throughout their entire lifespan”.

Only 6 states track cases, diagnosis treatment across communities varies widely and funding for 80% of these is sourced through state Medicaid agency maternal child health programs which rarely reimburse beyond the initial hospital stay. A national registry is needed to monitor and improve the heath status of the NAS population and interventions a major investment of Opioid Settlement funds received by states.

My take:

These populations are out of sight, out of mind in most consideration of the health system’s future, but they represent perhaps it’s greatest opportunities for innovation and public-private collaboration.

Let’s take a fresh look at each.




“As the market continues to cool slightly, we expect deal activity in the healthcare industry to remain strong. Although demand from buyers may be decreasing, the availability of sellers willing to strike a deal appears to be on the rise, which will have the cumulative effect of driving down prices. We will no doubt examine whether these trends continue through the final weeks of 2022.”

Healthcare Transactions Q3 2022 Bass Berry & Sims November 23, 2022

“In general, across the industry, I believe there is inadequate disclosure to consumers about the uses of their personal data, and a total absence of compensation to consumers for its business value. This isn’t just a health care industry problem. It’s an economy-wide issue. How much of global corporate earnings and enterprise value is derived from personal information, and what fraction of that value is being returned to the consumer?” Ernie Ludy, former CEO, Watson Health business in January.

He founded what became IBM’s most valuable health database. Now, he’s sounding an alarm about patient privacy Stat News February 1, 2022

Any policies, including monthly caps on insulin or out-of-pocket costs, that only address how much patients pay won’t solve the more systemic problem of rising healthcare costs.

Paul Shafer Our Biggest Health Insurance Concern Isn’t What You Think MedPage November 25, 2022

It is hardly a secret among medical school deans that the USNWR rankings are based on data not directly related to educational process, quality, and outcomes. Nor can they trust the veracity of the data that are provided, given the recent scandals reported in other professional schools and colleges that manipulate the formula to their own advantage.

But more importantly, the rankings fail to describe or measure any outcome of importance related to the quality of education provided by medical schools. In fact, the USNWR rankings do little more than reaffirm prestige and the financial prosperity of schools, promoting a cycle by which the wealthiest schools seek those students with the most privilege and wealth and vice versa, exacerbating disparities and creating competition that does nothing to advance the health of the public or the education of future physicians.

That the emperor has no clothes is not a secret. Comprehensive analyses of USNWR rankings have long demonstrated that the methodology is ill-conceived, that the response rate of those completing the questionnaires that feed into the ranking formula would not meet the standards of a peer-reviewed publication, and that the most important aspects of educational quality are largely ignored.

Deans: Dump that USNWR ‘best medical school’ survey Stat News November 23, 2022

As the world stares down the barrel of climate change, the health care system — which is responsible for about 9% of all U.S. greenhouse gas emissions — is finally starting to take action. Digital health is late to the party’: Can telehealth help hospitals mitigate their carbon footprints?

Digital health is late to the party’: Can telehealth help hospitals mitigate their carbon footprints? November 22, 2022

Tech and retail giants entering the healthcare space were eager to position themselves as potential partners of, rather than threats to, current industry players.

Innovators Place Bets on Healthcare’s Future at HLTH 2022 in Las Vegas Pitchbook November 22, 2022

“The current system of keeping prices and patients in the dark will continue to perpetuate a system where overcharging and price-gouging are the norm,” Marni Jameson Carey, president of advocacy group Power to the Patients, told federal officials. “Standing in the way are those profiting excessively from the status quo, and fighting to defend it.”

“We encourage the [federal government] to consider cost compensation to the providers or to the health care institutions,” wrote Meghan Woltman, the chief lobbyist of Advocate Aurora Health, a tax-exempt hospital that has registered more than $3 billion of net income since 2018.

Patient groups push federal government to enforce health care price estimates Stat News November 21, 2022

Alternative health

Study: Vitamin D supplements not associated with discontinued statin use: The Stanford-led research team analyzed data from 2083 participants in a randomized, double-blind trial of vitamin D supplementation who initiated statin therapy during follow-up and responded to a survey were equally likely to develop muscle symptoms (31% vs 31%) and discontinue statin therapy (13% vs 13%), whether assigned to vitamin D or to placebo. Key finding: “Vitamin D supplementation did not prevent SAMS or reduce statin discontinuation. These results were consistent across pretreatment 25-hydroxy vitamin D levels.”

Hlatky et al Statin-Associated Muscle Symptoms Among New Statin Users Randomly Assigned to Vitamin D or Placebo JAMA Cardiology November 23, 2022doi:10.1001/jamacardio.2022.4250

Study: evidence for acupuncture is not strong: This systematic review of evidence for use of acupuncture in adult health conditions identified 434 systematic reviews published since 2013; of these, 127 assessed the certainty or quality of evidence of their conclusions. Overall, 82 systematic reviews regarding 56 health conditions were mapped, and most reviews concluded the certainty of evidence was low or very low. Across these, there were 4 conclusions that were rated as high-certainty evidence, and 31 conclusions that were rated as moderate-certainty evidence. All remaining conclusions were rated as low- or very low-certainty evidence. Approximately 10% of conclusions rated as high or moderate-certainty were that acupuncture was no better than the comparator treatment, and approximately 75% of high- or moderate-certainty evidence conclusions were about acupuncture compared with a sham or no treatment.

