In late 2025, two events reset the U.S. health system’s future at least through 2026 and possibly beyond:
- November 5, 2024: The Election: Its post-mortem by pollsters and pundits reflects a country divided and unsettled: 22 Red States, 7 Swing States and 21 Blue States. But a solid majority who thought the country was heading in the wrong direction and their financial insecurity driving voters to return the 45th President to the White House. With slim majorities in the House and Senate, and a short-leash before mid-term elections November 3, 2026, the Trump team has thrown out ‘convention’ in their setting policies and priorities for their second term. That includes healthcare.
- December 4, 2024: The Murder of a Health Executive : The murder of Brian Thompson, United Healthcare CEO, sparked hostility toward health insurers and a widespread backlash against the corporatization of the U.S. health system. While UHG took the most direct hit for its aggressiveness in managing access and coverage disputes, social media and mainstream journalists exposed what pollsters affirmed—the majority of American’s distrust the health system, believing it puts its profits above their needs. And their polls indicate animosity is highest among young adults, in lower income households and among members of its own workforce.
These events provide the backdrop for what to expect this year and next. Four directional shifts seem to underly actions to date and announced plans:
- From elitism to populism: Key personnel and policy changes will draw less from Ivy League credentials, DC connections and recycled federal health agency notables and more from private sector experience, known disruptors and unconventional thought leaders. Notably, the new Chairs of the 7 Congressional Committees that control healthcare regulation, funding and policy changes in the 119th Congress represent LA, AL, WV, ID, VA, MO & KY constituents—hardly Ivy League territory.
- From workforce disparities to workforce modernization: The Departments of Health & Human Services, Labor, Commerce and Treasury will attempt to suspend/modify regulatory mandates and entities they deem derived from woke ideology. The Trump team will replace them with policies that enable workforce de-regulation and modernization in the private sector. Hiring quotas, non-compete contracts, DEI et al will get a fresh look in the context of technology-enabled workplaces and supply-demand constraints. The HR function in every organization will become ground zero for Trump Healthcare 2.0 system transformation.
- From western medicine to whole person wellbeing: HHS Secretary Nominee Robert F. Kennedy Jr. (RFK) Jr.’s “Make America Healthy Again” pledges war on ultra-processed foods. CMS’ designee Mehmet Oz advocates for vitamins, supplements and managed care. FDA nominee Marty Makary, a Hopkins surgeon, is a RFKJ ally in the “Health Freedom” movement promoting suspicion about ‘mainstream medicine’ and raising doubts about vaccination efficacy for children and low-risk adults. NIH nominee Jay Bhattacharya, director of Stanford’s Center for Demography and Economics of Health and Aging, opposed Covid-19 lockdowns and is critical of vaccine policies. Collectively, this four-some will challenge conventional western (allopathic) medicine and add wide-range of non-traditional interventions that are a safe and cost-effective to the treatment arsenal for providers and consumers. The food supply will be a major focus: HHS will work closely with the USDA (nominee Brooke Rollins, currently CEO of the America First Policy Institute, to reduce the food chain’s dependence on ultra-processed foods in public health.
- From DC dominated health policies to states: The 2022 Supreme Court’ Dobbs decision opened the door for states to play the lead role in setting policies for access to abortion for their female citizens. It follows federalism’s Constitutional preference that Washington DC’s powers over states be enumerated and limited. Thus, state provisions about healthcare services for its citizens will expand beyond their already formidable scope. Likely actions in some states will include revised terms and conditions that facilitate consolidation, allowance for physician owned hospitals and site-neutral payments, approval of “skinny” individual insurance policies that do not conform to the Affordable Care Act’s qualified health plan spec’s, expanded scope of practice for nurse practitioners, drug price controls and many others. At least for the immediate future, state legislatures will be the epicenters for major policy changes impacting healthcare organizations; federal changes outside appropriations activity are unlikely.
Transforming the U.S. health system is a bodacious ambition for the incoming Trump team. Early wins will be key—like expanding price transparency in every healthcare sector, softening restrictions on private equity investments, targeted cuts in Medicaid and Medicare funding and annulment of the Inflation Reduction Act. In tandem, it has promised to cut Federal government spending by $2 trillion and lower prices on everything including housing and healthcare—the two spending categories of highest concern to the working class. Healthcare will figure prominently in Team Trump’s agenda for 2025 and posturing for its 2026 mid-term campaign. And equally important, healthcare costs also figure prominently in quarterly earnings reports for companies that provide employee health benefits forecast to be 8% higher this year following a 7% spike the year prior. Last year’s 23% S&P growth is not expected to repeat this year raising shareholder anxiety and the economy’s long-term resilience and the large roles housing and healthcare play in its performance.
My take:
The 2024 election has been called a change election. That’s unwelcome news to most organizations in healthcare, especially the hospitals, physicians, post-acute providers and others who provide care to patients and operate at the bottom of the healthcare pyramid.
Equipping a healthcare organization to thoughtfully prepare for changes amidst growing uncertainty requires extraordinary time and attention by management teams and their Boards. There are no shortcuts. Before handicapping future state scenario possibilities, contingencies and resource requirements, a helpful starting point is this: On the four most pressing issues facing every U.S. healthcare company/organization today, Boards and Management should discuss…
- Trust: On what basis can statements about our performance be verified? Is the data upon which our trust is based readily accessible? Does the organization’s workforce have more or less trust than outside stakeholders? What actions are necessary to strengthen/restore trust?
- Purpose: Which stakeholder group is our organization’s highest priority? What values & behaviors define exceptional leadership in our organization? How are they reflected in their compensation?
- Affordability: How do we measure and monitor the affordability of our services to the consumers and households we ultimately depend? How directly is our organization’s alignment of reducing cost reduction and pass-through savings to consumers? Is affordability a serious concern in our organization (or just a slogan)?
- Scale: How large must we be to operate at the highest efficiency? How big must we become to achieve our long-term business goals?
