Category Archives: Public Health

Expect More Hunger in America with Big New Rips to the Safety Net

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Policy, Healthcare Cuts, Healthcare Reform, Hunger, Medicaid, Medicaid Cuts, Medicaid Eligibility, Medicaid Funding, Medicaid Work Requirements, Public Good, Public Health, Public Interest, Public Welfare, Safety Net, Supplemental Nutrition Assistance Program (SNAP) • Tagged , , , , • Leave a comment

https://healthcareuncovered.substack.com/p/expect-more-hunger-in-america-with

The recently passed One Big Beautiful Bill Act, which makes deep cuts to the Medicaid program, also puts the food assistance that 41 million low-income Americans rely on in jeopardy. Many of the families currently getting food provided by  the Supplemental Nutrition Assistance Program (SNAP) stand to lose that support.  

SNAP may well disappear for some families as the federal government moves to trim it. “The cuts are massive and extremely cruel when families need more support, not less,” says Signe Anderson, senior director of nutrition advocacy, at the Tennessee Justice Center in Nashville. 

Government food assistance was established during the Great Depression, but it wasn’t until 1977 that the program became more accessible when the requirement that recipients had to pay for a portion of their food stamps was ended. Throughout its history, foes of the program have tried to dismantle it and may have succeeded as a result of provisions in the bill President Trump signed on July 4. 

The new legislation calls for cutting spending for food stamps by $186 billion through 2034. “Everyone on food stamps will be affected in some way, and many will lose benefits,” Anderson says. “I don’t think the Congress understands the level of necessity in the community for food, health care and mental health treatment, some for the rest of their lives.” 

One major change is being made to work requirements that have historically been part of the Medicaid program, which is administered and partially funded by the states. Anderson points out that under the new arrangements, participants may find the task of enrolling and staying enrolled more onerous. “We see a lot of people cut off already because too many life circumstances make it difficult for them to meet work requirements.”  

Indeed when you look at the changes to SNAP, the first word that might come to mind is ‘draconian.’

To receive benefits those new to the program, and those already on it who are between 55 and 64 and do not have dependent children or who have children 14 and older, will have to prove they work. Or they will have to volunteer at least 20 hours a week or enroll in training programs. Parents of school-aged children will now be required to work.

Some five million people, including about 800,000 children and about a half million adults who are 65 and older, could lose their food benefits.  

The programs the new law targets have been a lifeline for some. Nikole Ralls, a 43-year-old woman in Nashville, who was once a drug addict but now counsels others who need help, says, “I got my life turned around because of Medicaid and SNAP.”  

In a recent memo to state agencies administering the SNAP program, Agriculture Secretary Brooke Rollins said she was concerned about what was described as abuse of the waiver system by states, noting that the new approach for the SNAP program would prioritize work, education and volunteering over what the department characterized as “idleness and excessive spending.” 

Anderson said, “The public doesn’t understand what hunger looks like and are misinformed about how well-run and streamlined the SNAP program is.”   

“Most of the people who can, do work.  We have parents working two and three jobs,” Anderson said. For families in this predicament food banks, which have become default grocery stores, may be of little help.  They, too, are stretched thin. The Wall Street Journal reported food banks across the country are already straining under rising demand, and some worry there won’t be enough food to meet demand.

What’s at stake from GOP megabill’s coverage losses

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, ACA, Bankruptcy, Chronic Care Management, Chronic Condition Management, Chronic Conditions, Chronic Diseases, Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, High Deductible Health Plans, High Drug Prices, High Premiums, Medicaid, Medicaid Cuts, Medical Debt, Out of Pocket Expenses, Public Health, Underinsured, Uninsured • Tagged , , , , • Leave a comment

https://www.axios.com/2025/07/01/real-cost-health-coverage-losses

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.

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.

The Next 100 Days: What Healthcare Should Expect

Posted on by • Posted in Economy, Funding, Health Insurance Industry, Health System, Hospital, Hospital Industry, Investing, Investment, Medicare, Medicare Advantage, Public Health, Public Opinion, Public Perception, Supreme Court, Wall Street • Leave a comment
The Next 100 Days: What Healthcare Should Expect

The Trump administration is moving into its second 100 days facing conditions more problematic than its first 100. For healthcare, this period will define the industry’s near-term future as changes in three domains unfold:

  • The Economy: The economy is volatile and consumer confidence is waning. The impact of tariffs on U.S. prices remains an unknown and escalating tension between the Ukraine and Russia, Israel and Palestine, Pakistan and India are worrisome. Household debt is mounting as student loans, medical debt and housing costs imperil financial security for more than half of U.S. households. The 3 major stock indices remain in the red YTD, prospects for a recession are high and investors are increasingly cautious. Net impact on healthcare organizations and public programs: negative, especially those without strong balance sheets and access to affordable private capital.
  • The Courts: Recent opinions by the Supreme Court and District Courts suggest a willingness to challenge the administration’s Executive Orders on immigrant deportation and due process, threats and funding cuts aimed at law firms and universities considered “woke” and layoffs initiated by DOGE and more. Court challenges will slow the administration’s agenda and create uncertainty in workplaces. Net impact: negative. Uncertainty paralyses planning and operations in every public and private healthcare organization.
  • The Public Mood: The afterglow of the election has dissipated and the public’s mood has shifted from guarded optimism to anxiety and despair. The public’s uncertain about tariffs and worried about household expenses. Net impact: negative. Healthcare affordability and prices are major concerns to consumers: the majority (76%) think the system is more concerned about profitability than patient care (Jarrard).

