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.
Five years ago, I started the Fixing Healthcare podcast with the aim of spotlighting the boldest possible solutions—ones that could completely transform our nation’s broken medical system.
But since then, rather than improving, U.S. healthcare has fallen further behind its global peers, notching far more failures than wins.
In that time, the rate of chronic disease has climbed while life expectancy has fallen, dramatically. Nearly half of American adults now struggle to afford healthcare. In addition, a growing mental-health crisis grips our country. Maternal mortality is on the rise. And healthcare disparities are expanding along racial and socioeconomic lines.
Reflecting on why few if any of these recommendations have been implemented, I don’t believe the problem has been a lack of desire to change or the quality of ideas. Rather, the biggest obstacle has been the immense size and scope of the changes proposed.
To overcome the inertia, our nation will need to narrow its ambitions and begin with a few incremental steps that address key failures. Here are three actionable and inexpensive steps that elected officials and healthcare leaders can quickly take to improve our nation’s health:
1. Shore Up Primary Care
Compared to the United States, the world’s most-effective and highest-performing healthcare systems deliver better quality of care at significantly lower costs.
One important difference between us and them: primary care.
In most high-income nations, primary care makes up roughly half of the physician workforce. In the United States, it accounts for less than 30% (with a projected shortage of 48,000 primary care physicians over the next decade).
Primary care—better than any other specialty—simultaneously increases life expectancy while lowering overall medical expenses by (a) screening for and preventing diseases and (b) helping patients with chronic illness avoid the deadliest and most-expensive complications (heart attack, stroke, cancer).
But considering that it takes at least three years after medical school to train a primary care physician, to make a dent in the shortage over the next five years the U.S. government must act immediately:
The first action is to expand resident education for primary care. Congress, which authorizes the funding, would allocate $200 million annually to create 1,000 additional primary-care residency positions each year. The cost would be less than 0.2% of federal spending on healthcare.
The second action requires no additional spending. Instead, the Centers for Medicare & Medicaid Services, which covers the cost of care for roughly half of all American adults, would shift dollars to narrow the $108,000 pay gap between primary care doctors and specialists. This will help attract the best medical students to the specialty.
Together, these actions will bolster primary care and improve the health of millions.
2. Use Technology To Expand Access, Lower Costs
A decade after the passage of the Affordable Care Act, 30 million Americans are without health insurance while tens of millions more are underinsured, limiting access to necessary medical care.
Furthermore, healthcare is expected to become even less affordable for most Americans. Without urgent action, national medical expenditures are projected to rise from $4.3 trillion to $7.2 trillion over the next eight years, and the Medicare trust fund will become insolvent.
With costs soaring, payers (businesses and government) will resist any proposal that expands coverage and, most likely, will look to restrict health benefits as premiums rise.
Almost every industry that has had to overcome similar financial headwinds did so with technology. Healthcare can take a page from this playbook by expanding the use of telemedicine and generative AI.
At the peak of the Covid-19 pandemic, telehealth visits accounted for 69% of all physician appointments as the government waived restrictions on usage. And, contrary to widespread fears at the time, patients and doctors rated the quality, convenience and safety of these virtual visits as excellent. However, with the end of Covid-19, many states are now restricting telemedicine, particularly when clinicians practice in a different state than the patient.
To expand telemedicine use—both for physical and mental health issues—state legislators and regulators will need to loosen restrictions on virtual care. This will increase access for patients and diminish the cost of medical care.
It doesn’t make sense that doctors can provide treatment to people who drive across state lines, but they can’t offer the same care virtually when the individual is at home.
Similarly, physicians who faced a shortage of hospital beds during the pandemic began to treat patients in their homes. As with telemedicine, the excellent quality and convenience of care drew praise from clinicians and patients alike.
Building on that success, doctors could combine wearable devices and generative AI tools like ChatGPT to monitor patients 24/7. Doing so would allow physicians to relocate care—safely and more affordably—from hospitals to people’s homes.
Translating this technology-driven opportunity into standard medical practice will require federal agencies like the FDA, NIH and CDC to encourage pilot projects and facilitate innovative, inexpensive applications of generative AI, rather than restricting their use.
3. Reduce Disparities In Medical Care
American healthcare is a system of haves and have-nots, where your income and race heavily determine the quality of care you receive.
Black patients, in particular, experience poorer outcomes from chronic disease and greater difficulty accessing state-of-the-art treatments. In childbirth, black mothers in the U.S. die at twice the rate of white women, even when data are corrected for insurance and financial status.
Generative AI applications like ChatGPT can help, provided that hospitals and clinicians embrace it for the purpose of providing more inclusive, equitable care.
Previous AI tools were narrow and designed by researchers to mirror how doctors practiced. As a result, when clinicians provided inferior care to Black patients, AI outputs proved equally biased. Now that we understand the problem of implicit human bias, future generations of ChatGPT can help overcome it.
The first step will be for hospitals leaders to connect electronic health record systems to generative AI apps. Then, they will need to prompt the technology to notify clinicians when they provide insufficient care to patients from different racial or socioeconomic backgrounds. Bringing implicit bias to consciousness would save the lives of more Black women and children during delivery and could go a long way toward reversing our nation’s embarrassing maternal mortality rate (along with improving the country’s health overall).
The Next Five Years
Two things are inevitable over the next five years. Both will challenge the practice of medicine like never before and each has the potential to transform American healthcare.
First, generative AI will provide patients with more options and greater control. Faced with the difficulty of finding an available doctor, patients will turn to chatbots for their physical and psychological problems.
Already, AI has been shown to be more accurate in diagnosing medical problems and even more empathetic than clinicians in responding to patient messages. The latest versions of generative AI are not ready to fulfill the most complex clinical roles, but they will be in five years when they are 30-times more powerful and capable.
