Skip to main content
The Keckley Report

Healthcare System in Campaign 2024: Out of Sight, Out of Mind?

By August 28, 2023No Comments

Last Wednesday’s GOP Presidential debate marked the unofficial start of the 2024 Presidential campaign. With the exception of continued funding for Ukraine, style points won over issue distinctions as each of the 8 White House aspirants sought to make the cut to the next debate September 27 at the Reagan Library in Simi Valley, CA.

For the candidates in Milwaukee, it’s about “Stayin’ Alive” per the BeeGee’s hit song: that means avoiding self-inflicted harm while privately raising money to keep their campaigns afloat. And, based on Debate One, with the exception of abortion, that means they’ll not face questions about their positions on the litany of issues that dominate healthcare these days i.e., drug prices, hospital consolidation, price transparency, workforce burnout and many others. In Milwaukee, healthcare was essentially ‘out of sight our of mind’ to the moderators and debaters despite being 18% of the U.S. economy and its biggest employer.

For now, each will enlist ghostwriters to produce position papers for their websites, and, on occasion, reporters will press for specifics to test their grasp on a topic but that’s about it. Based on last Wednesday’s 2-hour event, it’s unlikely general media outlets like Fox News (which also hosts Debate Two) will explore healthcare issues except for abortion. That means healthcare will be subordinated to the economy, inflation, immigration and crime—the top issues to GOP voters—for most of the Presidential primary season.  

Next November, voters will also elect 34 US Senators, 435 members of the House of Representatives, 11 Governors and their representatives in 85 state legislative bodies. This will be the first election cycle after reapportionment of votes in the United States Electoral College following the 2020 United States census. Swing states (WI, MI, PA, NV, AZ, GA, FL, OH, CO, VA) will again be keys to the Presidential results since demographics and population shifts have increased the concentrations of each party’s core voters in so-called Blue States and Red States:

  • The Democratic voter core is diverse, educated and culturally liberal with its strongest appeal to African-Americans, Latinos, women, educated professionals and urban voters. Blue States are predominantly in the Northeast, Upper Midwest and West Coast regions.
  • The Republican voter core consists of rural white voters, evangelicals, the elderly, and non-college educated adults. Red States are predominantly in the South and Southwest.

The increased concentrations of Blue or Red voters in certain states and regions has contributed to political polarization in the U.S. electorate and presents an unusual challenge to healthcare. Per Gallup: “Political polarization since 2003 has increased most significantly on issues related to federal government power, global warming and the environment, education, abortion, foreign trade, immigration, gun laws, the government’s role in providing healthcare, and income tax fairness. Increased polarization has been less evident on certain moral issues and satisfaction with the state of race relations.” Thus, healthcare issues are increasingly subject to hyper partisanship and often misinformation.

Given the limited knowledge voters have on most health issues and growing prevalence of social media fueled misinformation, political polarization creates echo chambers in healthcare—one that thinks the system works for those who can afford it and another that thinks that’s wrong. It’s dicey for politicians: it’s political malpractice to offer specific solutions on anything, especially healthcare. It’s safer to attack its biggest vulnerabilities—affordability and equitable access—even though they mean something different in every echo chamber.

My take:

Barring a second Covid pandemic or global conflict with Russia/China, it’s unlikely healthcare issues will be prominent in Campaign 2024 at the national level except for abortion.  At least through the May primary season, here’s the political landscape for healthcare:

Affordability and inequitable access will be the focus of candidate rhetoric at the national level: Trust and confidence in the U.S. health system has eroded. That’s fertile political turf for critics. In Congress, the fiercest defenders of the status quo have joined efforts to impose restrictions on consolidation and price transparency for hospitals and price controls for prescription drugs. There’s Bipartisan acknowledgement that inequities in accessing care are significant and increasing, especially in minority and low income populations. They differ over the remedy. Employers expect their health costs to increase at least 8% next year and blame hospitals and drug companies for price gauging and want Congress to do more. 85% of Democrats think “the government should insure everyone” vs. 33% of Republican voters which calcifies inaction in a divided Congress though. Opposition to the Affordable Care Act (2010) has softened and Medicaid expansion has passed in 40 Blue and Red states. In the 2024 election cycle, remedies for increased access and more affordability will pit Republicans calling for more competition, consumerism and transparency and Democrats calling for more government funding, regulation and fairness.  But more important, voter and employer frustration with partisan bickering sans solutions will set the stage for the vigorous debate about a single payer system in 2026 and after,

