Nearly 12 million people would lose their health insurance under President Trump’s “big, beautiful bill,” an erosion of the social safety net that would lead to more unmanaged chronic illnesses, higher medical debt and overcrowding of hospital emergency departments.
Why it matters:
The changes in the Senate version of the bill could wipe out most of the health coverage gains made under the Affordable Care Act and slash state support for Medicaid and SNAP.
“We are going back to a place of a lot of uncompensated care and a lot of patchwork systems for people to get care,” said Ellen Montz, a managing director at Manatt Health who oversaw the ACA federal marketplace during the Biden administration.
The big picture:
The stakes are huge for low-income and working-class Americans who depend on Medicaid and subsidized ACA coverage.
Without health coverage, more people with diabetes, heart disease, asthma and other chronic conditions will likely go without checkups and medication to keep their ailments in check.
Those who try to keep up with care after losing insurance will pay more out of pocket, driving up medical debt and increasing the risk of eviction, food insecurity and depleted savings.
Uninsured patients have worse cancer survival outcomes and are less likely to get prenatal care. Medicaid also is a major payer of behavioral health counseling and crisis intervention.
Much of the coverage losses from the bill will come from new Medicaid work reporting requirements, congressional scorekeepers predict. Work rules generally will have to be implemented for coverage starting in 2027, but could be earlier or later depending on the state.
Past experiments with Medicaid work rules show that many eligible people fall through the cracks verifying they’ve met the requirements or navigating new state bureaucracies.
Often, people don’t find out they’ve lost coverage until they try to fill a prescription or see their doctor. States typically provide written notices, but contacts can be out of date.
Nearly 1 in 3 adults who were disenrolled from Medicaid after the COVID pandemic found out they no longer had health insurance only when they tried to access care, per a KFF survey.
Zoom out:
The Medicaid and ACA changes will also affect people who keep their coverage.
The anticipated drop-off in preventive care means the uninsured will be more likely to go to the emergency room when they get sick. That could further crowd already bursting ERs, resulting in even longer wait times.
Changes to ACA markets in the bill, along with the impending expiration of enhanced premium subsidies, may drive healthier people to drop out, Montz said, skewing the risk pool and driving up premiums for remaining enrollees.
States will likely have to make further cuts to their safety-net programs if the bill passes in order to keep state budgets functioning with less federal Medicaid funding.
The other side:
The White House and GOP proponents of the bill say the health care changes will fight fraud, waste and abuse, and argue that coverage loss projections are overblown.
Conservative health care thinkers also posit that there isn’t strong enough evidence that public health insurance improves health.
Reality check:
Not all insurance is created equally, and many people with health coverage still struggle to access care. But the bill’s impact would take the focus off ways to improve the health system, Montz said.
“This is taking us catastrophically backward, where we don’t get to think about the things that we should be thinking about how to best keep people healthy,” she said.
The bottom line:
The changes will unfold against a backdrop of Health Secretary Robert F. Kennedy Jr.’s purported focus on preventive care and ending chronic illness in the U.S.
But American health care is an insurance-based system, said Manatt Health’s Patricia Boozang. Coverage is what unlocks access.
Scrapping millions of people’s health coverage “seems inconsistent with the goal of making America healthier,” she said.
Last Thursday, the Make America Healthy Again Commission released its 68-page report “Making America’s Children Healthy Again Assessment” featuring familiar themes—the inadequacy of attention to chronic disease by the health system, the “over-medicalization” of patient care vis a vis prescription medicines et al, the contamination of the food-supply by harmful ingredients, and more.
HHS Secretary Kennedy, EPA Administrator Zeldin and Agriculture Secretary Rollins pledged war on the corporate healthcare system ‘that has failed the public’ and an all-of-government approach to remedies for burgeoning chronic care needs.
Also Thursday, the House of Representatives passed its budget reconciliation bill by a vote of 215-214. The 1000-page bill cuts federal spending by $1.6 trillion (including $698 billion from Medicaid) and adds $2.3 trillion (CBO estimate/$3.4 to $5 trillion per Yale Budget Lab) to the national deficit over the next decade. It now goes to the Senate where changes to reduce federal spending to pre-pandemic level will be the focus.
With a 53-37 advantage and 22 of the 36 Senate seats facing mid-term election races in November, 2026, the Senate Republican version of the “Big Beautiful Bill” will include more spending cuts while pushing more responsibility to states for funding and additional cuts. The gap between the House and Senate versions will be wider than currently anticipated by House Republicans potentially derailing the White House promise of a final Big Beautiful Bill by July 4.
And, over the last week and holiday weekend, the President announced a new 25% tariff on Apple devices manufactured in India and new tariffs targeting the EU; threatened cuts to federal grants to Harvard and cessation of its non-citizen student enrollment, a ‘get-tougher’ policy on Russia to pressure an end of its Ukraine conflict, and a pledge to Americans on Memorial that it will double down on ‘peace thru strength’ in its Make America Great Again campaign.
