Category Archives: Public Health

What a Biden-Trump Re-Match means for Healthcare Politics: How the Campaigns will Position their Differences to Voters

Posted on by • Posted in 2024 Election Issues, ACA, Access & Quality of Healthcare, Access to IVF Treatments, Affordability, Antitrust, Competition, Federal Trade Commission, Federal Trade Commission (FTC), Health Insurance Coverage Adequacy, Health Policy, High Drug Prices, Market Consolidation, Market Power, Medicaid, Medicare, Monopoly Behavior, Out of Pocket Expenses, Price Transparency, Public Health • Leave a comment
What a Biden-Trump Re-Match means for Healthcare Politics: How the Campaigns will Position their Differences to Voters

With the South Carolina Republican primary results in over the weekend, it seems a Biden-Trump re-match is inevitable. Given the legacies associated with Presidencies of the two and the healthcare platforms espoused by their political parties, the landscape for healthcare politics seems clear:

Healthcare IssueBiden PolicyTrump Policy
Access to Abortion‘It’s a basic right for women protected by the Federal Government’‘It’s up to the states and should be safe and rare. A 16-week ban should be the national standard.’
Ageism‘President Biden is alert and capable. It’s a non-issue.’‘President Biden is senile and unlikely to finish a second term is elected. President Trump is active and prepared.’
Access to IVF Treatments‘It’s a basic right and should be universally accessible in every state and protected’‘It’s a complex issue that should be considered in every state.’
Affordability‘The system is unaffordable because it’s dominated by profit-focused corporations. It needs increased regulation including price controls.’‘The system is unaffordable to some because it’s overly regulated and lacks competition and price transparency.’
Access to Health Insurance Coverage‘It’s necessary for access to needed services & should be universally accessible and affordable.’‘It’s a personal choice. Government should play a limited role.’
Public health‘Underfunded and increasingly important.’‘Fragmented and suboptimal. States should take the lead.’
Drug prices‘Drug companies take advantage of the system to keep prices high. Price controls are necessary to lower costs.’‘Drug prices are too high. Allowing importation and increased price transparency are keys to reducing costs.’
Medicare‘It’s foundational to seniors’ wellbeing & should be protected. But demand is growing requiring modernization (aka the value agenda) and additional revenues (taxes + appropriations).’‘It’s foundational to senior health & in need of modernization thru privatization. Waste and fraud are problematic to its future.’
Medicaid‘Medicaid Managed Care is its future with increased enrollment and standardization of eligibility & benefits across states.’‘Medicaid is a state program allowing modernization & innovation. The federal role should be subordinate to the states.’
Competition‘The federal government (FTC, DOJ) should enhance protections against vertical and horizontal consolidation that reduce choices and increase prices in every sector of healthcare.’‘Current anti-trust and consumer protections are adequate to address consolidation in healthcare.’
Price Transparency‘Necessary and essential to protect consumers. Needs expansion.’‘Necessary to drive competition in markets. Needs more attention.’
The Affordable Care Act‘A necessary foundation for health system modernization that appropriately balances public and private responsibilities. Fix and Repair’‘An unnecessary government takeover of the health system that’s harmful and wasteful. Repeal and Replace.’
Role of federal government‘The federal government should enable equitable access and affordability. The private sector is focused more on profit than the public good.’‘Market forces will drive better value. States should play a bigger role’

My take:

Polls indicate Campaign 2024 will be decided based on economic conditions in the fall 2024 as voters zero in on their choice. Per KFF’s latest poll, 74% of adults say an unexpected healthcare bill is their number-one financial concern—above their fears about food, energy and housing. So, if you’re handicapping healthcare in Campaign 2024, bet on its emergence as an economic issue, especially in the swing states (Michigan, Florida, North Carolina, Georgia and Arizona) where there are sharp health policy differences and the healthcare systems in these states are dominated by consolidated hospitals and national insurers.

  • Three issues will be the primary focus of both campaigns: women’s health and access to abortion, affordability and competition. On women’s health, there are sharp differences; on affordability and competition, the distinctions between the campaigns will be less clear to voters. Both will opine support for policy changes without offering details on what, when and how.
  • The Affordable Care Act will surface in rhetoric contrasting a ‘government run system’ to a ‘market driven system.’ In reality, both campaigns will favor changes to the ACA rather than repeal.
  • Both campaigns will voice support for state leadership in resolving abortion, drug pricing and consolidation. State cost containment laws and actions taken by state attorneys general to limit hospital consolidation and private equity ownership will get support from both campaigns.
  • Neither campaign will propose transformative policy changes: they’re too risky. integrating health & social services, capping total spending, reforms of drug patient laws, restricting tax exemptions for ‘not for profit’ hospitals, federalizing Medicaid, and others will not be on the table. There’s safety in promoting populist themes (price transparency, competition) and steering away from anything more.

As the primary season wears on (in Michigan tomorrow and 23 others on/before March 5), how the health system is positioned in the court of public opinion will come into focus.

Abortion rights will garner votes; affordability, price transparency, Medicare solvency and system consolidation will emerge as wedge issues alongside.

PS: Re: federal budgeting for key healthcare agencies, two deadlines are eminent: March 1 for funding for the FDA and the VA and March 8 for HHS funding.