State elections will give more attention to healthcare issues than the Presidential race: That’s because Governors and state legislators set direction on issues like abortion rights, drug price controls, Medicaid funding, scope of practice allowances and others. Increasingly, state Attorney’s General and Treasurers are weighing in on consolidation and spending. States referee workforce issues like nurse staffing requirements and others. And ballot referenda on healthcare issues trail only public education as a focus of grassroots voter activity.  At the top of that list is abortion rights:

In 25 states and DC, there are no restrictions on access; in 14 states, abortion is banned and in 11 abortions—both procedures and medication—are legal, but with gestational limits from 6 weeks (GA), to between 12 and 22 weeks (AZ, UT, NE, KS, IA, IN, OH, NC, SC, FL). It’s an issue that divides legislators and increasingly delineates Blue and Red states and in many states remains unsettled.

Other healthcare issues, like ageism, will surface in Campaign 2024 in the context of other topics: Finally, healthcare will factor into other issues: Example: The leading Presidential candidates are seniors: President Biden was the oldest person to assume the office at age 78 and would be would be 86 at the end of his second term. Former President Trump was 70 when elected in 2016 and would be 81 if elected when his second term ends. The majority of Americans are concerned about the impact of age on fitness to serve among aspirants for high office: cognitive impairment, dementia, physical limitations et al. will be necessary talking points in campaigns and media coverage. Similarly, cybersecurity looms as a focus where healthcare’s data-rich dependence is directly impacted. Growing concern about climate and the food supply, sourcing of raw good and materials from China used in drug manufacturing and many other headlines will infer healthcare context.

Summary:  healthcare will be on the ballot in 2024 and might very well make the difference in who wins and loses in many state and local elections. It will make a difference in the Presidential campaign as part of the economy and a major focus of government spending. Beyond abortion, the lack of attention to other aspects of the health system in the Milwaukee debate last week should in no way be interpreted as a pass for healthcare insiders. Voters are restless and healthcare is contributing. Healthcare is far from  ‘out of sight, out of mind’ in Campaign 2024.






Re: health system reform: “Indeed, the evidence suggests that the health disparities among Americans are not driven by differences in access to health insurance or to medical care. Rather, the key to improving health is far more complex: It lies in changing health behaviors and reducing exposure to external sources of poor health… Indeed, there is widespread agreement among researchers that medical care, let alone health insurance, is not the only—or even the most important—determinant of health. Rather, the key to better health and smaller health disparities lies in the air we breathe, the food we eat, and the cigarettes we do or do not smoke. Which means that the key public policies for improving health must be those that tackle these sources of poor health through pollution regulation, or soda and cigarette taxes. The path to major health improvements doesn’t run through health insurance and health care policy.”

Liran Einev, Amy Finkelstein Health Insurance Reform Has Surprisingly Little Impact on Actual Health Time August 18, 2023

Re: future seniors: “In an aging US society, anticipating the challenges that future seniors will face is essential. This study analyzed the health and economic well-being of five cohorts of Americans in their mid-fifties between 1994 and 2018…Outcome disparities between people in these two groups widened substantially between the 1994 and 2018 cohorts. Quality-adjusted life expectancy increased (5%) for the upper-middle economic status group but stagnated for their lower-middle peers. We found that the combined value of the current stock (financial and housing wealth) and the present value of the expected flow of resources (income, health expenditures, and quality-adjusted life-years) after age sixty grew 13% for the upper-middle group between cohorts, whereas people in the lower-middle group in 2018 were left scarcely better off (3% growth) than their peers two decades earlier. The relatively neglected “forgotten middle” group of near-retirees in the lower-middle group may require stronger supports than are currently available to them.”