Allen Use of Acupuncture for Adult Health Conditions, 2013 to 2021A Systematic Review JAMA Network Open November 23, 2022 ;5(11):e2243665. doi:10.1001/jamanetworkopen.2022.43665

Health insurance

Payer Survey: Value-based model focus increasing: The 2022 Alternative Payment Model (APM) survey was conducted from May to July 2022, with a total of 63 health plans, 5 fee for service (FFS) Medicaid states, and traditional Medicare participating. These health plans and states representing approximately 233,870,081 of the nation’s covered lives and 77.7% of the national market. Findings:

·       APMs received 40% of health care payments, across all payer types.

·       Subscription to risk-based models rose with 1 in 5 (20%) of payments in US health care ascribed to risk-based advanced payment models.

·       46% are incentivizing providers to collect standardized race, ethnicity, and language data, and 37% are incentivizing screening for socioeconomic barriers.

·       96% of payers agree/strongly agree that APM adoption will improve quality of care and better care coordination, while 82% believe it will result in more affordable care.

·       Advanced payment models made up 51% of payments in Medicare Advantage (MA) plans, with 35% of payments crossing risk-based advanced payment models.

Survey Illustrates High Receptiveness From Payers to Alternative Payment Models November 24, 2022

CMS overpayments to MA plans unresolved: CMS released its summaries of 90 Medicare Advantage plan 90 audits for billings from 2011 through 2013 based on its CMS calls Risk Adjustment Data Validation, or RADV methodology. But CMS has delayed notifications to plans until February from this month due to continued criticism by plans of its methodology: Report highlights:

·       It found $12 million in net overpayments for the care of 18,090 patients sampled; if extrapolated across the total membership of MA plans for that period, $650 million would be recouped from plans. But after nearly a decade, that has yet to happen.

·       The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.

·       71 of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.

·       CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

CMS Audits

RWJF Study: 62% of Medicaid enrollees unaware of post-PHE status: 5% of respondents had heard a lot about the redeterminations, 16.2% who heard some, and 15.7% heard a little. Most of those who heard about redeterminations from their state agency, the most common source was a notification about the need to renew their coverage.

Most Adults in Medicaid-Enrolled Families are Unaware of Medicaid Renewals Resuming in the Future Robert Wood Johnson Foundation November 15, 2022

GA Governor Kemp expected to Georgia imposing work requirements on Medicaid recipients: Following Republican Gov. Brian Kemp’s reelection win, Kaiser Health News reported last Tuesday that he will seek to impose work requirements for Medicaid enrollees. Kemp’s plan would expand Medicaid eligibility in Georgia to adults with earnings below the federal poverty line who report at least 80 hours a month of work, volunteering, education or a handful of other activities. People with earnings above half of the poverty line would also need to pay a small monthly premium.

Why it matters: The Biden administration revoked federal approval for work requirements last year, but decided not to appeal after a federal judge ruled the administration couldn’t overrule Georgia’s plan. Georgia is one of 13 states that got approval from the Trump administration to require that Medicaid recipients work or volunteer in order to be eligible for the benefits.

Path Cleared for Georgia to Launch Work Requirements for Medicaid Kaiser Health News November 18, 2022

Millman: MA Supplements expanding:  A report from Milliman conducted on behalf of the Better Medicare Alliance showed details on how many plans expanded supplemental benefits between 2019 and 2023. Highlights:

•         The number of MA plans that offered at least one of five expanded supplemental benefits increased from 824 in 2022 to 1,111 in 2023, a 35% jump.

•         The most popular supplemental benefit among plans was in-home support services, with 794 plans offering them. The increase in plans offering such benefits comes amid the latest open enrollment period for MA that ends Dec. 7. The program is expected to surpass total enrollment in Medicare this year. 

Review of Contract Year 2023 Medicare Advantage expanded supplemental healthcare benefit offerings Millman

Study: health insurers spend 1% of their net income on SDOH programs: A study of social spending by the top 20 insurers found that payers invested less than 1% of their net income on SDOH in 2021 vs. 1.6% on their net income due to circumstances around the COVID-19 pandemic in 2020.

Between January 1, 2017, and December 31, 2021, the total spending for the top 20 insurers was at least $1.87 billion, with the top six payers by market share making up 72%. The top six, on average, spent 0.11% of their net income on SDOH in 2017 and 0.67% in 2021. Spending in 2020 peaked at 1.6%, which the researchers attribute to the COVID-19 pandemic. Investments in mental health, substance use, domestic violence, natural disaster relief, technological infrastructure, community health workers, and racial equity initiatives without specifically mentioning SDOH were excluded from the study.

·       The areas that saw the least investment were transportation ($13.4 million), social and community context ($49.7 million), education ($57.2 million), and employment ($58.6 million).