These have 2 things in common:
1-They’re incomplete. None is a finished product.
The MAHA Commission, working with the Departments of Health & Human Services, Interior and Agriculture, is tasked to produce another report within 90 days to provide more details about a plan. The FY26 budgeting process is wrought with potholes—how to satisfy GOP deficit hawks vs. centrist lawmakers facing mid-term election, how to structure a bill that triggers sequestration cuts to Medicare (projected $490 billion/10 yrs. per CBO), how to quickly implement Medicaid work requirements and marketplace enrollment cuts that could leave insurance coverage for up to 14 million in limbo, and much more. And the President’s propensity to “flood the zone” with headline-grabbing Truth Social tweets, Executive Orders and provocative rhetoric on matters at home and abroad will keep media occupied and healthcare spending in the spotlight.
2-They play to the MAGA core.
The MAGA core is primarily composed of older, white, Christian men driven by a belief that the United States has lost its exceptionalism through WOKE policies i.e. DEI in workplaces and government, open borders, globalization and excessive government spending and control. In the 2024 Presidential election, the MAGA core expanded incrementally among Black, Hispanic, and younger voters whose concerns about food, energy and housing prices prompted higher-than expected turnout. The MAGA core believes in meritocracy, nationalism, smaller government, lower taxes, local control and free-market policies that encourage private investment in the economy. The core is price sensitive.
The health system per se is not a concern but it’s the affordability and lack of price transparency are. They respect doctors and frontline caregivers but think executives are overpaid and prone to self-promotion. And the MAGA core think lawmakers have been complicit in the system’s lack of financial accountability largely beneficial to elites.
Looking ahead to the summer, a “Big Beautiful Bill” will pass with optics that allow supporters to claim fiscal constraint and lower national debt and opponents to decry insensitive spending cuts and class warfare against low-and-middle-class households.
Federal cuts to Medicaid and SNAP (Supplemental Nutrition Assistance Program) will be prominent targets in both groups—one a portrayal of waste, fraud and abuse and the other tangible evidence of societal inequity and lack of moral purpose. Each thinks the other void of a balanced perspective. Each thinks the health system is underperforming and in need of transformational change but agreement about how to get there unclear.
As MAHA promotes its agenda, Congress passes a budget and MAGA advances its anti-establishment agenda vis a vis DOGE et al, healthcare operators will be in limbo. The dust will settle somewhat this summer, but longer-term bets will be modified for most organizations as compliance risks change, state responsibilities expand, capital markets react and Campaign 2026 unfolds.
And in most households, concern about the affordability of medical care will elevate as federal and state funding cuts force higher out of pocket costs on consumers and demand for lower prices.
The summer will be busy for everyone in healthcare.
PS: Changes in the housing market are significant for healthcare: 36% of the CPI is based on shelter vs. 8% for medical services & products, 14% for food and 6% for energy/transportation. While the overall CPI increased 2.3% in the last 12 months, medical services prices increased 3.1%. contributing to heightened price sensitivity and delayed payments.
It has not escaped lawmaker attention: revenue cycle management business practices (debt collection) are being scrutinized in hospitals and community benefit declarations by not-for-profit hospitals re-evaluated. The economics of healthcare are not immune to broader market trends nor is spending for healthcare in households protected from day-to-day fluctuations in prices for other goods and services.
Medicaid is critical to our nation’s healthcare system, providing necessary care for more than 72 million Americans – including our neighbors and friends.
Who it Affects
Medicaid covers children, seniors in nursing homes, veterans, people with long-term chronic illnesses, those with mental health issues and working families.
The program helps keep Americans healthy at all stages of life, providing healthcare to families in need — especially as the country continues to recover from record-high inflation.
The Problem
Some policymakers are considering Medicaid cuts that would undermine coverage for countless patients and threaten Americans’ access to comprehensive, 24/7 hospital care.
Medicaid covers health services for patients who otherwise wouldn’t be able to pay for care. Coverage of services is essential for hospitals, and helps ensure all Americans have access to high-quality, 24/7 care, no matter where they live.
Who Medicaid covers
Providing Lifesaving Healthcare Services
Medicaid covers patients with complex and chronic illnesses in need of long-term care, as well as emergency services and prescription coverage.
As the nation faces a growing mental health crisis, Medicaid also ensures millions of Americans — including veterans — have access to mental healthcare and substance abuse services.
Without access to affordable mental healthcare through Medicaid, veterans often lack the long-term support they deserve, and are left to deal with complex health issues years after their service.
In these areas, where primary care providers are few and far between, hospitals become even more vital sites of care — and in some cases, the only sites of care available.
Rural hospitals, already more likely to be at risk of closure, rely on Medicaid funding to stay open and to continue providing lifesaving care to their patients. Nearly 150 rural hospitals have closed or converted since 2010 alone. Further cuts to care would eliminate a lifeline for Americans across the country — with devastating consequences for rural communities.