Chapel et al “The Forgotten Middle: Worsening Health And Economic Trends Extend To Americans With Modest Resources Nearing Retirement” Health Affairs August 23, 2023

Re: Making Care Primary: “A strong national health care system depends on a strong primary care foundation. But questions remain about how to support primary care clinicians and build toward such a foundation using population-based payments.

The Centers for Medicare and Medicaid Services (CMS) intends to advance this issue through a forthcoming accountable care program, Making Care Primary (MCP). Announced on June 8, 2023… Applications will be open later this summer for a July 1, 2024 start among eligible practices in eight states (Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington).

Based on available information, MCP is a welcome development in population-based payment reform. The model incorporates lessons from previous primary care programs, such as Comprehensive Primary Care (CPC), CPC Plus, and Primary Care First, while going beyond and using new features that help shift toward a more sustainable payment system…

MCP poses several potential implications for accountable care organization policy. First, the emergence of MCP creates a decision point for clinicians and groups currently participating in other accountable care models….

Second, MCP could generate insights that inform policymakers about future accountable care policy. In particular, the new program serves as a potential test bed for using capitation-based payments to pay for primary care services…”

Liao, Navathe “Distinctive Features In The Making Care Primary Model” Health Affairs August 21, 2023 10.1377/forefront.20230818.945949

Re: screening patients for social needs: “In 2022, the Centers for Medicare & Medicaid Services (CMS), along with standard-setting organizations such as the National Committee for Quality Assurance (NCQA) and The Joint Commission, established new quality measures aimed at promoting health equity. Many of these measures center around screening patients for health-related social needs (HRSN). For example, starting in 2024 CMS will require HRSN screening during adult hospitalizations. There is an indisputable connection between social factors (eg, low food security, housing instability), structural racism, poverty, and health. However, without additional considerations, these well-intentioned mandates will impede progress in health equity and have the potential to increase long-standing racial and socioeconomic inequities.

Garg et al “Inadequacy of Current Screening Measures for Health-Related Social Needs” JAMA August 21, 2023. doi:10.1001/jama.2023.13948

Re: PBMs: “…PBMs determine what medications patients can take for a specific condition and what they will pay for them. These companies are rewarded handsomely for this work. In fact, PBMs generally earn more than $315 billion  annually.

Cigna, one of the largest U.S. health insurers, purchased Express Scripts, a PBM, in 2018. CVS Caremark, another PBM, is owned by CVS, and CVS owns Aetna, a health insurer. Optum Rx, yet another PBM, is owned by UnitedHealth Group, another insurer. These three PBMs, each ultimately owned by health insurers, control more than 79%  of the market. The top six PBMs control 96% of the market share. Five of those six are owned by the nation’s largest insurance companies and pharmacies.

In other words: Insurers and pharmacies have indirect control over what medications PBMs allow patients. The incentive to choose by price point or profit, as opposed to efficacy or what is right for the patient, is embedded in the system.”

Adam Brown “It’s Time to Reform the Mysterious PBM System” Medpage Today August 25, 2023


Harris Poll July 2023: This survey was conducted online within the United States from July 19-20, 2023 among 2,068 registered voters by The Harris Poll and HarrisX.

Most important issues facing the nation today: inflation (34%), economy and jobs (26%), immigration (24%), guns (21%), crime and drugs (17%) and healthcare (16%)

Harvard Harris Poll July 19-20, 2023

KFF analysis of misinformation: Excerpts of the KFF Health Misinformation Tracking Poll Pilot:

“Some groups seem to be more susceptible to misinformation than others, with larger shares of Black and Hispanic adults, those with lower levels of educational attainment, and those who identify politically as Republicans or lean that way saying many of the misinformation items examined in the poll are “probably true” or “definitely true.” News sources also matter as those who say they regularly consume news from One America News Network (OANN), Newsmax, and to a smaller extent Fox News, are consistently more likely to believe most of the misinformation items asked about in the survey…

Large majorities of U.S. adults say that the spread of false and inaccurate information generally (86%) and the spread of false and inaccurate information related to health issues (74%) are major problems. This includes large shares across age, gender, education, and partisanship…

With large shares of the public unable to identify many health-related misinformation items as definitely false, trusted messengers and sources have an important role to play in efforts to combat the proliferation of health misinformation. Not surprisingly, individual doctors are the most trusted source, with 93% of the public saying they have a great deal or a fair amount of trust in their own doctor to make the right recommendations on health issues.

