Tomorrow night, the Presidential candidates square off in Philadelphia. Per polling from last week by the New York Times-Siena, NBC News-Wall Street Journal, Ipsos-ABC News and CBS News, the two head into the debate neck and neck in what is being called the “chaos election.”
Polls also show the economy, abortion and immigration are the issues of most concern to voters. And large majorities express dissatisfaction with the direction the country is heading and concern about their household finances.
The healthcare system per se is not a major concern to voters this year, but its affordability is. Out-of-pocket costs for prescription drugs, insurance premiums and co-pays and deductibles for hospitals and physician services are considered unreasonable and inexplicably high. They contribute to public anxiety about their financial security alongside housing and food costs. And majorities think the government should do more by imposing price controls and limiting corporate consolidation.
That’s where we are heading into this debate. And here’s what we know for sure about the 90-minute production as it relates to health issues and policies:
- Each candidate will rail against healthcare prices, costs, and consolidation taking special aim at price gouging by drug companies and corporate monopolies that limit competition for consumers.
- Each will promise protections for abortion services: Trump will defer to states to arbitrate those rights while Harris will assert federal protection is necessary.
- Each will opine to the Affordable Care Act’s future: Trump will promise its repeal replacing it “with something better” and Harris will promise its protection and expansion.
- Each will promise increased access to behavioral health services as memories of last week’s 26-minute shooting tirade at Apalachee High School fade and the circumstances of Colt Gray’s mental collapse are studied.
- And each will promise adequate funding for their health priorities based on the effectiveness of their proposed economic plans for which specifics are unavailable.
That’s it in all likelihood. They’re unlikely to wade into root causes of declining life expectancy in the U.S. or the complicated supply-chain and workforce dynamics of the industry. And the moderators are unlikely to ask probative questions like these to discover the candidate’s forethought on matters of significant long-term gravity…
- What are the most important features of health systems in the world that deliver better results at lower costs to their citizens that could be effectively implemented in the U.S. system?
- How should the U.S. allocate its spending to improve the overall health and well-being of the entire population?
- How should the system be funded?
My take:
I will be watching along with an audience likely to exceed 60 million. Invariably, I will be frustrated by well-rehearsed “gotcha” lines used by each candidate to spark reaction from the other. And I will hope for more attention to healthcare and likely be disappointed.
Misinformation, disinformation and AI derived social media messaging are standard fare in winner-take-all politics. When used in addressing health issues and policies, they’re effective because the public’s basic level of understanding of the health system is embarrassingly low: studies show 4 in 5 American’s confess to confusion citing the system’s complexity and, regrettably, the inadequacy of efforts to mitigate their ignorance is widely acknowledged. Thus, terms like affordability, value, quality, not-for-profit healthcare and many others can be used liberally by politicians, trade groups and journalists without fear of challenge since they’re defined differently by every user.
Given the significance of healthcare to the economy (17.6% of the GDP), the total workforce (18.6 million of the 164 million) and individual consumers and households (41% have outstanding medical debt and all fear financial ruin from surprise medical bills or an expensive health issue), it’s incumbent that health policy for the long-term sustainability of the health system be developed before the system collapses. The impetus for that effort must come from trade groups and policymakers willing to invest in meaningful deliberation.
The dust from this election cycle will settle for healthcare later this year and in early 2025. States are certain to play a bigger role in policymaking: the likely partisan impasse in Congress coupled with uncertainty about federal agency authority due to SCOTUS; Chevron ruling will disable major policy changes and leave much in limbo for the near-term.
Long-term, the system will proceed incrementally. Bigger players will fare OK and others will fail. I remain hopeful thoughtful leaders will address the near and long-term future with equal energy and attention. Regrettably, the tyranny of the urgent owns the U.S. health system’s attention these days: its long-term destination is out-of-sight, out-of-mind to most. And the complexity of its short-term issues lend to magnification of misinformation, disinformation and public ignorance.
That’s why this debate will frustrate healthcare voters.
Paul
PS: Congress returns this week to tackle the October 1 deadline for passing 12 FY2025 appropriations bills thus avoiding a shutdown. It’s election season, so a continuing resolution to fund the government into 2025 will pass at the last minute so politicians can play partisan brinksmanship and enjoy media coverage through September. In the same period, the Fed will announce its much anticipated interest rate cut decision on the heals of growing fear of an economic slowdown. It’s a serious time for healthcare!