The Solution
Cuts to Medicaid funding will create irreparable harm for our nation’s most vulnerable communities, including millions of children, veterans, those with chronic illnesses, seniors in nursing homes, and working families. Medicaid helps provide security to these Americans, keeping them healthy at every stage of life.
Congress should vote against efforts to reduce Medicaid funding and instead focus on policies that strengthen access to 24/7 care, rather than take it away.
Most Americans believe their healthcare is private, and the majority prefers it that way. Gallup polling shows more Americans favor a system based on private insurance rather than government-run healthcare.
But here’s a surprising reality: 91% of Americans receive government-subsidized healthcare.
Unless you’re among the uninsured or the few who receive no subsidies, government dollars are helping pay your medical bills — whether your insurance comes from an employer, a privately managed care organization or the online marketplace.
Now, as lawmakers face mounting budget pressures, those subsidies (and your coverage) could be at risk. If the government scales back its healthcare spending, your medical costs could skyrocket.
Here’s a closer look at the five ways the U.S. government funds healthcare. If you have health insurance, you’re almost certainly benefiting from one of them:
Medicare, the government-run healthcare program for those 65 and older, covers 67 million Americans at a cost of more than $1 trillion annually. Approximately half of enrollees are covered through the traditional fee-for-service plan and the other half in privately managed Medicare Advantage plans.
Medicaid and CHIP provide health coverage for around 80 million low-income and disabled Americans, including tens of millions of children. Even though 41 states have turned over their Medicaid programs over to privately managed care organizations, the cost remains public. Total Medicaid spending is $900 billion annually — the federal government pays 70% with states footing the rest.
The online healthcare marketplace is for Americans whose employer doesn’t provide medical coverage or who are self-employed. This Affordable Care Act program offers federal subsidies to 92% of its 23 million enrollees, which help lower the cost of premiums and, for many, subsidize their out-of-pocket expenses. The Congressional Budget Office projects that a permanent extension of these subsidies, which are scheduled to end this year, would cost $383 billion over the next 10 years.
Veterans and military families also benefit from government healthcare through TRICARE and VA Care, programs covering roughly 16 million individuals at a combined cost of $148 billion for the federal government annually.
Employer-sponsored health insurance comes with a significant, yet often overlooked, government subsidy. For nearly 165 million American workers and their families, U.S. companies pay the majority of their health insurance premiums. However, those dollars are excluded from employees’ taxable income. This tax break, which originated during World War II and was formally codified in the 1950s, subsidizes workers at an annual government cost of approximately $300 billion. For a typical family of four, this translates into approximately $8,000 per year of added take-home pay.
With 91% of Americans receiving some form of government healthcare assistance, the idea that U.S. healthcare is predominantly “private” is an illusion.
Now, as the new administration searches for ways to rein in the growing federal deficit, all five of these programs (collectively funding healthcare for 9 in 10 Americans) will be in the crosshairs.
Twelve percent of the federal budget already goes toward debt interest payments, and this share is expected to rise sharply. Many of the bonds used to finance existing debt were issued back when interest rates were much lower. As those bonds mature and are refinanced at today’s higher rates, federal interest payments are projected to double within the next decade, according to the Congressional Budget Office.
With deficits mounting and borrowing costs soaring, most economists agree this trajectory is unsustainable. Lawmakers will eventually need to rein in spending, and healthcare subsidies will almost certainly be among the first targets. Policy experts predict Medicaid, which the House has already proposed cutting by $880 billion over the next decade, and ACA subsidies for out-of-pocket costs will likely be the first on the chopping block. But given the CBO’s projections, these cuts won’t be the last.
A Better Way: Three Solutions To Lower Healthcare Costs Without Cuts
Cutting some or all of these healthcare subsidies may seem like the simplest way to reduce the deficit. In reality, it merely shifts costs elsewhere, making medical care more expensive for everyone and increasing future government spending. Here’s why:
Eliminating subsidies doesn’t eliminate the need for care. Under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals must treat emergency patients regardless of their ability to pay. When millions lose insurance, more turn to ERs for medical care they can’t afford. The cost of that uncompensated care doesn’t vanish. It gets passed on to state governments, hospitals and privately insured patients through higher taxes, inflated hospital bills and rising insurance premiums.
Delaying care drives up long-term costs. People who can’t afford doctor visits skip preventive care, screenings and early treatments. Manageable conditions like high blood pressure and diabetes then spiral into costly, life-threatening complications including heart attacks, strokes and kidney failures, which ultimately increase government spending.
The solution isn’t cutting coverage. It’s fixing the root causes of high healthcare costs. Here are three ways to achieve this:
1. Address The Obesity Epidemic
Obesity is a leading driver of diabetes, heart disease, stroke and breast cancer, which kill millions of Americans and cost the U.S. healthcare system hundreds of billions annually. Congress can take two immediate steps to reverse this crisis:
Tax high-calorie, highly processed foods and use the revenue to subsidize healthier options, making nutritious food more affordable for all Americans.