Second, the retail giants (Amazon, CVS, Walmart) will play an ever-bigger role in care delivery. Each of these retailers has acquired primary care, pharmacy, IT and insurance capability and all appear focused on Medicare Advantage, the capitated option for people over the age of 65. Five years from now, they will be ready to provide the businesses that pay for the medical coverage of over 150 million Americans the same type of prepaid, value-based healthcare that currently isn’t available in nearly all parts of the country.
American healthcare can stop the current slide over the next five years if change begins now. I urge medical leaders and elected officials to lead the process by joining forces and implementing these highly effective, inexpensive approaches to rebuilding primary care, lowering medical costs, improving access and making healthcare more equitable.
Albert Einstein determined that time is relative. And when it comes to healthcare, five years can be both a long and a short amount of time.
In August 2018, I launched the Fixing Healthcare podcast. At the time, the medium felt like the perfect auditory companion to the books and articles I’d been writing. By bringing on world-renowned guests and engaging in difficult but meaningful discussions, I hoped the show would have a positive impact on American medicine. After five years and 100 episodes, now is an opportune time to look back and examine how healthcare has improved and in what ways American medicine has become more problematic.
Here’s a look at the good, the bad and the ugly since episode one of Fixing Healthcare:
The Good
Drug breakthroughs and government actions headline medicine’s biggest wins over the past five years.
At first, health experts expressed doubts that Pfizer, Moderna and others could create a safe and effective Covid-19 vaccine with messenger RNA (mRNA) technology. After all, no one had succeeded in more than two decades of trying.
Thanks in part to Operation Warp Speed, the government-funded springboard for research, our nation produced multiple vaccines within less than a year. Previously, the quickest vaccine took four years to develop (mumps). All others required a minimum of five years.
The vaccines were pivotal in ending the coronavirus pandemic, and their success has opened the door to other life-saving drugs, including those that might prevent or fight cancer. And, of course, our world is now better prepared for when the next viral pandemic strikes.
Weight-Loss Drugs
Originally designed to help patients manage Type 2 diabetes, drugs like Ozempic have been helping people reverse obesity—a condition closely correlated with diabetes, heart disease and cancer.
For decades, America’s $150 billion a year diet industry has failed to curb the nation’s continued weight gain. So too have calls for increased exercise and proper nutrition, including restrictions on sugary sodas and fast foods.
In contrast, these GLP-1 medications are highly effective. They help overweight and obese people lose 15 to 25 pounds on average with side effects that are manageable for nearly all users.
The biggest stumbling block to their widespread use is the drug’s exorbitant price (upwards of $16,000 for a year’s supply).
Drug-Pricing Laws
With the Inflation Reduction Act of 2022, Congress took meaningful action to lower drug prices, a move the CBO estimates would reduce the federal deficit by $237 billion over 10 years.
It’s a good start. Americans today pay twice as much for the same medications as people in Europe largely because of Congressional legislation passed in 2003.
That law, the Medicare Prescription Drug Price Negotiation Act, made it illegal for Health and Human Services (HHS) to negotiate drug prices with manufacturers—even for the individuals publicly insured through Medicare and Medicaid.
Now, under provisions of the new Inflation Reduction Act, the government will be able to negotiate the prices of 10 widely prescribed medications based on how much Medicare’s Part D program spends. The lineup is expected to include prescription treatments for arthritis, cancer, asthma and cardiovascular disease. Unfortunately, the program won’t take effect until 2026. And as of now, several legal challenges from both drug manufacturers and the U.S. Chamber of Commerce are pending.
The Bad
Spiking costs, ongoing racial inequalities and millions of Americans without health insurance make up three disappointing healthcare failures of the past five years.
Cost And Quality
The U.S. spends nearly twice as much on healthcare per citizen as other countries, yet our nation lags 10 of the wealthiest countries in medical performance and clinical outcomes. As a result, Americans die younger and experience more complications from chronic diseases than people in peer nations.
As prices climb ever-higher, at least half of Americans can’t afford to pay their out-of-pocket medical bills, which remain the leading cause of U.S. bankruptcy. And with rising insurance premiums alongside growing out-of-pocket expenses, more people are delaying their medical care and rationing their medications, including life-essential drugs like insulin. This creates a vicious cycle that will likely prolong today’s healthcare problems well into the future.
Health Disparities
Inequalities in American medicine persist along racial lines—despite action-oriented words from health officials that date back decades.
Today, patients in minority populations receive unequal and inequitable medical treatment when compared to white patients. That’s true even when adjusting for differences in geography, insurance status and socioeconomics.
Racism in medical care has been well-documented throughout history. But the early days of the Covid-19 pandemic provided several recent and deadly examples. From testing to treatment, Black and Latino patients received both poorer quality and less medical care, doubling and even tripling their chances of dying from the disease.
The problems can be observed across the medical spectrum. Studies show Black women are still less likely to be offered breast reconstruction after mastectomy than white women. Research also finds that Black patients are 40% less likely to receive pain medication after surgery. Although technology could have helped to mitigate health disparities, our nation’s unwillingness to acknowledge the severity of the problem has made the problem worse.
Uninsurance
Although there are now more than 90 million Americans enrolled in Medicaid, there are still 30 million people without any health insurance. This disturbing reality comes a full decade after the passage of the Affordable Care Act.
On Capitol Hill, there is no plan in place to reduce the number of uninsured.
Moreover, many states are looking to significantly rollback their Medicaid enrollment in the post-Covid era. Kaiser Family Foundation estimates that between 8 million and 24 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provisions implemented during the pandemic. Without coverage, people have a harder time obtaining the preventive services they need and, as a result, they suffer more chronic diseases and die younger.
The Ugly
An overall decrease in longevity, along with higher maternal mortality and a worsening mental-health crisis, comprise the greatest failures of U.S. healthcare over the past five years.
