With the South Carolina Republican primary results in over the weekend, it seems a Biden-Trump re-match is inevitable. Given the legacies associated with Presidencies of the two and the healthcare platforms espoused by their political parties, the landscape for healthcare politics seems clear:
| Healthcare Issue | Biden Policy | Trump Policy |
| Access to Abortion | ‘It’s a basic right for women protected by the Federal Government’ | ‘It’s up to the states and should be safe and rare. A 16-week ban should be the national standard.’ |
| Ageism | ‘President Biden is alert and capable. It’s a non-issue.’ | ‘President Biden is senile and unlikely to finish a second term is elected. President Trump is active and prepared.’ |
| Access to IVF Treatments | ‘It’s a basic right and should be universally accessible in every state and protected’ | ‘It’s a complex issue that should be considered in every state.’ |
| Affordability | ‘The system is unaffordable because it’s dominated by profit-focused corporations. It needs increased regulation including price controls.’ | ‘The system is unaffordable to some because it’s overly regulated and lacks competition and price transparency.’ |
| Access to Health Insurance Coverage | ‘It’s necessary for access to needed services & should be universally accessible and affordable.’ | ‘It’s a personal choice. Government should play a limited role.’ |
| Public health | ‘Underfunded and increasingly important.’ | ‘Fragmented and suboptimal. States should take the lead.’ |
| Drug prices | ‘Drug companies take advantage of the system to keep prices high. Price controls are necessary to lower costs.’ | ‘Drug prices are too high. Allowing importation and increased price transparency are keys to reducing costs.’ |
| Medicare | ‘It’s foundational to seniors’ wellbeing & should be protected. But demand is growing requiring modernization (aka the value agenda) and additional revenues (taxes + appropriations).’ | ‘It’s foundational to senior health & in need of modernization thru privatization. Waste and fraud are problematic to its future.’ |
| Medicaid | ‘Medicaid Managed Care is its future with increased enrollment and standardization of eligibility & benefits across states.’ | ‘Medicaid is a state program allowing modernization & innovation. The federal role should be subordinate to the states.’ |
| Competition | ‘The federal government (FTC, DOJ) should enhance protections against vertical and horizontal consolidation that reduce choices and increase prices in every sector of healthcare.’ | ‘Current anti-trust and consumer protections are adequate to address consolidation in healthcare.’ |
| Price Transparency | ‘Necessary and essential to protect consumers. Needs expansion.’ | ‘Necessary to drive competition in markets. Needs more attention.’ |
| The Affordable Care Act | ‘A necessary foundation for health system modernization that appropriately balances public and private responsibilities. Fix and Repair’ | ‘An unnecessary government takeover of the health system that’s harmful and wasteful. Repeal and Replace.’ |
| Role of federal government | ‘The federal government should enable equitable access and affordability. The private sector is focused more on profit than the public good.’ | ‘Market forces will drive better value. States should play a bigger role’ |
My take:
Polls indicate Campaign 2024 will be decided based on economic conditions in the fall 2024 as voters zero in on their choice. Per KFF’s latest poll, 74% of adults say an unexpected healthcare bill is their number-one financial concern—above their fears about food, energy and housing. So, if you’re handicapping healthcare in Campaign 2024, bet on its emergence as an economic issue, especially in the swing states (Michigan, Florida, North Carolina, Georgia and Arizona) where there are sharp health policy differences and the healthcare systems in these states are dominated by consolidated hospitals and national insurers.
- Three issues will be the primary focus of both campaigns: women’s health and access to abortion, affordability and competition. On women’s health, there are sharp differences; on affordability and competition, the distinctions between the campaigns will be less clear to voters. Both will opine support for policy changes without offering details on what, when and how.
- The Affordable Care Act will surface in rhetoric contrasting a ‘government run system’ to a ‘market driven system.’ In reality, both campaigns will favor changes to the ACA rather than repeal.
- Both campaigns will voice support for state leadership in resolving abortion, drug pricing and consolidation. State cost containment laws and actions taken by state attorneys general to limit hospital consolidation and private equity ownership will get support from both campaigns.
- Neither campaign will propose transformative policy changes: they’re too risky. integrating health & social services, capping total spending, reforms of drug patient laws, restricting tax exemptions for ‘not for profit’ hospitals, federalizing Medicaid, and others will not be on the table. There’s safety in promoting populist themes (price transparency, competition) and steering away from anything more.
As the primary season wears on (in Michigan tomorrow and 23 others on/before March 5), how the health system is positioned in the court of public opinion will come into focus.