Current events in these areas portend headwinds for most public and private healthcare organizations where attention in the next 100 days will be focused in these areas:

  • Oversight: New rules, programmatic priorities, key personnel appointments and re-organization in HHS, CMS, the FDA and VA: RFKJ’s MAHA plans and Commission appointees, Oz’ affinity for Medicare Advantage predisposition toward value-based care and Makary’s overhaul of the FDA’s drug oversight process will be “on the table” in the next 100 days.
  • Funding: Healthcare funding in the FY 2026 federal budget. The GOP-controlled House and Senate can pass a budget with minimal support from Dem’s that reflects a serious effort to reduce the federal debt ($37 trillion/123% of GDP– up from $20 trillion in 2017). Healthcare cuts expected to be significant though rumored massive cuts to Medicaid unlikely.
  • States: State healthcare referenda and executive actions: states are evaluating price controls on drugs and hospitals, reparations from insurers for delays and prior-authorizations, scope of practice restrictions and more. Topping the watchlist in most states is Medicaid funding and potential fallout from discontinued ACA marketplace subsidies factored into the FY 2026 budget being finalized by the GOP-led Congress in DC.
  • SCOTUS: Supreme Court decisions will be handed down or before June 30 when SCOTUS’ 2024 term ends including Braidwood Management v. Becerra which will determine whether the Affordable Care Act’s requirement that private insurers cover preventive services without cost-sharing will continue. The court will also opine to the authority of the HHS secretary to appoint members of the U.S. Preventive Services Task Force. The potential impact of these decisions on coverage, insurance premiums and access to preventive health services is pervasive.
  • Financial markets: Capital markets are in a watchful waiting mode as US trade policy unfolds, inflation fluctuates, the fed’s interest rate determination is disclosed and consumer spending reacts. Private investing in healthcare remains opportunistic though deal flow is shifting and risk thresholds tightening.
  • Polls: Polls draw the attention of media and elected officials. They influence how organizations prioritize advocacy strategies, address consumer complaints and concerns and manage reputations. As reflected in numerous national polls, trust in the system and its key players—insurers, hospitals, drug companies—is at a historic low.

Each sector in U.S. healthcare will be impacted differently: Three face the strongest headwinds:

  • Hospitals: Hospitals face enormous financial challenges, especially not-for-profits, safety net, rural and veteran’s hospitals. Last week’s unfavorable SCOTUS decision against hospitals alleging DSH under-payments will cost $1 billion per year. Congressional adoption of site neutral payment policy could cost $15 billion/year. Drug prices, labor costs, insurer payment cuts and red-tape will negate operating margins and lower investment income knee-capping growth and innovation plans. Complicating matters, employed physicians will demand higher pay and more control.  And Congressional budget-creators believe the sector’s 31% share of total healthcare spending makes it ripe for cuts attributable to “waste, fraud and abuse”.
  • Insurers: Medicare Advantage (which enjoys support by key administrators including CMS’ Mehmet Oz) has become a lightening rod of insurer criticism alongside prior authorization policies that restrict care. Coverage remains key to household financial security but insurers are seen as barriers to rather than facilitators of evidence-based cost-effective care. And the concentration of power in corporate titans (United, Humana, Cigna, CVS, Centene and others) is viewed with skepticism.
  • Public Health: Public health is not a priority in the U.S. health system despite recognition that social determinants account for 70% of the system’s $5 trillion spending. Most programs are funded by state and local governments with federal support limited. Public health is not seen as an investment and, in some settings treated with disdain as welfare or waste. As Mayors and Governors develop plans for the rest of 2025 and through 2026, public health cuts will be likely as federal co-funding becomes scarce.

The next 100 days will define the national agenda for the mid-term election in November 2026, reflect the solidarity of the MAGA movement and show the impact of tariffs on inflation, consumer prices and the public’s mood.

Healthcare leaders will be watching closely. All will be impacted.

The State of Trust in Public Health in America

Posted on by • Posted in Centers for Disease Control & Prevention (CDC), Misinformation, Mislead, Misleading, Public Health, Public Health Crisis, Public Opinion, Public Perception, Public Safety, Public Trust, Vaccination, Vaccine, Vaccine Distribution, Vaccine Efficacy, Vaccine Hesitancy Rate, Vaccine Safety, Vaccine Skepticism • Leave a comment

https://www.kaufmanhall.com/insights/infographic/state-trust-public-health-america

In light of the recent confirmation of Secretary Kennedy to lead HHS and new survey data on trust in public health, this graphic highlights Americans’ declining positive perception of public health officials. Among respondents’ personal doctors, the CDC and their state and local public health officials, trust in all three, regardless of political identification, has decreased from June 2023 to January 2025. 

Respondents trusted their doctors more than public health officials, and there is less difference by political identification. In 2025, only 61% of surveyed Americans reported that they trusted the CDC. That prevalence drops to 39% among Republicans and increases to 85% among Democrats.

