Skip to main content
The Keckley Report

The Affordable Care Act is Back on Stage: What to Expect

By December 10, 2023No Comments

In the last 2 weeks, the Affordable Care Act (ACA) has been inserted itself in Campaign 2024 by Republican aspirants for the White House:

  • On Truth Social November 28, former President Trump promised to replace it with something better: “Getting much better Healthcare than Obamacare for the American people will be a priority of the Trump Administration. It is not a matter of cost; it is a matter of HEALTH. America will have one of the best Healthcare Plans anywhere in the world. Right now, it has one of the WORST! I don’t want to terminate Obamacare, I want to REPLACE IT with MUCH BETTER HEALTHCARE. Obamacare Sucks!!!!” 
  • Then, on NBC’s Meet the Press December 3, Florida Governor Ron DeSantis offered “We need to have a healthcare plan that works,” Obamacare hasn’t worked. We are going to replace and supersede with a better plan….a totally different healthcare plan… big institutions that are causing prices to be high: big pharma, big insurance and big government.”

It’s no surprise. Health costs and affordability rank behind the economy as top issues for Republican voters per the latest Kaiser Tracking Poll. And distaste with the status quo is widespread and bipartisan: per the Keckley Poll (October 2023), 70% of Americans including majorities in both parties and age-cohorts under 65 think “the system is fundamentally flawed and needs major change.” To GOP voters, the ACA is to blame.


The Affordable Care Act (aka Obamacare aka the Patient Protection and Affordable Care Act) was passed into law March 23, 2013.It is the most sweeping and controversial health industry legislation passed by Congress since Lyndon Johnson’s Medicare and Medicaid Act (1965). Opinions about the law haven’t changed much in almost 14 years: when passed in 2010, 46% were favorable toward the law vs. 40% who were opposed. Today, those favorable has increased to 59% while opposition has stayed at 40% (Kaiser Tracking Poll).

Few elected officials and even fewer voters have actually read the law. It’s understandable: 955 pages, 10 major sections (Titles) and a plethora of administrative actions, executive orders, amendments and legal challenges that have followed. It continues to be under-reported in media and misrepresented in campaign rhetoric by both sides. Campaign 2024 seems likely to be more of the same.

In 2009, I facilitated discussions about health reform between the White House Office of Health Reform and the leading private sector players in the system (the American Medical Association, the American Hospital Association, America’s Health Insurance Plans, AdvaMed, PhRMA, and BIO). The impetus for these deliberations was the Obama administration’s directive that systemic reform was necessary with three-aims:  reduce cost, increase access via insurance coverage and improve the quality of care provided by a private system. In parallel, key Committees in the House and Senate held hearings ultimately resulting in passage of separate House and Senate versions with the Senate’s becoming the substance of the final legislation. Think tanks on the left (I.e. the Center for American Progress et al.) and on the right (i.e. the Heritage Foundation) weighed in with members of Congress and DC influencers as the legislation morphed. And new ‘coalitions, centers and institutes’ formed to advocate for and against certain ACA provisions on behalf of their members while maintaining a degree of anonymity.

So, as the ACA resurfaces in political discourse in coming months, it’s important it be framed objectively. To that end, 3 major considerations are necessary to have a ‘fair and balanced’ view of the ACA:

1-The ACA was intended as a comprehensive health reform legislative platform. It was designed to be implemented between 2010 and 2019 in a private system prompted by new federal and state policies to address cost, access and quality. It allowed states latitude in implementing certain elements (like Medicaid expansion, healthcare marketplaces) but few exceptions in other areas (i.e.individual and employer mandates to purchase insurance, minimum requirements for qualified health plans, et al). The CBO estimated it would add $1.1 trillion to overall healthcare spending over the decade but pay for itself by reducing demand, administrative red-tape and leveraging better data for decision-making. The law included provisions to…

  • To improve quality by modernizing of the workforce, creating an Annual Quality Report obligation by HHS, creating the Patient Centered Outcome Research Institute and expanding the the National Quality Forum, adding requirements that approved preventive care be accessible at no cost, expanding community health centers, increasing residency programs in primary care and general surgery, implementing comparative effectiveness assessments to enable clinical transparency and more.
  • To increase access to health insurance by subsidizing coverage for small businesses and low income individuals (up to 400% of the Federal poverty level), funding 90% of the added costs in states choosing to expand their Medicaid enrollments for households earning up to 138% of the poverty level, extending household coverage so ‘young invincibles’ under 26 years of age could stay on their parent’s insurance plan, requiring insurers to provide “essential benefits” in their offerings, imposing medical loss ratio (MLR) mandates (80% individual, 85% group) and more.
  • To lower costs by creating the CMS Center for Medicare and Medicaid Innovation to construct 5-year demonstration pilots and value-based purchasing programs that shift provider incentives from volume to value, imposing price and quality reporting and transparency requirements and more.