Resources:
Harris v. Trump CBS News poll finds Pennsylvania, Michigan, Wisconsin race tight ahead of debate September 9, 2024 https://www.cbsnews.com/news/harris-trump-poll-pennsylvania-michigan-wisconsin-debate/
Harris v. Trump CBS News poll finds Pennsylvania, Michigan, Wisconsin race tight ahead of debate September 9, 2024 https://www.cbsnews.com/news/harris-trump-poll-pennsylvania-michigan-“wisconsin-debate/
Trump Vs. Harris 2024 Polls: Trump Takes 1-Point Lead in First Major Survey in Weeks (msn.com)
Center on Society and Health (vcu.edu)
National Center for Health Statistics. Health, United States, [edition year]: [Title of Topic Page]. Hyattsville, MD. [release year]. Available from: https://www.cdc.gov/nchs/hus/topics.htm.
Microsoft Word – RWJF-Harvard Report_FINAL-2-051321.docx May 2021
The Public’s Perspective on the United States Public Health System (rwjf.org)
Sections in today’s Report
- Quotables
- Consumers
- Economy
- Hospitals
- Insurers
- Physicians
- Policy: States
- Policy: States
- Prescription Drugs
- Workforce
Quotables
Re: system transformation: “Why is it that our nation has world class tertiary care and spends trillions of dollars on health care, more than any other industrialized nation, but is failing in patient outcomes, cost to the patient, and most recently, a decline in average lifespan. How do we turn this “frog” into a princess, thus offering our nation the care it deserves.”
Fixing American health care: Kissing the frog (medicaleconomics.com)
Re: AHA advocacy: “Right now, our field is balanced between two realities. On the one hand, the challenges — financial, regulatory, workforce, and other matters — continue to be significant. At the same time, we are undeniably at the dawn of an exciting new era of bold innovation, technological progress and expanded ways to advance health for a greater number of people than ever before.
That is why it is essential that federal lawmakers understand the immediate challenges hospitals and health systems face and make policy decisions that account for what’s at stake for access to care for the patients and communities they represent.”
“Rick Pollack, AHA Today
Re: access to mental health services for kids: “Companies offering virtual mental health services to younger people received 34% of all digital behavioral health venture funding in 2023, compared with 15% in 2018… Nearly half of mental telehealth companies serving younger patients sell to public entities such as local school districts… For schools, partnering with virtual mental health companies can be cheaper — and easier — than hiring full-time staff. There is a shortage of mental health professionals in schools. In 2023, there was just one psychologist for every 1,119 students in kindergarten through 12th grade, according to data from the National Association of School Psychologists. One roadblock to continued expansion of services, and companies’ growth may be the Sept. 30 end of the Elementary and Secondary School Emergency Relief Funds program, a $189.5 billion allocation from the Education Department to states’ local education agencies and districts. The funds allowed districts to purchase services from mental health startups.”
Re: energy poverty: “Energy poverty is the inability to afford utilities to heat or cool a home. Households that spend more than 6% of their income on energy bills are energy-poor…
Energy poverty can increase one’s exposure to extreme heat or cold, which raises the risk of developing respiratory issues, heart problems, allergies, kidney disorders, and other health conditions. And the burden falls disproportionately on households in communities of color, which experience it at a rate 60% greater than those in white communities.
Extreme heat is the No. 1 cause of weather-related deaths in the U.S., a risk that grows as temperatures rise. Last year, 2,302 people in the U.S. died from heat-related causes, a 44% increase from 2021…
Yet, 1 in 7 households spend about 14% of their income on energy, according to RMI, an energy and sustainability think tank. Nationally, 16% of households are in energy poverty, concluded an analysis co-authored by Noah Kittner, an assistant professor of public health at the University of North Carolina-Chapel Hill.
Re: Access to primary care: “Any system that is not in balance is doomed to failure. The US health care system is no exception. The warning signs are there: more people delaying or avoiding care because of costs; lagging gains in—or even diminishing—life expectancies; persistent disparities in outcomes based on race, ethnicity, income, and geography; and poor pandemic preparedness. Adding insult to injury, we spend more as a nation for health care than our international peers and have the least to show for it. It isn’t about lack of investment; it is how we spend it…
Primary care plays a foundational role in an efficient, high-quality health care system. It is the only element of the health care delivery system in which an increased supply is associated with better population health and a reduction in inequitable outcomes….