Abortion rights will garner votes; affordability, price transparency, Medicare solvency and system consolidation will emerge as wedge issues alongside.
Paul
PS: Re: federal budgeting for key healthcare agencies, two deadlines are eminent: March 1 for funding for the FDA and the VA and March 8 for HHS funding.
Sections
- Quotables
- Care Management
- Economic Reports
- Health Insurance
- Hospitals
- Physicians
- Polling
- Population Health
Quotables
Re: ageism: “The COVID-19 pandemic would be a wake-up call for America, advocates for the elderly predicted: incontrovertible proof that the nation wasn’t doing enough to care for vulnerable older adults.
The death toll was shocking, as were reports of chaos in nursing homes and seniors suffering from isolation, depression, untreated illness, and neglect. Around 900,000 older adults have died of COVID to date, accounting for three of every four Americans who have perished in the pandemic.
In the last week of 2023 and the first 2 weeks of 2024 alone, 4,810 people 65 and older lost their lives to COVID — a group that would fill more than 10 large airliners — according to data provided by the CDC. But the alarm that would attend plane crashes is notably absent. (During the same period, the flu killed an additional 1,201 seniors, and RSV killed 126.).”
Do We Simply Not Care About Old People? | MedPage Today February 18, 2024
Re: disconnect between value and affordability: “Much of the R&D enterprise now in health services research and health policy focuses on ways to change payment and delivery to get more value for the health spending we do. The primary constituencies for this work are payers, purchasers, and providers, all looking for ways to lower costs and improve quality. However, the polling suggests there is a ways to go before people see “value” as relevant to them. This matters as long as value-based payment remains a central strategy in health care. If consumers do not see these efforts as lowering their costs and improving their care, they will see only high prices and continue to believe no effort is being made to make health care more affordable for them by the institutions that serve them. There are many ways employers or hospital systems or government agencies can approach the challenge of making the value movement more relevant to consumers (spoiler alert: none of them involve marketing “value-based payment” as a concept itself to consumers).
Why Affordability Is the Big Tent | KFF February 20, 2024
Re: Public health is divisive: “We live in an era marked by intense political polarization, with partisan divides continuing to fracture the US. Even amidst political divisiveness, public health should be a unifying national value. Yet public health has emerged as among the country’s most contentious issues in recent years. From reproductive health, transgender care, and firearm safety to COVID-19 vaccines, public health is in the crosshairs of the culture wars. This will be a momentous year, with federal and state elections just months away and the US Supreme Court poised to reconsider fundamental health rights.”
Public Health in the Crosshairs of Culture Wars | JAMA Health Forum | JAMA Network February 22, 2024
Re: digital health: ” I am fairly sure (but it could be a rumor) that this is how Elon Musk came up with the Neuralink idea (a brain implant to help humans use their neural signals to control external technologies). He announced this week that the first patient to get the implant can now control a computer mouse just by thinking. This device is an example of how digital health is at once miraculous and terrifying. This is why it is good that groups are being launched that can explore how to handle all this terrifying wonderfulness, like the Peterson Health Technology Institute’s new Digital Health Collaborative. Participants include several major acronyms, whose spelled-out names will be the subject of next week’s quiz: AHIP, AMA, ATA, CTA, DiMe, and NCQA.”
Julie Barnes Maverick Health Policy February 23, 2024 www.maverickhealthpolicy.com
Re: Pharmacy benefits managers: “In recent years, our offices and other offices of state attorneys general have worked to hold Pharmacy Benefit Managers (PBMs) accountable. The PBMs’ original purpose was to protect and negotiate on behalf of employers and consumers after pharmaceutical manufacturers were criticized for overpricing medications. Unfortunately, in recent years, the PBMs have only made the pharmaceutical market more opaque and have been a cause of rising drug prices. A small number of PBMs hold significant market power and are reaping abundant profits at the expense of the patients, employers, and government payors the PBMs are supposed to help. Pharmaceutical buyers and sellers have little choice but to employ PBMs, allowing them to extract both monopoly profits from individuals and monopsony profits from the market. Moreover, PBMs often dictate reimbursement rates and rules to independent pharmacies, making it difficult for many to survive.”
Letter to Senate and House leadership from 39 state attorneys general PBM-Letter-_NAAG-Letterhead-Final.pdf February 20, 2024
Care Management
Study: telehealth aided medication abortion safety: “Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Findings: Overall, 99.8% of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.