Life Expectancy
Despite radical advances in medical science over the past five years, American life expectancy is back to where it was at the turn of the 20th century, according to CDC data.
Alongside environmental and social factors are a number of medical causes for the nation’s dip in longevity. Research demonstrated that many of the 1 million-plus Covid-19 deaths were preventable. So, too, was the nation’s rise in opioid deaths and teen suicides.
Regardless of exact causation, Americans are living two years less on average than when we started the Fixing Healthcare podcast five years ago.
Maternal Mortality
Compared to peer nations, the United States is the only country with a growing rate of mothers dying from childbirth. The U.S. experiences 17.4 maternal deaths per 100,000 live births. In contrast, Norway is at 1.8 and the Netherlands at 3.0.
The risk of dying during delivery or in the post-partum period is dramatically higher for Black women in the United States. Even when controlling for economic factors, Black mothers still suffer twice as many deaths from childbirth as white women.
And with growing restrictions on a woman’s right to choose, the maternal mortality rate will likely continue to rise in the United States going forward.
Mental Health
Finally, the mental health of our country is in decline with rates of anxiety, depression and suicide on the rise.
These problems were bad prior to Covid-19, but years of isolation and social distancing only aggravated the problem. Suicide is now a leading cause of death for teenagers. Now, more than 1 in every 1,000 youths take their own lives each year. The newest data show that suicides across the U.S. have reached an all-time high and now exceed homicides.
Even with the expanded use of telemedicine, mental health in our nation is likely to become worse as Americans struggle to access and afford the services they require.
The Future
In looking at the three lists, I’m reminded of a baseball slugger who can occasionally hit awe-inspiring home runs but strikes out most of the time. The crowd may love the big hitter and celebrate the long ball, but in both baseball and healthcare, failing at the basics consistently results in more losses than wins.
Over the past five years, American medicine has produced a losing record. New drugs and surgical breakthroughs have made headlines, but the deeper, more systemic failures of American healthcare have rarely penetrated the news cycle.
If our nation wants to make the next five years better and healthier than the last five, elected officials and healthcare leaders will need to make major improvements. The steps required to do so will be the focus of my next article.
Five recent Supreme Court rulings have reset the context for U.S. jurisprudence for years to come and open a can of worms for healthcare operators.
Last year’s SCOTUS decision ruling in Dobbs v. Jackson Women’s Health (June 24, 2022) set the tone: in its 6-3 decision, the high court determined that that access to abortion is a state issue, not federal thus nullifying the 50-year-old legal precedent in Roe v. Wade and reversing 2 lower court rulings.
On June 1, 2023, in the United States v. Supervalu, petitioners sued SuperValu and Safeway under the False Claims Act (FCA) alleging they defrauded the Medicare and Medicaid by knowingly filing false claims. Essentially, the plaintiffs sought financial remedy because the retailers’ prices were not explicitly and specifically “usual and customary” prices. In its unanimous ruling, SCOTUS agreed that “the phrase ‘usual and customary’ is open to interpretation, but reasoned that “such facial ambiguity alone is not sufficient to preclude a finding that respondents knew their claims were false.”
On June 29, 2023, in Students for Fair Admissions, Inc. v. President and Fellows of Harvard College, the court ruled 6-3 that affirmative action policies at Harvard and the University of NC that consider an applicant’s race in college admissions are unconstitutional.
On June 30, 2023, in 303 Creative LLC v. Elenis (June 30, 2023) By a vote of 6-3, SCOTUS ruled that the First Amendment right of free speech prohibits Colorado from forcing a website designer to create expressive designs speaking messages with which the designer disagrees.
On June 30, 2023, in Department of Education v. Brown: By a unanimous vote, SCOTUS ruled that the 2 plaintiffs lacked standing to “Article III standing to assert a procedural challenge to the student-loan debt-forgiveness plan adopted by the Secretary of Education pursuant to Higher Education Relief Opportunities for Students Act of 2003 (HEROES Act).” In effect, the court vacated and remanded the judgment of the United States Court of Appeals for the 5th Circuit because it felt Myra Brown and Alexander Taylor (plaintiffs) did not prove that any injury suffered from not having their loans forgiven. Therefore, the court had no jurisdiction to address their procedural claim.
Each of these is specific to a circumstance but collectively they expose industries like healthcare to greater compliance risk, potential court challenges and operational complexity. Here’s an example:
The 58-year-old Kennedy-era legal precedent of affirmative action to redress racial inequity was the focus in Students for Fair Admissions, Inc. v. President and Fellows of Harvard College. SCOTUS essentially sided with plaintiffs who argued affirmative action violates the 14th Amendment’s Equal Protection guarantee. In healthcare, research shows access to the healthcare system is disproportionately inaccessible to persons of color, especially if they’re poor. They improve when individuals are treated by clinicians of the same race but only about 5% of doctors in America are Black, compared to 12% of the general population and only 6% of doctors in the U.S. are Hispanic while the group accounts for nearly almost 20% of the general population.
Notwithstanding the uncanny similarities between higher education and healthcare (both have raised prices above GDP and overall inflation rates for 2 decades, both jealously protect their reputations against outside transparency and unflattering report cards, both feature competition between public and private institutions and both face questions about the value of their efforts), the issue of diversity is central in both. Affirmative action is a means to that end, but at least for now and in higher education, it’s not constitutional.
Might workforce diversity and clinician training efforts be stymied by the prospect of court challenges? Might “affirmative action” in healthcare be replaced by “holistic review” to enable consideration of an applicant’s life or quality of character as some conservative jurists have suggested?
My take:
Affirmative action per the example above is only one of many constructs widely accepted in healthcare today where court challenges may alter the future. Individual rights and free speech including online medical advice, the role of state governments, fraud and abuse and other domains are equally exposed.