Yet in the US, almost one-third of the adult population now reports they do not have a regular place to go for care—a figure that has steadily risen in the past decade. Press accounts abound of an inability to find a primary care clinician and long wait times for an appointment for those lucky enough to locate one who is taking new patients. Without a trusted primary care team, patients—especially those with chronic conditions—are left to navigate, coordinate, and interpret a dizzying array of narrowly focused specialty and diagnostic service providers, none of which fully comprehends or addresses the unique needs of each patient.”
Out Of Balance: Fixing Our Health System’s Neglect of Primary Care | Health Affairs
Re: primary care investment: “Despite what might appear to be the unattractive business model of primary care, recent years have seen a slew of acquisitions of primary care practices by large, investor-owned corporations…
Walgreen’s acquisition of VillageMD in 2021 marked a watershed for corporate investment in primary care. A flurry of multibillion dollar acquisitions soon followed, with Walgreens next acquiring Summit Health, Amazon purchasing One Medical (which had previously acquired Iora Health), and CVS purchasing Oak Street Health and Carbon Health. Walmart launched its own venture into operating primary care clinics, while United Health’s Optum subsidiary steadily took a controlling interest in a growing number of primary care practices…
When Walmart, the corporation ranked number one on the Fortune 500 list, cannot achieve a successful business model for primary care, it reveals the root problems of thoroughly inadequate payment for primary care and underestimation of the work of primary care. Corporate and private equity investors—seeking extractive short-term financial returns and not committed to long-term investment—destabilize an already fragile primary care sector. Rapid start-ups and closures of primary care practices add turbulence to forces already buffeting communities dealing with declining access to primary care. The failing experiment of corporate, investor-owned primary care highlights the need for bold public policy to address primary care payment, infrastructure, and corporate ownership.”
The Failing Experiment of Primary Care as A For-Profit Enterprise | Health Affairs
Re: Value creation in retail: “Our analysis of more than 280 publicly traded retailers reveals that, through bold action and disciplined execution, retailers of all sizes can become high-performing value creators—and can even move from the bottom quartile to the top quartile
Most strikingly, movers managed to deliver substantial improvements in EBITDA margin: nearly half of movers, versus only 12% of nonwinners, notched more than 400 basis points of improvement.
The clear takeaway from our analysis: scale is not destiny. Subsector dynamics notwithstanding, a retailer has ample control over its value creation trajectory. Retailers of any size, if they make bold moves, can become top-tier value creators—even if they’ve historically underperformed.”
Retail’s outperformers: Lessons in value creation | McKinsey
Re: CNBC profile on EPIC Performance: “Epic reported $4.9 billion revenue last year while expanding its market share, growing the Cosmos database and adding artificial intelligence-driven capabilities,
The company would have around $45 billion valuation based on S&P 500’s sub-index of software and services companies, but CEO Judy Faulkner is sticking to Epic’s first two commandments: “do not go public” and “do not be acquired.”
Epic would be an attractive target. The company, which has a 14,000-person workforce, added 153 acute care hospital clients last year, according to KLAS Research, nearly 100 more than its closest competitor, Oracle Health. Cosmos, Epic’s deidentified patient data trove, now has 270 million patients’ data and 1,568 hospital members. Epic’s revenue has grown 53% over the last five years, and 6% from 2022 to 2023.Epic doesn’t have a “preordained budget,” according to the report, and 8% of expenses are attributable to the upkeep of its 1,670-acre fantasy-themed headquarters. Despite Epic’s successes, Oracle Health generated more revenue from the legacy Cerner business last year, at $5.9 billion.”
A journey inside Epic Systems’ mythical and sprawling campus, a world away from Wall Street CNBC September 1, 2024https://www.cnbc.com/2024/09/01/inside-epic-systems-mythical-campus-a-world-away-from-wall-street-.html
Re: Goldman on Presidential Impact on Economy: “Trump’s economic proposals would increase the federal deficit by $5.8 trillion over the next decade, almost five times more than Harris’s proposals, which would add $1.2 trillion, according to recent studies from The University of Pennsylvania’s Penn Wharton Budget Model.”
Goldman Sachs sees economic boost in Kamala Harris election win (qz.com)
Consumers
Medical debt: “Lack of affordability is arguably the biggest challenge in US health care, and the high level of medical debt is a tangible reflection of this challenge. A 2022 KFF survey found that 41% of people had debt due to medical or dental care for themselves or someone else…
In fact, medical debt is simply a symptom of a broader problem: the inability of many people to afford health care. The root causes of unaffordable health care, and in turn medical debt, include the following:
- High patient cost sharing through deductibles, which lead to medical debt even for those with insurance. Deductibles now averagemore than $1700 per year per person in employer-sponsored health plans.