Healthcare 2024: The 10 Themes that will Dominate Discussion

Posted on by • Posted in Accountable Care Organization (ACO), Antitrust, Board, Board Effectiveness, C-Suite, Distrust, Health Policy, Health System, Hospital, Hospital Industry, Market Consolidation, Market Trends, Market Uncertainty, Non-Profit Healthcare Industry, Physician Independence, Public Health, Workforce Issues, Workforce Strategy • Leave a comment
Healthcare 2024: The 10 Themes that will Dominate Discussion

The U.S. health system has experienced three major shifts since the pandemic that set the stage for its future:

  • From trust to distrust: Every poll has chronicled the decline in trust and confidence in government: Congress, the Presidency, the FDA and CDC and even the Supreme Court are at all-time lows. Thus, lawmaking about healthcare is met with unusual hostility.
  • From big to bigger: The market has consistently rewarded large cap operators, giving advantage to national and global operators in health insurance, information technology and retail health. In response, horizontal consolidation via mergers and acquisitions has enabled hospitals, medical practices, law firms and consultancies to get bigger, attracting increased attention from regulators. Access to private capital and investor confidence is a major differentiator for major players in each sector.
  • From regulatory tailwinds to headwinds: in the last 3 years, regulators have forced insurers, hospitals and drug companies to disclose prices and change business practices deemed harmful to fair competition and consumer choice. Incumbent-unfriendly scrutiny has increased at both the state and federal levels including notable bipartisan support for industry-opposed legislation. It will continue as healthcare favor appears to have run its course.

Some consider these adverse; others opportunistic; all consider them profound. All concede the long-term destination of the U.S. health system is unknown. Against this backdrop, 2024 is about safe bets.

These 10 themes will be on the agenda for every organization operating in the $4.5 trillion U.S. healthcare market:

  1. Not for profit health: “Not-for-profit” designation is significant in healthcare and increasingly a magnet for unwelcome attention. Not-for-profit hospitals, especially large, diversified multi-hospital systems, will face increased requirements to justify their tax exemptions. Special attention will be directed at non-operating income activities involving partnerships with private equity and incentives used in compensating leaders. Justification for profits will take center stage in 2024 with growing antipathy toward organizations deemed to put profit above all else.
  2. Insurer coverage and business practices: State and federal regulators will impose regulatory constraints on insurer business practices that lend to consumer and small-business affordability issues.
  3. Workforce wellbeing: The pandemic hangover, sustained impact of inflation on consumer prices, increased visibility of executive compensation and heightened public support for the rank-and-file workers and means wellbeing issues must be significant in 2024.
  4. Board effectiveness: The composition, preparedness, compensation and independent judgement of Boards will attract media scrutiny; not-for-profit boards will get special attention in light of 2023 revelations in higher education.
  5. Employer-sponsored health benefits: The cost-effectiveness of employee health benefits coverage will prompt some industries and large, self-insured companies to pursue alternative strategies for attracting and maintaining a productive workforce. Direct contracting, on-site and virtual care will be key elements.
  6. Physician independence: With 20% of physicians in private equity-backed groups, and 50% in hospital employed settings, ‘corporatization’ will encounter stiff resistance from physicians increasingly motivated to activism believing their voices are unheard.
  7. Data driven healthcare: The health industry’s drive toward interoperability and transparency will will force policy changes around data (codes) and platform ownership, intellectual property boundaries, liability et al. Experience-based healthcare will be forcibly constrained by data-driven changes to processes and insights.
  8. Consolidation: The DOJ and FTC will expand their activism against vertical and horizontal consolidation that result in higher costs for consumers. Retrospective analyses of prior deals to square promises and actual results will be necessary.
  9. Public health: State and federal funding for public health programs that integrate with community-based health providers will be prioritized. The inadequacy of public health funding versus the relative adequacy of healthcare’s more lucrative services will be the centerpiece for health reforms.
  10. ACO 2.0: In Campaign 2024, abortion and the Affordable Care Act will be vote-getters for candidates favoring/opposing current policies. Calls to “Fix and Repair” the Affordable Care Act will take center stage as voters’ seek affordability and access remedies.

Every Board and C suite in U.S. healthcare will face these issues in 2024.

Respiratory virus activity is high and rising across the United States, CDC data shows

Posted on by • Posted in Centers for Disease Control & Prevention (CDC), Coronavirus, Flu Season, Flu Shot, Flu Transmission, Flu-Related Hospitalizations, Infection Control, Personal Protective Equipment (PPE), Pneumococcal Pneumonia, Public Health, Respiratory Syncytial Virus (RSV), Vaccination, Vaccine, Vaccine Booster • Leave a comment

https://www.yahoo.com/lifestyle/respiratory-virus-activity-high-rising-192815114.html

As seasonal virus activity surges across the United States, experts stress the importance of preventive measures – such as masking and vaccination – and the value of treatment for those who do get sick.

Tens of thousands of people have been admitted to hospitals for respiratory illness each week this season. During the week ending December 23, there were more than 29,000 patients admitted with Covid-19, about 15,000 admitted with the flu and thousands more with respiratory syncytial virus, or RSV, according to data from the US Centers for Disease Control and Prevention.

Nationally, Covid-19 levels in wastewater, a leading measure of viral transmission, are very high – higher than they were at this time last year in every region, CDC data shows. Weekly emergency department visits rose 12%, and hospitalizations jumped about 17% in the most recent week.

