By KAT MCDAVITT and LESLIE KIRK

Innsena has made a $100,000 contribution to CancerX, making Innsena the public-private partnership’s first Impact Supporter.

Why? There are few conditions in which the disparity in innovations benefiting underserved communities is more apparent than in the treatment and prevention of cancer.

Patients without insurance are more likely to present with more advanced cancers, and the cancer death rate for people of color is significantly higher than for white patients. More people die from cancer in rural communities than in urban settings. 

In CancerX, we found a community of partners taking on hard problems to equitably deploy innovative solutions that can reduce the risk of, and cure cancer for all patients. Even—and especially—when financial incentives do not otherwise exist for the private sector to solve those problems.  

Innsena is committed to improving equitable access, treatment and outcomes for the most vulnerable among us. We focus on supporting improved outcomes for Medicaid members and underserved communities. The disparity caused by the absence of incentives and funding for innovators to enter the Medicaid market can’t be overstated. 

But innovators, and the investors who fund these pioneers, are exactly what our industry needs to change health outcomes in underserved communities. 

We decided that, if the incentives to innovate in cancer care for vulnerable populations don’t exist, then we would create them. Our financial commitment to CancerX is a step forward that we hope will start a broader movement. 

Our team’s $100,000 contribution will help the team at CancerX to accelerate programs underway—including its effort to improve equity and reduce financial toxicity in cancer care and research—and to more rapidly launch new initiatives. 

We’re particularly proud to support the public-private partnership’s efforts to improve equity and reduce financial toxicity. Cancer deaths are inequitably distributed across the United States—and those patients who do survive are 2.5 times more likely to declare bankruptcy than those without disease. 

Likewise, a key component of CancerX is a start-up accelerator for companies bringing more digital solutions for the treatment and prevention of cancer, with special attention given to organizations that focus on disadvantaged populations. We’re honored to support the start-ups selected for the first CancerX accelerator cohort with both mentorship and financial support. 

And to that end, as individuals, we’ve gone one step further to support start-ups focused on preventing and curing cancer for vulnerable patients. We’ve also partnered with Ben Freeberg and his team at Oncology Ventures to ensure that digital health start-ups innovating for all patients in the oncology space have funding available to advance their causes. 

Innsena is joining more than 150 organizations already working together to make a difference for all patients in the prevention and treatment of cancer. CancerX is co-hosted by the Moffitt Cancer Center and Digital Medicine Society, alongside the US Department of Health and Human Services Office for the National Coordinator for Health Information Technology and Office of the Assistant Secretary for Health. 

We need more innovators working to improve care for the underserved. Join us in supporting CancerX. As a community we’ll make a difference. 

Kat McDavitt is President and founding partner of Innsena. Leslie Kirk is CEO and managing partner of Innsena.

By JONATHON S. FEIT

If ideas presented in essays on The Health Care Blog and other healthcare forums are meant to be rhetorical, without intention of turning notions into reality on behalf of patients who need genuine, intimate, desperate help…then feel free to ignore this essay entirely. 

Some among us—the State of Washington’s Co-Responder Outreach Alliance; Lisa Fitzpatrick’s Grapevine Health, which specializes in “street medicine” and advocacy in and around Washington, D.C.; Thorne Ambulance Service, an inspirational ambulance entrepreneur bringing both emergency and nonemergency medical transportation to underserved rural spaces (and more) across South Carolina; and the RightCare Foundation in Phoenix, a firefighter-driven organization dedicated to ensuring that patients’ needs and wishes are honored during critical moments, spring fast to mind—are stretching hands across the care continuum while pounding the table for interoperability at scale because PEOPLE. ARE. FALLING. THROUGH. THE. CRACKS. AND. DYING.  

Thatincludes responders who run toward the crises; into alleys; who risk their own lives, health, psyches, families, and futures because, as Josh Nultemeier—Chief Paramedic and Operations Manager of San Francisco’s King-American Ambulance, and a volunteer firefighter in the Town of Forestville—put it so simply in a social media post: “People could get hurt.” Moral override—that matter-of-fact willingness to risk himself for strangers who lack any other path to save themselves—is what makes Josh (and others who believe as he does) heroic.