It’s clear this court is not threatened by legal precedent nor cautious about public opinion on touchy issues. Thus, immediate imperatives for healthcare organizations are these:
Revisit legal precedents on which the ways we operate are based: Roles and responsibilities in US healthcare are sacrosanct and protected by legal precedent: Physicians diagnose and treat; others don’t. Insurers pay claims but don’t practice medicine. Not for profit hospitals serve community needs in exchange for tax-exemption. Public health programs that serve the poor are funded by local and state governments. Employer sponsored benefits underwrite the system’s profitability and fund its hospital Part A obligations and so on. Might a conservative court revisit these in the context of the constitution’s “general welfare” purpose and redirect its focus, roles and structure?
Revisit terms and phrases where consensus is presumed but specific definition is lacking: Just as SCOTUS recognized ambiguity in applying terms like “usual and customary” in its Supervalu-Safeway ruling, it is likely to challenge other widely used phrases used in healthcare that often lack specific referents i.e., quality, safety, efficacy, effectiveness, community benefit, charity care, evidence-based care, cost-effectiveness, not-for-profit, competition, value” and many others. Might SCOTUS force the industry to more specifically define its most widely used phrases in order to justify its claims?
For everyone in healthcare, these rulings open a can of worms. Compliance risk assessments, scenario plan updates required!
A health insurer launched a pilot program that takes aim at food insecurity in addressing the healthcare needs of beneficiaries—the first time that’s ever happened, according to those who spearheaded the effort.
Kaiser Permanente and Geisinger Health Plan have also used a food-as-medicine approach in attempting to improve health outcomes, but here’s the difference: They are integrated health systems that own their own hospitals and physician practices, while Blue Cross and Blue Shield of North Carolina is not.
Blue Cross NC unveiled data published in NEJM Catalyst about its proof-of-concept pilot program that involved delivering food to individuals in Affordable Care Act plans who suffer from Type 2 diabetes as well as connecting them with health advisers. Despite the success of the effort, the findings included many caveats that suggest that it could be some time before the pilot program evolves and lands a spot on the insurer’s roster of benefits packages.
Still, the authors called it a good first step that underscores great potential.
They also noted that “payers are in a unique position to integrate food-as-medicine interventions into more sustainable financial models. As a payer, the business case needs to be made for offering products and services that address the food and nutritional needs of its members.”
More than 600,000 North Carolina residents struggle to put food on the table, with the state ranking as the tenth hungriest in the country. The pilot’s results come at a time when the expansion of food-aid programs because of the COVID-19 pandemic has run out and inflation is driving up the price of groceries.
Blue Cross NC’s program was launched in December 2020, and invitations to eligible beneficiaries were sent out in January 2021. The insurer hired the digital health coaching vendor Pack Health, a division of Quest Diagnostics, to help administer the program.
A typical box of food could include salmon, carrots, beans, rice, pasta, sauce, applesauce, milk and crushed tomatoes. Deliveries included easy-to-make recipes, according to the study.
Blue Cross NC researchers compared the results of surveys at three and six months to baseline metrics. The surveys measured physical and mental health, body mass index, hemoglobin A1c levels, self-reported food security and member satisfaction.
They also looked at medical expenses for the 555 “completes,” those who finished the program, and the 327 “partials.” Completes received 12 boxes of food and six months of coaching. Partials received six to 11 boxes of food and three to five months of coaching but dropped out of the program.
Most participants (81%) were satisfied with the frequency of food delivery as well as the amount of food delivered (82%).
Food insecurity for the completes dipped from 38% to 20%, BMI (35 kg/m2 to 33 kg/m2) and obesity (72% to 61%). Completes saw an increase in individuals who reached the U.S. average for physical health measures (51% to 65%) and mental health measures (70% to 80%).
In addition, completes saw a $139 reduction per member per month in total medical costs and an increase of $8 per member per month in pharmacy costs, which the researchers interpreted as evidence of greater medication adherence.
Partials, meanwhile, saw a decrease of $10 per member per month in pharmacy costs, but an increase in all other cost types.
“The relative number of partials responding to the 3- and 6-month surveys was low; therefore, we do not discuss the 6-month results of this group, nor do we attempt to draw meaningful conclusions regarding differences across participation groups,” the study said.
Nonetheless, researchers estimate that if the program becomes available to all eligible beneficiaries, it could cut medical expenses by as much as $8.5 million to $13.1 million a year.
“These findings highlight that an upfront investment by an insurer can help improve health outcomes,” according to a Blue Cross NC spokesperson. “The food delivery and health coaching pilot program is one of a series focused on long-term strategies for eliminating health disparities, strengthening communities and making health care more affordable, accessible and easier to navigate for all North Carolinians.”
In April 2021, the health plan unveiled partnerships with state organizations including Benefits Data Trust, Manna Food Bank, Food Bank of Central & Eastern North Carolina and Second Harvest Food Bank of Northwest NC that focused on trying to boost enrollment in the Supplemental Nutrition Assistance Program.
“With an initial focus on food security, the insurer is advancing its work to promote health equity with new prevention programs and value-added services,” Blue Cross NC said in a statement at the time. “Beyond just offering these services for members, the insurer is also measuring their impact. This research will identify which steps will be effective long-term strategies for eliminating health disparities, strengthening communities, developing impactful member products, and reducing health care costs for North Carolinians.”
Researchers also note that the results from its food delivery and health coaching program published in NEJM Catalyst are far from conclusive, and further study needs to be done.
“Because all program participants received health coaching, the design makes it impossible to disentangle the effects of the food delivery component from those of the health coaching,” the study states. “Interaction with the [health adviser] was regular, with program participants and [health advisers] communicating at least once per week by telephone and six to seven times per week via text message.”
In addition, researchers want to evaluate whether the gains seen in a six-month period could be sustained over the long haul and what effect greater member participation might have on the program’s sustainability.