Another important public health indicator, the percentage of kindergarteners with vaccine exemptions, also illustrates the challenging place in which public health officials find themselves. During the 2023-2024 school year, about 3.3% of kindergartners received an exemption, an increase from 2022-2023 that still does not provide a complete picture. Exemption rates vary widely by state, with 6 states having exemption rates more than double the median. These differences are a reflection of how easy it is to receive an exemption in some states rather than a clear trend.

The shift also underscores how easily an outbreak could occur in some states. Alarmingly, the perceived importance of vaccines has dramatically decreased, from 94% in 2001 to 69% in 2024. 

We will have to wait and see what Kennedy, long considered a vaccine skeptic, does regarding vaccines, but amid immense distrust in the healthcare system, providers’ role of giving thorough, honest information to their patients is more important than ever.

Why thousands cheered a tragedy: unpacking America’s healthcare anguish

Posted on by • Posted in Health Policy, Healthcare Reform, Public Good, Public Health, Public Health Crisis, Public Health Strategy, Public Perception, Public Trust, State of the Union • Leave a comment

https://www.linkedin.com/pulse/why-thousands-cheered-tragedy-unpacking-americas-robert-pearl-m-d–apdhc/

The murder of UnitedHealthcare CEO Brian Thompson in December 2024 represented a horrific and indefensible act of violence. As a physician and healthcare leader, I initially declined to comment on the killing. I felt that speculating about the shooter’s intent would only sensationalize a terrible act.

Regardless of the circumstances, vigilante violence has no place in a free and just society.

Now, more than a month later, I feel compelled to address one aspect of the story that has been widely misunderstood: the public’s reaction to the news of Thompson’s murder. Specifically, why tens of thousands of individuals “liked” and “laughed” at a post on Facebook announcing the CEO’s death.

What causes someone to ‘like’ murder?

News analysts have attributed the social media response to America’s “simmering anger” and “frustration” with a broken healthcare system, pointing to rising medical costs, insurance red tape and time-consuming prior authorization requirements as justifications.

These are all, indeed, problems and may explain some of public’s reaction. Yet these descriptions grossly understate the lived reality for most of those affected. When I speak with individuals who have lost a child, parent or spouse because of what they perceive as an unresponsive and uncaring system, their pain is raw, intense. What they feel isn’t frustration—it’s agony.

By framing healthcare’s failures in terms of statistical measures and policy snafus, we reduce a deeply personal crisis to an intellectual exercise. And it’s this very detached, cognitive approach that has allowed our nation to disregard the emotional devastation endured by millions of patients and their families.

When journalists, healthcare leaders and policymakers cite eye-popping statistics on healthcare expenditures, highlight exorbitant insurer profits or deride the bloated salaries of executives, they leave out a vital part of the story. They omit the unbearable human suffering behind the numbers. And I fear that until we approach healthcare as a moral crisis—not merely an economic or political puzzle to solve—our nation will never act with the urgency required to relieve people’s profound pain.

A pain beyond reason

In Dante’s Inferno, hell is a place where suffering is eternal and the cries of the damned go unheard. For countless Americans who feel trapped in our healthcare system, that metaphor rings true. Their anguish and pleas for mercy are met with silence.

It is this sense of abandonment and powerlessness, not mere frustration, that fuels both a desperate rage and an anger at a system and its leaders who appear not to care. The response isn’t one of glee—it’s a visceral reaction born of pain and unrelenting remorse.

As a clinician, I’ve seen life-destroying pain in my patients—and even within my own family. When my cousin Alan died in his twenties from a then-incurable cancer, my aunt and uncle were powerless to save him. Their grief was profound, unrelenting and eternal. They never recovered from the loss. But Alan’s death, heartbreaking as it was, stemmed from the limits of science at the time.

What millions of Americans endure today is different. Their loved ones die not because cures don’t exist but because the healthcare system treats them like a number. Bureaucratic inefficiencies, profit-driven delays and systemic indifference produce avoidable tragedies.

To appreciate this depth of pain, imagine standing behind a chain-link fence, watching someone you love being tortured. You scream and plead for help, but no one listens. That is what healthcare feels like for too many Americans. And until all of us acknowledge and feel their pain, little will improve.

Curing America’s indifference

When we focus solely on cold numbers—the millions who’ve lost Medicaid coverage, the hundreds of thousands of avoidable deaths each year, or the life-expectancy gap between the U.S. and other nations—we strip healthcare of its humanity.

But once we stop framing these failures as bureaucratic inefficiencies or frustrations and, instead, focus on the devastation of having to watch a loved one suffer and die needlessly, we are forced to confront a moral imperative. Either we must act with urgency and resolve the problem or admit we simply don’t care.

In the halls of Congress, lawmakers continue to weigh modest reforms to prior authorization requirements and Medicaid spending—baby steps that won’t fix a system in crisis. The truth is that without bold, transformative action, healthcare will remain unaffordable and inaccessible for millions of families whose anguish will grow.