Solving problems like substance use disorder—coupled with an increasing awareness of the lack of interoperability with prescription drug monitoring programs (PDMPs), many of which are run by Bamboo Health, which today imports zero data regarding out-of-hospital overdoses—is urgent. If an overdose is reversed in an alley, an abandoned home, a tent or “under the bridge downtown,” by an ambulance, fire, or police service pumping Narcan to get breathing going again, the agency’s lifesaving efforts get zero “credit” in the data. The downstream effects of this information sharing breakdown make it difficult to settle for less-than-bona fide interoperability: there is neither time to waste nor margin of error, yet hospitals and healthcare systems cannot even “see” the tip-of-the-tip-of-the-spear.

A similar emotionality makes it difficult to tolerate lamentations about information sharing when states like California—and the federal Office of EMS, inside the National Highway Traffic Safety Administration—are transforming interoperability into a standard operating procedure. As a listener to the “Health Tech Talk Show” since its start, I have struggled with hearing Lisa Bari and Kat McDavitt deride whether interoperability is “real.” It is real. It is happening, and has been automated for years—for example, with both the Quality Health Network and Contexture (formerly CORHIO) in Colorado—empowering agencies of all sizes to care for patients experiencing healthcare emergencies, and those who have children with Duchenne’s Muscular Dystrophy and other diseases. Such efforts should be celebrated for their meaningful impact on patients who rely on ambulance services to get them the care that they need—and sometimes to get them to the care that they need. 

Yet no panel at the national conference for CIVITAS was dedicated to interoperability to or from ambulances, despite that some of America’s most active health information exchanges—coast to coast—have automated interoperability involving Fire, EMS, Non-Emergency / Interfacility Medical Transport, Critical Care, and Community Paramedicine. No mention highlighted widespread efforts to make POLST forms accessible to Mobile Medical professionals, thanks to prioritization of the ethical treatment of medically frail patients after COVID-19 and a New York Times piece called “Filing Suit for Wrongful Life.”

Critical document registries are now built into several large HIEs but these are generally invisible to Mobile Medical professionals. No less an enabler of interoperability than Amazon Web Services has acknowledged that caring for underserved patients must incorporate Mobile Medicine because the poorest in America get much of their care from ambulance services. Leading medical directors and the executive director of National POLST have cited interoperability as a key to empowering Responders to best care for our loved ones when seconds count. Yet when the “Health Tech Talk Show” hones in on discussions about public insurance and safety net medicine—“I heard ‘Medicaid is hard,’ more times than I can count. Public health? Barely a word…

Individuals on Medicaid and the underserved make up nearly 25% of the country. Public health? SUD is a public health issue. Behavioral health is a public health issue. Maternal health is a public health issue. CANCER Is [sic] a public health issue. Public health is more than covid tests and flinging around vaccines and we should treat it as such.”—ambulances are not mentioned once. 

Fire and ambulance services are successfully closing information sharing gaps, but they remain left out of the advocacy efforts—and worse, they end up as an unintended target. Mobile Medicine could be a case study in the power of sharing clinical insights in real-time to do what is best for the patient and the healthcare ecosystem simultaneously. Instead, advocacy efforts in the name of interoperability have traversed a path—twice, now—that risks blocking Mobile Medical professionals from participating in the modern healthcare ecosystem, to the detriment of patients, families and the agencies themselves.

This first such instance occurred when the “Health Tech Talk Show” fanned the flames of the Health Data Utility (HDU) movement. In America and globally, ambulance services are unique, as the only health care providers that routinely engage Unknown Patients (patients who need care while unconscious, unable to communicate, and/or “altered mental status” so one cannot trust their self-assessment). Mobile Medical professionals routinely engage patients in places like alleyways and in abandoned basements. It is worth noting that none of the above pertains necessarily to emergency care, as Mobile Medical professionals engage the most severely ill and underserved chronic care patients wherever they are, and that frequently is on the streets. 

Estimates of the size of the non-emergency medical transport sector range from par to double that of emergency medical transportation. Yet Mobile Medical professionals are largely shut out of the national healthcare data interoperability discussion because they don’t document in HL7-based data systems; they use a different, essential, standard called the National EMS Information System. 