“Analyses are planned to evaluate the long-term impact of the … program,” the study states.
President Joe Biden last night highlighted several healthcare priorities during his State of the Union address, including efforts to reduce drug costs, a universal cap on insulin prices, healthcare coverage, and more.
COVID-19
In his speech, Biden acknowledged the progress the country has made with COVID-19 over the last few years.
“Two years ago, COVID had shut down our businesses, closed our schools, and robbed us of so much,” he said. “Today, COVID no longer controls our lives.”
Although Biden noted that the COVID-19 public health emergency (PHE) will come to an end soon, he said the country should remain vigilant and called for more funds from Congress to “monitor dozens of variants and support new vaccines and treatments.”
The Inflation Reduction Act
Biden highlighted several provisions of the Inflation Reduction Act (IRA), which passed last year, that aim to reduce healthcare costs for millions of Americans.
“You know, we pay more for prescription drugs than any major country on earth,” he said. “Big Pharma has been unfairly charging people hundreds of dollars — and making record profits.”
Under the IRA, Medicare is now allowed to negotiate the prices of certain prescription drugs, and out-of-pocket drug costs for Medicare beneficiaries are capped at $2,000 per year. Insulin costs for Medicare beneficiaries are also capped at $35 a month.
“Bringing down prescription drug costs doesn’t just save seniors money,” Biden said. “It will cut the federal deficit, saving tax payers hundreds of billions of dollars on the prescription drugs the government buys for Medicare.”
Caps on insulin costs for all Americans
Although the IRA limits costs for seniors on Medicare, Biden called for the policy to be made universal for all Americans. According to a 2022 study, over 1.3 million Americans skip, delay purchasing, or ration their insulin supply due to costs.
“[T]here are millions of other Americans who are not on Medicare, including 200,000 young people with Type I diabetes who need insulin to save their lives,” Biden said. “… Let’s cap the cost of insulin at $35 a month for every American who needs it.”
With the end of the COVID-19 PHE, HHS estimates that around 15 million people will lose health benefits as states begin the process to redetermine eligibility.
The opioid crisis
Biden also addressed the ongoing opioid crisis in the United States and noted the impact of fentanyl, in particular.
“Fentanyl is killing more than 70,000 Americans a year,” he said. “Let’s launch a major surge to stop fentanyl production, sale, and trafficking, with more drug detection machines to inspect cargo and stop pills and powder at the border.”
He also highlighted efforts by to expand access to effective opioid treatments. According to a White House fact sheet, some initiatives include expanding access to naloxone and other harm reduction interventions at public health departments, removing barriers to prescribing treatments for opioid addiction, and allowing buprenorphine and methadone to be prescribed through telehealth.
Access to abortion
In his speech, Biden called on Congress to “restore” abortion rights after the U.S. Supreme Court overturned Roe v. Wade last year.
“The Vice President and I are doing everything we can to protect access to reproductive healthcare and safeguard patient privacy. But already, more than a dozen states are enforcing extreme abortion bans,” Biden said.
He also added that he will veto a national abortion ban if it happens to pass through Congress.
Progress on cancer
Biden also highlighted the Cancer Moonshot, an initiative launched last year aimed at advancing cancer treatment and prevention.
“Our goal is to cut the cancer death rate by at least 50% over the next 25 years,” Biden said. “Turn more cancers from death sentences into treatable diseases. And provide more support for patients and families.”
According to a White House fact sheet, the Cancer Moonshot has created almost 30 new federal programs, policies, and resources to help increase screening rates, reduce preventable cancers, support patients and caregivers and more.
“For the lives we can save and for the lives we have lost, let this be a truly American moment that rallies the country and the world together and proves that we can do big things,” Biden said. “… Let’s end cancer as we know it and cure some cancers once and for all.”
Healthcare coverage
Biden commended the fact that “more American have health insurance now than ever in history,” noting that 16 million people signed up for plans in the Affordable Care Act marketplace this past enrollment period.
In addition, Biden noted that a law he signed last year helped millions of Americans save $800 a year on their health insurance premiums. Currently, this benefit will only run through 2025, but Biden said that we should “make those savings permanent, and expand coverage to those left off Medicaid.”
Advisory Board’s take
Our questions about the Medicaid cliff
President Biden extolled economic optimism in the State of the Union address, touting the lowest unemployment rate in five decades. With job creation on the rise following the incredible job losses at the beginning of the COVID-19 pandemic, there is still a question of whether the economy will continue to work for those who face losing Medicaid coverage at some point in the next year.
The public health emergency (PHE) is scheduled to end on May 11. During the PHE, millions of Americans were forced into Medicaid enrollment because of job losses. Federal legislation prevented those new enrollees from losing medical insurance. As a result, the percentage of uninsured Americans remained around 8%. The safety net worked.
Starting April 1, state Medicaid plans will begin to end coverage for those who are no longer eligible. We call that the Medicaid Cliff, although operationally, it will look more like a landslide. Currently, state Medicaid regulators and health plans are still trying to figure out exactly how to manage the administrative burden of processing millions of financial eligibility records. The likely outcome is that Medicaid rolls will decrease exponentially over the course of six months to a year as eligibility is redetermined on a rolling basis.
In the marketplace, there is a false presumption that all 15 million Medicaid members will seamlessly transition to commercial or exchange health plans. However, families with a single head of household, women with children under the age of six, and families in both very rural and impoverished urban areas will be less likely to have access to commercial insurance or be able to afford federal exchange plans. Low unemployment and higher wages could put these families in the position of making too much to qualify for Medicaid, but still not making enough to afford the health plans offered by their employers (if their employer offers health insurance). Even with the expansion of Medicaid and exchange subsidies, it, is possible that the rate of uninsured families could rise.