- Complexityin the US health care system, which hinders access and affordability.2
- Lack of liquid assetsthat allow people to pay unexpected medical bills. For example, 68% of adults with medical debt reported that they had no “rainy day fund.”
- Lack of affordable health insurance. Health insurance coverage provides not only better access to care, but also financial security…
However, effective long-term solutions to mitigate new medical debt would mean making health care more affordable in employer-sponsored insurance, which covers the majority of the population, including many low-income people…
Increasing patient cost sharing has been the preferred tactic of employers to respond to increasing costs for health care. Until health care costs (and particularly the prices patients pay) are addressed, patients will not be well protected from going into debt. Medical debt is the canary in the coal mine for health care affordability, and the canary is not doing well.”
Gallup: Financial security: % of U.S. Adults Categorized as Cost Secure (No recent problems affording health care or medicine and can easily access care) by Age
| Age group | 2021 | 2022 | 2023-2024 |
| All U.S. adults | 56% | 61% | 55% |
| 18 to 49 | 49% | 52% | 47% |
| 50 to 64 | 58% | 63% | 55% |
| 65 and older | 73% | 79% | 71% |
Gallup, In U.S., Affording Healthcare More of a Struggle Since 2022, July 2024
Economy
BLS August Jobs report: The U.S. economy added 142,000 jobs in August, while the unemployment rate edged slightly lower to 4.2% from 4.3%, the Labor Department said on Friday. Highlights:
- The August figures came in below expectations of 161,000 job gains.
- The report showed notable revisions for months past: The economy added just 89,000 jobs in July—25,000 fewer than initially reported. And June’s gainswere revised down by 61,000 to 118,000.
- Top gainers were hospitality (+46k), construction (+34k) and health care (+31k), while biggest losers were manufacturing (-24k) and retail (-11k).
- Average hourly earnings, a measure of wage growth, rose 0.4% last month. Over the past 12 months, average hourly earnings are up 3.8%
- “Health care added 31,000 jobs in August, about half the average monthly gain of 60,000 over the prior 12 months. In August, employment rose in ambulatory health care services (+24,000) and hospitals (+10,000).
- In August, employment in social assistance continued its upward trend (+13,000) but at a slower pace than the average monthly gain over the prior 12 months (+21,000). Individual and family services added 18,000 jobs over the month.”
Note: Re: BLS’ benchmark downward revision of 818,000 for April 2023 to March 2024: “Estimates of job growth have been drastically overstated for some time now, but we will need to wait until February 2025 to see the final benchmark revision. In my opinion, it will likely show the same directional trend. Simply put, the labor market is weaker than headlines suggest.”
Employment Situation Summary – 2024 M08 Results (bls.gov)
Jordan Keckley CPA, Independent Market Analyst jpkeckley@gmail.com
Eurozone economy status: The eurozone economy grew less rapidly in the three months through June than previously estimated, making it more difficult for the European Central Bank to secure a soft landing as it seeks to tame inflation.
The European Union’s statistics agency Friday said the combined gross domestic product of the eurozone’s 20 members grew by just 0.2% in the second quarter from the first, having previously estimated that output increased by 0.3%…While the U.S. economy grew at an annualized rate of 3%, the eurozone expanded by just 0.8%. The figures also showed that investment fell sharply during the quarter, while consumer spending also declined, both indications that high interest rates were cooling demand. Growth was mainly driven by exports and government spending.
Eurozone Economy Weaker Than Previously Estimated as ECB Prepares to Meet – WSJ
Hospitals
Kaufman Hall: Hospital financial performance: Despite ongoing cost pressures, hospitals’ median operating margin held steady at 4.2% to close out the first half of the year, dropping slightly in July to 4.1%– compared to a median operating margin of 1.3% in July 2023 and -0.98% in July 2022. KF Insights:
- Things are getting better than they were last year: Increasing patient volumes and decreasing length of stay are two recent positive signs of improving fortunes at health systems. In July, hospitals’ outpatient and inpatient revenue grew by 9% and 8%, respectively, from July 2023, according to Kaufman Hall’s data. Discharges grew by 3% year-over-year as of July, while average length of stay decreased by 2%…
- Cost pressures are unabating: Hospitals continue to feel the pains of rising labor and non-labor expenses, and those pressures show no signs of slowing anytime soon, stated Wasson of Strata Decision Technology. Hospitals’ total expenses per day grew by 6% from July 2023 to July 2024… Costs for drugs and other supplies rose by nearly 10%, and labor expenses increased by 4%.