2. Enhance Chronic Disease Management With Technology
In every other industry, broad adoption of generative AI technology is already increasing quality while reducing costs. Healthcare could do the same by applying generative AI to more effectively manage chronic disease. According to the Centers for Disease Control and Prevention, improved control of these lifelong conditions could cut the frequency of heart attacks, strokes, kidney failures and cancers by up to 50%.
With swift and reasonable Food and Drug Administration approval, generative AI and wearable monitors would revolutionize how these conditions are managed, providing real-time updates on patient health and identifying when medications need adjustment. Instead of waiting months for their next in-office visit, patients with chronic diseases would receive continuous monitoring, preventing costly and life-threatening complications. Rather than restricting AI’s role in healthcare, Congress can streamline the FDA’s approval process and allocate National Institutes of Health funding to accelerate these advancements.
3. Reform Healthcare Payment Models
Under today’s fee-for-service system, doctors and hospitals are paid based on the how often they see patients for the same problem and the number of procedures performed. This approach rewards the volume of care, not the best and most effective treatments. A better alternative is a pay-for-value model like capitation, in which providers do best financially when they help keep patients healthy. To encourage participation, Congress should fund pilot programs and create financial incentives for insurers, doctors and hospitals willing to transition to this system. By aligning financial incentives with long-term health, this model would encourage doctors to prioritize prevention and effective chronic disease control, ultimately lowering medical costs by improving overall health.
The Time For Change Is Now
If Congress slashes healthcare subsidies this year, restoring them will be nearly impossible. Once the cuts take effect, the financial and political pressures driving them will only intensify, making reversal unlikely.
The voices shaping this debate can’t come solely from industry lobbyists. Elected officials need to hear from the 91% of Americans who rely on government healthcare assistance for some or all of their medical coverage. Now is the time to speak up.
On August 8, 2014, Walmart announced it would expand on its existing five primary care centers to a total of 12 by the end of the year. These centers would offer more extensive services than those provided in Walmart walk-in clinics, including chronic disease management.
On September 13, 2019, Walmart announced it was opening the first expanded Walmart Health center, which would provide patients with primary care, laboratory, X-ray, EKG, counseling, dental, optical, and hearing services, with the “goal of becoming America’s neighborhood health destination.”
On April 30, 2024, Walmart announced it would close all 51 of its health centers in five states, as well as its virtual care services. “The challenging reimbursement environment and escalating operating costs create a lack of profitability that make the care business unsustainable for us at this time,” Walmart said.
Make no mistake, this announcement is a big deal.
Walmart is the largest retailer in the world, with about $650 billion in annual revenue, 10,500 stores in 19 countries, and 2.1 million employees—nearly 1.6 million in the U.S. alone. Healthcare services were an important corporate goal for Walmart, a goal the company pursued with significant financial investment and talented executives. Walmart’s healthcare strategy was carefully mapped out, with an expanding set of services tested in various formats and locations in Walmart’s formidable geographic and online presence.
Of course, one of Walmart’s goals was to create profit for the company through its foray into healthcare.
However, Walmart’s primary care strategy also held great promise for improving the health of the people Walmart serves, as well as reducing overall healthcare costs. A recent study by researchers at the University of Chicago Booth School of Business and University of Chicago Medicine, focusing on more than 500,000 Medicare beneficiaries, found that regular primary care visits were associated with fewer risk-adjusted ED visits and hospitalizations, lower risk-adjusted expenditures, and greater cost savings. According to the study, results improved as the regularity and continuity of care increased, both of which potentially would have been facilitated by the highly accessible and affordable primary care that Walmart aimed to deliver.
These benefits to patients and communities would have been especially powerful in rural America. Walmart plays a central role in the rural ecosystem, both as an economic and a social center. Ninety percent of the population is located within 10 miles of a Walmart.
Four thousand of Walmart’s stores are located in HRSA-designated medically underserved areas. In a time when rural healthcare providers are struggling to remain viable and healthcare deserts are becoming more problematic, Walmart had a unique opportunity to be, as the company itself said, “the front door of healthcare for all Americans.”
That enormous opportunity to tackle one of the most significant and persistent problems in American healthcare has now been lost.
Walmart is a corporation with a great history, a great reputation, great resources, and great operational abilities. If any company could make primary care work effectively and efficiently on a large scale in this country, it should have been Walmart.
But, after nearly two decades of trying, Walmart couldn’t succeed as a healthcare provider.
We can draw at least three important conclusions from Walmart’s healthcare failure.
Healthcare as a cash business is a very difficult business model. Like other retailers, Walmart focused on healthcare as a cash business, providing high-volume, low-price services that consumers would pay for largely out-of-pocket. Walmart’s healthcare failure strongly indicates that, even with Walmart’s U.S. footprint of 4,615 stores and 255 million weekly customers, the company could not generate the volume necessary at acceptable price points to make cash healthcare profitable.