And while Covid-19 remains the leading driver of respiratory virus hospitalizations, flu activity is rising rapidly. The CDC estimates that there have been more than 7 million illnesses, 73,000 hospitalizations and 4,500 deaths related to the flu this season, and multiple indicators are high and rising.

RSV activity is showing signs of slowing in some parts of the US, but many measures, including hospitalization rates, remain elevated. Overall, young children and older adults are most affected.

“It’s a wave of winter respiratory pathogens, especially respiratory viruses. So it’s Covid, it’s flu, and we can’t diminish the importance of RSV,” said Dr. Peter Hotez, dean of the National School of Tropical Medicine at the Baylor College of Medicine. “So it’s a triple threat, and arguably a fourth threat because we also have pneumococcal pneumonia, which complicates a lot of these virus infections.”

Respiratory virus activity has been on the rise for weeks. Now, flu-like activity is high or very high in two-thirds of the United States, including California, New York City and Washington, as well as throughout the South and Northeast, according to the CDC.

“Remember, all of these numbers are before people got together for the holidays,” Hotez said. “So don’t be disappointed or surprised that we even see a bigger bump as we head into January.”

Vaccines can help prevent severe illness and death, but uptake remains low this season – despite a historic first, with vaccines available to protect against each of the three major viruses. Just 19% of adults and 8% of children have gotten the latest Covid-19 vaccine, and 17% of adults 60 and older have gotten the new RSV vaccine, CDC data shows. Less than half of adults and children have gotten the flu vaccine this season.

“We have, as a population, underutilized both influenza and the updated Covid vaccines, unfortunately,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University. “But it’s not too late to get vaccinated, because these viruses are going to be around for a while yet.”

According to the CDC, hospital bed capacity remains “stable” nationally, including within intensive care units. But with high levels of respiratory viruses, hospitals in at least five states are returning to requiring masks.

Mass General Brigham spokesman Timothy Sullivan said it will require masking for health-care staff who interact directly with patients starting Tuesday, and patients and visitors will be “strongly encouraged to wear a facility-issued mask.”

In Wisconsin, UW Health and UnityPoint Health – Meriter have expanded mask policies to cover more people. UW requires all staff, patients and visitors to wear a mask for patient interactions in clinic settings, including waiting areas and exam rooms.

UnityPoint Health – Meriter says masks continue to be required for team members and visitors in patient rooms.

Bellevue, a public hospital in New York City, said on social media last week that it had reinstated its mandatory masking policy due to an uptick in respiratory illnesses.

In Pennsylvania, the University of Pittsburgh Medical Center has required everyone to wear a mask when entering or inside since December 20. The systemwide masking policies were adjusted to “address the increase of respiratory virus cases” but may change when there is a “marked decrease in respiratory health cases,” according to the health care system.

An order posted last week by the Los Angeles County Health Officer requires all health-care personnel and visitors to mask while in contact with patients or in patient-care areas, based on the CDC’s categorization of Covid-19 hospital admission levels.

During the week ending December 23, more than 230 US counties were considered to have “high” levels of Covid-19 hospital admissions, defined by the CDC by at least 20 new hospital admissions for every 100,000 people. Nearly a thousand other counties, about a third of the country, have “medium” Covid-19 hospital admission levels, with at least 10 admissions for every 100,000 people.

Vaccines and masks can help reduce the risk of severe illness before getting sick, but treatments are also available to help prevent people from getting very sick if they do become infected.

Antiviral treatments for Covid-19, such as Paxlovid, and flu, such as Tamiflu, can be especially helpful for people who are more likely to get very sick, including people who are 50 or older and those with certain underlying conditions, such as a weakened immune system, heart disease, obesity, diabetes or chronic lung disease.

“If more people at higher risk for severe illness get treatment in a timely manner, we will save lives,” the CDC said in a recent blog post. But “not enough people are taking them.”

Seasonal respiratory virus activity can be hard to predict, but CDC forecasts suggest that hospitalization rates will continue at elevated levels for weeks and that this season, overall, will probably result in a similar number of hospitalizations as last season.

“One of the ways to help us all go into a happy new year is for us to be as protected as we can against these viruses,” Schaffner said.

“Of course, I continue to recommend vaccination, prudent use of the mask by high-risk people and, should you become sick, do not go to work and spread the virus further. Call your health care provider, because you may have some treatment available that will get you healthier sooner.”

The ACA’s Promise of Free Preventive Health Care Faces Ongoing Legal Challenges

Posted on by • Posted in ACA, Dept of Health and Human Services (HHS), District Court, District Court of Appeals, Health Policy, Lawsuit, Medicaid, Preventable Disease, Preventative Care, Prevention, Preventive Screening, Public Health, Quality of Care, Supreme Court, United States Preventive Services Task Force (USPSTF) • Leave a comment
https://www.commonwealthfund.org/blog/2023/acas-promise-free-preventive-health-care-faces-ongoing-legal-challenges?utm_campaign=Achieving%20Universal%20Coverage&utm_medium=email&_hsmi=279218032&_hsenc=p2ANqtz-9zDeEtOawTu_XlAtH44MhtF0pskow9Np3hYpbHYjISSFzah0E6zBTL84n3AeOQ8gGyhdTdr6AtdEF017WhYC8AnMM58A&utm_source=alert

An ongoing legal challenge is threatening the guarantee of free preventive care in the Affordable Care Act (ACA).