- The performance gap is getting bigger: While hospital finances seem to be stabilizing overall, a closer review shows that there is a widening gap between the highest- and lowest-performing organizations.
- For-profit vs. nonprofit: Unsurprisingly, the hospitals that have performed best this year are large, for-profit systems. During the second quarter of 2024, the nation’s two largest for-profit hospital chains — Nashville-based HCA Healthcare and Dallas-based Tenet Healthcare — posted a net income of $1.5 billionand $259 million, respectively. HCA ended the quarter with an operating margin of 12.8%, and Tenet finished with a 14.9% operating margin. The story for nonprofit health systems isn’t as rosy, though they are doing better as a whole than this time last year.
“Though over 60% of hospitals are producing more sustainable cash flows of 6% or greater compared with less than half in 2022, margins still remain weaker than pre-pandemic levels in the 8-9% range… Performance improvements for these health systems will “largely hinge on improved payer rates, increased volumes and disciplined cost cutting,” Steingart said in his statement.”
National Hospital July 2024 Kaufman Hall https://www.kaufmanhall.com/sites/default/files/2024-09/KH-NHFR_Report-July-2024-Metrics.pdf
ERI Report: Executive compensation in non-profit hospitals: Per ERI: “Nonprofit organizations operate under a distinct set of principles compared to for-profit organizations. They exist to serve a public or mutual benefit, and their financial resources often come from donations, grants, and other forms of charitable funding. This mission-driven nature impacts every aspect of their operations, including executive compensation…Median pay was mostly similar, hovering around the $100,000 mark, with the most notable exceptions being the “Universities,” “Hospitals,” and “Religion” bands. Median CEO pay in the “Universities” band was more than two and half times that mark, while median CEO pay in the “Hospitals” band was more than four times that value. The “Religion Related” industry band had the lowest median CEO pay at just above $71,000.”
Of note: Per ERI, of the 10 highest paid CEOs in U.S. nonprofit organizations in 2022, hospital system CEOs occupied 8 of the slots. The mean for all hospital CEOs was $698,596; median: $400,284; $200,288 at the 25th percentile and $801,440 at the 75th. CEOs in healthcare are the highest paid of 11 industries analyzed by ERI.
Economic Research Institute https://www.erieri.com/nonprofitcomparablesassessor
Insurers
Paragon study: ACA marketplace plan performance: quality erosion noted: Per Paragon Health Institute analysis of ACA marketplace plans from 2014-2023:
- Provider networks: The percentage of individual market consumers enrolled in plans with broad provider networks declined from 36% to 11% between 2014 and 2023. An increasing share of individual market enrollees are in Medicaid-managed-care-like plans.
- Cost-sharing: As overall premiums have risen, middle-income exchange enrollees with incomes above 200% of the federal poverty level were much more likely to choose a bronze plan in 2023 (54%) than they were a decade ago (33%).
- Premiums: Individual market premiums have increased more rapidly —50% more—than employer plan premiums over the past decade. Middle-income enrollees have been more likely to pick a lower-level plan than previously, the group found.
It’s Not Just the Prices: ACA Plans Have Declined in Quality Over the Past Decade https://paragoninstitute.org/private-health/its-not-just-the-prices-aca-plans-have-declined-in-quality-over-the-past-decade/
Physicians
Physician Compensation: Median Change, 2021-2024
| Specialty | 2024 | 2023 | 2022 | 2021 |
| Overall | 5.3% | 3.5% | 3.7% | 0.1% |
| Primary Care | 3.6% | 6.0% | 3.0% | 0.4% |
| Medical Specialties | 5.1% | 1.4% | 4.1% | -0.4% |
| Surgical Specialties | 5.5% | 1.6% | 3.9% | -0.8% |
| Radiology/Anesthesiology/Pathology | 5.8% | 1.0% | 3.8% | -0.3% |
New AMGA Survey Reveals Compensation Increases Across All Specialty Groupings, July 2024
Policy: Federal
CMS’ Telehealth policy comment letters due today: On July 31, 2024, CMS” issued its proposed rule for the 2025 Medicare Physician Fee Schedule, which includes telehealth services reimbursable by Medicare. Although the majority of telehealth waivers enacted during the COVID-19 pandemic are set to expire at the end of 2024. Key provisions included in the extension include:
- Extended flexibility for ‘Remote Direct Supervision’ and use of enrolled location as ‘Distant site’ designation
- Revision of “Telecommunications System” Definition to Allow Permanent Use of “Audio-Only” in Certain Circumstances,
- Additions to the List of Telehealth Services’ Codes re: Caregiver Training (CMS also rejected AMA’s recommendation for 17 new Telemedicine Evaluation and Management (E/M) Services Codes)
CMS seeks comments on what impact, if any, the expiration of current flexibilities may have on overall service utilization for CY 2025. Comments are due on September 9, 2024.