It is unbelievably hard to work around the fundamental reimbursement model of American healthcare. Unable to make healthcare as a cash business work, the company ran smack into America’s unfriendly reimbursement system as its source of revenue. For Walmart as for many other healthcare providers, the predominant payers were Medicare and Medicaid, which, as every hospital executive experiences every day, do not pay at rates sufficient to cover costs—not a workable situation for a profit-oriented company in a capitalistic economy.
Even a behemoth like Walmart could not manage around the current healthcare expense-to-revenue problem. Walmart is a company with all the tools any company could ask for to drive down operating expenses. It has the potential for economies of scale other companies could only dream of. It has processes for logistical efficiency that are viewed world-wide as a model of excellence. Yet even Walmart was unable to solve that most basic of healthcare economic problems: expenses—including labor, supplies, and drugs—are rising faster than revenue. Relatively few healthcare providers are able to achieve a positive margin in this environment, and for those that do achieve a margin, it is usually razor thin.
Obviously, healthcare’s business fundamentals are hard, and now we can see they are hard not only on traditional healthcare providers but also hard on a $650 billion retail company. These business fundamentals are unlikely to change anytime soon.
Walmart’s primary care failure is not only a disappointment for Walmart, but also for the healthcare ecosystem at large. What Walmart was trying to do was important, and that was establish a comprehensive retail system of primary care. Although Walmart’s effort, at least for the moment, has not worked, this is unlikely to be the end of the line. Hospitals and health systems will continue to experiment, will continue to apply their unique visions, their considerable talents, and their enormous dedication to the goal of finding primary care solutions that work for their communities.
As the Walmart failure demonstrates, the challenge is incredibly difficult. But the game must not be over.
Clinician burnout is a major problem. However, as I pointed out in a previous newsletter post, it is not a distinctly American problem.
A recent report from the Commonwealth Fund compared the satisfaction of primary care physicians in 10 high-income nations. Surprisingly, U.S. doctors ranked in the middle, reporting higher satisfaction rates than their counterparts in the U.K., Germany, Canada, Australia and New Zealand.
A Surprising Insight About Burnout
In self-reported surveys, American doctors link their dissatisfaction to problems unique to the U.S. healthcare system: excessive bureaucratic tasks, clunky computer systems and for-profit health insurance. These problems need to be solved, but to reduce clinician burnout we also need to address another factor that negatively impacts doctors around the globe.
Though national healthcare systems may vary greatly in their structure and financing, clinicians in wealthy nations all struggle to meet the ever-growing demand for medical services. And that’s due to the mounting prevalence and complications of chronic disease.
At the heart of the burnout crisis lies a fundamental imbalance between the volume and complexity of patient health problems (demand) and the amount of time that clinicians have to care for them (supply). This article offers a way to reverse both the surge in chronic illnesses and the ongoing clinician burnout crisis.
Supply vs. Demand: Reframing Burnout
When demand for healthcare exceeds doctors’ capacity to provide it, one might assume the easiest solution is to increase the supply of clinicians. But that outcome remains unlikely so long as the cost increases of U.S. medicine continue to outpace Americans’ ability to afford care.
Whenever healthcare costs exceed available funds, policymakers and healthcare commentators look to rationing. The Oregon Medicaid experiment of the 1990s offers a profound reminder of why this approach fails. Starting in 1989, a government taskforce brought patients and providers together to rank medical services by necessity. The plan was to provide only as many as funding would allow. When the plan rolled out, public backlash forced the state to retreat. They expanded the total services covered, driving costs back up without any improvement in health or any relief for clinicians.
Consumer Culture Can Drive Medical Culture
Ultimately, to reduce burnout, we will have to find a way to decrease clinical demand without raising costs or rationing care.
The best—and perhaps only viable—solution is to embrace technologies that empower patients with the ability to better manage their own medical problems.
American consumers today expect and demanded greater control over their lives and daily decisions. Time and again, technology has made this possible.
Take stock trading, for example. Once the sole domain of professional brokers and financial advisors, today’s online trading platforms give individual investors direct access to the market and a wealth of information to make prudent financial decisions. Likewise, technology transformed the travel industry. Sites like Airbnb and Expedia empowered consumers to book accommodations, flights and travel experiences directly, bypassing traditional travel agents.
Technology will soon democratize medical expertise, as well, giving patients unprecedented access to healthcare tools and knowledge. Within the next five to 10 years, as ChatGPT and other generative AI applications become significantly more powerful and reliable, patients will gain the ability to self-diagnose, understand their diseases and make informed clinical decisions.
Today, clinicians are justifiably skeptical of outsized AI promises. But as technology proves itself worthy, clinicians who embrace and promote patient empowerment will not only improve medical outcomes, but also increase their own professional satisfaction.
Here’s how it can happen:
Empowering Patients With Generative AI
In the United States, health systems (i.e., large hospitals and medical groups) that heavily prioritize preventive medicine and chronic-disease management are home to healthier patients and more satisfied clinicians.
In these settings, patients are 30% to 50% less likely to die from heart attack, stroke and colon cancer than patients in the rest of the nation. That’s because their healthcare organizations provide effective chronic-disease prevention programs and assist patients in managing their diabetes, hypertension, obesity and asthma. As a result, patients experience fewer complications like heart attacks, strokes, and cancer.