When it comes to government agencies, most adults have at least a fair amount of trust in the FDA and CDC to make the right recommendations on health issues, though just one in four have a great deal of trust in the CDC and one in five have a great deal of trust in the FDA. Fewer say they trust the Biden Administration on health issues, and Republicans are less likely than Democrats to trust the Administration, as well as the CDC and the FDA.”

Lopes et al KFF Health Misinformation Tracking Poll Pilot KFF August 22, 2023

“Few Firm Beliefs and Low Trust: Americans Not Sure What’s True in Age of Health Misinformation” KFF News August 22, 2023

“Poll: Most Americans Encounter Health Misinformation, and Most Aren’t Sure Whether It’s True or False” KFF August 22, 2023

Morning Consult Wellness Poll: Per Morning Consult’s July 2023 poll:

  • 64% of adults said they plan to choose healthier foods and drinks next month– up 8% from July 2022.
  • S. adults are more likely than not to say they need to lose weight. Among those who said they need to slim down, more than half reported that they need to drop more than 20 pounds.
  • At least half of U.S. adults who have health apps or wearables said they use them daily, and a majority (73% of app users and 81% of wearable users) reported engaging with them at least weekly.
  • Baby boomers are less likely to report feeling most negative emotions. Baby boomers are less likely than other generations to report feeling tired (54%), anxious (39%), sad (28%) and angry (25%)

American Health and Wellness Trends Morning Consult August 2023


States initiating hospital charity care policies: States are increasing their oversight of nonprofit hospitals’ financial assistance policies, seeking to ensure hospitals are earning their tax exemptions by doing enough to help the poor. Recent activity:

  • Oregon: In July, Oregon Gov. Tina Kotek (D) signed a bill in July that looks to increase access to free or discounted healthcare by requiring hospitals to proactively screen patients and streamline the signup process.
  • A Minnesota law that will take effect Nov. 1 requires hospitals to screen certain patients for charity care eligibility. Washington enacted a bill in 2022 that established mandatory discounts for patients with incomes below 200% of the federal poverty level.
  • California has a law mandating that hospitals provide charity care to patients whose income is below 400% of the federal poverty level.

Note: a recent KFF report that found nonprofit hospitals received $28 billion in taxpayer subsidies in 2020 but only provided $16 billion in charity care.

Alex Kacik “Hospitals facing stricter charity care oversight” Modern Healthcare August 21, 2023

Prescription drugs

Study: weight loss drug side effects: In the blinded study, researchers followed 529 obese (30+ BMI) patients for 52 weeks to test the efficacy of semaglutide treatment. Results: “In patients with heart failure with preserved ejection fraction and obesity, treatment with semaglutide (2.4 mg) led to larger reductions in symptoms and physical limitations, greater improvements in exercise function, and greater weight loss than placebo.”

Kosiborod et al “Semaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity”  NEJM August 25, 2023

USC Study: savings if weight loss drugs universally available: Currently, Medicare does not cover weight loss drugs: Difference from status quo projections based on reduction in healthcare spending from fewer hospitalizations, surgeries, doctors’ visits, drugs, nursing home stays and other medical needs associated with a healthier Medicare population.

  10 Years 20 Years 30 Years
Medicare $176.6B $479.0B $704.4B
Medicare + Private 245.1B 479.0B 1,484.6B

USC Schaeffer, Benefits of Medicare Coverage for Weight Loss Drugs, April 2023

Study: Conflicts of interest in drug company Patient advocacy organizations (PAOs): PAOs advance patient interests through promotion of disease awareness, engagement with policymakers, and partnership with medical product manufacturers in research and development. Yales researchers examined whether their senior leadership had been or were currently employed by the pharmaceutical and medical device industries in the 50 highest-revenue US-based PAOs. Findings:

  • Of the 50 PAOs reviewed, 74% had board members with prior or current industry ties, and 50% had paid staff or executives with these ties.
  • 11 PAOs had executive directors or CEOs with industry ties, 4 served on pharmaceutical company boards at the same time and of the 10 highest-revenue PAOs, five executive directors or CEOs had prior or current industry ties,
  • Of the 50 highest-revenue PAOs, 19 were focused on therapeutic areas, 28 on specific diseases, and three on medical support services. Median annual revenue was $49.7 million and varied by disease focus. The PAOs had a median of 20 board members and 8.5 paid staff or executives. Of 1,091 total board members across the organizations, 10.9% had prior or current industry ties, as did 10.9% of paid staff or executives.