CMS to Include Telehealth Services in Medicare Reimbursement (natlawreview.com)
Antitrust claim against RealPage: “Department of Justice, which on August 23rd filed an antitrust complaint against RealPage, a property-software platform that landlords use to help them set rents for flats. According to the DoJ’s lawsuit, RealPage enables landlords to collude, pushing up rents on properties across America. RealPage says that its software is “built to be legally compliant” and notes it has worked with the DoJ to ensure this is the case
The RealPage case is interesting because it targets a pricing algorithm, rather than landlords gathering in a smoke-filled room. RealPage’s commercial-revenue-management software has an 80% market share for multifamily housing rentals, which include apartment blocks and condo buildings. Landlords submit private information about their properties and the rents they command. The firm’s software then makes suggestions for rents.”
Are American rents rigged by algorithms? (economist.com)
International health system comparisons: “Coming off the deadly pandemic, health care has taken center stage as a global issue. While the U.S. is facing health care struggles that include increased maternal mortality and lower life expectancy compared to some developed nations, other countries have systems that foster better medical outcomes. More accessible and affordable medical care can improve people’s quality of life and decrease inequality across social classes.” These are four of the world’s best health care systems.
- Belgium: Belgium’s health care system is affordable and accessible… Belgium spends a significant amount on health care. The country is “among the top ten spenders on health across EU countries, reaching 10.7% of GDP in 2019. With relatively high public spending on health, households’ out-of-pocket payments amounted to 18.2%, spent mainly on non-reimbursed services, official co-payments and extra billings.
- Japan: Japan has “maintained a health insurance system that all permanent residents of Japan for more than three months are required to join, allowing people living in Japan to access appropriate health care services at a cost they can afford…. In addition, patients are allowed to “choose any health care provider, from small clinics to large hospitals with the latest medical facilities, and all medical services are provided at a uniform price anywhere in Japan.” The system is mostly publicly funded through taxpayer dollars, with some aspects of the system requiring self-pay or coinsurance. The health care system “covers 98.3% of the population, while the separate Public Social Assistance Program, for impoverished people, covers the remaining. Life expectancy is 88 for women and 82 for men. Infant and maternal mortality is also some of the lowest globally.
- Sweden: Sweden’s health care system is decentralized, or “nationally regulated and locally administered,” where the “Ministry of Health and Social Affairs sets overall health policy,” and the country’s “regions finance and deliver health care services and the municipalities are responsible for the elderly and disabled… The life expectancy is approximately 85 for women and 82 for men, and maternal and infant mortality rates are low. “These attributes contribute to low levels of unmet needs, favorable health outcomes and good health status in the population compared with other countries.”
- Taiwan: Taiwan has a universal health care system. “The single-payer system is funded primarily through payroll-based premiums, although the government provides generous premium subsidies for low-income households, civil servants and others, “The country’s single-payer system has been quite successful following decades of unsuccessful health care systems. Life expectancy is 84 for women and 78 for men, and infant and maternal mortality rates are low. But hospitals are understaffed and overfilled.
The best health care systems in the world (msn.com)
Mammography accuracy: Starting tomorrow, the Food and Drug Administration will require that women nationwide be notified whether their mammograms reveal dense breast tissue. Mammography reports will also encourage women to speak with doctors about their breast density and personal risk.
Nearly 40 states already require that women be notified about dense breast tissue. But there isn’t consensus on what to do with such results. The U.S. Preventive Services Task Force, a government-backed group that sets guidance on screening and preventive care, says there isn’t enough evidence to recommend more testing. And insurance coverage for ultrasounds or MRIs varies by state and insurer.