The Office of the National Coordinator of Healthcare IT (ONC) has focused on bringing Mobile Medical data into the broader health data fold, including most recently by holding the second EMS data summit concurrently with the 2023 ONC annual meeting. The movement toward implementation of Health Data Utilities (HDU) risks undoing this critical progress to date, careening Mobile Medical professionals toward second-class status. The advocates of this approach do not appear to be considering its downstream effects: HDUs risks devolving Mobile Medical professionals into shoppers on Christmas Day who are forced to watch sales happening inside the store, while standing outside in the snow. 

Put another way: “Where the HDUs do not currently consume Mobile Medical data, the ambulance, fire and CP/MIH agencies will stay shut out until outsized pressure forces a change (say, an adverse encounter that could that have avoided if the crew had had real-time access to the more complete information in real-time).”

More recently, the Health Tech Talk Show team has begun advancing the notion that America needs a “Chief Patient Officer” (they even went so far as to propose a candidate). Like the HDU concept, this proposal is risky for Mobile Medicine professionals, which is why this author is speaking up. It obviates the reality that, for many, ambulance-based care is nothing short of a lifeline—an entryway to the healthcare ecosystem where no other exists. In their article for The Health Care Blog, Lisa Bari and Kat McDavitt write that “Because of this lack of access, resources, and representation, and because there is no single senior staff member in the federal government dedicated to ensuring the voice of the patient is represented, the needs and experiences of patients are deprioritized by corporate interests.” What about Americans whose needs and challenges are so basic, fundamental, and neglected over time that they’re utterly irrelevant to corporate interests?

There are many such people, and they deserve attention. 

They receive it from caregivers who work in ambulances.

Put another way: What realistic hope is there for a white, educated, socioeconomically “just fine,” city (or countryside) dwelling caregiver hope to muster sufficient empathy for the reality of being a single parent of color, whose child has a major disability, who lives far away from everything that they need to care for their kid? What does it feel like to be a Black woman, who is pregnant, short of breath, living in a one room apartment that smells of feces, whose doctor is all the way over there while she’s in an ambulance going nowhere in rush hour traffic? (Note: this is no theoretical situation—I did a ridealong with just such a patient in Pittsburgh, Pennsylvania). How can one person purport to represent America’s “So Many Patients”, channeling the challenges of race, lack of access to care, language, disability, religion, understanding of healthcare, fear of maltreatment, and more?

If one purports to advocate seriously for a Chief Patient Officer…where will they come from? Will they speak English as a second (or third) language? Will they have a child, spouse, or parent with a mortal disability (or must they have already lost one or more of the above)? Will they be straight, gay, intersex, or transgender? Must they have processed an end-of-life medical order for themselves or for a loved one, to know what it’s like to contemplate the ethics of demise? Must they have an implant that failed, or “get” why patients use ambulances as doctor’s offices? 

“We need a Chief Patient Officer” makes a catchy bumper sticker message, just like “QHINs aren’t real” makes a snazzy alien-themed shirt. But in reality, lightheartedness about life-and-death issues can feel disrespectful of the minutes, hours, and lifetimes that are being invested in making such necessities a reality. The varieties of human experience are so diverse that to suggest enough empathy can be found in one person—anywhere but in a committee of Chief Patient Officers—denigrates the struggle that ambulance-based care providers face in their mission to bring care to patients, families, and communities that lack options but face critical needs. 

Worse yet is that Mobile Medical professionals can end up with the short end of the stick: not just kept outside the glass, pining for a seat at Healthcare’s Table at the Future, but indeed, being blamed for the lack of such tools, made to look like Luddites. This author hopes we will collectively adjust our investments of time and passion into spreading ideas that make things easier—more effective in terms of time and medicine—for those who work to deliver care, with fewer resources than they need, to those who lack the basics.

Jonathan Feit is the CEO of Beyond Lucid Technologies

By KIM BELLARD

Well, congratulations, America.  The child poverty rate more than doubled from 2021 to 2022, jumping from 5.2% to 12.4%, according to new figures from the Census Bureau.  Once again, we prove we sure have a funny way of showing that we love our kids.

The poverty rate is actually the Supplemental Poverty Measure (SPM), which takes into account government programs aimed at low income families but which are not counted in the official poverty rate. The official poverty rate stayed the same, at 11.5% while the overall SPM increased 4.6% (to 12.4%), the first time the SPM has increased since 2010.  It’s bad enough that over 10% of our population lives in poverty, but that so many children live in poverty, and that their rate doubled from 2021 to 2022 — well, how does one think about that?