This week, thousands of healthcare’s operators will be in San Francisco (JPM Healthcare Conference), Naples (TGI Leadership Conference) and in Las Vegas (Consumer Electronics Show) as healthcare begins a new year. No one knows for sure what’s ahead or who the winners and losers will be. What’s for sure is that healthcare will be in the spotlight and its future will not be a cut and paste of its past.
Paul
PS: The parallels between radical changes facing the health system and other industries is uncanny. College athletics is no exception. As you enjoy the College Football Final Four this weekend, consider its immediate past—since 2021, the impact of Name, Image and Likeness (NIL) monies on college athletics, and its immediate future–pending regulation that will codify permanent revenue sharing arrangements (to be implemented 2026-2030) between college athletes, their institutions and sponsors. What happened to the notion of student athlete and value of higher education? Has the notion of “not-for-profit” healthcare met a similar fate? Or is it all just business?
Resources
- Confronting the dangers of ultra-processed food
- A doctor who says he’s reversed his age by 20 years shares the 6 bare-minimum things you can do to live longer
- Texas Executive Order GA-46 and the Erosion of Trust in Health Care | New England Journal of Medicine
Sections in today’s Report
- Quotables
- Economy
- Hospitals
- Insurers
- Physicians & Dentists
- Prescription Drugs
- Public Health
Quotables
Jimmy Carter and Global Health: “Former President Jimmy Carter’s oft-stated desire was to see the last Guinea worm die before he did. Though America’s 39th president, who died Sunday at age 100, did not quite achieve that dream, he left a huge legacy in the field of global health.
The causes he espoused are diseases whose names most of us barely know…There was nothing glamorous about helping people affected by these diseases, which mainly afflict the poor and powerless in sub-Saharan Africa; no one throws black-tie galas at Carter’s namesake foundation, the Carter Center, to fund work to combat them. They are generally the purview of card-carrying members of a tribe of specialists. Who else would choose to focus on what are known as neglected tropical diseases, awful ailments contracted by drinking contaminated water or being bitten by infected flies?
“Anybody who has that prominence and that influential of a voice could choose to use their voice in lots of different ways. And to say: ‘I’m going to use my voice for the poorest, most marginalized, most remote people in faraway countries with diseases that we can’t pronounce,’ that means a lot,” said Ellen Agler, former CEO of the End Fund, a private philanthropic organization that works on many of the same neglected diseases the Carter Center targets and that funds some of its work..”
How Jimmy Carter’s global health efforts elevated ‘the art of the possible’ StatNews December 30, 2024 https://www.statnews.com/2024/12/29/how-jimmy-carters-global-health-efforts-elevated-the-art-of-the-possible
Court Challenges to CON laws: “In 2017, M’Moupientila “Marc” N’da sought state approval to drive older and disabled Nebraskans to doctor’s appointments. Given what he was seeing among clients of his home health business — who often complained about unreliable rides — the need seemed obvious.
But would-be competitors protested, backed by laws that give them sway over new entrants to the market. Though state regulators determined N’da was qualified to run a medical transport operation, they denied his application because he hadn’t demonstrated it would be “harmless” to the businesses that had come before him.
N’da responded with a lawsuit accusing the state of denying him due process. The case is now before the Nebraska Supreme Court.
N’da is part of a wave of litigants pressing to dismantle regulations that plaintiff lawyers say have fomented health care “cartels” in more than 30 states — limiting, for example, the number of methadone clinics in West Virginia, youth mental health beds in Arkansas and MRI centers in North Carolina.”
Health care start-ups are trying to open. An old law stands in their way. Washington Post January2, 2025 https://www.washingtonpost.com/business/2025/01/02/certificate-of-need-competition-health-care
Access to Obesity medication: “Imagine a disease so prevalent it affects more than two-fifths of the adult population and one-fifth of children, yet its most effective treatments remain out of reach for those who need them most. This is the reality of obesity, a condition that drives chronic disease but is met with barriers to care at every turn. Obesity isn’t a mere lifestyle choice or lack of willpower; it’s a complex, chronic disease that heightens the risk of many of the most common chronic conditions: diabetes, heart disease, hypertension, osteoarthritis, and more.
Yet, despite the power of GLP-1 anti-obesity medications to reduce these risks, many insurers continue to deny coverage, leaving millions of Americans to fend for themselves.”
CMS Moved to Expand Obesity Drug Coverage. Private Insurers Need to Step Up. | MedPage Today
Insurers role in health costs: “It’s hard to avoid the conclusion that, in this area, as in others, the opaqueness and complexity of the health-insurance system is designed to benefit insurers and other insiders to the detriment of policyholders. As a political slogan, “Transparency Now” perhaps doesn’t have the ring of “Medicare for All.” In the current conjuncture, it may be worth adopting anyway. “
How did we End Up with such an Opaque and Costly Health System New Yorker https://www.newyorker.com/news/the-financial-page/how-did-we-end-up-with-such-an-opaque-and-costly-health-care-system
Economist on 2025 forecast: “What happens when the world’s biggest economy takes a sharp protectionist turn? When the global superpower decides that a transactional foreign policy beats alliances? And when the reset takes place as wars rage, menacing adversaries join forces and artificial intelligence (AI) is changing everything from health care to warfare? The world is about to find out.
In the campaign Donald Trump promised massive change. That is possible, but the rhetoric of campaign speeches is quite different from the reality of governing. The people Mr. Trump chooses for his team and the priorities they focus on will determine how much he can accomplish. His early appointments suggest an emphasis on loyalty, hawkishness and disruption…. With luck, the most consequential part of Mr. Trump’s domestic agenda will lie elsewhere: in a programme to deregulate and reinvent the machinery of government, from drug regulation to military procurement. These reforms will determine how quickly America adopts and diffuses cutting-edge technologies including biotech and AI. Elon Musk will be in charge. His promise to slash the federal budget by $2trn is absurd. But the idea that America needs government reform to maintain its lead in radical new technologies is surely right.