Ultrasounds catch roughly two more cancers per 1,000 women with dense breast tissue compared with mammograms alone. MRIs are even more sensitive…
But there isn’t evidence from large clinical trials to show the tests reduce breast-cancer deaths for women with dense tissue, an important consideration for medical groups that set recommendations. Regular mammograms reduce deaths from breast cancer.”
Why a Mammogram Isn’t Always Enough to Rule Out Cancer – WSJ
Policy: States
Study: state-level health policy initiatives 2014-2023: Using public data from Ballotpedia and the National Conference of State Legislatures, researchers analyzed health-related state ballot policy-making initiatives (referenda, constitutional amendments) between 2014 and 2023. Highlights:
- Of the 534 state referenda and constitutional amendment ballot initiatives that passed nationwide between 2014 and 2023, 339 (63.5%) were related to population health in the categories of health care, public health, and social determinants of health. The majority of both citizen-initiated (76%) and legislator-initiated (60%) measures were health related.
- The most common topics of ballot measures related to health care were abortion and Medicaid. In the category of public health, the most common topics were decriminalization of marijuana, gambling, environmental exposures, and firearms. Regarding social determinants of health, the most common topics were criminal justice system reform, voting and political representation, education, housing, transportation, and labor policy.
- Although citizen-initiated ballot measures have advanced population health policy in many states, they also face many challenges. Only twenty-six states give citizens some form of direct democracy power, and getting an issue or proposition on a statewide ballot requires a significant amount of organizing, advocacy, and resources.
NCSL, NASHP: Key health policy issues in states:
- Workforce: More than 450 bills related to the health workforce were enacted in 2024, with about half related to licensure and certification amid workforce shortages and worker burnout.
- Prescription drug prices:12 states enacted legislation to lower drug costs by reining in the pharmaceutical middlemen, or PBMs, that manage prescription drugs for health insurers, according to NASHP. 18 weighed legislation related to prescription drug affordability boards, though just Vermont enacted legislation establishing such a watchdog to lower drug costs, according to NASHP.
- Behavioral health:States enacted at least 158 bills to address drug overdoses and suicide and bolster access to substance use disorder treatment, Johnson said.
- Hospital prices:12 states are considering legislation to lower hospital prices, including addressing consolidation, including in “red and purple” states. Consolidation and ownership changes are major concerns to state lawmakers.
- Medicaid eligibility: As enhanced pandemic-era Medicaid funding has wrapped up; states will have to grapple with more constrained budgets. Issues with eligibility system technology will complicate matters.
- Telehealth: Expect lawmakers to continue to weigh the future of telehealth
- Public health funding: Pandemic emergency relief funding for public health is shrinking: will states pick up the balance.
States not shying away from reforming health care – POLITICO
Errors in Deloitte-Run Medicaid Systems Can Cost Millions and Take Years to Fix – KFF Health News
2022 National Profile of Local Health Departments https://www.naccho.org/uploads/downloadable-resources/NACCHO_2022_Profile_Report.pdf
Polling
New York Times-Siena: Results of a nationwide poll conducted among 1,695 registered voters from September 3 to 6, 2024:
- Do you think the United States is on the right track, or is it headed in the wrong direction? Right track 28%, Wrong track:60%, DK/NA 12%
- What one issue is most important in deciding your vote this November? Economy 21%, Abortion 14%, immigration 12% Inflation/COL 7% State of democracy 7% (Healthcare 2% #10)
- Thinking about the nation’s economy, how would you rate economic conditions today? Excellent/good 21% vs. 51% in 2020; Fair 28% vs. 29% in 2020; Poor: 51% vs.20% in 2020.
CBS Poll: “In Pennsylvania, Michigan and Wisconsin — all tight races — we see the larger contours of the entire presidential contest ahead of the first Harris-Trump debate.
What makes these states close?… On the one hand: Trump leads with voters who just don’t think they’re better off financially since the pandemic, whose incomes aren’t keeping up with inflation and especially with non-college and White voters who say this. The bulk of those White non-college voters, always a critical group in these states, say that opportunities for working-class people specifically would be better with Trump.