Effectiveness and safety of telehealth medication abortion in the USA | Nature Medicine February 15, 2024
Study: Seniors’ use of the health system: In 2019, seniors spent an average of 20.7 total contact days on healthcare, which includes 17.3 days on ambulatory days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment), PLUS institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility. 11.1% of the adults had 50 or more total contact days. Most of the total contact days were spent on ambulatory care, including:
- 5 mean days on primary care visits;
- 7 days on specialty care visits;
- 3 days on tests;
- 6 days on imaging;
- 5 days on procedures; and
- 7 days on treatments.
Notes: Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Research based on Medicare data from a nationally representative sample of 6,619 people 65 and older.
Annals of Internal Medicine, Health Care Contact Days Among Older Adults in Traditional Medicare, January 23, 2024
Economic Reports
2023 was a worse year for corporate bankruptcies than 2020, S&P Global finds | Fortune January 9, 2024
ADP Study: workforce hours: While the post-pandemic job recovery was strong, it was accompanied by a rise in part-time labor and a decline in median hours worked.
In December 2019, part-time jobs accounted for 43% of all hourly jobs. By December 2023, they accounted for 47%. At the same time, U.S. hourly workers have been putting in less time on the job. Between December 2019 and December 2023, the median number of hours worked fell from 38.4 to 37.7 a week, a decline of almost 2%.
The people driving this four-year decline in hours worked fall into four main groups: Women, young adults, highly paid workers, and employees at small businesses. Adults 35 and younger are working an hour less than they did four years ago, while hours worked by older age groups held steady.”
People are working less. Who – and why? – ADP Research Institute (ADPRI) February 22, 2024
Pitchbook: Medtach VC Funding down in Q4 2024: “Medtech VC funding slowed in Q4, raking in $2.6 billion, down from $3 billion raised in Q3, according to PitchBook’s latest Emerging Tech Research. PE dealmaking was more resilient, with deal count up to 105 from 99 in 2022. The Q4 2023 Medtech Report lays out the ongoing challenges for dealmaking, though there is still funding available for startups in the later stages, such as Neuralink’s $323.2 million Series D.
Brain therapy devices, which are less invasive than the brain-interface computers of Neuralink, could be the next big opportunity for investors. New treatments for neurological conditions like depression and migraines are gaining traction and could propel medtech innovation. “
Q4 2023 Medtech Report | PitchBook February 23, 2024
Health Insurance
Paragon Health Institute (PHI): Reform, expand Medicare Advantage: Per the conservative think-tank’s recommendations, these policy changes would save $250 billion (3.3%) of total Medicare outlays over 10 years:
- Cap MA benchmarks at 100% of local FFS costs outside of areas with lower MA penetration and calculate them based on the FFS population with both Part Aand Part B
- End quality bonuses for benchmarks and focus star ratings on core health outcomes and patient experience.
- Improve risk adjustment by scaling the coding intensityreduction for individual plans within a statutory range, expanding auditing diagnostic practices in MA and FFS, and establishing a transparent rulemaking process for changes to the Medicare risk model.
- Restrict first-dollar coverage of FFS cost-sharing by Medigap
- Direct beneficiaries to choose between FFS and MA rather than enroll them in FFS by default.
- Remove restrictions on benefits such as MA coverage of hospice and medical savings account plan coverage of Part Dbenefits or free preventive services.
- Initiate demonstrations for non-standard contracts such as long-term plans.
- Align FFS and MA rules, including program integrity policies, insurance rules for Medigapplans, and budget neutrality for administrative MA changes.
- Repeal excessive restrictions on MA plan governance and activities
Improving Medicare Through Medicare Advantage (paragoninstitute.org)
Hospitals
STAT: not for profit hospital finances: “A million nonprofit hospital systems released financial statements last week, showing how they fared in the last three months of 2023. The gist: Most hospitals made a healthy amount of money on patient care and, especially, their investments, as we’ve observed previously. Many also benefited from federal lump-sum payouts as part of a ruling to repay hospitals for 340B drug payment cuts.
- Allina Health: The $5 billion system is struggling a lot more than most, posting a -6.8% operating margin in 2023. Allina laid off employees and outsourced its billing operations to Optum.
- Ballad Health: The last quarter of 2023 was good for Ballad, but the system said it has been having problems with Medicare Advantage plans using proprietary criteria to push patients to lower-paying codes or outpatient observation status, “even if the admission was prior-authorized by the payer.”
- Baylor Scott & White Health: Everything’s bigger in Texas, including the hospital profits.