For providers, this means the payer mix in their market will likely not return to the pre-pandemic levels. For managed care organizations with state Medicaid contracts, a loss of members means a loss of revenue. A loss of Medicaid revenue could have a negative impact on programs built to address health equity and social determinants of health (SDOH), which will ultimately impact public health indicators.
For those of us who have worked in the public health and Medicaid space, the pandemic exposed the cracks in the healthcare ecosystem to a broader audience. Discussions regarding how to address SDOH, health equity, and behavioral health gaps are now critical, commonplace components of strategic business planning for all stakeholders across our industry’s infrastructure.
But what happens when Medicaid enrollment drops, and revenues decrease? Will these discussions creep back to the “nice to have” back burners of strategic plans?
Welcome to Friday’s Health 202, where today we have a special spotlight on the pandemic two years in.
🚨 The federal government is about to be funded. The Senate sent the long-term spending bill to President Biden’s desk last night after months of intense negotiations.
Two years since the WHO declared a pandemic, what health-care system changes are here to stay?
Nurses screened patients at a drive-through testing site in March 2020. (Win McNamee/Getty Images)
Exactly two years ago, the World Health Organizationdeclared the coronavirus a pandemic and much of American life began grinding to a halt.
That’s when the health-care system, which has never been known for its quickness, sped up. The industry was forced to adapt, delivering virtual care and services outside of hospitals on the fly. Yet, the years-long pandemic has exposed decades-old cracks in the system, and galvanized efforts to fix them.
Today, as coronavirus cases plummet and President Biden says Americans can begin resuming their normal lives, we explore how the pandemic could fundamentally alter the health-care system for good. What changes are here to stay — and what barriers are standing in the way?
A telehealth boom
What happened: Telehealth services skyrocketed as doctors’ offices limited in-person visits amid the pandemic. The official declaration of a public health emergency eased long-standing restrictions on these virtual services, vastly expanding Medicare coverage.
But will it stick? Some of these changes go away whenever the Biden administration decides not to renew the public health emergency (PHE). The government funding bill passed yesterday extends key services roughly five months after the PHE ends, such as letting those on Medicare access telehealth services even if they live outside a rural area.
But some lobbyists and lawmakers are pushing hard to make such changes permanent. Though the issue is bipartisan and popular, it could be challenging to pass unless the measures are attached to a must-pass piece of legislation.
“Even just talking to colleagues, I used to have to spend three or four minutes while they were trying desperately not to stare at their phone and explain to them what telehealth was … remote patient monitoring, originating sites, and all this wonky stuff,”said Sen. Brian Schatz (D-Hawaii), a longtime proponent of telehealth.
“Now I can go up to them and say, ‘So telehealth is great, right?’ And they say, ‘yes, it is.’ ”
A new spotlight on in-home care
What happened: The infectious virus tore through nursing homes, where often fragile residents share rooms and depend on caregivers for daily tasks. Ultimately, nearly 152,000 residents died from covid-19.
The devastation has sparked a rethinking of where older adults live and how they get the services they need — particularly inside their own homes.
“That is clearly what people prefer,” said Gail Wilensky, an economist at Project HOPE who directed the Medicare and Medicaid programs under President George H.W. Bush. “The challenge is whether or not it’s economically feasible to have that happen.”
More money, please: Finding in-home care — and paying for it — is still a struggle for many Americans. Meanwhile, many states have lengthy waitlists for such services under Medicaid.
Experts say an infusion of federal funds is needed to give seniors and those with disabilities more options for care outside of nursing homes and assisted-living facilities.
For instance, Biden’s massive social spending bill included tens of billions of dollars for such services. But the effort has languished on Capitol Hill, making it unclear when and whether additional investments will come.
A reckoning on racial disparities
What happened: Hispanic, Black, and American Indian and Alaska Native people are about twice as likely to die from covid-19 than White people. That’s according to age-adjusted data from a recent Kaiser Family Foundation report.
In short, the coronavirus exposed the glaring inequities in the health-care system.
“The first thing to deal with any problem is awareness,” said Georges Benjamin, the executive director of the American Public Health Association. “Nobody can say that they’re not aware of it anymore, that it doesn’t exist.”
But will change come? Health experts say they hope the country has reached a tipping point in the last two years. And yet, any real systemic change will likely take time. But, Benjamin said, it can start with increasing the number of practitioners from diverse communities, making office practices more welcoming and understanding biases.
We need to, as a matter of course, ask ourselves who’s advantaged and who’s disadvantaged” when crafting new initiatives, like drive-through testing sites, Benjamin said. “And then how do we create systems so that the people that are disadvantaged have the same opportunity.”
The COVID-19 pandemic revealed the need for substantial investment in public health. Journalist Anna Maria Barry-Jester, in an investigation published in California Healthline and the Los Angeles Times last week, reported that the need is pressing and that the time is ripe to formulate solutions.
“As we’ve continued to make progress in bringing the COVID-19 emergency under control, many California leaders are turning their attention to the future,” Barry-Jester wrote.
This year’s state budget set aside $3 million for an assessment of California’s public health infrastructure. “Public health leaders believe it will show that staffing and training are major issues,” Barry-Jester reported.
Starting in July 2022, annual state budgets will include $300 million to be spent to improve public health infrastructure.
The pandemic highlighted two significant public health needs in California. One is basic investment in public health infrastructure, as highlighted by Barry-Jester. The other is to address housing, diet, livable wages, and access to quality health care as part of an overarching public health strategy — a necessity highlighted by the stark racial, ethnic, and economic disparities among those who contracted and died from COVID-19.
Many Reasons for Staff Attrition
Before the pandemic, the state’s public health infrastructure already required shoring up. The COVID-19 crisis hammered the already underfunded and understaffed county and state public health systems.
In California, public health workers are leaving their jobs in droves. Counties are “losing experienced staffers to retirement, exhaustion, partisan politics, and higher-paying jobs,” Barry-Jester reported.