On the other hand, Harris holds her own in one sense. She’s actually a little better than even with Trump on looking out for the interests of the middle class. Trump is also seen as much likelier to try to help the interests of the wealthy across states,”
Harris v. Trump CBS News poll finds Pennsylvania, Michigan, Wisconsin race tight ahead of debate September 9, 2024 https://www.cbsnews.com/news/harris-trump-poll-pennsylvania-michigan-“wisconsin-debate/
Trump Vs. Harris 2024 Polls: Trump Takes 1-Point Lead in First Major Survey in Weeks (msn.com)
Prescriptions Drugs
GLP-1 Medication demand in working age population: 42% or 57.4 million U.S. adults under 65 with private insurance could be eligible under clinical criteria for GLP-1 drugs used to treat people with type 2 diabetes, obesity, or excess weight and weight-related health issues, according to a new analysis. Non-elderly adults who are obese make up the largest share of those clinically eligible in the private insurance market: 45.8 million people or 80% of those indicated as possibly eligible in the private market are obese, of which 41.8 million people are indicated based on obesity alone. Over ten million people are eligible because of a combination of being overweight and having ever been told that they have another weight-related risk factor. Among non-elderly adults with ESI (estimated to be 116.8 million from NHIS), 42%, or 49.3 million people, are clinically eligible for GLP-1 drugs; 36.2 million people with ESI are potentially eligible for GLP-1 drugs based on an obesity diagnosis alone. Similar shares of those with employer-sponsored coverage are potentially eligible for a GLP-1 antagonist as private coverage overall.
Reuters analysis: IRA drug discounts compared to other countries’ prices: Medicare, which covers more than 67 million people, recently unveiled new maximum prices for the first 10 high-cost medicines negotiated under the Biden Administration’s Inflation Reduction Act. The lower prices will result in savings of $6 billion in 2026, the first year they take effect, but a review of publicly available maximum prices set by other wealthy nations — Australia, Japan, Canada, and Sweden — show that they have negotiated far lower prices for the same drugs. A 30-day supply of nine of the 10 drugs will cost $17,581 for Medicare in 2026, compared with $6,725 in Sweden this year.
US will still pay at least twice as much after negotiating drug prices Reuters September 3, 2024 https://www.reuters.com/world/us/us-will-still-pay-least-twice-much-after-negotiating-drug-prices-2024-09-03
Opioid settlement with wholesalers announced: The 2 largest agreed to pay $300 million to resolve claims by health insurers and benefit plans that they helped fuel the U.S. opioid crisis. The companies had previously agreed to pay $21 billion to resolve claims by state and local governments accusing them of having lax controls that allowed massive amounts of addictive painkillers to be diverted into illegal channels. The wholesalers did not admit wrongdoing as part of the settlement. The $300 million will be paid 38.1% by McKesson, 30.9% by Cardinal and 31% by Cencora, which was previously known as AmerisourceBergen
Drug distributors agree to $300M settlement for role in opioid epidemic (yahoo.com)
CDC: Drug adherence: Between 2021 and 2022, 3.6% of adults 65 and older in the U.S. didn’t get their prescribed medications due to the cost. Another 3.4% got their meds, but don’t take them exactly as prescribed because of costs, according to new CDC data.
These two measures of “cost-related nonadherence” were six times higher among those who experienced food insecurity than those who didn’t. People who live with a disability were twice as likely not to get or take their meds compared to those without a disability
Prescription Medication Use, Coverage, and Nonadherence Among Adults Age 65 and Older: United States,2021-2022 CDC September 5, 2024 https://www.cdc.gov/nchs/data/nhsr
Workforce
Mercer: Workforce forecast to 2028: Mercer forecasts a projected shortage of more than 73,000 nursing assistants and overall shortage of 100,000 healthcare workers nationwide by 2028. Only 13 states are expected to meet or exceed future demand.
“The projected supply of nursing assistants — an occupation that constitutes 8% of the total US healthcare workforce and 40% of healthcare support occupations in 2023 — is discouraging. Future of the U.S. Healthcare Industry: Labor Market Projections by 2028.”
“The slow growth rate (0.1%) of nursing assistants, particularly in states such as New York, Texas and California, where shortages of over 11,000, 12,000 and 14,000 workers respectively are projected, will directly impact patient care and the burnout and attrition rates of other healthcare workers that depend on them,” the report states.
If current U.S. workforce trends continue, the healthcare workforce is projected to reach 18.6 million by 2028, an increase of over 1.5 million from 2023.
Future of the U.S. Healthcare Industry: Labor Market Projections by 2028 (mercer.com)