Here are three examples of the scale of transformation required:

  1. Reverse the obesity epidemic with a two-part strategy. Congress will need to tax ultra-processed, sugary foods that drive hundreds of billions of dollars in healthcare costs each year. In parallel, lawmakers should cap the manufacturer-set price of weight-loss medications like Ozempic and Wegovy to be no higher than in peer nations.
  2. Change clinician payments from volume to value. Current fee-for-service payment systems incentivize unnecessary tests, treatments and procedures rather than better health outcomes. Transitioning to pay-for-value would reward healthcare providers, and specifically primary care physicians, who successfully prevent chronic diseases, better manage existing conditions, and reduce complications such as heart attacks, strokes and kidney failure.
  3. Empower patients and save lives with generative AI. Tools like ChatGPT can help reduce the staggering 400,000 annual deaths from misdiagnoses and 250,000 more from preventable medical errors. By integrating AI into healthcare, we can enable at-home care, continuous disease monitoring and personalized treatment, making medical care safer, more accessible and more efficient.

If elected officials, payers and regulators fail to act, they will have chosen to perpetuate the unbearable pain and suffering patients and families endure daily. They need to hear the cries of people. The time for transformative action is now.

Changing American Demographics Make Hospital Operations Harder

Posted on by • Posted in Chronic Conditions, Consumer Segmentation, Culture, Demographics, Family, Medication Management, Mental Health, Public Health, Social Determinants of Health, Social Isolation, Social Support & Isolation, Solo Living • Leave a comment

https://www.kaufmanhall.com/insights/thoughts-ken-kaufman/changing-american-demographics-make-hospital-operations-harder

Regular readers know I’ve long been curious about the forces driving one essential question in healthcare today:

Why is it so hard to run a hospital now? One area worth exploring is the interplay between the healthcare system and our nation’s changing demographics.

Baby Boomers have been displaced as the largest generation of adults in America. Millennials now hold that position, and Gen Z will likely outnumber Baby Boomers in the workplace sometime this year. Our nation is rapidly diversifying, as more than two-fifths of Americans identify as people of color.

It’s not just a matter of who we are as a nation that’s changing; how we live is evolving, too. The number of 40-year-olds who’ve never been married reached record highs in 2022, according to the Pew Research Center, dovetailing with a steadily growing trend since 1970 toward single living.

The U.S. Census published a report earlier this year showing that nearly 29% of American households include only one person. Further, the U.S. fertility rate is at an all-time low — and, according to a Pew survey, may not recover, given that 47% of those under 50 said they were unlikely to have children. That’s an increase of 10 percentage points since 2018.

The effects of this are starting to shape our broader culture. Solo living has been cited as a contributing factor to the housing crisis, and we’re starting to hear more about how people are grappling with the practical implications of retiring while living alone. This column in The New York Times is just one example. 

As for the potential health effects of living alone, in 2023, U.S. Surgeon General Vivek Murthy raised an alarm with a report documenting the negative effects of social isolation on individual and public health. Murthy outlined a host of risks, including cardiovascular disease, hypertension, diabetes and increased susceptibility to infectious disease. Mental health is a major concern. A 2024 study published in National Health Statistics Reports found that people who live alone were more likely to be depressed, particularly if they lacked social or emotional support. 

All of this adds up to an increasing burden on the U.S. healthcare system.

As providers who care for the socially isolated already know, it’s impossible to operate as usual if a patient lacks family support. Hospitals and the traditional American family structure are fundamentally intertwined. When family support is not available for a medical emergency, then the entire hospital episode becomes more fragile. Patient discharge procedures assume someone is available at home to help with care, assist in transporting patients for follow-up visits, and engage with the business office around billing and insurance.

Without this family safety net, the potential for readmission rises, harming patient outcomes, increasing costs and putting quality ratings at risk. The rise in younger people living alone also raises further financial implications, given that about 45% of Americans access health insurance through employer-sponsored programs. If someone living alone becomes too sick to work, patients may be less able to pay for care when they need it most.

This is just another in a long list of challenging hospital operational dilemmas. How best to respond to such profound change in the American demographic landscape? The right strategy may be to re-think consumer segmentation.

Consumer segmentation has become very popular at the clinical product level, but perhaps the next level of service segmentation is not among disease types but based on demographic characteristics. 

As an increasing portion of the American population has less family support to navigate a hospital stay or chronic illness, it will become more important to identify these patients and determine which new and enhanced services need to be provided to them by the hospital. Social work programs will need to be more robust, and health systems should invest in community partnerships to help bridge the resource gap. But the wide-ranging nature of patients’ practical needs will likely require healthcare leaders to think creatively. 

Consider the scope:

  • Care coordinators: Particularly for patients with complex conditions, it may be beneficial to designate a care coordinator to oversee healthcare planning.
  • Home health care: Without family members to help with day-to-day care, more nurses and aides will be needed to provide healthcare at home as well as help with day-to-day living. For patients with less demanding healthcare needs, adult day care may be useful.
  • Medication management: Patients need to understand how to take their medications, watch for potential side effects and interactions, and develop a system to make sure they take them on time. Further, they may need help navigating the pharmacy, either in getting prescriptions filled or with financial assistance programs.
  • Meal delivery: Nutrition is vital to a patient’s recovery, and ensuring patients have access to healthy options can help to reduce the likelihood of readmission.
  • Personal emergency response systems: Patients may need devices to call for help during an emergency as well as medical bracelets or other methods for communicating important information to first responders.
  • Housekeeping assistance: Hospitals may need to help connect patients with resources to maintain clean, safe homes. 
  • Volunteer companions: While volunteer companions usually help elderly patients with social interaction and basic needs, it may be necessary to develop programs that target a wider range of ages.
  • Transportation services: Patients need help getting to and from follow-up visits.
  • Telehealth: Remote care will become increasingly important. Clinical services should consider whether care plans could be adjusted to reduce the number of in-person visits.