If Mr. Trump truly wants to make America great, this is where his administration should focus. It would be ironic if the man who loves tariffs led the charge to accelerate technologies that may eventually reshape or replace many American jobs. But extending America’s lead in AI would do far more to ensure its future prosperity and military security than any other part of the MAGA agenda. Over to you, Elon. “
The three forces that will shape 2025 The Economist
Economist on Ageism: “…America’s political gerontocracy is a symptom of deeper problems, not the cause of them
Meanwhile, the average age of world leaders is increasing—it has risen from 55 to 62 over the past five decades… And it is not just presidents and prime ministers who are getting older. On Capitol Hill, two-thirds of America’s senators and half of its representatives were born before 1964. No doubt many are robust, but not all: 11 lawmakers have died in office since 2020. Half of them were over 80. Supreme Court judges are also appointed for life, rather than serving until a designated age, or for a fixed tenure.
Every democracy sets a minimum age for holding office. Some, such as France, are exceptionally liberal, allowing 18-year-olds to run for president, a position with near-monarchical powers. Others are more circumspect. Italy’s president must be at least 50, even though the position is largely ceremonial. But no country sets an upper age limit for wielding power. Should they? Wisdom and experience count for a lot. But so do vitality, dynamism and fresh ideas…
As Donald Trump, aged 78, returns to the White House, the global debate about political age limits seems likely to intensify in 2025. Autocrats would, by their nature, ignore such restrictions. Democracies should think very carefully before imposing them.
The debate around age limits for politicians will get louder in 2025 The Economist November 20, 2024 https://www.economist.com/the-world-ahead/2024/11/20/the-debate-around-age-limits-for-politicians-will-get-louder-in-2025
Wellness industry: “The $5.6 trillion wellness industry sells a seductive premise: pursue personal well-being and empowerment by bypassing the perceived failures of conventional medicine. This narrative fuels a market of unregulated supplements, unproven tests, and vague diagnoses — all sold under the guise of taking control of your health.
With the incoming Trump administration tapping individuals like Robert F. Kennedy Jr. , Mehmet Oz, MD , Jay Bhattacharya, MD, PhD , and others to be in top health and science roles, we fear that the wellness industry could gain unprecedented power to shape public health policy, dismantle regulatory oversight, and institutionalize medical conspiracism.
Among these nominees are people who do more than just dabble in pseudoscience and conspiracies — they are, arguably, its creators. We believe they are a threat to science-based public health and the very institutions designed to protect people from predatory, profit-driven wellness schemes.”
Will the Trump Administration Be a Dangerous Ally to the Wellness Industry? | MedPage Today
GOP Pollster on “unity” in America: “As we close out 2024, something important is unfolding in America that hasn’t happened in many years: We’re more united in our outlook about our country’s institutions. There is rising and perhaps unexpected alignment between Americans of different walks of life, from left to right. Granted, this alignment may at first glance seem like a problem, for what unites us, increasingly, is what we distrust. ..Since the early 1990s, majorities of Americans have said that our nation is “greatly divided when it comes to our most important values,” except for the year after the Sept. 11 terrorist attacks. This year, in the weeks before the 2024 election, Americans reported a record high level of division. Fewer than one in five said we were mostly “united and in agreement about our most important values,” and that figure held true for Republicans, Democrats and independents alike…
Regardless of intentions, the reality is that we are in a low-trust moment, and it binds right and left together.
Part of what’s driving this are the ways in which the faults of our institutions are laid bare and amplified, at times unfairly, in our current information ecosystem. While the average American has greater visibility than ever into many of our key institutions’ actions, that transparency has not led to more trust. Actions that cause anger and shock and outrage generate attention in a way a job well done does not. When the misdeeds or failings of our institutions are illuminated — sometimes done with the good intention to hold a university or health agency or company to account for mistakes or behavior, sometimes done to exaggerate a threat and destabilize an institution — distrust can go viral. There is a cumulative effect, and today it appears that agitation with many established institutions and the status quo knows no party. Even satisfaction with our own democracy is dreadfully low, and in bipartisan fashion. Only 17 %of Republicans and 38% of Democrats felt “satisfied” with the way democracy was working in our country over the past year, figures that are miles away from the generally satisfied view of Americans as recently as the late 1990s.
One might assume that repeated negative experiences over time lead people to distrust others, but today it is the youngest among us who look the most skeptically at their fellow Americans or institutions. I believe distrust in institutions is related to general decreases in the extent to which we trust one another at an interpersonal level…
Speaking to that distrust — acknowledging Americans’ well-founded frustration with the status quo, and doing so in a way that is actually unifying — is what I believe Americans are looking for, at least as a first step.”
Here’s Something We Agree on in America NYT December 31, 2024 https://www.nytimes.com/2024/12/31/opinion/american-politics-trust-institutions
Birx vs. CDC on Bird Flu risk: potential: “We kind of have our head in the sand about how widespread this is from the zoonotic standpoint, from the animal-to-human standpoint”
CDC reaction:” .:comments about avian flu (H5N1) testing are out of date, misleading and inaccurate. Despite data indicating that asymptomatic infections are rare, CDC changed its recommendations back in November to widen the testing net to include testing asymptomatic people with high-risk exposure to avian flu, and during the summer, it instructed hospitals to continue subtyping flu viruses as part of the nationwide monitoring effort, instead of the normal ramping down of surveillance at the end of flu season. The result: more than 70,000 specimens have been tested, looking for novel flu viruses; more than 10,000 people exposed to avian flu have been monitored for symptoms, and 540 people have been tested specifically for H5N1. Additionally, CDC partnerships with commercial labs mean that H5N1 tests are now available to doctor’s offices around the country, significantly increasing testing capacity.
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(the risk to the general public). has not changed and remains low, but said the detection of the genetic mutations underscores the importance of ongoing genomic surveillance in people and animals, containment of avian influenza A(H5) outbreaks in dairy cattle and poultry, and prevention measures among people with exposure to infected animals or environments.”