The ACA was ambitious: it was modeled after Romneycare in MA and premised on the presumption that meaningful results could be achieved in a decade. But Romneycare (2006) was about near-universal insurance coverage for all in the Commonwealth, not the triple aim, and the resistance calcified quickly among special interests threatened by its potential.

2-The ACA passed at a time of economic insecurity and hyper-partisan rancor and before many of the industry’s most significant innovations had taken hold. The ACA was the second major legislation passed in the first term of the Obama administration (2009-2012); the first was the $831 billion American Recovery and Reconstruction Act (ARRA) stimulus package that targeted “shovel ready jobs” as a means of economic recovery from the 2008-2010 Great Recession. But notably, it included $138 billion for healthcare including requirements for hospitals and physicians to computerize their medical records, extension of medical insurance to laid off workers and additional funding for states to offset their Medicaid program expenses. The Obama-Biden team came to power with populist momentum behind their promises to lower health costs while keeping the doctors and insurance plans they had. Its rollout was plagued by miscues and the administration’s most popular assurances (‘keep your doctor and hospitals’) were not kept. The Republican Majority in the 111th Congress’ (247-193)) seized on the administration’s miss fueling anti-ACA rhetoric among critics and misinformation.

3-Support for the ACA has grown but its results are mixed. It has survived 7 Supreme Court challenges and more than 70 failed repeal votes in Congress.  It enjoys vigorous support in the Biden administration and among the industry’s major trade groups but remains problematic to outsiders who believe it harmful to their interests. For example, under the framework of the ACA, the administration is pushing for larger provider networks in the 18 states and DC that run their own marketplaces, expanded dental and mental health coverage, extended open enrollment for Marketplace coverage and restoration of restrictions on “junk insurance’ but its results to date are mixed: access to insurance coverage has increased. Improvements in quality have been significant as a result of innovations in care coordination and technology-enabled diagnostic accuracy. But costs have soared: between 2010 and 2021, total health spending increased 64% while the U.S. population increased only 7%.

So, as the ACA takes center stage in Campaign 2024, here are 4 things to watch:

1-Media attention to elements of the ACA other than health insurance coverage. My bet: attention from critics will be its unanticipated costs in addition to its federal abortion protections now in the hands of states. The ACA’s embrace of price and quality transparency is of particular interest to media and speculation that industry consolidation was an unintended negative result of the law will energize calls for its replacement. Thus, the law will get more attention. Misinformation and disinformation by special interests about its original intent as a “government takeover of the health system” will be low hanging fruit for antagonists.

2- Changes to the law necessary intended to correct/mitigate its unintended consequences, modernize it to industry best practice standards and responses to court challenges will lend to the law’s complex compliance challenges for each player in the system. New ways of prompting Medicaid expansion, integration of mental health and social determinants with traditional care, the impact of tools like ChatGPT, quantum computing, generative AI not imagined as the law was built, the consequences of private equity investments on prices and spending, and much more.

3-Public confusion. The ACA is a massive law in a massive industry. Cliff’s Notes are accessible but opinions about it are rarely based on a studied view of its intent and structure. It lends itself to soundbites intended to obscure, generalize or misdirect the public’s attention.  

4-The ACA price tag. In 2010, the CBO estimated its added cost to health spending at $1.1 trillion (2010-2019) but its latest estimate is at least $3 trillion for its added insurance subsidies alone. The fact is no one knows for sure what its costs are nor the value of the changes it has induced into the health system. The ranks of those with insurance coverage has been cut in half. Hospitals, physicians, post-acute providers, drug manufacturers and insurers are implementing value-based care strategies and price transparency (though reluctantly) but annual health cost increases have consistently exceeded 4% annually as the cumulative impact of medical inflation, utilization, consolidation and price increases are felt.

Final thought:

I have studied the ACA, and the enabling laws, executive orders, administrative and regulatory actions, court rulings and state referenda that have followed its passage. Despite promises to ‘repeal and replace’ by some, it is more likely foundational to bipartisan “fix and repair’ regulatory reforms that focus more attention to systemness, technology-enabled self-care, health and wellbeing and more.