Beyond targeting resources, consumer segmentation also offers an opportunity to communicate with patients in a more effective and personalized way. This sort of engagement fosters trust and increases loyalty that’s particularly important, given the intimate nature of healthcare.

It’s long been true that the stronger the family system, the better off hospitals are. But as the concept of the American family shifts, and in this case, unwinds, healthcare leaders need to be attuned to new demands—and nimble enough to meet them. This requires making the most of the information you have today to plan for tomorrow.

Trump picks HHS and CMS nominees

Posted on by • Posted in Center for Medicare and Medicaid Services (CMS), Dept of Health and Human Services (HHS), Health Insurance Industry, Health Policy, Healthcare Reform, Medicare Advantage, Pharmaceutical Industry, Pharmacy Benefits Management, Privatization, Profit, Profit Motive, Public Health, Vaccine, Vaccine Hesitancy Rate • Leave a comment

https://www.kaufmanhall.com/insights/blog/gist-weekly-november-22-2024

Last week, President-elect Donald Trump announced that Robert F. Kennedy, Jr. would be his nominee for Secretary of Health and Human Services (HHS). He followed this up on Tuesday with his selection of Dr. Mehmet Oz as his nominee for the Centers for Medicare and Medicaid Services (CMS) Administrator. If confirmed, the two men would replace Xavier Becerra and Chiquita Brooks-LaSure, respectively.

Kennedy, who ended his independent presidential campaign and endorsed Trump in August, has become known for his heterodox views on public health, including vaccine skepticism and opposition to water fluoridization.

Dr. Oz, first famous as a TV personality and more recently a Republican candidate for Pennsylvania Senator, is a strong proponent of Medicare Advantage, having co-authored an op-ed advocating for “Medicare Advantage for All” in 2020.

The Gist: 

These nominees, especially Kennedy, hold a number of personal beliefs at odds with the public health consensus. 

They are both likely to be confirmed, however, as the last cabinet nominee to be rejected by the Senate was John Tower in 1989. (This does not include nominees who have chosen to withdraw themselves from consideration, as former Representative Matt Gaetz has just done.)

Should they be confirmed, they will be responsible for implementing not their own but President Trump’s agenda, the specific priorities of which also remain relatively undefined. 

However, possible consensus points between Trump and his nominees include public health cuts and deregulation, greater scrutiny of pharmaceutical companies, and a favoring of Medicare Advantage over traditional Medicare.

    Could new FLiRT variants lead to a summer COVID-19 surge?

    Posted on by • Posted in Coronavirus, Coronavirus FLiRT Variants, Coronavirus Mutation, Infection Control, Infectious Virus, Public Health • Leave a comment

    https://www.advisory.com/daily-briefing/2024/06/03/flirt-variant

    Although COVID-19 cases are currently declining, some health experts have voiced concerns that circulating FLiRT variants could lead to a spike in cases as more people gather in the summer months.

    What are the FLiRT variants?

    Over the winter, the dominant COVID-19 variant was JN.1, which spread globally. However, a new variant called KP.2, or FLiRT due to the location of its mutations, began to emerge in March.

    There are several different FLiRT variants, including KP.2, KP.1.1, and KP.3. In a two-week period ending May 11, KP.2 made up 28.2% of COVID-19 cases in the United States, while KP.1.1 made up over 7% of cases.

    According to some health experts, KP.2 and KP.1.1 could be more transmissible than previous COVID-19 variants. So far, early data suggests that KP.2 may be “rather transmissible” since its new mutations help “its ability to transmit, but also now evades some of the pre-existing immunity in the population,” said Andrew Pekosz, a virologist at Johns Hopkins University.

    Currently, there’s no evidence to suggest that the FLiRT variants cause more severe illness than previous COVID-19 variants. Some of the symptoms associated with the FLiRT variants include fever or chills, cough, sore throat, fatigue, a loss of taste or smell, and brain fog.

    “The CDC is tracking SARS-CoV-2 variants KP.2 and KP.1.1, sometimes referred to as ‘FLiRT,’ and working to better understand their potential impact on public health,” the agency said. “Currently, KP.2 is the dominant variant in the United States, but laboratory testing data indicate low levels of SARS-CoV-2 transmission overall at this time. That means that while KP.2 is proportionally the most predominant variant, it is not causing an increase in infections as transmission of SARS-CoV-2 is low.”

    Could these variants lead to another COVID-19 surge?

    Currently, COVID-19 cases and deaths are declining, but health experts say the FLiRT variants’ potential to evade immunity could lead to a spike in cases as people gather for summer holidays.

    Immunity may also be waning since few people received updated COVID-19 vaccines last fall. According to CDC, only 22.6% of adults reported receiving an updated vaccine since September 2023, though vaccination increased by age and was highest among those ages 75 and older.