The increase was expected. In fact, the outlier number was the “low” 2021 rate.  Poverty dropped due to COVID relief programs; in particular, the child tax credit (CTC).  It had the remarkable (and intended) impact of lowering child poverty, but was allowed to expire at the end of 2021, which accounts for the large increase. We’re basically back to where we were pre-pandemic.

President Biden was quick to call out Congressional Republicans (although he might have chided Senator Joe Manchin just as well):

Today’s Census report shows the dire consequences of congressional Republicans’ refusal to extend the enhanced Child Tax Credit, even as they advance costly corporate tax cuts…The rise reported today in child poverty is no accident—it is the result of a deliberate policy choice congressional Republicans made to block help for families with children while advancing massive tax cuts for the wealthiest and largest corporations.

Many experts agree: child poverty, and poverty more generally, is a choice, a policy choice.

“This data once again highlights that poverty in our country isn’t a personal failing, but rather a policy choice,” said Melissa Boteach, vice president of income security at the National Women’s Law Center.

Economist Paul Krugman blasts the failure to continue the expansion of the CTC, calling it both stupid and cruel for two reasons:

First, avoiding much of this human catastrophe would have cost remarkably little money. Second, child poverty is, in the long run, very expensive for the nation as a whole: Americans who live in poverty as children grow up to become less healthy and productive adults than they should be.

Bruce Leslie, President of First Focus on Children, agrees, telling Time that poverty “really does affect every aspect of the lives of kids. It affects kids’ education, their health, their nutrition, and then has negative consequences on things like child abuse and homelessness.”

But, as Professor Krugman noted: “Unfortunately, children can’t vote and poor adults tend not to vote either. So politicians can get away with policies that harm poor children.”

We’re better than that…aren’t we? “Ensuring that children have their basic needs met is the bare minimum of what we can and should do,” Renee Ryberg, senior research scientist at Child Trends, a research organization, told CNN. “The payoff for the health and wellbeing of our nation’s children and for our society as a whole is immeasurable.”

It’s worth pointing out that, compared to our peer nations, we fare badly, in the bottom quartile, with child poverty rates comparable to Bulgaria and Chile. So, no, we’re not remotely even doing the bare minimum. 

Speaking of child statistics on which the U.S. falls far short, we have both maternal and infant mortality rates that rival third world nations. It’s hard to argue that we love mothers and children when we allow them to die at these shockingly high levels.

A bare minimum we should be doing for moms and kids is to make sure they have health insurance, yet ten states still have not passed Medicaid expansions despite the federal incentives to do so. I’ll leave it as an exercise for the interested reader to compare the states without Medicaid expansion with the ones with the worst maternal/infant mortality

To add insult to injury, COVID allowed millions more to qualify for Medicaid, but those special provisions are “unwinding” and – you guessed it – children are being disproportionately impacted, with millions losing their coverage (often due to procedural reasons rather than ineligibility).

I’ve written before about the value of programs that give direct assistance to low income individuals (e.g., cash transfers and SNAP), and there’s new evidence that such a program helps mothers and infants in particular. The Delaware Healthy Mother and Infant Consortium is testing giving a guaranteed income of $1,000/month to low income pregnant women, and is already claiming a 324% return on investment. Mothers are more likely to get prenatal care and less likely to have birth complications. 

“We’ve demonstrated not only that there’s a great return on investment, but there’s actually decreased cost on the healthcare side,” says DHMIC Chair Dr. Pricilla Mpasi. 

Similarly, despite SNAP and various school lunch programs, the Children’s Defense Fund estimates that 1 in 7 kids – some 10.5 million – are still food insecure, living in households where not everyone gets enough to eat. Massachusetts is trying to put a dent in that for its school-aged children, by making school breakfast and lunch free for all K-12 students. No more red tape, no more stigma for poor kids getting subsidized meals. 

California, Colorado, Maine, Michigan, Minnesota, New Mexico, and Vermont have similar programs. For Pete’s sake, why don’t all states?

————

It’s embarrassing that our overall poverty rate is so high, among the highest in the world. We’re the richest nation in the world but have among the highest percentage of poor people. It is literally killing us. Somehow, we’ve allowed poverty to be a political debate, a policy decision we persist in. 