It will be interesting to see how the ACA plays in Campaign 2024 and how moderators for the CNN-hosted debates January 10 in Des Moines and January 21 in New Hampshire address it. In the 2-hour Tuscaloosa debate last Wednesday, it was referenced in response to a question directed to Gov. DeSantis about ‘reforming the system’ 101 minutes into the News Nation broadcast. It’s certain to get more attention going forward and it’s certain to play a more prominent role in the future of the system.

The ACA is back on the radar in U.S. healthcare. Stay tuned.


PS The resignations under pressure of Penn President Elizabeth Magill and Board Chair Scott Bok over inappropriate characterization of Hamas’ genocidal actions toward Jews are not surprising. Her response to Congressional questioning was unfortunate. The eventuality turned in 4 days, sparked by student outrage and adverse media attention that tarnished the reputations of otherwise venerable institutions like Penn, MIT and Harvard. The lessons for every organization, including the big names in healthcare, are not to be dismissed: Beyond the issues of genocide, our industry is home to a widening number of incendiary issues like Hamas. They’re increasingly exposed to public smell tests that often lead to more: Workforce strikes. CEO compensation. Fraud and abuse. Tax exemptions and community benefits. Prior authorization and coverage denial. Corporate profit. Patient collection and benevolent use policies. Board independence and competence and many more are ripe for detractors and activist seeking attention. Public opinion matters. Reputations matter. Boards of Directors are directly accountable for both.  


Donald Trump Truth Social post November 28, 2023

Ron DeSantis, Meet the Press, NBC December 3, 2023

The Patient Protection and Affordable Act March 23, 2010 Careppacacon.pdf (

Julie Appleby “Biden Wants States to Ensure Obamacare Plans Cover Enough Doctors and Hospital” Kaiser Health News December 6, 2023

“5 Charts About Public Opinion on the Affordable Care Act”

The Keckley Report November 20, 2023

Tara Bannow “Sen. Warren pushes for more data on Medicare Advantage coverage hurdles, denials” STAT December 8, 2023


Re: the ACA: “With other GOP presidential candidates following Donald Trump’s lead in calling for an end to the Affordable Care Act, Democrats are jumping on an issue they think will favor them in the 2024 elections. The Biden administration almost immediately rolled out a controversial proposal that could dramatically decrease the price of drugs developed with federally funded research dollars. The drug industry and the business community at large are vehemently opposed to the proposal, but it is likely to be popular with voters.”

Julie Appleby “Democrats See Opportunity in GOP Threats to Repeal Health Law” Kaiser Health News December 7, 2023

Re: consolidation: “If there’s one lesson we’ve learned from the recent history of the airline industry, it’s this: The bigger airlines get, the worse they become. The prices get higher, the seats smaller, the service ever snarkier.

The mergers over the past 15 years that produced the “big three” of United Airlines, Delta Air Lines and American Airlines (eliminating Continental, Northwest and US Airways) — which, along with Southwest Airlines, now dominate the market — have not done Americans any favors. We’ve ended up with airlines that offer less for more and have become better than ever at getting bailouts from Congress…

As a result, we now have an economy of consolidated sectors, including not just airlines but also such key areas as health insurance, big tech and agriculture. Consolidation often yields high corporate profits, as well as higher prices for consumers and lower wages for employees, contributing to economic inequality and fueling a pervasive popular feeling that the system is unfair…

In the hands of highly talented economists, even mergers that anyone can see will limit competition can be depicted as somehow generating more of it.”

Tim Wu “The Bigger Airlines Get, the Worse They Become” New York Times Dec. 4, 2023

Re: consolidation: “Big deals are coming. And companies are betting there’s nothing anyone — including the highest office in the land — can do to stop them.  Shortly after US President Joe Biden took office in 2021, he looked to make good on his promise of scrutinizing corporate dealmaking, particularly in Big Tech.  But as he enters the final year of his initial term, the floodgates for big M&A deals have opened…The strict anti-trust stance of Biden and Lina Khan, the Federal Trade Commission chief he appointed, hasn’t stopped a wave of deal announcements since September that total more than $170 billion. A key turning point was Khan’s failure to stop Microsoft’s $69 billion bid to buy Activision Blizzard. “

Dan DeFrancesco “Aint no stopping M&A” Insider Today December 6, 2023

Re: market concentration: “Across the American economy, in industries ranging from air travel to veterinary medicine, big companies keep getting bigger and more powerful. Swallowing smaller rivals has become a widely accepted practice. This concentration of corporate power, however, is neither inevitable nor desirable for the health of the American economy.