    “We’ve got a population of people with waning immunity, which increases our susceptibility to a wave,” said Thomas Russo, chief of infectious disease at the Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo.

    Otto Yang, associate chief of infectious diseases at the University of California, Los Angeles‘ David Geffen School of Medicine, said that while healthcare systems can manage COVID-19 waves, immunocompromised and older adults at a higher risk of developing severe disease are often overlooked.

    “Those people unfortunately carry a heavy burden,” Yang said. “I’m not sure there is a good solution for them, but one thing could be better preventive measures.”

    However, COVID-19 protections that were common in the past, including testing before events and mask requirements, have now fallen by the wayside, the Washington Post reports. Even events with preventive measures in place have faced difficulties enforcing them.

    “Culturally we are coming away from it as a society, so it gets much harder to ask people to really be consistent, because they aren’t doing it anywhere else,” said D Schwartz, who organized a large LGBTQ+ community gathering event in Washington, D.C. “You go into a movie theater now, you see maybe five people wearing a mask.”

    Declining data collection has also impacted how people view the current COVID-19 situation. Although CDC still tracks coronavirus levels in wastewater and the percentage of ED visits with a diagnosed case of COVID-19, hospitals stopped reporting confirmed COVID-19 cases in April.

    “We’re kind of shooting blind now,”

    said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine and co-director of the Texas Children’s Hospital Center for Vaccine Development. Hotez also noted that a lack of data collection will make it harder to convince Americans that COVID-19 is enough of a threat to require continued vaccination.

    “If a wave materializes this summer, we’re less poised to navigate the rough waters,” said Ziyad Al-Aly, an epidemiologist and long COVID researcher at the Veterans Affairs health system in St. Louis.

    Medicare Can Cover Anti-Obesity Drugs for Heart Disease — But at What Cost?

    Posted on by • Posted in Cardiovascular Disease, Chronic Diseases, Congressional Budget Office (CBO), Food and Drug Administration (FDA), Health Equity, Health Policy, Medicare Part D, Obesity, Obesity Treatment, Public Health, Wegovy, Weight Loss Drugs • Leave a comment
    https://www.medpagetoday.com/opinion/the-health-docket/109555?xid=nl_secondopinion_2024-04-09&eun=g885344d0r

    On March 8, 2024, FDA approved Wegovy (semaglutide)opens in a new tab or window to treat cardiovascular disease risks — heart attack, stroke, and death — for obese or overweight adults with a history of cardiovascular disease, making it the first anti-obesity medication (AOM) to obtain such approval. Studies showopens in a new tab or window that semaglutide reduces heart disease risks when accompanied by blood pressure and cholesterol management and healthy lifestyle counseling. FDA noted that this approval is “a major advance in public health.”

    Less than 2 weeks after FDA approved the new indication (semaglutide is also approved for chronic weight management and type 2 diabetes), CMS issued a memorandumopens in a new tab or window stating that Medicare Part D plans may cover AOMs if they are FDA approved for an additional medically accepted indication beyond only weight management. CMS’ guidance is prospective and is not limited to semaglutide. The guidance applies to all AOMs that may be approved in the future to treat other conditions. To ensure that AOMs are used for medically accepted indications, CMS clarified that Part D sponsors may employ common utilization management tools like step therapy and prior authorization.

    Notably, FDA’s approval of semaglutide for cardiovascular disease is likely a harbinger of similar approvals in the near future — along with their coverage by Medicare. While the benefits are substantial, so too may be the costs as more and more drugs and patients receive coverage.

    Obesity and Public Health

    Obesity is a pressing public health crisis that requires robust, multidimensional solutions, including medical interventionsopens in a new tab or window. The CDC considers obesity an epidemicopens in a new tab or window, and in 2013, the American Medical Association recognized obesity as a diseaseopens in a new tab or window. Although there isn’t consensus in the scientific community as to whether obesity is a disease, one thing is clear: medical interventions (including AOMs) are key to addressing obesity, along with other public health measures.

    Obesity prevalence in the U.S. is 41.9%opens in a new tab or window, with rates higher for Black and Hispanic adults — the very populations that face the greatest socioeconomic barriersopens in a new tab or window to accessing healthcare and medications. While AOMs offer a significant public health benefit, ensuring equitable and affordable access is vital.

    Economic Implications

    Analyses have foundopens in a new tab or window extraordinarily high prices for Wegovy , with a list price up to $1,349 and a net price (received by the manufacturer) of $701 for a 4-week supply. It is estimated that 6.6 million Americans opens in a new tab or window would benefit from medications like semaglutide for cardiovascular event reduction. Because AOMs are so costly, increasing their coverage and use could result in substantial Medicare spending, as well as higher premiums and cost-sharing for enrollees.

    In 2022, Medicare gross total spending on semaglutide and tirzepatide for diabetes reached $5.7 billionopens in a new tab or window, up from $57 million in 2018. With FDA’s approval of these drugs as AOMs, Medicare spending for new indications can be expected to increase dramatically in the next few years.