Most primary care physicians, however, don’t have the time to accomplish this by themselves. According to one study, physicians would need to work 26.7 hours per day to provide all the recommended preventive, chronic and acute care to a typical panel of 2,500 adult patients.
GenAI technologies like ChatGPT can help lessen the load. Soon, they’ll be able to offer patients more than just general advice about their chronic illnesses. They will give personalized health guidance. By connecting to electronic health records (EHR)—even when those systems are spread across different doctors’ offices—GenAI will be able to analyze a patient’s specific health data to provide tailored prevention recommendations. It will be able to remind patients when they need a health screening, and help schedule it, and even sort out transportation. That’s not something Google or any other online platform can currently do.
Moreover, with new tools (like doctor-designed plugins expected in future ChatGPT updates) and data from fitness trackers and home health monitors, GenAI will be capable of not just displaying patient health data, but also interpreting it in the context of each person’s health history and treatment plans. These tools will be able to provide daily updates to patients with chronic conditions, telling them how they’re doing based on their doctor’s plan.
When the patient’s health data show they’re on the right track, there won’t be a need for an office visit, saving time for everyone. But if something seems off—say, blood pressure readings remain excessively high after the start of anti-hypertensive drugs—clinicians will be able to quickly adjust medications, often without the patient needing to come in. And when in-person visits are necessary, GenAI will summarize patient health information so the doctor can quickly understand and act, rather than starting from scratch.
ChatGPT is already helping people make better lifestyle choices, suggesting diets tailored to individual health needs, complete with shopping lists and recipes. It also offers personalized exercise routines and advice on mental well-being.
Another way generative AI can help is by diagnosing and treating common, non-life-threatening medical problems (e.g., musculoskeletal, allergic or viral issues). ChatGPT and Med-PaLM 2 have already demonstrated the capability in diagnosing a range of clinical issues as effectively and safely as most clinicians. Looking ahead, GenAI’s will offer even greater diagnostic accuracy. When symptoms are worrisome, GenAI will alert patients, speeding up definitive treatment. Its ability to thoroughly analyze symptoms and ask detailed questions without the time pressure doctors feel today will eradicate many of our nation’s 400,000 annual deaths from misdiagnosis.
The outcomes—fewer chronic diseases, fewer heart attacks and strokes and more medical problems solved without an office visit—will decrease demand, giving doctors more time with the patients they see. As a result, clinicians will leave the office feeling more fulfilled and less exhausted at the end of the day.
The goal of enhanced technology use isn’t to eliminate doctors. It’s to give them the time they desperately need in their daily practice, without further increasing already unaffordable medical costs. And rather than eroding the physician-patient bond, the AI-empowered patient will strengthen it, since clinicians will have the time to dive deeper into complex issues when people come to the office.
A More Empowered Patient Is Key To Reducing Burnout
AI startups are working hard to create tools that assist physicians with all sorts of tasks: EHR data entry, organizing office duties and submitting prior authorization requests to insurance companies.
These function will help clinicians in the short run. But any tool that fails to solve the imbalance between supply (of clinician time) and demand (for medical services), will be nothing more than a temporary fix.
Our nation is caught in a vicious cycle of rising healthcare demand, leading to more patient visits per day per doctor, producing higher rates of burnout, poorer clinical outcomes and ever-higher demand. By empowering patients with GenAI, we can start a virtuous cycle in which technology reduces the strain on doctors, allowing them to spend more time with patients who need it most. This will lead to better health outcomes, less burnout for clinicians and further decreases in overall healthcare demand.
Physicians and medical societies have the opportunity to take the lead. They’ll have to educate the public on how to use this technology effectively, assist in connecting it to existing data sources and ensure that the recommendations it makes are reliable and safe. The time to start this process is now.
Published this week in the Washington Post, this unsparing article packages a year of investigative reporting into a thorough accounting of why US life expectancy is undergoing a rapid decline.
After peaking in 2014, US life expectancy has declined each subsequent year, trending far worse than peer countries. In a quarter of US counties, working-age Americans are dying at the highest rates in 40 years, reversing decades of progress. While deaths from firearms and opioids play a role, chronic diseases remain our nation’s greatest killer, erasing more than double the years of life as all overdoses, homicides, suicides, and car accidents combined.
The drivers of this trend are too numerous to list, but experts suggest targeting “the causes of the causes”, namely social factors, as the death rate gap between the rich and poor has grown almost 15x faster than the income gap since 1980.
The Gist: This reporting is a sobering reminder of the responsibilities—and failures—borne by our nation’s healthcare system.
The massive death toll of chronic disease in this country is not an indictment of the care Americans receive, but of the care and other resources they cannot access or afford.
While it’s not the mandate of health systems to reduce systemic issues like poverty, there is no solution to the problem without health systems playing a key role in increasing access to care, while convening community resources in service of these larger goals.