This reassertion of an active government role in protecting competition has the potential to deliver significant benefits. Competition keeps pressure on prices. It encourages the development of better and more diverse products and services. It holds open the gates of opportunity so workers can pursue other jobs or start their own businesses. It helps to ensure that prosperity and political power are broadly distributed.

Americans have been living as subjects in a large-scale experiment in letting big companies do as they please, and the consequences are increasingly apparent in daily life…

Antitrust authorities have failed in their responsibility to the American people by assigning to themselves the burden of trying to figure out which mergers may be harmful, rather than taking seriously their marching orders from Congress to prevent concentration.”

“Americans Pay a Price for Corporate Consolidation” The Editorial Board New York Times August 26, 2023

Re: Economist’ global market for healthcare: “Money will not cure all ills for the health-care industry in 2024. Health spending, still boosted by the pandemic and inflation, will grab more than 10% of global GDP but Nigerians’ life expectancy will remain 30 years below Hong Kongers’. Even so, 10% of humanity will be 65 or older. Developed countries with ageing populations will compete for health workers. Many more medical staff will suffer burnout; some will quit.

Governments will try to fill the gaps. Nearly 80% of spending will come from public sources such as tax or compulsory insurance, up from 75% before covid…America will concentrate on cost-cutting and ending or defending abortion rights, depending on the state. Private care will see patchy growth: Amazon and Walmart will roll out new clinics but CVS Health will cut staff.

Global pharmaceutical sales will surpass $1.6trn, with America swallowing over a third and China a tenth. Patent expiries are mounting. In 2024 medicines worth $38bn in sales, including many biotech drugs, will meet competition from cheaper generics. Researchers will battle over patents, as trials of anti-obesity drugs bulk up. “

The Economist “Ten business trends for 2024, and forecasts for 15 industries” November 13, 2023

Re: PE fund consolidation: “There is currently a pretty material mismatch between the demand for capital from GPs and the capital available from LPs. This is not just the denominator effect, it’s about the lack of distribution and flow of capital, with weak exits due to a closed IPO market and diminished M&A. For a time, I expect it to be materially more difficult for many GPs to raise capital, and some will not achieve their growth ambitions or be able to achieve the level of fundraising they have been accustomed to…One of the consequences of that, I think, is going to be a period of consolidation. People have talked about consolidation in our industry for years, but we think it is now starting to happen.”

“Q&A: Liquidity logjam means pain, consolidation for PE world” Pitchbook December 7, 2023

Re: weight loss drug market potential: “Will the world actually soon spend $100 billion a year on the new obesity medicines? Plenty of people in pharma and at the banks that invest in it seem to think so. Goldman Sachs, Barclays, BMO Capital Markets and Pfizer have all arrived at the glossy, cut-for-headline number for spending by around 2030…

In theory, Holz said, the market could actually soar well past $100 billion. Yet these estimates seem to assume that “every last individual” will take them. So far, he said, only around 3 million to 3.5 million people are taking a GLP-1 drug like Wegovy specifically for obesity, many of them in wealthier, coastal enclaves. That number is rising fast, but other forces could dampen the overall market. Half of all large pharma’s have now invested in the space.. And 29 different GLP-1 drugs are now in development across the industry, along with 57 other obesity drugs that work by other means…

Competition could eventually drive down prices… Meanwhile, as more people seek out prescriptions, insurers and particularly Medicaid could negotiate lower prices or otherwise restrict access…”

Jason Mast “100 billion estimate for Ozempic-style weight loss drugs gets wary eye from analysts” STAT December 5, 2023

Re: Medicare Advantage: “The popularity of private Medicare plans has been a huge driver of profits for insurance companies in recent years. There are signs the gold rush isn’t quite what it once was…

Investors have been worried all year as the Biden administration phases in a new system that insurers say will reduce federal payments to Medicare Advantage plans. Developments last week at the top two insurers in the Medicare business,

Medicare Advantage is still a highly attractive business, and it will continue to grow indefinitely as seniors age into it. The opportunity just might not be as stellar as it once was as fewer seniors convert into it, competition grows and government scrutiny increases.”

David Wainer “The Medicare Gold Rush Is Slowing Down” Wall Street Journal December 6, 2023

Re: private equity deals: ”Over the past decade, private-equity firms like Apollo have spent $1 trillion buying health-care businesses, including hospitals, nursing homes, physician practices and hospital staffing companies. To finance these deals, private-equity owners typically burden the companies they buy with debt, then slash company costs to increase earnings and appeal to potential buyers in a few years.