Dr. Deborah Birx, the White House Coronavirus Response Coordinator under President Donald Trump, on “CNN Newsroom” with Pamela Brown December 26, 2024.
Health insurer prior authorization disputes: “…Cancer patients and their families said that protracted peer review processes, where insurers require a physician to discuss a patient’s case with a doctor paid by the insurance company, are harrowing. The insurance company doctor, not the patient’s personal physician, rules yes or no on a procedure. Prescribing doctors characterize these processes as interference.
Last year, 17 % of Americans reported that their insurance company had denied coverage for care recommended by their physician…
Other families, desperate to find care for a loved one, go into debt. Nearly one-third of working-age American adults reported having medical or dental debt last year, according to another Commonwealth survey. Academic research shows that cancer patients are directly and disproportionately harmed by health insurers’ care denials and authorization delays.
A 2022-member survey conducted by the American Society of Clinical Oncology, a network of 50,000 cancer professionals, found that 42% of prior authorizations were delayed by more than one business day and that 14% of the delays resulted in a “serious adverse event for a patient.”
The oncologists described the serious adverse event as “delay of treatment” 96% of the time, “denial of treatment” 87% of the time, “disease progression” 80% of the time, and “loss of life” 36% of the time.
A study published last year in JAMA Network, a publication of the Journal of the American Medical Association, found that 22% of cancer patients did not receive the care their doctors prescribed because of authorization delays or outright denials.
Researchers have found that delays and other prior authorization problems extend to combination drugs used to combat cancer. They include nonspecialty drugs, which treat diseases affecting large populations, and specialty drugs, which treat complex or rare conditions.
The number of nonspecialty branded oncology drugs that required prior approvals rose from 16% in 2010 to 78% in 2020, according to a 2023 report in JAMA Network. During the same period, specialty branded oncology drugs requiring prior authorization rose from 73% to 93%, researchers found.”
‘Would he have lived?’ When insurance companies deny cancer care to patients: Health insurers are increasingly interfering in care, an NBC News investigation found. Doctors say the stakes are highest in cancer care, when delays can be the difference between life and death NBC News December 27, 2024 https://www.nbcnews.com/news/investigations/-lived-health-insurance-companies-deny-cancer-care-patients-rcna182611?utm_medium=email
Forbes on governance in 2025: “Top 10 Governance and Leadership Trends for 2025:…“ Chiefly, directors will need to confront the implications of continued political, social, economic, and regulatory volatility. Other trends to expect range from increased board oversight of artificial intelligence to heightened pressure on the board/management dynamic to renewed scrutiny of whether directors are committing enough time and energy to their board duties. Board composition and refreshment will also be a notable trend in 2025, Peregrine writes, as will the “preservation of a positive workforce culture.”
Forbes December 30, 2024
Corporate DEI programs: “Corporate America pulled back on diversity programs in 2024 under pressure from activists. In the new year, it will face an even more powerful challenger.
Trump’s second administration is gearing up to end diversity, equity and inclusion, or DEI, policies in dozens of government and business programs after many of the same concepts came under attack at some of the biggest U.S. companies…
Wisconsin Institute for Law & Liberty, which has sued companies over DEI policies, is pointing to 61 federal programs it considers ripe for litigation and elimination, including technical assistance for minority farmers and contracting preferences for minority-owned law firms helping to collect U.S. debts. It will have an ally inside the White House: Trump adviser Stephen Miller, who ran a group that has also sued companies over DEI policies. “
From Ford to Walmart, Corporate America Drew Back From DEI. The Upheaval Isn’t Over. – WSJ
Cybersecurity threat protection: “…As of mid-December, 567 data security incidents had been reported to HHS in 2024, cumulatively exposing the health information of nearly 170 million people. Healthcare was the third-most targeted sector in 2023, behind professional services and retail, according to an annual threat report from International Business Machines.
A February ransomware attack against UnitedHealth Group-owned Change Healthcare spurred lawmakers to propose stricter cybersecurity laws for the industry. Change, which handles insurance claims and prescriptions for a swath of U.S. healthcare organizations, was forced to disable its software after the attack. For months, health providers couldn’t transmit claims. Some took in no revenue, forcing owners to rely on lines of credit, personal savings or emergency loans from UnitedHealth to stay afloat.
Healthcare Providers Face Stiffer Cyber Rules Even as They Cry for Help – WSJ
Economy
Big Retailers gain relative market share: The three biggest retailers by revenue in the U.S. Costco , Walmart and Amazon —accounted for about 11% of total retail sales back in 2014, based on their reported figures measured against national retail sales data from the Commerce Department. Their share of the market has been growing since then. In their last three reported quarters, the behemoths selling everything from groceries to appliances made up about 17% of retail sales and roughly 57% of retail sales growth over that period.
Supermarkets have been a chronic casualty of the big retailers’ rise. Grocery stores accounted for about two-thirds of food-at-home spending in the U.S. in 2000, but their share shrank to 54% in 2023, according to the U.S. Department of Agriculture. Over the same period, warehouse clubs and supercenters such as Costco and Walmart nearly doubled their market share to 23%. Amazon hasn’t grown its share of the grocery market much, but it captures a sizable share of everything else: About three-fourths of U.S. households have Amazon Prime, its paid membership program, according to a 2024 survey from Evercore…
It will be a challenging catch-up game for the rest. The three big retailers spent an estimated $47 billion on capital expenditures in 2023. That is about four times what Target, Best Buy,, and the two largest supermarket chains—Kroger and Albertsons —collectively spent…
those from third-party sellers—help them generate high-margin profit streams such as advertising and third-party fulfillment services. That in turn gives these retailers room to cut pricing to attract more customers. While Walmart’s advertising business is a fraction of Amazon’s, it has been growing at a healthy pace and has helped the company grow its operating profit faster than revenue.