Ramachandran et al “Medical Product Industry Ties to Patient Advocacy Organizations’ Executive Leadership” JAMA Internal Medicine August 21, 2023 doi:10.1001/jamainternmed.2023.2842  .

46Brooklyn analysis of mid-year drug prices: “On July 1, drugmakers raised the wholesale price on over 123 drugs in what’s the largest number of mid-year price hikes since 2013. The median price increase for these drugs was 3.4%, just above the one-year inflation rate of 3.2%.  So, over half of these medications could potentially face rebates, including 10 Pfizer drugs whose prices increased by 10%, such as long-acting penicillin Bicillin and blood thinner Fragmin.

Drug prices in the United States are uniquely high, with Americans paying twice or three times as much as patients in other developed countries. And this problem has only gotten worse over time, with launch prices increasing from an average $2,115 per year in 2008 to $180,000 in 2021. Among the top-25 Medicare Part D drugs, all but one have seen lifetime price increases beyond inflation rates. For example, the insulin drug Lantus, from Sanofi, was introduced to the market in 2000, and inflation rose by 71% since. Meanwhile, the price of Lantus increased by 739%.”

46Brooklyn Research

Health insurers

Blue Shield of California (BCCA) reduces PBM contract with CVS: BCCA announced plans to diversify its pharmacy benefit management (PBM) contracts to add Amazon Pharmacy for at-home deliveries, Mark Cuban Cost Plus Drugs Company (MCCPDC) for a transparent pricing model, and Prime Therapeutics for negotiations with pharmaceutical companies. Costs while continuing to use CVS Health’s Caremark for Blue Shield’s specialty pharmacy needs.

Blue Shield of California taps Amazon, Mark Cuban’s Cost Plus Drugs for its pharmacy network

JD Power: MA Enrollees rate plans good but room for improvement noted:  MA Plans Per the 9th Annual J.D. Power 2023 U.S. Medicare Advantage Study released last Tuesday based on the responses of 5,887 members of Medicare Advantage plans in five market-based U.S. regions: California, Florida, New York, Pennsylvania and Texas. It was fielded from January through June 2023. Highlights:

  • Overall satisfaction with Medicare Advantage plans is generally good: Overall customer satisfaction with Medicare Advantage plans is 652 (on a 1,000-point scale), which is squarely in the good-to-great range.
  • Trust and problem resolution hold keys to customer loyalty: Level of trust and resolving problems or complaints are the most highly correlated factors associated with members renewing their health plan. Satisfaction with trust increases 353 points among those likely to renew with their health plan compared with those who are unlikely to renew. Similarly, satisfaction with problem resolution increases 351 points among those likely to renew.
  • Ease of finding care and digital tools now biggest pain points: 31% of Medicare Advantage plan members say their plan made it easy for them to find care and just 34% say they used two or more digital tools offered by their plan. Overall customer satisfaction scores are 158 points higher, on average, when members say it is easy to find care and 62 points higher, on average, when members use two or more digital tools.
  • Health plan ratings and customer reviews spur customer satisfaction: The most effective sources of information about Medicare Advantage plans are health plan ratings, information received directly from the plan itself and recommendations from friends, relatives and co-workers.