The exodus from public health predated this surge of resignations. Since the early days of the pandemic, experienced California public health leaders have been leaving the field, including 17 county public health officers and 27 county-level directors or assistant directors of public health. Both the director and the deputy director of the state’s department of public health resigned during the pandemic.
“Public health nurses, microbiologists, epidemiologists, health officers, and other staff members who fend off infectious diseases like tuberculosis and HIV, inspect restaurants, and work to keep communities healthy are abandoning the field,” Barry-Jester wrote. “The collective expertise lost with those departures is hard to overstate.”
Public health laboratories illustrate how much we rely on public health infrastructure for our everyday safety. The labs are largely invisible to the public but touch every aspect of daily life. “Public health labs sample shellfish to make sure it is safe for eating. They monitor drinking water and develop tests for emerging health threats such as antibiotic-resistant viruses. They also test for serious diseases, such as measles and COVID-19. And they typically do it at a fraction of the cost of commercial labs — and faster.”
Yet labs across the state are unable to hire and retain staff, and they are in danger of closing. “The biggest threat to [public health labs] right now is not the next emerging pathogen,” said Donna Ferguson, director of the public health lab in Monterey County, “but labs closing due to lack of staffing.”
Addressing Social Needs as Public Health Strategy
The pandemic highlighted the effects of income inequality and racial disparitieson health in California. Data from the California Department of Public Health highlight the stark disparities in COVID-19 outcomes. The COVID-19 death rate for Latinx people is 19% higher than the statewide death rate, and the death rate for Black people is 16% higher. The case rate for Pacific Islanders is 45% higher than the statewide rate, while the rate of Pacific Islanders earning less than $40,000 annually is 33% higher than average.
“There is an 80% higher rate of diabetes among Hispanics compared to non-Hispanic whites. We think early life nutrition is very important but also the environment where people live, which can include a combination of factors like poor access to healthy food, poor access to resources, air pollution, even chemical contaminants in the environment we found contribute to this disparity,” he told Los Angeles Times reporter Alejandra Reyes-Velarde.
These chronic diseases then put Latinx people at higher risk for worse COVID outcomes. “One of the most common recurring risk factors, not so much for rates of infection but the severity of the infection, is blood-glucose levels,” he said. “Individuals with higher blood-glucose levels seem to have a more severe response to COVID-19 infection, and of course, higher blood glucose is what contributes to diabetes.”
A Health Affairs study from the early days of the pandemic, which drew on data from California’s Sutter hospitals, noted that Black people are similarly at higher risk from the chronic illnesses that make people more susceptible to poor outcomes from COVID infections, including type 2 diabetes and congestive heart failure, as do other populations disproportionately harmed by COVID-19.
“Already underfunded and neglected even before the pandemic, public health has been further undermined in ways that could resound for decades to come,” wrote journalists Mike Baker and Danielle Ivory. The Times investigation of hundreds of health departments in all 50 states revealed that “local public health across the country is less equipped to confront a pandemic now than it was at the beginning of 2020.”
Threats, harassment, and anger directed at public health officials and workers drove many out of the field since the beginning of the pandemic and was identified as an ongoing problem by Baker and Ivory. “We have learned all the wrong lessons from the pandemic,” Adriane Casalotti told them. Casalotti is the chief of public and government affairs for the National Association of County and City Health Officials, an organization representing the nearly 3,000 local health departments across the nation. “We are attacking and removing authority from the people who are trying to protect us.”
Officials interviewed by Baker and Ivory noted that while additional funds are crucial to rebuilding public health departments, they aren’t sufficient to address the problems that have long weighed down the system or those that emerged during the pandemic.
Melissa Lyon, public health director for Erie County, Pennsylvania, put it this way: “If a ship is sinking, throwing treasure chests of gold at the ship is not going to help it float.”
Democrats’ push to extend health coverage to millions of very low-income people in red states has a lot working against it: It’s expensive, it’s complicated, it may invite legal challenges, and few national Democrats stand to gain politically from it.
Yes, but: The policy is being framed as a test not only of Democrats’ commitment to universal health coverage, but also their commitment to racial equity.
The big picture: Democrats are still figuring out how much money they have to spend in their massive social policy legislation, but there’s already intense competition among policies — including between health care measures.
Progressives are adamant about expanding Medicare to cover dental, vision and hearing benefits. But a handful of prominent Democrats are making the case that closing the Medicaid coverage gap is equally, if not more, important.
The gap exists in 12 Republican-controlled states that have refused to accept the Affordable Care Act’s Medicaid expansion, the majority of which are in the South.
What they’re saying: Closing the coverage gap is “very, very important to people of color. The majority of Black people in this country still live in the South,” said Rep. Jim Clyburn, one of the leading proponents of the measure.
More than 2 million adults are in the coverage gap, and 60% of them are people of color, according to the Center on Budget and Policy Priorities.
“What is the life expectancy of Black people compared to white people? I could make the argument all day that expanding Medicare at the expense of Medicaid is a racial issue, because Black people do not live as long as white people,” Clyburn added. “If we took care of Medicaid, maybe Black people would live longer.”
Between the lines: In terms of raw politics, it’s pretty easy to see why many Democrats would prioritize Medicare expansion over closing the Medicaid gap: Seniors live in every district and state in the U.S.
Only three Democratic senators represent non-expansion states, and in 2020, only ine of the 41 battleground House seats identified by Ballotpedia were in non-expansion states.
Yes, but: Sens. Jon Ossoff and Raphael Warnock, both from Georgia, are the reason that Democrats are able to consider their social policy legislation at all. Warnock is up for re-election next year.
“This is about people in this country, and I wish we’d stop this red state and blue state stuff,” Clyburn said. “Warnock and Ossoff won a runoff that nobody gave them a chance to win by promising they would close this gap.”