Academic studies show that private-equity firms’ involvement in health care is associated with significant cost increases for patients and payers, such as Medicare. A lower quality of care has also been associated with the firms’ investments in health care. A 2021 study of nursing home ownership by academics at New York University, the University of Chicago and the University of Pennsylvania found that death rates were 10% higher at facilities owned by private equity than by other owners, including for-profit companies, while compliance with Medicare standards of care declined. Taxpayer costs rose by 11% at the facilities…”

Gretchen Morgenson “Senators launch bipartisan probe of private equity’s growing role in U.S. health care” NBC News December 6, 2023

Re: Pfizer exits BIO: “Pfizer has decided to leave the Biotechnology Innovation Organization, according to STAT. The departure is a blow to the trade group, which represents members ranging from small biotech startups to massive pharmaceutical companies. It is also the latest instance in a growing trend of pharmaceutical companies re-evaluating their memberships in large trade groups following a historic lobbying loss when Democrats passed a new drug-pricing reform law in August 2022. Pfizer is a prominent member of PhRMA, the lobbying group for brand-name drug companies, and its chief executive officer, Albert Bourla, is its board treasurer.”

Rachel Cohrs “Pfizer plans to depart BIO” STAT December 5, 2023

Re: Unionization, discontent in healthcare workforce: “Once accustomed to a status outside the usual management-labor hierarchy, many health professionals now feel as put upon as any clock-punching worker…and doctors are not the only health professionals who are unionizing or protesting in greater numbers. Health care workers, many of them nurses, held eight major work stoppages last year — the most in a decade — and are on pace to match or exceed that number this year. This fall, dozens of nonunion pharmacists at CVS and Walgreens stores called in sick or walked off the job to protest understaffing, many for a full day or more.

The reasons for the recent labor actions appear straightforward. Doctors, nurses and pharmacists said they were being asked to do more as staffing dwindles, leading to exhaustion and anxiety about putting patients at risk. Many said that they were stretched to the limit after the pandemic began, and that their work demands never fully subsided…

But in each case, the explanation runs deeper: A longer-term consolidation of health care companies has left workers feeling powerless in big bureaucracies. They say the trend has left them with little room to exercise their professional judgment.”

Norm Scheiber “Why Doctors and Pharmacists Are in Revolt” New York Times December 3, 2023


Premier study: Top Performing Hospitals: The PINC 15 Top Health Systems™ study profiles the top-performing health systems* in the country based on inpatient and extended care quality, operational efficiency, and patient experience. The composite score derived from these measures reflects excellence in hospital care, management and leadership.” Highlights:

Our study’s highest-performing health systems:

  • Had lower inpatient mortality and fewer patient complications, considering patient severity.
  • Delivered care that resulted in fewer healthcare-associated infections (HAIs).
  • Had lower 30-day readmission rates.
  • Sent patients home sooner.
  • Kept episode-of-care expenses low, both in-hospital and through the aftercare process.
  • Scored higher on patient ratings of their overall hospital experience.

Our study projections also indicate that if the benchmarks of performance established by this year’s winners were achieved by all hospitals in the U.S., the following could be true:

  • More than 200,00 additional lives could be saved in-hospital.
  • Over 177,000 additional patients could be complication-free.
  • Over 20% fewer infections would be acquired by hospital patients.
  • The typical patient could be released from the hospital a half-day sooner and would have 3% fewer expenses related to the complete episode of care than the median patient in the U.S.

My take: the PINC methodology is solid for analyzing comparisons of hospital inpatient performance. It is an important but incomplete picture of a hospital’s overall performance since outpatient, physician, ancillary, post-acute, in-home and insurance services are key capabilities in many hospitals.

PINC 15 Top Health Systems 2023 4ab8a55d8561d6e52e231b728f0ea5a8e09fae38.pdf (

Population Health Status

United Health Foundation 2023 America’s Health Rankings: In partnership with the American Public Health Association, UHF analyzed 87 measures across five categories of health: social and economic factors, physical environment, behaviors, clinical care and health outcomes. Highlights:

  • “In 2022, more than 29 million adults reported having three or more chronic conditions. The prevalence of all eight chronic conditions measured — arthritis, asthma, chronic kidney disease, chronic obstructive pulmonary disease, cardiovascular disease, cancer, depression and diabetes — reached its highest level recorded since America’s Health Rankings added these measures.
  • The premature death rate increased for a second consecutive year, reaching its highest rate in America’s Health Rankings history (1990). Chronic conditions played a significant role in driving this rate, contributing to six of the top 10 leading causes of death before age 75. Other measures of mortality also worsened, with increases in drug deaths, firearm deaths and homicide.