Six individuals and the owners of two small businesses sued the federal government, arguing that the ACA provision “makes it impossible” for them to purchase health insurance for themselves or their employees that excludes free preventive care. The plaintiffs argue that they do not want or need such care. They specifically name the medication PrEP (used to prevent the spread of HIV), contraception, the HPV vaccine, and screening and behavioral counseling for sexually transmitted diseases and substance use; however, they seek to invalidate the entire ACA preventive benefit package.

A federal trial court judge agreed with some of their claims and invalidated free coverage of more than 50 services, including lung, breast, and colon cancer screenings and statins to prevent heart disease.

This ruling, which is currently being appealed, strips free preventive services coverage from more than 150 million privately insured people and approximately 20 million Medicaid beneficiaries who are covered under the ACA’s Medicaid expansion.

This suit was first filed in 2020. The plaintiffs in the case, Braidwood Management v. Becerra, continue to oppose the entire preventive benefit package, which consists of four service bundles: services rated “A” or “B” by the United States Preventive Services Task Force (USPSTF); routine immunizations recommended by the Advisory Committee on Immunization Practices (ACIP); evidence-informed services for children recommended by the Health Resources and Services Administration (HRSA); and evidence-informed women’s health care recommended by HRSA. The trial judge invalidated all benefits recommended by the USPSTF after March 23, 2010, the date the ACA became law. (The court also exempted the plaintiffs on religious grounds from their obligation to cover PrEP.) The Fifth Circuit put the trial court’s decision on temporary hold while the case is on appeal.

The Fifth Circuit, one of the nation’s most conservative appeals courts, will hear the Biden administration’s appeal of the trial court’s USPSTF ruling and the entirety of the plaintiffs’ original challenge, thereby putting all four coverage guarantees in play. The court also will hear whether the ruling should apply only to the plaintiffs or to all Americans.

The trial court held that the USPSTF lacks the legal status necessary under the Constitution to make binding coverage decisions, and that the Secretary of the U.S. Department of Health and Human Services (HHS) — who can make such binding decisions — lacks the power to rectify matters by formally adopting USPSTF recommendations. The judge concluded that federal law fails to require that members be presidential nominees confirmed by the Senate under the Appointments Clause; in the judge’s view, this means that members are not politically accountable for their decisions, which is constitutionally problematic. The judge also ruled that federal law makes the USPSTF the final coverage arbiter, which means that the HHS Secretary, who is nominated and confirmed under the Appointments Clause and thus politically accountable, cannot cure the constitutional problem by ratifying USPSTF recommendations.

On appeal, the Biden administration argues that the USPSTF passes constitutional muster because the HHS Secretary, who oversees the Task Force, is a nominated and confirmed constitutional officer. Alternatively, the administration argues the appeals court should interpret the statute as allowing the HHS Secretary to ratify USPSTF recommendations, since the law specifies that USPSTF members are independent of political pressure only “to the extent practicable.” The administration makes similar arguments on behalf of ACIP and HRSA.

The plaintiffs argue that secretarial ratification cannot cure the constitutional problems with all three advisory bodies. According to the plaintiffs, none of the advisory bodies has the status of constitutional officers demanded by the Appointments Clause, and so their recommendations must remain recommendations only, unenforceable by HHS on insurers, health plans, and state Medicaid programs.

The second issue is the scope of the remedy if the law is found unconstitutional. The trial court did not limit its holding to the four individual plaintiffs and two companies who sued, but instead applied its order nationwide. The Biden administration argues that, if the coverage guarantee is unconstitutional, the court only should prohibit HHS from enforcing the preventive services provision against the plaintiffs who brought the lawsuit and should allow the coverage guarantee to remain in force for the rest of the country. Citing an amicus brief filed by the American Public Health Association and public health deans and scholars, the administration argues that barring HHS from enforcing the preventive services requirement nationwide “pose[s] a grave threat to the public health” by decreasing Americans’ access to lifesaving preventive services. The plaintiffs argue that a nationwide prohibition is necessary, the broader public interest in free preventive coverage is irrelevant, and insurers will voluntarily continue to offer free preventive coverage if people want it.

The administration’s arguments on appeal have attracted amicus briefs by bipartisan economic scholars, organizations concerned with health equity and preventive health, health care organizations, and 23 states.

Crucially, the economists point out that, prior to the ACA, comprehensive free preventive coverage was extremely limited because it is not in insurers’ interest to make a long-term economic investment in members’ health. Indeed, prior to the ACA, insurers did not even uniformly cover the basic screenings for newborns to detect treatable illnesses and conditions.

Amicus briefs supporting the plaintiffs have been filed by Texas and an organization dedicated to “protecting individual liberties . . . against government overreach.” All briefing will be complete by November 3, 2023, with oral argument thereafter. A decision is likely in early to mid-2024. Whatever the outcome, expect a Supreme Court appeal given the size of the stakes in the case.