Big Retail Gets Bigger as Smaller Players Struggle – WSJ
Hospitals
Price transparency compliance update: January 1 federal rules for how hospitals have to disclose their prices changed. The government is requiring hospitals to include additional data to improve their consistency and make it easier to compare across hospitals. Specifically, hospitals must now include three new fields: “estimated allowed amount (based on avg. amount hospital historically received),” “drug unit of measurement and drug type of measurement,” and “modifiers.” It’s the final of three phases in the Centers for Medicare and Medicaid Services’ hospital price transparency rollout. The first phase was the original rollout in 2021, followed by an update in July 2024.
CMS updates to hospital price transparency rules for 2025 | STAT
Study: employer sponsored benefits cost increases: “Over the past 25 years, the gap between the increase in health insurance costs and workers’ wages has significantly expanded. This trend has led to significant concerns about healthcare affordability, with surveys revealing conflicting opinions regarding whether hospitals or health insurance companies bear the blame for escalating costs. To better understand these dynamics, we examined consumer price indices for health insurance, hospital services, and professional services from 2006 to 2023 using Bureau of Labor Statistics data. Our analysis shows that the hospital price index rose steadily between 2006 and 2023, faster than insurance premiums or professional services. To examine whether differences in underlying costs are driving higher hospital price increases, we evaluated the profit margins of hospitals and health insurance companies using the National Academy for State Health Policy’s Hospital Cost Tool and National Association of Insurance Commissioners Industry Reports. Our findings reveal that hospitals (for-profit and nonprofit) have consistently maintained higher profit margins than insurance companies. As health insurance costs continue to weigh heavily on working Americans, our analysis suggests that high hospital prices drive insurance premiums.
Why does the cost of employer-sponsored coverage keep rising? Salpy Kanimian, Vivian Ho Health Affairs Scholar, Volume 2, Issue 6, June 2024, qxae078, https://doi.org/10.1093/haschl/qxae078
CONs as platform equity and inclusion: “Of the 35 States with CoN programs, 22 have a statute that requires the establishment of a state health promotion plan; in each of these states, there exists an opportunity to advance health equity… entrenched health and racial inequities in outcomes will only be solved through a focus on social and environmental community conditions, and when the people experiencing the impact of inequities are driving the decisions about what to do. Similarly, the continued rise in health care costs without resulting gains in eliminating health inequities requires different approaches. Health care systems across the U.S. already invest large amounts of funding in their communities. By strategically aligning community benefits, CoN processes, and health care efforts to address individual-level health related social needs, health care systems and communities will see increased opportunity to address root cause issues. While we believe these approaches will produce significant advantages to community health, additional research is needed to study the varied approaches to adapting and aligning CoN, community benefit, and other health related initiatives and to ensure that CoN more effectively serves its core purpose of reducing duplicative services and discouraging unnecessary and expensive health facilities.
Leveraging Certificates Of Need To Increase Public Health Spending: The Massachusetts Example December 17, 2024 Health Affairs https://www.healthaffairs.org/content/forefront/leveraging-certificates-need-increase-public-health-spending-massachusetts-example
Study: upcoding in hospitals: “Diagnosis-based payment systems can create incentives to upcode patients to a higher level of severity to increase payment. In some instances, upcoding can be a form of fraud if providers code patients to a higher complexity than is appropriate, whereas in other instances, upcoding can accurately reflect patient acuity. We estimated the increase in Medicare Severity Diagnosis-Related Group (MS-DRG) upcoding during the period 2011–19, using all-payer discharge-level data from five states. During this period, the number of discharges with the highest MS-DRG coding intensity increased by 41 percent. Adjusting for changes in patient characteristics, length-of-stay, and hospital characteristics, we estimated that the increase would have been 13 percent in the absence of changes in coding behavior. We estimated that in 2019, the increase in upcoding (relative to 2011 coding practices) was associated with $14.6 billion in hospital payments, including $5.8 billion from private health plans, $4.6 billion from Medicare, and $1.8 billion from Medicaid. These findings can contribute to the growing body of evidence supporting the design of payment models that limit distortions in payment and resource allocation.
Insurers
Study: MA Market competition: Context: “The Medicare Advantage (MA) market now covers more than half of Medicare enrollees and is expanding. MA depends heavily on competition, relying on plan bids to set payments to plans and benefits. Evidence suggests that more competitive MA markets are associated with lower bids and more generous benefits. Moreover, competition is central to MA payment reform proposals that rely on bidding to set benchmarks.
The degree of competition in MA varies geographically and has been changing. Specifically (and paradoxically at first blush), the national MA market has become more concentrated (that is, less competitive) while local markets (counties) have, on average, become somewhat less concentrated (that is, more competitive). This pattern has emerged as large MA carriers have expanded the number of counties they serve. Thus, a major question is whether the increasing competitiveness of local markets should be expected to continue after larger insurers establish a presence in a high proportion of counties… Findings:
National carriers expanded their national market share significantly from 2012 to 2023, whereas the collective market share of regional carriers without affiliation to Blue Cross and Blue Shield organizations declined because of acquisitions. For example, the combined national market share of national carriers increased from 46% in 2012 to 66% in 2023, while the combined national market share of non-Blue regional carriers decreased from 25% to 6%. Conversely, concentration in local markets has declined but remains highly concentrated, and evidence suggests that further declines may be unlikely. Specifically, declines in local market concentration have been limited to markets with low MA penetration. Once MA penetration exceeds 20%, further MA growth is not associated with further drops in concentration, on average. Thus, policy makers should be aware that MA program reforms that assume MA markets are competitive are unlikely to achieve program goals without ensuring the competitiveness of those markets.”
Medicare Advantage: National Carriers Expand Market Share While Regional Carriers Without Affiliation Decline, 2012–23Joseph G. P. Hnath, J. Michael McWilliams, and Michael E. ChernewDecember 2024 Health Affairs https://doi.org/10.1377/hlthaff.2024.00577
WSJ Investigation of UnitedHealth Group’s Medicare Advantage business practices:” Throughout the past year, The Wall Street Journal investigated how UnitedHealth Group and other giant insurers extracted billions in extra payments from the $450-billion-a-year Medicare Advantage system, the federal government program that outsources health benefits to private companies.