United Health Foundation 2023 America’s Health Rankings ahr_2023annual_comprehensivereport_final2-web.pdf (

Study: Veterans health and wellbeing: A 2435 veterans participated in the 2022 National Health and Resilience in Veterans Study (NHRVS). Highlights:

Younger, female, and Hispanic veterans had the lowest well-being scores, with the largest magnitude difference observed between veterans aged 65 years or older (mean age, 74.5 years) and veterans aged 21 to 54 years (mean age, 44.1 years).

The strongest correlates of well-being were protective psychosocial characteristics (β = 0.41), physical health conditions (β = −0.14), and greater age (β = 0.19). Purpose in life moderated the negative association of the number of physical health conditions with well-being (β = 0.25; P < .001). Among veterans with a greater number of physical health conditions, those with a higher purpose in life scored substantially higher (effect size difference, Cohen d > 1.80) than those with lower purpose in life.

Na et al “Well-Being of US Military Veterans” JAMA Network Open December 7, 2023;6(12):e2346709. doi:10.1001/jamanetworkopen.2023.46709

Study: Prison health access: This cohort study assessed data from a sample of 6675 patients who were incarcerated in the Texas prison system and underwent a general or vascular surgery procedure between 2012 and 2021 and found that 30-day morbidity, mortality, and readmission rates were comparable with those in a nonincarcerated population treated at the same institution.

Findings of this study suggest that patients who are incarcerated and undergo surgery have overall acceptable perioperative outcomes as demonstrated by equivalent rates of mortality and readmission compared with the general population.

Mao et al “Quality of Surgical Care Within the Criminal Justice Health Care System” JAMA Surg. Published online December 6, 2023. doi:10.1001/jamasurg.2023.6236

Study: Out of state travel for abortions: Per the Guttmacher Institute study, abortion-related out of state travel:

  • 92,100 patients traveled out of state for abortion care in the first six months of 2023 vs. 40,600 patients did so in the first half of 2020.
  • Illinoissaw the largest increase in the number of patients traveling to the state for abortion services, increasing from 13,300 to 18,870.
  • Like Illinois, other states bordering those with strict abortion limits also saw big increases.
  • In South Carolina, the share of patients who traveled into the state to receive abortion services increased from 3% in the first half of 2020 to 42% in the first six months of 2023, the largest increase of any state.

New Data Show that Interstate Travel for Abortion Care in the United States Has Doubled Since 2020 Guttmacher Institute December 7, 2023


Physicians Advocacy Institute survey: 1,000 physicians employed by insurers, health systems, staffing agencies and private equity firms were surveyed by NORC. Highlights:

  • 58% think physician employment has hurt patient care quality vs. 18% who think their care is improved. This is consistent across all physician age and specialty cohorts. Among those who see harm, reduced clinical autonomy is seen as the root cause by a majority in each ownership cohort: 83% hospital/ health system-owned practices, 79% at venture capital or equity firm-owned practice, 93% at insurance company-owned practices and 83% at staffing agencyowned practices.
  • A majority of physicians in hospitals (59%), VC/PE firms (60%), and staffing agencies (75%) reported reduced patient care quality. 45% employed by insurers agreed.

Note: In 2022, 47% of physicians worked in private practices, compared with 60% of physicians in 2012, according to a report earlier this year from the American Medical Association

Physicians Advocacy Institute > PAI Research > Employed Physician Survey PAI November 2023

Clinical Innovation

National Geographic: 7 Clinical Innovations in 2023:

  1. The world’s first CRISPR-based gene therapy (CASGEVY) becomes available.
  2. The first drug that slows down Alzheimer’s disease (Leqembi) gets approved.
  3. Japanese researchers produce healthy mice pups from two fathers; no female required.
  4. Scientists map all the connections in an insect brain.
  5. Pigment-producing cells (melanocytes) get “stuck” causing gray hairs.
  6. Bacteria shown to help cancer cells spread more aggressively.
  7. AI identifies people at the highest risk of pancreatic cancer