Ryder Cup Lessons for Team USA Healthcare

Posted on by • Posted in Affordability, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Lobbyist, Medical Debt, Mortality, Out of Pocket Expenses, Outcomes, Profit Motive, Public Health, Public Health Strategy, Quality of Care, Quality of Life, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment
Ryder Cup Lessons for Team USA Healthcare

Saturday, Congress voted overwhelming (House 335-91, Senate 88-9) to keep the government funded until Nov. 17 at 2023 levels. No surprise.  Congress is supposed to pass all 12 appropriations bills before the start of each fiscal year but has done that 4 times since 1970—the last in 1997. So, while this chess game plays out, the health system will soldier on against growing recognition it needs fixing.

In Wednesday night’s debate, GOP Presidential aspirant Nicki Haley was asked what she would do to address the spike in personal bankruptcies due to medical debt. Her reply:

“We will break all of it [down], from the insurance company, to the hospitals, to the doctors’ offices, to the PBMs [pharmacy benefit managers], to the pharmaceutical companies. We will make it all transparent because when you do that, you will realize that’s what the problem is…we need to bring competition back into the healthcare space by eliminating certificate of need systems… Once we give the patient the ability to decide their healthcare, deciding which plan they want, that is when we will see magic happen, but we’re going to have to make every part of the industry open up and show us where their warts are because they all have them”

It’s a sentiment widely held across partisan aisles and in varied degrees among taxpayers, employers and beyond. It’s a system flaw and each sector is complicit.

What seems improbable is a solution that rises above the politics of healthcare where who wins and loses is more important than the solutions themselves.

Perhaps as improbable as the European team’s dominating performance in the 44th Ryder Cup Championship played in Rome last week especially given pre-tournament hype about the US team.

While in Rome last week, I queried hotel employees, restaurant and coffee shop owners, taxi drivers and locals at the tournament about the Italian health system. I saw no outdoor signage for hospitals and clinics nor TV ads for prescriptions and OTC remedies. Its pharmacies, clinics and hospitals are non-descript, modest and understated. Yet groups like the World Health Organization (WHO) and the Organization for Economic Cooperation Development (OECD) rank Servizio Sanitario Nazionale (SSN), the national system authorized in December 1978, in the top 10 in the world (The WHO ranks it second overall behind France).

“It covers all Italian citizens and legal foreign residents providing a full range of healthcare services with a free choice of providers. The service is free of charge at the point of service and is guided by the principles of universal coverage, solidarity, human dignity, and health. In principle, it serves as Italy’s public healthcare system.” Like U.S. ratings for hospitals, rankings for the Italian system vary but consistently place it in the top 15 based on methodologies comparing access, quality, and affordability.

The U.S., by contrast, ranks only first in certain high-end specialties and last among developed systems in access and affordability.

Like many systems of the world, SSN is governed by a national authority that sets operating principles and objectives administered thru 19 regions and two provinces that deliver health services under an appointed general manager. Each has significant independence and the flexibility to determine its own priorities and goals, and each is capitated based on a federal formula reflecting the unique needs and expected costs for that population’s health. 

It is funded through national and regional taxes, supplemented by private expenditure and insurance plans and regions are allowed to generate their own additional revenue to meet their needs. 74% of funding is public; 26% is private composed primarily of consumer out-of-pocket costs. By contrast, the U.S. system’s funding is 49% public (Medicare, Medicaid et al), 24% private (employer-based, misc.) and 27% OOP by consumers.

Italians enjoy the 6th highest life expectancy in the world, as well as very low levels of infant mortality. It’s not a perfect system: 10% of the population choose private insurance coverage to get access to care quicker along with dental care and other benefits. Its facilities are older, pharmacies small with limited hours and hospitals non-descript.

But Italians seem satisfied with their system reasoning it a right, not a privilege, and its absence from daily news critiques a non-concern.

Issues confronting its system—like caring for its elderly population in tandem with declining population growth, modernizing its emergency services and improving its preventive health programs are understood but not debilitating in a country one-fifth the size of the U.S. population.

My take:

Italy spends 9% of its overall GDP on its health system; the $4.6 trillion U.S spends 18% in its GDP on healthcare, and outcomes are comparable.  Our’s is better known but their’s appears functional and in many ways better.

Should the U.S.copy and paste the Italian system as its own? No. Our societies, social determinants and expectations vary widely. Might the U.S. health system learn from countries like Italy? Yes.

Questions like these merit consideration:

Might the U.S. system perform better if states had more authority and accountability for Medicare, CMS, Veterans’ health et al?

Might global budgets for states be an answer?

Might more spending on public health and social services be the answer to reduced costs and demand?

Might strict primary care gatekeeping be an answer to specialty and hospital care?

Might private insurance be unnecessary to a majority satisfied with a public system?

Might prices for prescription drugs, hospital services and insurance premiums be regulated or advertising limited?

Might employers play an expanded role in the system’s accountability?

Can we afford the system long-term, given other social needs in a changing global market?

Comparisons are constructive for insights to be learned. It’s true in healthcare and professional golf. The European team was better prepared for the Ryder Cup competition. From changes to the format of the matches, to pin placements and second shot distances requiring precision from 180-200 yards out on approach shots: advantage Europe. Still, it was execution as a team that made the difference in its dominating 16 1/2- 11 1/2 win —not the celebrity of any member.

The time to ask and answer tough questions about the sustainability of the U.S. system and chart a path forward. A prepared, selfless effort by a cross-sector Team Healthcare USA is our system’s most urgent need. No single sector has all the answers, and all are at risk of losing.