But child poverty? Allowing it to double? When asked about it, Joe Manchin shrugged: “We all have to do our part. The federal government can’t run everything.” I agree, the federal government can’t do everything, but if it is going to do one thing, helping poor kids should be pretty high on the list.

We shouldn’t just be embarrassed; we should be ashamed.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and a regular THCB contributor.

Plenty of reason to worry about the future of American health care this week. The biggest for-profit hospital chain–HCA–was accused of aggressively pushing patients into hospice care, sometimes in the same room, in order to make their hospitality mortality numbers look better. Most of the leading benefits consulting companies were exposed as taking payments from PBMs–yup, the same organizations their employer clients thought they were negotiating with on their behalf. And one of the biggest names in digital health, Babylon Health, tumbled into destitution, taking billions of dollars with it and leaving uncertain the fate of the medical groups in California it bought less than two years ago. Even the most successful capitalists in health care — United HealthGroup and its fellow insurers — saw their stock fall because apparently outpatient surgery volume is ticking up. 

On the policy front the malaise is spreading too. The end of the public health emergency (remember Covid?) is being used as an excuse by the old  confederate states to kick people off Medicaid. Georgia and Arkansas appear to be bringing back work requirements, even though I thought CMS has banned them and every study has acknowledged that they are cruel and ineffective. About 20 million people got on to Medicaid during the public health emergency and KFF estimates up to 17 million may be kicked off, while over 1.7 million already have.

Finally an article by Bob Kocher and Bob Wachter in Health Affairs Scholar remins us that big academic medical centers are nowhere near ready for value-based care (VBC). Jeff Goldsmith has been vocal on THCBGang and elsewhere about how VBC is becoming a religion more than a reality. And I remind you that Humana’s MA program is still basically a Fee-For-service program in drag (even though that’s now illegal in their home state). 

I grew up in American health care expecting that eventually a combination of universal insurance mixed with value-based purchasing would lead to a series of tech-enabled companies doing the right thing by patients and making money to boot. With the managed care revolution, the ACA and the boom in digital health all firmly in the rear view mirror, the summer of 2023 is a lesson that you can never be too cynical about health care in America.

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BY GEORGE HALVORSON

2022 Medicare Advantage data gathering process change made last year just made upcoding for plans irrelevant and impossible, but the critics do not accept that it happened. 

CMS just ended that upcoding debate for 2022 by completely killing the coding system for the plans, effective immediately. The plans can’t code risk levels up because the coding system was eliminated entirely for 2022.

RAPS is dead.

The payment approach for Medicare Advantage now has no upcoding components and the government just used their new and more accurate numbers to create the 2023 payment level for the plans.

The numbers went up a bit with the real risk levels because the plans actually seemed to have been undercoding in spite of their best efforts to have higher numbers in their RAPS data flow.

We should now be able to put that issue to bed and look at what has been accomplished overall by the Affordable Care Act.

The Medicare Payment component of the Affordable Care Act just evolved to a new level — and the entire Obamacare package should now be recognized for what it is now and what it has become. 

When the Affordable Care Act was designed, there were people helping with that process who understood that the only way of getting care in America to continuously improve is to buy care as a package, and not by the piece, and to reward the organizations who re-engineered care for achieving those goals in ways that encouraged using the best tools for care delivery in our markets.

The Medicare Advantage plans all know that clean socks and dry feet reduce foot ulcers that create 90 percent of amputations by 40 percent. The plans also know that congestive heart failure is extremely expensive and painful, and they identify the high-risk patients and help them reduce their risk by doing helpful things in people’s homes to make that happen. Some plans even have scales that send an alert to the care plan nurses when people have unexpected weight gains from fluid retention that indicated a CHF crisis is impending.

Interventions at that moment in time work — and the JAMA study cited above shows that the plans have 40 percent fewer hospital admissions for both congestive heart failure and asthma.

Managing blood sugar for diabetic patients cuts blindness by 60 percent for the patients who achieve that goal — and one of the most important goals in the Medicare Advantage five-star plan has always had blood sugar as a major priority. The plans even improved performance in that area under Covid.

The tools used by the plans are very flexible and are aimed at continuous improvement in many settings. The overlap with other patients in those settings is significant because it’s too hard for caregivers to deliver multiple patterns of care for their patients.  