The investigation, which was under way before the killing of a UnitedHealth executive in December sparked an outpouring of public rage against the industry, relied on exclusive access to billions of records of Medicare services obtained through a data-use agreement with the federal government. The Journal’s analysis of those records showed how private insurers took extra payments after diagnosing patients with conditions that no doctor ever treated, recruited patients who use few services and, at times, obstructed access to care for the sickest patients.
Here are some key findings:
- Insurers packed on diagnoses that made them more money. Medicare Advantage insurers diagnosed patients with conditions that triggered extra paymentsof $50 billion from 2019 to 2021, even though no doctor ever treated the diseases.
- Insurers sent nurses to find diagnoses that doctors hadn’t. Insurers dispatched their own nurses to visit patients at home and diagnose them with conditions that their doctors hadn’t, triggering an average of $1,818 in extra annual payments during each visit from 2019 to 2021—$15 billion in total.
- Insurers got paid to cover patients who were already getting their healthcare elsewhere. Medicare Advantage insurers collected billions of dollars a year in premiums to provide medical coverage to patients who used the Department of Veterans Affairs health system—and not Medicare—for some or all of their healthcare needs…About one in five members of Medicare Advantage plans that enroll lots of veterans didn’t use a single Medicare service in 2021, the Journal found. That compares with 3.4% of members of other Medicare Advantage plans. Insurers can profit when members have low costs.
- Doctors who work for UnitedHealth generated billions of dollars in extra paymentsfor their employer by adding more diagnoses. UnitedHealth provided doctors with checklists of possible diagnoses for their patients and paid bonuses for completing them…
- Sicker patients who needed expensive treatments like nursing-home care left Medicare Advantage at high rates—suggesting that insurers may have been denying them costly coverage. Medicare Advantage insurers netted $3.5 billion in savings from their sickest patients dropping outto return to traditional Medicare in the last year of life from 2016 to 2022, the Journal found.
…After the Journal’s report, an independent research group published its own analysis showing patients with a range of serious illnesses left Medicare Advantage more often than healthy patients.
How Health Insurers Racked Up Billions in Extra Payments From Medicare Advantage – WSJ
Stat News’ UHG Investigation: “For Tara Bannow, Casey Ross, Lizzy Lawrence, and me, a good chunk of 2024 was occupied with UnitedHealth Group.
We spent all year talking to doctors and others who work in the conglomerate. We listened to people frustrated with UnitedHealth’s Optum clinics or their UnitedHealthcare coverage. We combed through documents, texts, and data files.
The themes became clear: UnitedHealth’s business empire expanded to all kinds of communities across America, to the detriment of patients, taxpayers, and competitors. Patients, in particular, had their care disrupted and felt confused by the company’s coding practices and wellness visits. UnitedHealth’s power is now catching the attention of lawmakers. “
Health Care’s Colussus Lawmakers call for curbs on UnitedHealth’s growing empire StatNews December 23, 2024 https://www.statnews.com/2024/12/23/unitedhealth-group-lawmakers-consider-antitrust-breakup-health-care-giant
Study: ASO market concentration, profitability: “For 165 million nonelderly Americans, employers provide health insurance either by purchasing a fully insured plan or through self-insurance. By self-insuring, employers bear the financial risk for enrollees’ health care spending and are accountable for plan management, either directly or by contracting with a third-party administrator. Using National Association of Insurance Commissioners data, we demonstrate that insurers are deeply entrenched in the provision of administrative services only (ASO) contracts for self-insured employers. In 2022, insurers administered to nearly 4 times as many ASO enrollees as they covered in fully insured plans, with 56 insurer-based ASO contractors providing services for 118 million enrollees. The largest ASO contractors—CVS Group, Cigna Health Group, and Elevance Health Inc. Group—collectively served more than 70 million ASO enrollees and demonstrated less variable and stronger profitability relative to other ASO contractors. This study expands understanding of this increasingly important market for employer-sponsored insurance
Prevalence And Profits Of Insurers In The Administrative Services Only Market Serving Self-Insured Employers, 2010–22 Jean M. Abraham, Amanda C. Cook, and E. Tice Sirmans Health Affairs December 2024 https://doi.org/10.1377/hlthaff.2024.00359
WSJ Report: Luigi Mangione pre-existing medical issues: “Luigi Mangione was preoccupied with a litany of health problems years before he disappeared.
Mangione posted on social media about back pain, sleeplessness and brain fog. He sought advice from people experiencing similar symptoms. In the years before he was charged this month with murder in the fatal shooting of UnitedHealthcare Chief Executive Officer Brian Thompson, Mangione wrote about attempts to manage what ailed him through diet and exercise and expressed frustration with healthcare providers.
Mangione posted over the years on Reddit forums about Pokémon Go, the University of Pennsylvania and bioinformatics. In 2018, he posted on forums about irritable bowel syndrome and visual snow, a neurological disorder that causes people to see flickering dots or static. Those conditions don’t have clear causes or uniform treatments.
Mangione’s disappearance from social media, friends and family before his arrest has left detectives and amateur internet sleuths working to fill the gaps. One question is whether his health has any connection to Thompson’s fatal shooting. “
Luigi Mangione Was Fixated on ‘Brain Fog’ and Other Health Symptoms WSJ December 27, 2024 https://www.wsj.com/us-news/luigi-mangione-mental-health-ceo-shooting-
Stat News investigation of United Health: “It is facing a federal antitrust investigation and a Justice Department lawsuit seeking to block its proposed acquisition of the home health provider Amedisys. Lawmakers and regulators have sharply criticized the company for excessive profiteering within its Medicare Advantage business. It is being sued for allegedly using an error-prone algorithm to systematically deny care to older Americans. Earlier this year, the company’s failure to secure its computer systems led to a debilitating cyberattack that shut down much of the nation’s health payments infrastructure. And among numerous other legal disputes, its top executives were accused in a civil lawsuit of insider trading.