    In March 2024, the Congressional Budget Office (CBO) found that Medicare coverage of AOMs would result in considerable demand for and use of AOMsopens in a new tab or window by enrollees. CBO expects that generic competition, which could moderate prices and lead to higher rebates, would start in earnest only in the second decade of a policy allowing Medicare Part D to cover AOMs. However, even that assumption is not certain as pharmaceutical companies seek to “evergreen”opens in a new tab or window patent protection and market exclusives. CBO also acknowledges the possibility of new drugs that are more effective, have fewer side effects, or can be taken less often, which could translate to higher prices. Furthermore, if AOMs are stopped, weight then increases, meaning that these medications may have to be taken lifelong.

    Arguably, reducing obesity rates could reduce the incidence of many chronic diseases such as diabetes and heart disease, potentially creating a net benefit in the long term. And even in the near-term, the Inflation Reduction Act (IRA) may help curb costs.

    CBO and other reportsopens in a new tab or window suggest that semaglutide is likely to be selected by CMS for drug price negotiation opens in a new tab or window under the IRA within the next few years. If chosen in 2025, a negotiated Medicare price would be available by 2027. Successful CMS price negotiation is likely to address some of the cost concerns.

    The IRA also has other mechanisms that may help address the high costs. The IRA’s rebate program, for example, ensures cost containment by requiring manufacturers of drugs that don’t have competitors to pay rebates to HHS if the prices of those drugs increase faster than the inflation rate. The IRA also caps out-of-pocket spending for prescription drugs at $2,000 starting in 2025opens in a new tab or window. (Although a $2,000 cap helps limit costs, spending that amount of money is still burdensome, especially for people of low socioeconomic status who are disproportionately impacted by obesity.)

    In short, the IRA may alleviate, but not eliminate, Medicare spending concerns. The IRA’s ability to address the cost concerns of AOM coverage depends on various factors, and it is likely that those cost containment measures will take many years to materialize. As AOMs continue to be approved for new uses, the intense demand for these drugs coupled with their high costs are likely to place pressures on Medicare spending for years to come.

    Takeaways

    CMS has made clear that Medicare should cover semaglutide or other AOMs only when needed to avert cardiovascular or other serious diseases. This rule will have to be rigorously enforced and monitored.

    Savvy Medicare enrollees could try to game the system, using medications primarily for weight loss purposes — which would be inconsistent with CMS’s approval. Some physicians might also engage in dishonest prescribing. Also, given the racial and ethnic disparities in access to obesity treatment, marginalized groups are unlikely to reap equal benefit from AOMs. For those reasons, robust and thoughtful strategies are needed to ensure that coverage for such drugs is not exploited. Without clear limits on the use of AOMs, Medicare could be overwhelmed with costs.

    Beyond Medicare spending, there are wider equity concerns about access to drugs that treat medical conditions associated with obesity. Even if marginalized individuals can gain access to the medication, obtaining optimal health benefits of AOMs is likely to remain a challenge. FDA notes that semaglutide is most effective when it is taken together with other lifestyle or behavioral changesopens in a new tab or window, such as diet and exercise. Because healthy lifestyles and behaviors are mostly influenced by broader social and commercial determinants, the full health benefits of AOMs may elude those most at risk. To harness the public health benefits, AOMs must be seen as part of a broader approach to address health risks associated with obesity; they should not detract from the interventions targeted at socio-structural determinants of health that shape individual and population health outcomes.

    To some, semaglutide and other AOMs are a miracle of modern science. Yet, we should entertain some skepticism about miracle solutions to deeply complex health threats. Medicare should extend coverage for AOMs under criteria that meaningfully considers the competing concerns and tradeoffs. Meanwhile, public health professionals and clinicians should continue to use all the tools at our disposal to reduce the burdens of disease caused by overweight and obesity, while also fighting against the stigma, shaming, and discrimination that are widely prevalent in our society.

    Is Private Equity the Solution or the Problem in Healthcare?

    Posted on by • Posted in Affordability, Cherry Picking, Health Policy, Lobbyist, Market Consolidation, Market Power, Mergers & Acquisitions, Price Transparency, Pricing Leverage, Private Equity, Public Good, Public Health, Public Opinion, Public Perception • Leave a comment
    Is Private Equity the Solution or the Problem in Healthcare?

    Of late, private equity investors in healthcare services have faced intense criticism that their business practices have compromised patient safety and raised costs for consumers. March 5, the FTC, DOJ and HHS announced the launch of an investigation into the inner workings of PE in healthcare. It comes on the heels of U.S. Senate investigations in their Finance, HELP and Budget Committees to explore legislative levers they might pull to address their growing concerns about affordability, competition and accountability in the industry.

    PE funds don’t welcome the spotlight. 

    Their business model lends to misinformation and disinformation: company takeovers by new owners are rarely treated as good news unless the circumstance under prior ownership was dire. Even then, attention shifts quickly to the fairness of the PE business model playbook: acquire the asset on favorable terms, replace management, reduce operating costs, grow and the sell in 5-7 years at a profit using debt to finance the deal along the way. In exchange, the PE fund’s General Partner gets an annual management fee of 2% plus 20% of the value they create when they sell the company or take it public, and favorable tax treatment (carried interest) on their gain.