The catch: States that have already expanded Medicaid are covering a small portion of those costs themselves, and may question the fairness full federal funding for the holdout states.
That could create an incentive for existing expansion states to drop the ACA’s Medicaid expansion and pick up the new program instead. And any effort Congress makes to stop them could invite legal challenges.
“The case law in this domain is a bit of a moving target, and as we’ve seen over the past decade, there’s an awful lot of litigation over things pertaining to health reform,”said Nick Bagley, a professor at theUniversity of Michigan Law School.
The bottom line: Like Democrats’ other proposed health policies, filling the coverage gap could cost hundreds of billions of dollars.
But “if your goals are relieving health care cost burdens or expanding access to care, then it’s hard to do better on a dollar-for-dollar basis than buying coverage for uninsured people below the poverty line,” said Brookings’ Matt Fiedler.
What we’re watching: “I don’t see Medicaid as being on the radar of some of my friends in the caucus who seem to feel it’s more important to do Medicare,” Clyburn said. “I’m trying to get Medicaid on their agenda.”
“I’m tired of my party perpetuating … inequity,” he added. “Treating people according to their needs is what breaks the cycle.”
At a certain point, it was no longer a matter of if the United States would reach the gruesome milestone of 1 in 500 people dying of covid-19, but a matter of when. A year? Maybe 15 months? The answer: 19 months.
Given the mortality rate from covid and our nation’s population size, “we’re kind of where we predicted we would be with completely uncontrolled spread of infection,” said Jeffrey D. Klausner, clinical professor of medicine, population and public health sciences at the University of Southern California’s Keck School of Medicine. “Remember at the very beginning, which we don’t hear about anymore, it was all about flatten the curve.”
The idea, he said, was to prevent “the humanitarian disaster” that occurred in New York City, where ambulance sirens were a constant as hospitals were overwhelmed and mortuaries needed mobile units to handle the additional dead.
The goal of testing, mask-wearing, keeping six feet apart and limiting gatherings was to slow the spread of the highly infectious virus until a vaccine could stamp it out. The vaccines came but not enough people have been immunized, and the triumph of science waned as mass death and disease remain. The result: As the nation’s covid death toll exceeded 663,000 this week, it meant roughly 1 in every 500 Americans had succumbed to the disease caused by the coronavirus.
While covid’s death toll overwhelms the imagination, even more stunning is the deadly efficiency with which it has targeted Black, Latino, and American Indian and Alaska Native people in their 30s, 40s and 50s.
Death at a younger age represents more lost years of life. Lost potential. Lost scholarship. Lost mentorship. Lost earnings. Lost love.
Neighborhoods decimated. Families destroyed.
“So often when we think about the majority of the country who have lost people to covid-19, we think about the elders that have been lost, not necessarily younger people,” said Abigail Echo-Hawk, executive vice president at the Seattle Indian Health Board and director of the Urban Indian Health Institute. “Unfortunately, this is not my reality nor that of the Native community. I lost cousins and fathers and tribal leaders. People that were so integral to building up our community, which has already been struggling for centuries against all these things that created the perfect environment for covid-19 to kill us.”
Six of Echo-Hawk’s friends and relatives — all under 55 — have died of covid.
“This is trauma. This is generational impact that we must have an intentional focus on. The scars are there,” said Marcella Nunez-Smith, chair of President Biden’s COVID-19 Health Equity Task Force and associate dean for health equity research at Yale University. “We can’t think that we’re going to test and vaccinate our way out of this deep pain and hurt.”
The pandemic has brought into stark relief centuries of entwining social, environmental, economic and political factors that erode the health and shorten the lives of people of color, putting them at higher risk of the chronic conditions that leave immune systems vulnerable to the coronavirus. Many of those same factors fuel the misinformation, mistrust and fear that leave too many unprotected.
Take the suggestion that people talk to their doctor about which symptoms warrant testing or a trip to the hospital as well as the safety of vaccines. Seems simple. It’s not.
Many people don’t have a physician they see regularly due in part to significant provider shortages in communities of color. If they do have a doctor, it can cost too much money for a visit even if insured. There are language barriers for those who don’t speak English fluently and fear of deportation among undocumented immigrants.
“Some of the issues at hand are structural issues, things that are built into the fabric of society,” said Enrique W. Neblett Jr., a University of Michigan professor who studies racism and health.
Essential workers who cannot avoid the virus in their jobs because they do not have the luxury of working from home. People living in multigenerational homes with several adult wage-earners, sharing housing because their pay is so low. Even the fight to be counted among the covid casualties — some states and hospitals, Echo-Hawk said, don’t have “even a box to check to say you are American Indian or Alaskan Native.”
It can be difficult to tackle the structural issues influencing the unequal burden of the pandemic while dealing with the day-to-day stress and worry it ignites, which, Neblett said, is why attention must focus on both long-term solutions and “what do we do now? It’s not just that simple as, ‘Oh, you just put on your mask, and we’ll all be good.’ It’s more complicated than that.”
The exacting toll of the last year and a half — covid’s stranglehold on communities of color and George Floyd’s murder — forced the country to interrogate the genealogy of American racism and its effect on health and well-being.
“This is an instance where we finally named it and talked about structural racism as a contributing factor in ways that we haven’t with other health disorders,” Neblett said.
But the nation’s attention span can be short. Polls show there was a sharp rise in concern about discrimination against Black Americans by police following Floyd’s murder, including among White Americans. That concern has eroded some since 2020, though it does remain higher than years past.
“This mistaken understanding that people have, almost this sort of impatience like, ‘Oh, we see racism. Let’s just fix that,’ that’s the thing that gives me hives,” Nunez-Smith said. “This is about generational investments and fundamental changes in ways of being. We didn’t get here overnight.”
HENRY KOTULA 