The Affordable Care Act also aspired to improve care for everyone — and it’s good for the country that most major employers are self-insured for their care, and it’s good that the vast majority of those employers hire administrators to manage their self-insurance.

The organizations who do that administrative work for the employers tend to be the same major carriers who also own the vast majority of Medicare Advantage plans and the vast majority of Medicaid administrators and they have an overlap with the care goals set by the significant majority of union trust fund administrators as well. Over 5 million union members are in their own Medicare Advantage plans, and those union plans tend to have some of the highest Medicare Advantage five-star quality scores in the country.

So when the people designing the Affordable Care Act were doing that design work for care improvement, they aspired to have the care improvement spill over to the rest of American health care.

This is the right time for that spillover of best processes to happen.

We should be on the cusp of a golden age for care delivery in America.

We should be able to use artificial intelligence and FIHR like data connection systems to do things like the cancer moon shot now being set up for the best cancer sites in America to make care both cheaper and better for everyone. The very best care team will be able to predict multiple types of cancer a year or more in advance with simple blood tests and other monitoring devices, and that could significantly reduce the cost of care for us as a country, because a stage 1 cancer costs a lot less to treat than a stage 4 cancer.

Fee-for-service Medicare will not support any of those enhancements or improvements in care because they have never supported that level of care improvement and flexibility. The Medicare Advantage plans will now have some plans that support everything that happens to enhance care, and that enhanced care from those programs will create a competitive advantage for those plans that other plans will need to follow by also improving care.

That’s obviously good for everyone. It’s how markets should work and it’s very different from how market forces have been working in fee-for-service American health care.

So, as we look at the Affordable Care Act, the key pieces are clearly supporting some things we need to happen to make care affordable for the country — and we should understand that process and build on those successes in every area that they’re happening, and we should have it anchor continuously improving care for us all.

When the Affordable Care Act was passed, the health care economists fairly consistently projected that America was on a slippery slope to spend more than 20 percent of our GDP on care — and the new markets that use better tools for many patients, and that create better purchasing mechanisms in both Medicaid and private insurance, seem to have had a major positive impact on that agenda.

We are now at 18 percent of our GDP being spent on care — and that is high, but significantly better than the path to 20 percent that we were on before the law was enacted. The timing of those trajectories tells us that is isn’t coincidental.

The problem we face today is that there are some serious enemies to the process of using Medicare Capitation and Medicare Advantage to improve care.

We need to keep the people who clearly and openly still want to kill all of the plans, because they think some version of election fraud happened in some settings, from doing the damage that those opponents seem committed to be doing in order to make Medicare Advantage disappear and die.

That warning about those critics at this point in time should not be necessary, but those people who want to kill those programs and processes do exist and that death is their open goal — and we just need to recognize what they’re doing and keep them from sneaking in back doors and using distorted data flows of various kinds to somehow make those changes happen in damaging ways for our care as a country.

Let’s celebrate Obamacare on each level that it exists.

The Medicaid program is a huge win.

The employment direct access and open enrollment insurance programs and the functional insurance exchanges in every state are major wins.

The Capitated Medicare program is creating better care and doing it for about 10 percent less money than fee-for-service Medicare spends on those same patients in all of those counties.

The people who lost their political careers because they got that Affordable Care Act law passed should be heroes to us now because the wins are so clear today for what they put in motion, and Americans have better lives because those programs exist.

Thank you.

George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14.

BY GEORGE HALVORSON

When the Affordable Care Act was passed, the politics were so intense and the debates were so filled with rhetoric in all directions that most people actually didn’t understand that there were three major component parts to the strategy and program that function very directly as a package, and should be looked at now in the context of several years of implementation to see how each part of that law is currently doing.

Medicaid was our first priority.

The first component part — and the one that had the highest need for passage when the law was passed because we were doing such a horrible job as a country in providing coverage to our children and to our low-income people — was Medicaid expansion.

We were the only country in the industrialized world that did not have health care available to our low-income children, and that deficiency damaged so many people and was so terrible as a reality that we needed to correct it as soon as we could.

That program is on the right track.

Most states have now used the full Medicaid package and we now have a total of 90 million people enrolled in Medicaid. About 41 million of the members are in the CHIPS program, and a majority of the births in a majority of the states are now Medicaid births.