Medical Breakthroughs in 2023 National Geographic

Prescription Drugs

Weight loss drug market competition: The  weight loss drug market is expected to top $100 billion by 2030 and is ripe for new entrants, as drugmakers struggle to keep up with demand. And should Medicare ultimately cover weight-loss drugs, that would take things to another order of magnitude. Current landscape:

  • GLP-1 agonists like Novo Nordisk’s Wegovy and Ozempic have soared in popularity despite high price tags, mixed insurance coverage and a number of unpleasant side effects.
  • Last Monday, Swiss drugmaker Roche entered the race with a $2.7 billion acquisition of the California-based biotech Carmot Therapeutics which gives it access to two obesity drug candidates, an injectable ready for phase 2 clinical trial and a daily pill version in a phase 1 trial. Another candidate is a treatment for Type 1 diabetics who are overweight or obese.
  • AstraZeneca last month paid $185 million to acquire global development rights for an experimental GLP-1 pill from Chinese biotech Eccogene, with up to $1.8 billion more promised if it meets clinical, regulatory and commercial milestones.
  • Eli Lilly, which last month became the secondto gain approval for a weight-loss drug, in July announced a deal worth up to $1.9 billion to acquire obesity drugmaker Versanis, which is developing a drug that works differently from the appetite-suppressing GLP-1s.

Supreme Court hears Purdue case: Last Monday, The Supreme Court heard arguments on Monday in Harrington v. Purdue Pharma, 22-859 about whether the Sackler family, the owner of Purdue Pharma, could be shielded from future civil lawsuits under the terms of their bankruptcy deal earlier agreed to by the U.S. Bankruptcy Trustee. As part of the deal, the Sacklers would pay up to $6 billion toward compensating people affected by the opioid crisis and, in exchange, would not face personal liability in the future. SCOTUS has to decide whether the bankruptcy court has authority to approve such a plan, but beyond the legal matter is the question of how much the Sackler’s should pay — financially and otherwise. Complicating the issue is the fact that the vast majority of the 60,000 plaintiffs agree to the settlement, which they see as a faster and surer way to get compensation ranging from $3500 to $48000 per claimant. Opponents to the agreement content that current plaintiffs don’t have the right to decide on behalf of possible future ones. The court appeared divided during the hearing, and it was unclear which way it will lean in its decision, expected next year.

Note: OxyContin came to the market in 1996: Purdue Pharma’s aggressive marketing targeted prescribing physicians with Counsel of McKinsey Consulting is often cited as a catalyst of the nationwide opioid epidemic which claims 80,000 lives annually.

Supreme Court wrestles with OxyContin maker’s bankruptcy deal STAT December 4, 2023

Study: drug inspections: “During the initial phase of the COVID-19 pandemic, the Food and Drug Administration (FDA) halted inspections of most overseas drug manufacturing establishments. Looking at data from the period 2012–22, we observed steep declines in both foreign and domestic inspections in 2020. By 2022, numbers of inspections remained well below prepandemic levels, with a 79% decrease in foreign inspections and a 35% decline in domestic inspections compared with 2019. There was no corresponding reduction in drug manufacturing or imports. Also, the resources allocated per inspection surged, although the FDA’s overall budget and staffing remained steady. Finally, citations rose dramatically, despite all establishments being given advance notice of inspections. The findings of our study underscore the pressing need to explore alternative methods for ensuring drug safety.”

Cuddy et al “FDA Global Drug Inspections: Surveillance of Manufacturing Establishments Remains Well Below Pre-COVID-19 Levels” Health Affairs December 2023

CVS’ new retail drug pricing plan: CVS Health will move away from the complex formulas used to set the prices of the prescription drugs it sells, shifting to a new plan (CostAdvantage) in which its 9,500 pharmacies get reimbursed by pharmacy-benefit managers (PBMs) and other payers based on the amount that CVS paid for the drugs plus a flat fee to cover handling and dispensing the prescriptions.

The program rolls out next year with the new prices available to consumers paying cash for their prescriptions using an array of drug discount cards and in 2025, the incorporated into CVS pharmacies’ contracts with pharmacy-benefit managers covering drugs paid for under employer plans.