Team USA lost the Ryder Cup because it was out-performed by Team Europe: its data, preparation and teamwork made the difference.

Today, there is no Team Healthcare USA: each sector has its stars but winning the competition for the health and wellbeing of the U.S. populations requires more.

2023 Nobel Prize in Medicine: Karikó, Weissman awarded prize for mRNA research

Posted on by • Posted in Clinical Research, Clinical Research Funding, Coronavirus, mRNA-based Vaccines, Nobel Prize, Pandemic, Public Health, Public Health Emergency (PHE), Public Health Strategy, Vaccine, Vaccine Development, Vaccine History, Vaccine RNA • Leave a comment
2023 Nobel Prize in Medicine: Karikó, Weissman awarded prize for mRNA research

Two pioneers of mRNA research — the technology that helped the world tame the virus behind the Covid-19 pandemic — won the 2023 Nobel Prize in medicine or physiology on Monday.

Overcoming a lack of broader interest in their work and scientific challenges, Katalin Karikó and Drew Weissman made key discoveries about messenger RNA that enabled scientific teams to start developing the tool into therapies, immunizations, and — as the pandemic spread in 2020 — vaccines targeting the SARS-CoV-2 coronavirus. Moderna and the Pfizer-BioNTech partnership unveiled their mRNA-based Covid-19 shots in record time thanks to the foundational work of Karikó and Weissman, helping save millions of lives.

Karikó, a biochemist, and Weissman, an immunologist, performed their world-changing research on the interaction between mRNA and the immune system at the University of Pennsylvania, where Weissman, 64, remains a professor in vaccine research. Karikó, 68, who later went to work at BioNTech, is now a professor at Szeged University in her native Hungary, and is an adjunct professor at Penn’s Perelman School of Medicine. 

The duo will receive 11 million Swedish kronor, or just over $1 million. Their names are added to a list of medicine or physiology Nobel winners that prior to this year included 213 men and 12 women.

The award was announced by Thomas Perlmann, secretary general of Nobel Assembly, in Stockholm. Perlmann said he had spoken to both laureates, describing them as grateful and surprised even though the pair has won numerous awards seen as precursors and had been tipped as likely Nobel recipients at some point.  

Every year, the committee considers hundreds of nominations from former Nobel laureates, medical school deans, and prominent scientists from fields including microbiology, immunology, and oncology. Members try to identify a discovery that has altered scientists’ understanding of a subject. And according to the criteria laid out in Alfred Nobel’s will, that paradigm-shifting discovery also has to have benefited humankind.

The Nobel committee framed Karikó and Weissman’s work as a prime example of complementary expertise, with Karikó focused on RNA-based therapies and Weissman bringing a deep knowledge about immune responses to vaccines.

But it was not an easy road for the scientists. Karikó encountered rejection after rejection in the 1990s while applying for grants. She was even demoted while working at Penn, as she toiled away on the lower rungs of academia.

But the scientists persisted, and made a monumental discovery published in 2005 based on simply swapping out some of the components of mRNA.

With instructions from DNA, our cells make strands of mRNA that are then “read” to make proteins. The idea underlying an mRNA vaccine then is to take a piece of mRNA from a pathogen and slip it into our bodies. The mRNA will lead to the production of a protein from the virus, which our bodies learn to recognize and fight should we encounter it again in the form of the actual virus.

It’s an idea that goes back to the 1980s, as scientific advances allowed researchers to make mRNA easily in their labs. But there was a problem: The synthetic mRNA not only produced smaller amounts of protein than the natural version in our cells, it also elicited a potentially dangerous inflammatory immune response, and was often destroyed before it could reach target cells.

Karikó and Weissman’s breakthrough focused on how to overcome that problem. mRNA is made up of four nucleosides, or “letters”: A, U, G, and C. But the version our bodies make includes some nucleosides that are chemically modified — something the synthetic version didn’t, at least until Karikó and Weissman came along. They showed that subbing out some of the building blocks for modified versions allowed their strands of mRNA to sneak past the body’s immune defenses.

While the research did not gain wide attention at the time, it did catch the attention of scientists who would go on to found Moderna and BioNTech. And now, nearly 20 years later, billions of doses of mRNA vaccines have been administered.

For now, the only authorized mRNA products are the Covid-19 shots. But academic researchers and companies are exploring the technology as a potential therapeutic platform for an array of diseases and are using it to develop cancer vaccines as well as immunizations against other infectious diseases, from flu to mpox to HIV. An mRNA vaccine is highly adaptable compared to earlier methods, which makes it easier to alter the underlying recipe of the shot to keep up with viral evolution.

As she gained global fame, Karikó has been open about the barriers she encountered in her scientific career, which raised broader issues about the challenges women and immigrants can face in academia. But she’s said she always believed in the potential of her RNA research.

“I thought of going somewhere else, or doing something else,” Karikó told STAT in 2020, recalling the moment she was demoted. “I also thought maybe I’m not good enough, not smart enough. I tried to imagine: Everything is here, and I just have to do better experiments.”

Signs of a summer COVID bump could signal a tougher fall.