STAT’s investigation of the company exposed deeply embedded conflicts within its sprawling network of businesses. As the nation’s largest insurer and provider, with more than 90,000 physicians under its control, the company stands on both sides of countless transactions whose terms it can bend to serve its own financial interests, often at the expense of doctors and patients. In recent years, UnitedHealth has stealthily gobbled up a range of different medical groups, surgery centers, and urgent care clinics in places where it was a dominant insurer, leading to concerns from consumer advocacy groups and researchers about whether the company was manipulating prices and forcing patients to use its own providers.”
Health Care’s Colussus: Lawmakers call for curbs on UnitedHealth’s growing empire StatNews December 23, 2024 https://www.statnews.com/2024/12/23/unitedhealth-group-lawmakers-consider-antitrust-breakup-health-care-giant
Fitch: MA outlook for 2025: “A moderate improvement in Medicare Advantage (MA) margins due to integration of higher healthcare utilization into 2025 bid submissions is incorporated into the U.S. health insurance neutral sector outlook in 2025, Fitch Ratings says. However, these are partially offset by challenges in Medicaid rate adequacy expected to persist into 1H25 as insurers continue negotiating payment rates with individual states.
Weaker combined operating performance for the largest seven publicly traded health insurers yoy for 9M24 primarily reflected continued increases in healthcare service utilization in the senior population and higher acuity in the remaining Medicaid population following completion of the redetermination process. Combined operating performance for the group for 9M24 fell yoy, with operating EBITDA margins expected to be down roughly 110bp from 2023 to approximately 5.8% forecasted for 2024.”
Govt-Funded Business Pricing to Continue to Challenge U.S. Health Insurers Fitch Ratings December 27, 2024 https://www.fitchratings.com/research/insurance/govt-funded-business-pricing-to-continue-to-challenge-us-health-insurers-27-12-2024
Physicians and Dentists
Survey: Psychologists: Highlights: Per the 2024 Practitioner Pulse Survey by the American Psychological Association:
- 53% of psychologists this year did not have openings for new patients
- 33% reported feeling burned out—”disproportionately affecting early career psychologists.”
- 66% currently accepted some form of insurance; 34% did not accept insurance due to concerns about insufficient reimbursement rates (82%) and pre-authorization requirements (62%)
- 71% use AI at least monthly for tasks such as note-taking or reducing administrative burdens; 27% were worried that AI
Barriers to Care in a Changing Practice Environment: American Psychological Association 2024 Practitioner Pulse Surveyhttps://www.apa.org/pubs/reports/practitioner/2024/practitioner-pulse-2024-full-report
Study: Accessibility of dentists: Researchers analyzed population proximity to dental practices from November 2023-April 2024. Findings:
“This cross-sectional study of 205 762 US dentists found that nearly 1.7 million people in the US did not have access to dental clinics within a 30-minute drive, and 24.7 million lived in dental care shortage areas. Rural block groups and those with high levels of segregation and socioeconomic deprivation were more likely to experience dental care shortages compared with urban block groups and those with low levels of segregation and socioeconomic deprivation.”
Dental Clinic Deserts in the US: Spatial Accessibility Analysis JAMA Network December 23, 2024 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2828397
Study: Using reference prices to generate savings for Medicare, payers and patients: Researchers analyzed within-hospital maximum-to-minimum commercial hospital price gaps negotiated by 5 national insurers to project savings if the minimum prices were used as new payment level. Results:
“In this cross-sectional study of 40,382 commercial prices negotiated by 5 national insurers, the lowest mean within-hospital prices were 168% and 220% of Medicare rates for inpatient and outpatient services, respectively; and estimated 21% savings for inpatient services and 29% savings for outpatient services could be achieved by using the lowest within-hospital prices as new payment levels.”
Prescription Drugs
ProPublica investigation: Endo bankruptcy, behind the scenes maneuvers: ProPublica’s analysis found:
- Delayed Justice: After a whistleblower exposed the criminal behavior of Endo, a drug manufacturer, the Justice Department waited more than a decade to bring charges against the company.
- A Steep Discount: Federal agencies said Endo owed up to $7 billion in criminal fines, back taxes and other charges. The government settled this year for just $200 million.
- Winners and Losers: Endo is still selling narcotics. Lawyers made $350 million. A few executives shared $95 million in bonuses. Thousands of opioid victims are to share $40 million.
“The focus of Endo’s activity was code named Project Zed which allowed Endo to restructure its debt to retain control of the company and hand out $95 million in executive bonuses before seeking protection in bankruptcy. The result for U.S. taxpayers: Endo paid a tiny fraction — three pennies on the dollar — of the $7 billion that officials said it owed the U.S. government, including $4 billion in taxes…Endo is not a household name. But by 2018, a year when 15,000 Americans overdosed and died on prescription painkillers, Endo and the firms it purchased had sold 33 billion opioid pills over two decades, almost three times the number sold by Purdue Pharma, the …Sackler family’s OxyContin powerhouse.”
Endo’s End Around: How One of the Nation’s Largest Opioid Makers Escaped a $7 Billion Federal Penalty ProPublica December 17, 2024 https://www.propublica.org/article/endo-settlement-opioids-justice-department
Drug Price increases: Nearly all the price increases are under 10%, with the median increase across all the affected medications being 4.5%, matching the median increase last year, Reuters reported Thursday, citing data from healthcare research firm 3 Axis Advisors.
The increases apply to list prices before accounting for insurance, rebates to pharmacy benefit managers, or other discounts.
This year’s increases reflect a sizable increase from Dec. 29 of last year, when drugmakers had unveiled plans to raise prices on over 140 brands. More price hikes are also expected throughout January, historically the busiest month for drugmakers to announce increases.