The pandemic accelerated the outpatient shift, which had been progressing steadily for decades, into a new gear, as safety-minded consumers avoided inpatient settings.
Using the latest forecasting data from strategic healthcare consulting firm Sg2, the graphic above illustrates how the outpatient shift will continue to accelerate in the coming years. With each projected to grow by 20 percent or more, outpatient, virtual, and home-based care services will continue far outpace growth in hospital-based care over the next decade.
Ambulatory surgery centers (ASCs) will be at the center of this care shift, reflected by a projected 25 percent rise in ASC volumes by 2032.
The breadth of care available at home will also expand as care delivery technology improves. With the population becoming older and sicker, higher incidence of chronic disease will be met by a rapid expansion of home evaluation and management services (E&M),reflecting a shift away from hospitals and doctors’ offices as hubs for complex care management.
Instead, the patients still coming to hospitals will present with increasingly acute conditions, driving up demand for resource-intensive critical care, as broader inpatient volume remains relatively flat.
Value-based healthcare, the holy grail of American medicine, has three parts: excellent clinical quality, convenient access and affordability for all.
And as with the holy grail of medieval legend, the quest for value-based care has been filled with failure.
In the 20th century, U.S. medical groups and hospital systems could—at best—achieve two elements of value-based care, but always at the sacrifice of the third. Until recently, American medicine lacked the clinical knowhow, technology and operational excellence to accomplish all three, simultaneously. We now have the tools. The only thing missing is “system-ness.”
What Is System-ness?
System-ness is the effective and efficient coordination of healthcare’s many parts: outpatient and inpatient, primary and specialty care, financing and care delivery, prevention and treatment.
By bringing these disparate pieces together within a well-functioning system, healthcare providers have the opportunity to maximize clinical outcomes, weed out waste, lower overall costs and provide greater levels of convenience and access.
Who Are The Search Parties?
In the future, system-ness will be the variable that determines whether healthcare transformation is led by (a) incumbent health systems like Kaiser Permanente and Geisinger Health or (b) the retail giants like Amazon, CVS and Walmart. The latter group has become an ever-growing threat in the healthcare arms race, quickly amassing their own (though still modest) systems of care through billion-dollar acquisitions.
Although both the incumbents and new entrants will struggle to implement value-based care on a national scale, the victor stands to earn hundreds of billions of dollars in added revenue and tens of billions in profits.
To better understand the power of system-ness, and the challenges all organizations will face in providing it, here are three examples of value-based-care solutions implemented successfully by Kaiser Permanente.
1. Preventing Problems, Managing Disease
Research demonstrates that preventive medicine and early intervention reduce heart attacks, strokes and cancer. Yet our nation falls far short in these areas when compared to its global peers.
One example is hypertension, the leading cause of strokes and a major contributor to heart attacks. With help from doctors, nearly all patients can keep high blood pressure under control. Yet, nationally, hypertension is controlled only 60% of the time.
We see similarly poor rates of performance when it comes to prevention and screening for cancers of the colon, breast and lung.
Undoing these troubling trends requires system-ness. In Kaiser Permanente, 90% of patients had their blood pressure controlled and were screened for cancer. Getting there required a comprehensive electronic health record, a willingness for every doctor (regardless of specialty) to focus on prevention, leadership that communicated the value of prevention and a salary structure that rewarded group excellence.
2. Continuous Care, Without Interruption
Most doctors’ offices are open Monday to Friday during normal business hours—only one-fourth of the time that a medical problem might occur.
At night and on weekends, patients have no choice but to visit ERs. There, they often wait hours for care, surrounded by people with communicable diseases. Their non-emergent problems generate bills 12-times higher than if they’d waited to be seen in a doctor’s office.
There’s a better way. In large-enough medical groups, hundreds of clinicians can provide round-the-clock care on a rotating, virtual basis—using video to assess patients and make evidence-based recommendations.
This approach, pioneered by physicians in the Mid-Atlantic Permanente Medical group, solved the patient’s problem immediately 70% of the time without a trip to the ER and, for the other 30%, enabled coordination of medical care with the ER staff.
3. Specialized Medicine, Immediate Attention
When a primary care physician needs added expertise (from a dermatologist, urologist or orthopedist), it’s usually the responsibility of the patient to make their own specialty appointments, check with insurance for coverage and provide their medical records.
This takes hours or days to coordinate and can delay care by weeks, resulting in avoidable complications.
But in a well-structured system, there’s no need to wait. Using telehealth tools at Kaiser Permanente, primary care doctors can connect instantly with dozens of different specialists—often while the patient is still in the exam room. Once connected, the specialist evaluates the patient and provides immediate expertise.
This way, care is not only faster and less expensive, but also better coordinated. Data from within Kaiser Permanente show that these virtual consultations resolve the patient’s problem 40% of the time without having to schedule another appointment. For the other 60%, the diagnostic process can begin immediately.