Posted on by • Posted in Coronavirus, Flu Season, Flu Transmission, Public Health, Respiratory Syncytial Virus (RSV), Vaccine • Leave a comment

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After experiencing steadily declining numbers across 2023, the country is currently seeing an uptick in COVID-19 hospitalizations, which increased 12 percent week-over-week, to approximately 8,000 in the week ending July 22. This rise, the largest since December, follows an increase in national wastewater levels of COVID across the past month, particularly in the Northeast and South. Given that most health agencies are no longer tracking COVID case levels, and many Americans are no longer getting tested or testing themselves, actual case counts are unclear. 

The Gist: Though COVID hospitalizations are up, weekly totals are still among the lowest the nation has seen since the pandemic began. And while COVID deaths are a lagging indicator, the most recent Centers for Disease Control and Prevention (CDC) data charts them at their lowest level since the start of the pandemic. 

Nonetheless, if this COVID uptick continues into fall, we could once again be facing a “tripledemic” of COVID, flu, and respiratory syncytial virus (RSV) circulating at high levels all at once, straining hospital resources. 

Fortunately, an updated COVID vaccine is coming this fall. Urging Americans, particularly older and vulnerable patients, to get vaccinated for all three viruses will be critical—although convincing individuals to get three separate shots will increase the challenge.

Should some clinical services be considered a public good? 

Posted on by • Posted in Community Benefit, Health Policy, Master Planning, Public Funding, Public Good, Public Health, Regional Master Planning, Tax Exempt Status • Leave a comment

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We caught up recently with a healthcare leader who had spent time in Atlanta in a previous role, and the conversation turned to last year’s closure of Atlanta Medical Center.

One major impact: the closure immediately left the Atlanta metro region, home to over 6M people, with only one Level 1 trauma center (a second Level 1 center opened an hour north of the city in February). “It’s devastating for the community to lose those services,” he shared, “but I also get why the health system made that choice, given how hard the economy has hit hospitals.” When all health systems are feeling the worst margin pressures in more than a decade, most would be reticent to step in and launch a new trauma program, which despite bringing prestige, is often a money-loser. 


The conversation got us thinking about whether healthcare needs a new approach to securing essential services needed by the community which aren’t well supported by the payment system. 

Our current model largely relies on nonprofit systems to meet the community need as a tenet of that status. But as one CMO shared, “If there’s more than one system in the market, we toss the responsibility back and forth like a hot potato.”

His solution: there needs to be top-down redesign of urgently needed critical services like trauma and behavioral health, as well as highly specialized services like transplant and pediatric subspecialty care, which he considered oversupplied in his market, with multiple subscale programs.

His hope was that health systems could cross competitive lines and collaborate to think about a rational approach to “regional healthcare master planning”, along with a new funding model.

It’s a tall order, he continued, but if health systems can’t find a solution on their own, they leave themselves open to government intervention that might mandate a solution—or further questions of the value communities are receiving from supporting nonprofit status. 

We’ve become even less prepared for the next pandemic

Posted on by • Posted in Health Policy, Pandemic, Pandemic Preparedness, Public Health, Public Health Infrastructure, Public Health Strategy • Leave a comment

https://mailchi.mp/28f390732e19/the-weekly-gist-march-10-2023?e=d1e747d2d8

Published this week in the Washington Post, this sobering article surveys the dismantling of our nation’s patchwork public health infrastructure, driven by a backlash to COVID pandemic restrictions. Positioning themselves as defenders of freedom, a coalition of conservative and libertarian activists, legislators, and judges have neutered many of the nation’s public health authorities. State health officials and governors in over half the country are now unable to issue mask mandates or order school closures without the permission of their state legislatures.

While the implications for a hypothetical “next COVID” are dire, we’re already seeing the consequences today: officials in Columbus, OH can no longer, for example, quarantine a child with measles, or shut down a restaurant experiencing a hepatitis A outbreak. 

The Gist: The anti-public health backlash in the wake of COVID has now been codified, with far reaching consequences for future disease outbreaks. COVID protections for hospital-based healthcare providers are winding down, even in states like California which quickly embraced masking.

But now in over half the country, many reasonable responses to unknown future health threats won’t even be on the table, or will involve debate and legislative action, wasting precious response time. 

Sports betting has risen tenfold in three years. Addiction experts fear the next opioid crisis

Posted on by • Posted in Addiction, Hidden Addiction, Public Health, Public Health Crisis, Sports Gambling Crisis, Supreme Court • Leave a comment

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The sports betting market has multiplied tenfold in three years and may have reached $7 billion in 2022. More than half of the nation can now legally gamble on sports. Fifty million Americans are expected to bet on the upcoming Super Bowl.  

Five years ago, betting on live games was illegal in most of the United States. A Supreme Court ruling in 2018 removed the ban and transformed the industry. Now, 33 states and the District of Columbia allow wagers on games.  

Addiction experts fear a coming national epidemic to rival the opioid crisis. 

“Gambling is a very different addiction from drugs or alcohol,” said Lia Nower, a professor and director of the Center for Gambling Studies at Rutgers University. “If I’m drunk or high, at some point my family is going to figure it out. With gambling, I can be sitting with my kids, watching cartoons, and gambling away my house, my car, everything I own, on my mobile phone. How would you know?” 

The Supreme Court ruling struck down a federal law that had banned most commercial sport wagering outside Las Vegas. The subsequent spread of legal gambling was stunningly swift.  

Lobbyists pampered state lawmakers with parties and promises, predicting millions in new tax dollars. Much of the promised revenue hasn’t reached the states, according to a New York Times investigation. 