    Concern about PE in healthcare services comes at a particularly delicate time: hospitals. nursing homes, outpatient care, medical practices, clinics et al) are still feeling the after-effects of the pandemic, proposed reimbursement bumps by Medicare for hospitals and physicians do not offset medical inflation and the Change Healthcare cybersecurity breach February 21 has created cash flow issues for all.

    Concern about PE ownership was high already.

    Innovations funded through PE-backed organizations have been drowned out by the steady drip of peer reviewed and industry-sponsored studies a causal relationship between PE ownership decreased quality and patient safety and increased prices and worker discontent. Nonetheless, PE-owns 4% of hospitals (among 36% that are investor-owned, 13% of medical practices and 6% of nursing homes today and they’re increasing in all cohorts of health services.

    Here are the facts:

    Private equity enjoys significant influence in public policy including healthcare. Direct lobbying activity by PE funds in Congress and state legislatures is well-funded and effective, especially by the It is increasingly 20 global fund sponsors that control 46% of assets under management. Cash on hand and fund-raising by PE are strong and healthcare remains an important but non-exclusive target of PE investing.

    2023 was a down year for PE, 2024 will be strong: the IPO market and sponsor- to sponsor transactions dipped, and deal values shrank. Even with interest rates remaining high, returns exceeded overall growth in the stock market for deals consummated. At the same time, PE raised $1.2 trillion last year and has $2.6 trillion of dry powder to invest. Healthcare services will be a target as PE deal activity increases in 2024.

    In U.S. healthcare, PE investments are significant and increasing.  Technology-enabled services that lower unit costs and AI-based solutions that enable standardization and workforce efficiency will garner higher valuations and greater PE interest than traditional services. Valuations will recover from record 2023 lows and dry powder will be deployed for roll-ups despite antitrust concerns and government investigations. Congress will investigate the impact on PE on patient safety, prices and competition and, in tandem with FTC and DOJ issue guidance: compliance will be mandated and financial penalties added. But displacement of PE in health services is unlikely.

    Some notable data:

    • Private equity funds have $2.49 trillion of cash on hand to invest—up 7% from 2022. They raised $1.2 trillion globally in 2023. 26% of its global dry powder is more than 4 years old—undeployed.
    • Private equity groups globally are sitting on a record 28,000 unsold companies worth more than $3tn. 40% of the companies waiting to be sold are at least four years old. Last year, the combined value of companies that the industry sold privately or on public markets fell 44% and the value of companies sold to other buyout groups fell 47%.
    • Private equity investments in almost every sector in healthcare are significant, and until lately, increasing. Last year, deals were down 16.2% (from 940 to 788) cutting across every sector. In some sectors, like physician services, PE deals were tuck-in’s to their previous platform investments increasing from 75 deals in 2012 to 484 deals in 2021.
    • PE investments in US healthcare exceeded $1 trillion in the last 10 years. Investments in healthcare services i.e. acute, long-term, ambulatory and physician services– have been less profitable to investors than PE investments in technology, devices and therapeutics (based on the ratio of Enterprise Value to EBITDA) but exceed equity-market returns overall.
    • Peer reviewed studies have shown causal relationships between private equity ownership of hospitals, nursing homes and medical practices with lower operating costs, higher staff turnover, high prices and higher profits.

    My take:

    Like it or not, private equity investment in healthcare is here to stay. The likelihood of higher taxes paid by employers and individuals to fund the health system is nil. The majority (69%) of the public think it wasteful and inefficient (See Polling below). The majority believe it puts its profits above all else. The majority think it needs major change. That’s not new, but it’s felt more intensely and more widely than ever.

    That means accommodation for private capital, including private equity, is not a major concern to voters: the prices they pay matters more than who owns the organization.

    Tighter regulation of private equity, including more rights given to the Limited Partners who invest in the PE funds and limitations on public officials who become fund advisors, are likely. Bad actors will be vilified by regulators and elected officials. Media scrutiny of specific PE funds and their GPs will intensify as PE public reporting regulations commence. And investments made by not-for-profit multi-hospital systems and independent hospitals will be critical elements in upcoming Congressional and regulatory policy setting about their community benefit accountability and tax exemptions.

    The public’s major concern about its healthcare industry is affordability. To the extent PE-backed solutions offer lower-cost, higher-value alternatives on a playing field that’s level with respect to equitable access and demand-management, they will be at the table.

    To the extent PE-backed solutions cherry-pick the system’s low-hanging fruit at the expense of patient safety and affordability sans any regulatory restriction, they’ll breed public discontent from those they choose to ignore.

    So, the reality is this: PE’s focus is generating profits for its GP and their LPs. Doing business in a socially responsible way is a fund’s prerogative. Some do it better than others.

    PE is part of healthcare’s solution to its poorly structured, perpetually inadequate and mal-distributed funding. But creating a level playing field through meaningful regulatory reform is necessary first.

    PS Among the stickier issues facing hospitals is site-neutral payments. Hospitals oppose the proposal reasoning the overhead structure for their outpatient services (HOPD) include indirect & direct costs for services provided those unable to pay i.e. emergency services. Proponents of the change argue that what’s done is the key, not where it’s done, and uniform pricing is common sense. Leavitt Partners has advanced a compromise: a Unified Ambulatory Payment System for HOPDs, ASCs and physician clinics that would be applied to 66 services starting