The 2023 U.S. Medicare Advantage Study

Public Health

CDC: One in five U.S. women said they were mistreated during maternity care: Per the CDC analysis:

  • Mistreatment is higher among Black (30%), Hispanic (29%), and multiracial (28%) women.
  • Women who had public insurance (26%) or no insurance (28%) reported higher rates of mistreatment compared with women with private insurance (16%)
  • The most commonly reported experience of mistreatment was being ignored by a healthcare provider or having a request for help denied (10%). being shouted at (7%), violations of physical privacy (5%), and threats to withhold treatment or being made to accept unwanted care (5%).
  • The report also detailed high levels of discrimination, with 29% of women overall saying they were discriminated against during maternity care — Black (40%), Hispanic (37%), and multiracial (39%) women flagged even higher levels of discrimination. Overall, age (10%), weight (10%), and income (7%) discrimination were most common, but differed by race and ethnicity, according to the researchers.
  • 45% of respondents said they suppressed questions or stopped short of raising concerns during maternity care. The most common reasons for this included thinking that what they were feeling was normal (29%), or being told that it was by friends and family (21%); embarrassment or not wanting to make a big deal out of something (22%); worrying that their healthcare provider would think they were being difficult (21%); and observing that their provider seemed rushed (17%).

Vital Signs: Maternity Care Experiences — United States, April 2023 CDC August 22, 2023


Business Group on Health Survey: BGH surveyed 152 members with 19 million total insured workers. Highlights:

  • Re: costs: Respondents estimated that average per-capita costs (employer and employee combined) would be $17,201 in 2023, with employers shouldering an average $11,762– up from $15,862 in 2022, and $15,412 in 2021.Employers pointed to the cost of drugs as a major concern. The survey found medications accounted for almost one-fourth of employer healthcare spending in 2022.
  • Re: Virtual care: 64% think the impact of virtual health is significant down from 74% in 2022 vs. 85% in 2021. 43% said the digital health solution market is saturated.
  • Re: weight loss drugs: 46% cover the drugs for weight loss. An additional 3% are adding GLP-1s as a benefit for weight loss in 2024, and 13% said they are considering coverage for 2025. 85% of employers said they are worried about the long-term financial implications of GLP-1s and other weight management medications.
  • Re: therapeutic focus: top clinical areas of attention: cancer (86%) and 75% said musculoskeletal diseases (75%), cardiovascular (30%) diabetes (27%) and maternity-related needs (23%).

Business Group on Health

PWC employer survey: Per PWC’s August survey of over 600 leaders of public and private companies. Highlights:

  • 17% of business executives strongly agree that there will be a recession in the next six months, a drop from 35% in October 2022.
  • 27% want to embed new technologies into their business model, and 24% are focused on new revenue streams — more than any other strategic priority.
  • 88% say achieving measurable value from new technology is a challenge, followed by updating their operating model to support their new vision (85%), covering the cost of new technology (85%) and training the workforce (84%) on new tech.
  • 74% say they can attract and retain the talent they need. Similarly, 74% say they have the right culture in place for reinvention.

PwC Pulse Survey: Focused on reinvention PWC

Nursing Homes, Long Term Care

WSJ Study: nursing home market challenging: Per the Wall Street Journal analysis of CMS data:

  • The number of nursing homes in the U.S. has fallen by 97 this year through July 25. The U.S. has at least 600 fewer nursing homes than it did six years ago.
  • 7 out of 10 nursing homes don’t have enough nursing employees to dedicate 4.1 hours/day to each resident.

Context: 17% of Americans, nationally, are 65 or older–56 million in 2020 to 81 million by 2040. In the pandemic’s first year, before the introduction of Covid-19 vaccines, 167,800 nursing-home residents died from Covid-19.

MSSP 2022 Results: CMS

  • Medicare said it saved $1.8 billion in 2022—the second-highest savings since the program started more than a decade ago.
  • 63% of ACOs in the program earned money back last year.
  • About 11 million beneficiaries were part of the main ACO program last year, representing about 30% of enrollees in the traditional Medicare program.
  • ACOs dominated by primary care physicians generated more per-member savings than those led by hospitals. Low-revenue ACOs collected $228 per capita in net savings while high-revenue ACOs saved $140 per capita. Low-revenue ACOs comprising at least 75% primary care clinicians reaped $294 per capita in net savings. CMS noted it’s exploring ways to help ACOs boost primary care investments.
  • At the beginning of 2023, it had 456 participants, down 5.6% from last year