But gambling dollars have reached the betting operators. The industry reaped $4.3 billion in revenue on $57 billion in wagers in 2021. In the first 11 months of 2022, Americans bet $83 billion on sports and delivered $6.6 billion to betting firms. That figure is 15 times what the sports gambling industry reaped in 2018.  

https://flo.uri.sh/visualisation/12698958/embed?auto=1

A Flourish chart

“We have a movement toward expanding what was once considered a sin, what was once considered a vice, and embedding it at every level of American culture, down to kindergarten,” said Timothy Fong, a clinical professor of psychiatry at the Jane and Terry Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

“Sports gambling market. Ten years ago, those words didn’t exist,” Fong said. “What you have is this massive, exponential expansion of gambling into homes, faster than we can study or monitor it.”

A record 50 million Americans, one adult in five, will bet on Super Bowl LVII, according to an American Gaming Association survey. They will wager $16 billion, twice as much as last year. 

Celebrity athletes shill for betting firms on television. Betting firms promote gambling on college campuses. Professional teams court “official mobile sports betting partners.”  

The Washington Post offers a sports betting page for readers. Gannett, publisher of more than 200 sports pages, recently announced a “strategic partnership” with an online gambling marketer. Nexstar Media, owner of The Hill, has forayed into sports betting. 

“Pete Rose was banned from baseball and blocked from the Hall of Fame because he gambled,” said Nower, of Rutgers. “Now, we’ve got professional ballplayers who are partnering with gambling companies. Now, kids are seeing these things inextricably linked.” 

Teams and league owners love sports betting because they “have found that engagement is off the charts among people who are placing bets on games,” said Daniel Barbarisi, author of “Dueling with Kings: High Stakes, Killer Sharks, and the Get-Rich Promise of Daily Fantasy Sports.”

People who bet on games “are not just tuning out if it’s a blowout,” Barbarisi said, because they bet on more than the final score. Fans can place wagers on the margin of victory, the combined point total from both teams and other metrics — such as whether Aaron Judge will hit a home run or Max Scherzer will ring up double-digit strikeouts.  

Sports bettors are predominantly male, surveys show. They are mostly under 45. Some are wealthy, but a Rutgers study found that half of sports gamblers earn less than $50,000 a year. Some hail from a distinct subpopulation of Americans who get a thrill from risking money on the Next Big Thing.  

“You can kind of draw a through line from the people who were involved in the poker boom in the early 2000s to the daily fantasy thing in the 2010s and then to the crypto thing,” Barbarisi said.  

“I don’t know if you can say it’s a small group of guys anymore. It’s a big group of guys.” 

Gambling is unquestionably addictive, and arguably immoral: Not for nothing did Las Vegas earn the Sin City sobriquet. Now that betting on sports is broadly legal, however, Americans are warming to the idea. 

A poll by The Washington Post and University of Maryland found that 66 percent of Americans approved of legal sports betting in 2022, up from 55 percent in 2017, a year before the Supreme Court decision.  

Nower suspects most Americans remain naive about gambling’s ills, much as society once cheerily embraced smoking and drinking. “We are where cigarettes were in the 1940s and alcohol was in the 1950s,” she said.  

Most Americans ignored the opioid crisis, a staggering increase in overdose deaths in the 1990s and 2000s, until the government and news media processed the data and tendered a response.

With sports betting, “you have the exact same players you had with opioids,” Fong said. “You have government. You have industry. You have civilians, a lot of whom will benefit from this. And then you have a population who will develop an addiction, let’s say 1, 1.5 percent of the population.” 

With legal sports gambling, “It’s a hidden addiction,” Fong said. “You can’t see it, you can’t smell it, you can’t taste it.” 

Fong points to one of his patients, a man in his 20s who earns $160,000 a year and owes $40,000 in gambling debts.  

“On face value, he can pay his rent, he’s not gonna die,” Fong said. “But he’s miserable. He’s just not happy.” 

Over time, researchers say, sports-betting addiction will take a toll in rising rates of bankruptcy, domestic violence, depression, anxiety and suicide.  

The federal government takes a keen interest in regulating alcohol, tobacco and drugs. In sports gambling, by contrast, “there is no federal presence at all,” Nower said. “And that is the biggest problem.” 

Oversight of the booming sports-betting industry has been mostly left to states.  

States that allow legal sports gambling “are not disinterested parties,” the Times wrote in its 2022 investigation. “They collect taxes on gambling, and the more people bet, the more governments get. One result is that states have, in many ways, given gambling companies free rein.” 

New Jersey, the state at the heart of the 2018 Supreme Court ruling, offers a rare exception, Nower said.  

Gambling regulators in New Jersey studied “the relationship between gambling and problem gambling” before they allowed legal gambling on sports, Nower said. She knows of no other state that took that step. 

New Jersey uses gambling data to identify “people who may be exhibiting problem symptoms,” Nower said: Shuffling several payment methods, overdrawing their cards, doubling down on bets, gambling more frequently.  

Most other states “are just legalizing this stuff without any idea of the effects,” she said.  

The sports betting landscape will remain untamed, researchers say, until governments recognize gambling as a matter of public health. 

“I do think there are watershed moments in all public health crises,” Nower said. “Unfortunately, it usually takes some kind of crisis or tragedy to turn the tide.”