CVS Plans to Overhaul How Much Drugs Cost Wall Street Journal December 5, 2023


Morning Consult: Parent attitudes about use of weight loss drugs for children:

  • 1 in 3 parents said they are “definitely” or “probably” interested in having their children use GLP-1 prescription drugs if they were available, while nearly 2 in 3 parents who have children with weight-related issues said the same.
  • Among all U.S. adults, 28% said they support the use of prescription GLP-1 weight loss drugs to help address childhood obesity. Shares of support were higher among various parent demographics.
  • Much of the public doesn’t know or have an opinion on the use of weight loss drugs to address childhood obesity, likely due to a lack of awareness and because GLP-1 clinical tests for children are ongoing

“A Third of Parents Are Interested in Weight Loss Drugs Like Ozempic for Their Children” Morning Consult December 4, 2023

KFF Tracking Poll October 31-Nov 7: Highlights: In the poll of 675 adults, Democrats voiced higher concern on each of the 9 healthcare issues polled:

  • To Republican voters, the top issues are affordability (71%), the future of Medicare and Medicaid (70%), access to mental health care (64%) and prescription drug costs (60%). To Democratic voters, top issues are affordability (90%), gun violence (89%), the future of Medicare and Medicaid (84%) and access to mental healthcare (78%).
  • The widest gaps: gun violence (Republicans 43% vs. Democrats 89%), the future of the ACA (Republicans 32% vs. 70% Democrats), and abortion (Republicans 38% vs. Republicans 72%).
  • The strongest consensus among voters is opioid crisis (R-54% vs. 58% Democrats), prescription drug costs (Republican 60% vs. Democrat 69%) and access to mental health care (Republican 64% vs. 78% Democrats.

KFF Tracking Poll October 31-November 7, 2023

Health Insurers

Institute for Medicaid Innovation’s (IMI) Annual Medicaid managed care survey: Highlights from 31 states:

  •  91% of Medicaid MCOs cited provider readiness and willingness as a barrier to adoption, while 83%, 74%, and 52% percent cited data sharing challenges between payers and providers, staffing shortages, and Medicaid payment rates.
  • 65% said provision of additional policy and/or fiscal levers for MCOs to ensure provider engagement in VBP models. 65% said better education for providers on state and health plan expectations. Another 65% said reporting of consistent metrics, and 61% said policies to facilitate data sharing between payers and providers.

2023 Annual Medicaid MCO Survey Institute for Medicaid Innovation

 Investing, Private Equity

Re: Board responsibility: “…If alumni could sue like shareholders can sue, they’d have a solid case for malfeasance—especially after this week…this week the presidents of three of the nation’s most elite schools—Harvard, Penn and MIT—came before congress, where they put on a masterclass in lawyerly contextualism over whether or not calling for the genocide of Jews violated their school’s code of conduct. It was quite an outing—the slipperiest show since tobacco executives were asked to testify on whether or not their product was dangerous…Whenever there’s the equivalent level of chaos in the business world—from Enron to Tyco to AOL to Theranos or any number of other catastrophic failures of leadership and governance in the past few decades—the immediate question is, of course, where was the board? It’s the thing directors live most in fear of seeing in their morning’s edition of The Wall Street Journal.

It’s now time—especially after this week’s ethics class in Washington—to ask the same question at our most prestigious universities… There are various factors at play but ultimately, it is the boards of directors who have failed.”

Wayne Cooper “Blame the Boards: How America’s Elite Colleges Flunked Humanity 101” Corporate Board Member December

Regulatory, Government Reports

Census Bureau: American Community Survey (ACS): The U.S. official poverty rate as measured by the American Community Survey (ACS), was 12.6% in 2022—age 18) poverty rate was 16.3%, 3.7 percentage points higher than the overall rate. But the poverty rate among those ages 65 and over was 10.9%, 1.6 percentage points lower than the overall rate.

CDC: Healthcare-associated infections at U.S. hospitals dropped  in 2022. COVID hospitalizations increased for the third week in a row , surpassing 19,000 admissions in the most recent week reported.

Federal Reserve: Income distribution through mid-2023:

CMS: Primary care: Only 7 of the 199 hospitals that have received federal dollars for new residency slots in initial funding rounds are in rural areas. Only 13 rural hospitals have so far applied for new slots. In the first tranche of new residency slots awarded, about 6% went to geographically rural hospitals, while 42% went to geographically urban hospitals that reclassified as rural.

Labor Department: November Jobs Report: Employers added 199,000 jobs in November while the unemployment rate dropped to 3.7%, from 3.9%. The increase in employment includes tens of thousands of autoworkers and actors who returned to their jobs after strikes, and others in related businesses that had been stalled by the walkouts, meaning underlying job growth is slightly weaker.

FDA:  Drug approval: Friday, the FDA approved first therapy based on CRISPR gene-editing technology to address sickle cell disease along with a second treatment using conventional gene therapy for sickle cell that does not use gene editing