- CommonSpirit Health: Patient volumes are up so much across the country that even CommonSpirit is in the black. The hospital giant also disclosed it received $234 million last year from the extra 340B drug payments.
- Johns Hopkins Health System: A 12% net margin was fueled by massive investment gains. If patient care doesn’t work out, Johns Hopkins has a future as a hedge fund.
- Mass General Brigham: Holy investment income, Batman. It also banked an extra $98 million from 340B drug underpayments.
- RWJBarnabas Health: Nurses went on strike for roughly four months at one of the New Jersey system’s main hospitals, and it cost RWJBarnabas $184 million, pushing it into the red. However, if the hospital would have paid its own nurses and avoided a strike, instead of having to hire expensive temporary nurses, it would have turned a profit.
- Sanford Health: It turns out that not all rural hospitals are dying! Sanford is one of the largest rural health systems in the country, and yet it was profitable across the board in 2023, surpassing several years of pre-pandemic operations.”
Bob Herman STAT Health Care Inc. February 20, 2024 www.statnews.com
Study: Hospital surgical care discharges procedures: Researchers analyzed care transition interventions by hospitals for surgical patients “used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patients.” Findings:
“…important components for a surgical discharge that are not incorporated in current care transition models included wound care education and supplies; pain control; approvals for nonhome post discharge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included home environment, caregiver availability, team communication issues, and post discharge care coordination.
These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.”
Mapping the Discharge Process After Surgery | Surgery | JAMA Surgery | JAMA Network
Physicians
Athena Health Physician Sentiment Survey: 1003 primary and specialty care physicians completed the 13-minute online survey between October 23 – November 8, 2023. Findings:
- 93% of physicians say that they feel burned out on a regular basis, with doctors reporting that they spend an average of 15 hours per week working in “pajama time,” outside their normal work hours.
- 56% said they have considered leaving the field or remaining in the field but no longer seeing patients.
- 83% think AI could eventually reduce many of the problems facing healthcare. A majority of physicians already use electronic health record (EHR) solutions and praise them for helping provide high-quality care (65%) and improving efficiencies (54%).
- 38% physicians believe their organization/practice is on solid financial footing and fewer than half (45%) believe they have the resources and/or tools to deliver quality care. An additional indication of their financial vulnerability: over the past 12 months half (50%) felt they have been unable to provide quality care based on volume and cost, at least once a week or more frequently.
Athena Health February 21, 2024 www.athenahealth.com
Polling
KFF Poll: healthcare affordability major concern: “Unexpected medical bills and health care costs top the list of expenses that adults, regardless of partisanship, say they worry about affording, with 3 in 4 adults saying they are “very” or “somewhat worried” about being able to afford unexpected medical bills (74%) or the cost of health care services (73%) for themselves and their family. Just over half (55%) report worrying about being able to afford prescription drug costs, and about half of insured adults (48%) say they are worried about being able to afford their monthly health insurance premium.
Voters are divided along party lines over which candidate they think has the better approach to the future of the Affordable Care Act, with partisans overwhelmingly choosing their party’s candidate. Nine in ten Democratic voters (90%) say Biden has the better approach and nine in ten Republican voters (91%) say Trump does. Although the vast majority of Republicans say Trump has a better approach to the ACA, few (30%) Republican voters think Trump has a health care plan to replace it. At the same time, most of the public does not associate President Biden with playing a major role in the passage of the ACA, which was signed into law when he was Vice President. One in five (21%) say he had a major role in the law’s passage, including a larger share of Democrats ages 50 and older (42%).”
KFF Health Tracking Poll February 2024: Voters on Two Key Health Care Issues: Affordability and ACA | KFF February 21, 2024
Axios-Ipsos American Health Index Poll: Comparing young adults to seniors about their public health concerns:
- Mental health is the top concern for young adults ages 18-29 (22%) vs. 10% for seniors.
- Opioids/fentanyl is the top concern to seniors (26%%) vs. 19% for young adults.
- Seniors were about twice (21% vs. 12%) as likely to say access to guns was the biggest threat.