·       The spike in SDOH spending in 2020 coincided with significant profit for insurers, but the researchers posit that the uptick in investment was due to urgency around the pandemic and not necessarily based on an increase in net income.

Trends in Social Spending by Private Health Insurers Journal of General Internal Medicine November 10, 2022

Study: coverage disruptions associated with higher mortality rates: “Little is known about health effects of coverage disruptions among privately insured adults, the majority of the working-age population. In this study, we evaluated associations of a prior coverage disruption with mortality risk among large, nationally representative cohorts of working-age adults with either public or private health insurance coverage.” Findings:

“Among working-age adults with either private or public health insurance, a prior coverage disruption was associated with increased mortality risk, underscoring the need to assess health insurance coverage instability in clinical practice.”

Yabroff et al Association of Health Insurance Coverage Disruptions With Mortality Risk Among US Working-Age Adults JAMA Health Forum November 23,2022;3(11):e224258. doi:10.1001/jamahealthforum.2022.4258

Medicaid MCOs face data obstacles: Key findings of the Institute for Medicaid Innovation’s (IMI) 2022 Medicaid managed care organization (MCO) survey:

•         71% of health plan respondents cited access to information from previous providers as a key barrier to care coordination.

•         67% of health plans said their information technology systems were a barrier to setting up effective telehealth delivery services. Data collection issues hamper Medicaid’s ability to effectively measure, monitor, and assess population health and improve equity.

•         68% of respondents said they are making global or capitated payments to primary care providers or integrated provider entities.

•         53% are making bundled or episode-based payments.

•         47% said they are making arrangements with downside risk.

•         32% say payment withholds are tied to performance.

Annual Medicaid MCO Survey/


Study: Global comparisons of primary care access: Commonwealth surveyed 9,500 primary care physicians in 10 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the U.K. and the U.S. collected between February and September of this year. Findings:

·       65% of U.S. primary care physicians said their workloads have increased since the pandemic began, compared with 93% in Germany and 91% in the U.K.

·       At least one-third of younger primary care physicians (younger than 55 years) in all countries—and nearly three-quarters of those in New Zealand, Germany, and the United Kingdom—reported having a “very stressful” or “extremely stressful” job. Although about half or more of older primary care physicians (aged 55 years or older) in 8 countries reported job stress, in each of these countries, the older physicians were significantly less likely than their younger peers to report being stressed by their jobs.

·       Physicians under the age of 55 were more likely to feel stress, emotional distress or burnout compared to older physicians in all countries.

·       Half of primary care physicians over age 55 in the U.S. said they would stop seeing patients in the next three years.

Stressed Out and Burned Out: The Global Primary Care Crisis Common Wealth Fund November 17, 2022

Joan Stephenson Study Highlights Effects of COVID-19 Burnout on Primary Care Physicians in 10 High-Income Countries JAMA Health Forum November 22. 2022;3(11):e225101.doi:10.1001/jamahealthforum.2022.5101

Bain: Physician participation in value-based models dependent on the level of financial risk required: Per the Bain About 80% of physicians say they have an interest in participating in a value-based care program. However, that interest drops as the risk level to the provider rises.

Physicians say that they would be more disposed to adopt a value-based care model if they were guaranteed improved financial resources, medical coding and billing processes that are more effective, and adequate staff that can manage the reporting and outreach requirements. The majority of the physicians surveyed by Bain—37%—cite “sufficient financial resources” as the key factor in their willingness to adopt value-based care.

What Will It Take for Physicians to Adopt Value-Based Care? Bain November 14, 2022


Report: Digital health funding slowdown continues: The global digital health market declined in Q3’22 as funding decreases 36% quarter-over-quarter per CB Insights.

·       Global digital health funding reached $4.6B in Q3’22, its lowest total since Q1’19. This marks the 3rd straight quarter with a decline of at least 30% and a 72% decline from the quarterly investment peak seen in Q2’21.

·       The number of deals dropped for the 4th consecutive quarter to 427, the lowest quarterly total in more than 5 years.

·       US-based companies raised $3B in Q3’22. From a deals perspective, the US led with 233 deals — more than all the other regions combined. Some of the largest rounds in the US went to companies including ArsenalBio, Alma, and Senda Biosciences.

The State of Digital Health Q3 2022 CB Insights October 20, 2022

Campaign 2022

Billionaire influence on elections increasing: In the 2022 midterms, the 100 largest donors collectively spent 60% more than every small donor in the United States combined, according to a Brennan Center analysis of publicly available data. (Small donors are those who give $200 or less.) Highlights:

·       The U.S. 700 billionaires provided 15% of the funding for the most recent federal elections.

·       Super PACs primarily backed by corporations, spent $63 million in the 2010 midterms vs. $345 million in 2014, $822 million in 2018, and $1.3 billion in 2022.

Billionaires Provided 15 Percent of Funding for the Midterms Brennan Center November 22, 2022 /

One Comment

  • Jim Freeburg says:

    How about patients? How are patients represented in state capitals around the country? How many lobbyists do they have?