Pfizer (PFE+0.45%) led the latest round of hikes, raising prices on over 60 drugs — more than any other company. This includes a 3% increase for the company’s COVID-19 treatment, Paxlovid, and hikes of 3% to 5% for treatments such as the migraine medication Nurtec and cancer drugs Adcetris, Ibrance, and Xeljanz…
This shift also coincided with the 2022 Inflation Reduction Act, which requires drug manufacturers to pay rebates to the government for price increases that exceed the inflation rate on medications covered by Medicare. In response, some pharmaceutical companies have adjusted their strategy by introducing new drugs at higher launch prices and embracing treatments for rare diseases, also called orphan diseases. These illnesses typically affect a small population, usually 200,000 or less. Drug companies can leverage a lack of alternative treatments for these diseases to justify high prices.
pharma price hikes in 2024: 250 drugs see increase | quartz
Biopharma to raise more than 1,000 drug prices in 2025, advisory firm predicts
Pharma patent expiration: Big Pharma will hunt for more acquisitions in 2025 as industry giants face patent expiration for some of their best-selling drugs, according to a top M&A banker. Ex:
- Merck’s cancer drug Keytruda, the top-selling medication in the world, will lose patent exclusivity at the end of 2028.
- Eliquis, made by Pfizerand Bristol-Myers Squibb to treat and prevent blood clots, will lose its exclusivity earlier that same year. The two drugs raked in $25 billion and $12 billion, respectively, for their manufacturers in 2023.
Here’s What Big Pharma Could Buy in 2025, From Obesity to Cancer Drugs – Business Insider
Public Health
Surgeon General Directive on Alcohol risk: “This advisory highlights alcohol use as a leading preventable cause of cancer in the United States, contributing to nearly 100,000 cancer cases and about 20,000 cancer deaths each year. Alcohol use is very common—in 2019-2020, 72% of U.S. adults reported they consumed one or more drinks per week, but less than half of U.S. adults are aware of the relationship between alcohol consumption and cancer risk. The direct link between alcohol use and cancer was first established in the late 1980s, and evidence for this link has strengthened over time. This body of scientific evidence demonstrates a causal relationship between alcohol use and increased risk for at least seven different types of cancer, including breast (in women), colorectum, esophagus, liver, mouth (oral cavity), throat (pharynx), and voice box (larynx). The more alcohol consumed, the greater the risk of cancer. For certain cancers, like breast, mouth, and throat cancers, evidence shows that this risk may start to increase around one or fewer drinks per day.”.”
Alcohol and Cancer Risk 2025 | HHS.gov
Gen X and Boomers: “If Margaritaville’s residents are representative of their age cohort, there will be a lot more to the toga parties than fancy dress. Whereas young people in rich countries these days are addicted to their phones, more anxious than previous generations and far less likely than them to use mind-altering substances or to party recklessly, their grandparents belong to a generation that experimented with sex, drugs and rock’n’roll. As they reach older age, they are not giving up their old habits….
Among those for whom time’s winged chariot is hurrying a little nearer, drug and alcohol use—and abuse—have surged. And since many have also long since struck coyness from the statute books, sexually transmitted diseases are also spreading. The prevalence of gonorrhoea, to name but one, among Americans aged 55 and up has increased by more than six times since 2010. “
Why people over the age of 55 are the new problem generation The Economist January 2, 2025
Study: Social risk screening by U.S. physicians: Researchers evaluated s social risk screening (food, housing, utilities, interpersonal violence, and transportation) in US physician practices between 2017 and 2022 using the Survey of Healthcare Organizations and Systems. Results:
“ In this cross-sectional study, 3442 practice survey responses were studied. Weighted results showed that in 2022, 27% (95% CI, 23%-32%) of practices reported screening for all 5 of the social risks, an increase from 15% (95% CI, 13%-18%) of practices in 2017 (P < .001). Unadjusted results showed a significant increase in the mean number of social risks screened per practice, from 1.71 (95% CI, 1.60-1.82) in 2017 to 2.34 (95% CI, 2.12-2.55) in 2022. Practice characteristics associated with screening for more social risks remained consistent between 2017 and 2022; these included being a federally qualified health center (incidence rate ratio [IRR], 1.550 [95% CI, 1.336-1.799]) and having higher innovation culture scores (IRR, 1.012 [95% CI, 1.010-1.015]), higher advanced information system scores (IRR, 1.003 [95% CI, 1.001-1.005]), and higher payment reform exposure scores (IRR, 1.002 [95% CI, 1.000-1.003]).
Report: Homelessness in US: “The number of people in the United States experiencing homelessness reached a new record this year, with lingering inflation and high housing prices among likely drivers, a government report said Friday. An estimated 771,480 people were homeless on a single night in January 2024, rising 18% from 2023…. to about 23 in every 10,000 people in the country, home to the world’s biggest economy.
The uptick came as households felt the pressure from housing costs, with the median rent for January 2024 being 20% higher than that in January 2021, according to the National Low Income Housing Coalition. Apart from housing costs, the HUD report flagged “stagnating wages among middle- and lower-income households, and the persisting effects of systemic racism” as other factors. Other contributing issues included natural disasters that displaced people, rising immigration, and an end to homelessness prevention programs introduced during the Covid-19 pandemic.
- Nearly 150,000 children experienced homelessness on a single night this year — a 33% jump over 2023 — the report said. Children under the age of 18 were the age group seeing the biggest surge in homelessness between 2023 and 2024.
- Individuals identifying as Black, African American, or African remain overrepresented among homeless. While people identifying as Black form 12% of the United States’ population, they made up 32% of people experiencing homelessness. Those in families with children saw the biggest single-year rise in homelessness, the report said, adding that migration had “a particularly notable impact on family homelessness.
- Homelessness among veterans, however, fell to the lowest number on record
source
2024 Crime Rate: Per the New York Times Real Time Crime Index for 2024:
- Murders 11/23-10/24, down to 7161—down 16% from 2023.
- Violent crimes: 422, 265
Real-Time Crime Index | Nationwide Crime Data & Trends Real Time Crime Index: New York Times January 1, 2025
2025 Global Medical Trends Survey https://www.wtwco.com/en-ie/insights/2024/10/2025-global-medical-trends-survey