Mental health is seen as a top threat, bigger than drugs and guns (msn.com)
Commonwealth Poll: comparing MA and traditional Medicare: Commonwealth surveyed 3,280 Medicare beneficiaries age 18 and older between November 6, 2023, and January 4, 2024 about the comparative value of their coverage by Medicare comparing Medicare Advantage (MA) to traditional Medicare (TM). Findings:
| % who say they experienced the following: | MA | TM |
| Waited more than a month to see a doctor | 36 | 34 |
| Care was delayed because it needed approval | 22 | 13 |
| Difficulty getting to the doctor due to transportation/distance | 10 | 7 |
| Coverage would not cover the service needed | 12 | 12 |
| A doctor/hospital would not accept your Medicare coverage | 10 | 8 |
| Couldn’t afford care due to co-payments/deductible | 12 | 7 |
| Other challenges accessing care | 5 | 5 |
- 7 in 10 beneficiaries in MA said they used some of their plan’s supplemental benefits in the past year; 3 in 10 did not use any. Four in 10 reported using their dental or vision benefits or an allowance for over-the-counter medications.
- Among beneficiaries reporting a challenge in getting care, about a third in MA plans (33%) and a third in traditional Medicare (32%) said the problem occurred when trying to access primary care (data not shown). Smaller shares said the challenge occurred when trying to get surgery (13% for MA plans and 15% for traditional Medicare), physical therapy or rehabilitative care (13% for both), or cardiology care (13% vs. 10%; data not shown).
- About 1 in six beneficiaries said they were told to go to urgent care because their provider had no appointments available, with no significant difference between people with MA or traditional Medicare (16% vs. 18%; data not shown)
What Do Medicare Beneficiaries Value About Their Coverage? | Commonwealth Fund February 22, 2024
Population health
RAND: Overdose prevalence: RAND researchers asked 2,072 adults who participate in the RAND American Life Panel about whether they knew someone who had died of a drug overdose and to characterize how the death affected their life.
“In the study, 42.4% of respondents reported personally knowing at least one person who died by overdose, suggesting that 125 million American adults have experienced such a loss. The study found that 13%of those who responded had had their lives disrupted by an overdose loss. More than 4% of those surveyed reported that the loss conferred a significant or devastating effect that they still feel.”
More Than 40 Percent of Americans Know Someone Who Died of Drug Overdose; 13 Percent Say Deaths Have Disrupted Their Lives | RAND February 21, 2024
McKinsey: wellness market size: “82% of US consumers consider wellness a top or important priority in their everyday lives, which echoes our findings in China, the United Kingdom, and other countries. Wellness interests consumers not only across geographies (often with more similarities in their preferences than differences) but also across demographic and income groups. The market—which we consider to be made up of categories that address health, sleep, fitness, nutrition, appearance, and mindfulness—has grown to around $1.8 trillion globally, up from $1.5 trillion in 2021. We expect the US market to continue to grow between 5 and 10% annually.”
The trends defining the $1.8 trillion global wellness market in 2024 | McKinsey January 24, 2024
Re: primary care in US vs. world’s developed systems: The share of US health care spending devoted to primary care declined from 6.5% of total health spending in 2002 to 5.4% in 2016. This compares to an average of 7.8% of spending for primary care in 22 OEDC countries. More recent data from 2020 suggest only 4.6% of US health care spending was devoted to primary care. Thus, the NASEM report concludes that primary care in the US is under-resourced – accounting for about 35% of health care visits but only 5% of health care spending. The report calls for a redistribution of funding; calling on the Centers for Medicare and Medicaid Services (CMS) to increase rates for primary care evaluation and management (E&M) codes by 50% and reducing other service rates to maintain budget neutrality.
Primary-Care-Report_2024_v11.pdf (njhcqi.org)
Center for Healthcare Quality and Payment Reform: Maternal child health disappearing in rural hospitals: Per the report:
- 55% of the rural hospitals in the U.S. do not offer labor and delivery services, and in 10 states, more than two-thirds do not. Over the past decade, more than 200 rural hospitals across the country have stopped delivering babies.
- “… among the world’s advanced economies, the US has the highest rates of both infant and maternal mortality. Pregnant people in the US are 3 times more likely to die as those in developed countries including Australia, Britain, Canada, France, and Germany. This discrepancy continues to increase—between 2018 and 2021, the US maternal mortality rate almost doubled.”
More Than Half of US Rural Hospitals No Longer Offer Birthing Services—Here’s Why | Obstetrics | JAMA | JAMA Network February 21, 2024
CDC: single person households, depression: 6.4% of U.S. adults living alone reported feelings of depression, compared to 4.1% of those who live with others — regardless of gender, race or income level. The disparity is especially pronounced among middle-aged Americans. The share of single-person households has increased from 13.6% in 1962 to 28.9% in 2022.
CDC, National Health Interview Survey www.cdc.gov