The Foundations For System-ness
Few organizations in the U.S. can or do offer these system-based improvements. Doing so requires skilled physician leadership, a shift in the financial model and a willingness to accept risk.
In fact, most organizations across the U.S. that claim to operate “value-based” systems actually rely on doctors who are scattered across the community, disconnected from each other and paid on the basis of volume (fee-for-service) rather than value (capitation).
As a result, patient care is fragmented and uncoordinated, leading to repeated tests and ineffective treatments, thus increasing medical costs and compromising medical outcomes.
Value-based care (superior quality, access and affordability) requires teams of clinicians working together as one—all paid on a capitated basis.
Without capitation, dermatologists will insist on seeing every patient in their office where they can bill insurance five-times more than with a tele-dermatology visit. And gastroenterology specialists will insist that all patients have colonoscopy rather than recommending low-risk patients do a safe, convenient, at-home colon cancer screening (called a fecal immunochemical test or “FIT”) at 5% of the cost.
In these cases, individual doctors don’t consciously make care inconvenient for patients. Rather, it is the only choice they have when working in a fee-for-service payment model. Ultimately, system-ness is best achieved when health systems are integrated, prepaid, tech-enabled and physician-led.
Amazon, CVS, Walmart Know About Systems
These three companies are global leaders in “system-ness,” at least in retail. Combined, they have a market cap of $1.88 trillion, employ 3.4 million Americans and are looking to take a slice of U.S. healthcare’s $4.3 trillion annual expenditures.
Already, they manage complex order-entry and fulfillment systems. They use technology to streamline everything from customer service to supply-chain management. They are led through a clear and effective reporting structure.
In terms of competing for healthcare’s holy grail, these are huge competitive advantages compared to today’s uncoordinated, individualized, leaderless healthcare industry.
As retailers vie to bring their system knowhow to American medicine, they are acquiring the pieces needed to compete with the healthcare incumbents. They’ve spent tens of billions of dollars on medical groups that are committed to value-based care (One Medical, Oak Street Health, etc.). They’ve also spent massive sums on home-health companies (Signify) and on pharmacies (PillPak), along with expanding their in-store, at-home and online care options. Many of these care-delivery subsidiaries are focused on Medicare Advantage, the capitated half of Medicare where financial success is dependent on high quality medical care provided at lower cost.
What’s more, all these retailers have a national presence with brick-and mortar facilities in nearly every community in the country—a leg up on nearly every existing health system.
Who Will Win—And Why?
Trying to pick the victor in the battle to transform American medicine at this point is like selecting the winner of a heavy-weight championship boxing match after three evenly matched rounds. Intangibles like stamina, courage and willingness to absorb pain have yet to be tested.
In The Innovator’s Dilemma, the late Clayton Christensen examined historical battles between incumbent organizations and new entrants. After analyzing dozens of industries, he concluded new entrants routinely become the victors because the incumbents move too slowly and fail to embrace the need for major change.
And from that perspective, if I had to wager, I’d put my money on the retail giants.
But there’s an even more worrisome potential outcome: neither those inside nor outside of healthcare will make the necessary investments or accept the risk of leading systemic change. As a result, the movement toward value-based healthcare will stall and die.
In that context, purchasers of healthcare (businesses, the government and patients) will encounter a difficult reality: over the next eight years, medical costs will nearly double, creating an unaffordable and unsustainable scenario. As a result, our nation will likely experience reduced medical coverage, increased rationing, ever-longer delays for care and a growth in health disparities.
If that day arrives, our country will regret its inaction.
At a recent meeting of physician leaders, we sat next to the head of the health system’s bariatric surgery program. Given the recent and rapid uptake of GLP-1 inhibitors like Ozempic and Wegovy, we asked how he thought these drugs, which can generate dramatic weight loss, would affect his practice.
He chuckled, “they’re really good drugs…they could put me out of business!
It’s too early to say if they’ll be effective over a lifetime, but there’s no doubt they’re going to have a huge impact on our work.” It got us thinking about the other reverberations this class of drugs could have on care needs, if a majority of obese Americans had access to them.
Some effects are obvious.
We could see significant declines in treatment needs for chronic diseases like obesity and heart failure, for which obesity is a strong risk factor. Given that obese patients are much more likely to need joint replacement surgery, we could see a big hit to that demand—although some patients who are poor candidates for surgery because of weight-related complications could become eligible.
Even longer-term, if American’s aren’t dying of chronic disease, we’ll still die of something, so expect diseases of advanced age, like Alzheimer’s and many cancers, to increase. Other pharmaceutical innovations, like the growth of immunotherapy and more targeted cancer treatments, also have the potential to radically alter how disease is managed.
We may be at the beginning of another wave of disruptive medical innovation on the order of the introduction of statins in the 1990s, which combined with minimally invasive catheterization, slashed the need for bypass surgery.
Given their sky-high prices, it’s too soon to tell how quickly the use of these new obesity drugs will grow, but innovations like these will serve to pull more care out of hospitals and into less invasive outpatient medical management.
HENRY KOTULA 