The states have all used a number of modern care improvement tools to provide and deliver significantly better care than the old Medicaid programs that are far too often delivered to their beneficiaries.

A small number of states have not done the full Medicaid expansion for their own political reasons, but it’s increasingly clear that the voters in most of those states want it to happen and it’s only a matter of time before we see more states going down that path. It makes so much sense for our low-income people and it stabilizes both hospital and community care in many settings, and that’s good for everyone in those settings.

Our second major agenda for the Affordable Care Act was expanded insurance coverage for working adults. 

We eliminated pre-existing condition exclusion policies and we removed some underwriting restrictions from the insurance world, and then we functionally set up relatively affordable insurance exchanges in every state to enroll our working people in coverage.

We had 46 million uninsured and uncovered Americans in those categories in 2010, and we are down to about 27 million uninsured adult Americans now. That is far better and it’s a trajectory we will continue to improve. It isn’t a perfect response, but it has done extremely good things for millions of people and we should consider that to be a successful program.

The third major leg of the Affordable Care Act was to become a much better purchaser of Medicare benefits — moving people from the care failures and the far too extensive care delivery deficiencies of fee-for-service Medicare to a capitated Medicare purchasing program that both improves the quality of care and reduces the cost for both the government and the patients.

The law cut the payments to the prior Medicare Advantage plans significantly and it has put in place a very intentional and well-targeted quality and expanded benefits agenda that has now shown the ability to both improve care and to make care more affordable, widely, for growing numbers of Medicare patients. Almost exactly half of our Medicare enrollees have chosen Medicare Advantage plans for their coverage this year.

The most recent JAMA study that looked at both Medicare approaches showed that Medicare Advantage had higher quality than fee-for-service Medicare in all eight quality measures and has much lower costs — with 40 percent fewer people going into the hospital for asthma and congestive heart failures because the care teams and the care approaches are so much better for Medicare Advantage patients.

The purchase and capitation payment model was carefully chosen to give the country a mechanism that significantly improves care and then rewards the care sites when that happens.

The very clear and intentional point of paying capitation rather than just paying fees for care is that the plans can use the capitation money to improve care.

Fee-for-service Medicare buys care badly and ends up with some major care deficiencies for too many of our lowest income people. Fee-for-service Medicare has some of the highest amputation rates in the world for low-income people, and those amputations cost billions of dollars for Medicare today.

The capitated Medicare Advantage plans look at the relevant care processes and they all know the unchallenged basic science that 90 percent of the amputations are caused by foot ulcers — and the plans all know that you can reduce foot ulcers by more than 40 percent with dry feet and clean socks.

Those amputations cost more than $100,000 each — so the capitated plans have people in homes helping people with dry socks, and fee-for -service Medicare doesn’t do that work and has people losing limbs at the highest rate in the world, but billing $100,000 for every cut.

The only major care category in American hospitals that jumped up under Covid in the first months and year of Covid care was a major increase in amputations for fee-for-service Medicare patients.

That’s just wrong.

But it is what it is, and that pattern of care will continue to happen for those patients until we get more people enrolled in Medicare Advantage Special Needs plans for our lowest income and highest health-need patients — and have much better results for those patients.  

The Medicare Advantage critics, who shamelessly and repeatedly say explicitly and clearly that the business model of the plans is to distort the diagnosis codes of members to increase revenue for the plans, always forget to mention or talk about the 5 million people who have dual eligibility for Medicare and Medicaid, and who have the highest care needs in Medicare and who are enrolled today with Medicare Advantage special needs plans. The government studied the care for those dual eligible Medicare Advantage plans carefully for a year and concluded that the plans have the lowest death rates and the best care results in government programs today for those high-risk and low-income patients.

The Medicare Advantage critics who say that the business model of plans is enhanced coding approaches very intentionally and inaccurately create a climate of distrust and suspicion about Medicare Advantage with both patients and policy people that keep enrollment lower than it should be in the Medicare Advantage special needs plans. 

The upcoding attacks are actually bad and inaccurate distortions of what is really happening with those numbers, because  the functional reality is that fee-for-service Medicare is so bad and so expensive that the average cost of care for fee-for-service Medicare in every county already generates far more money than the plans can use today, and there’s no upside to upcoding given the current payment model because the plans already have more money than they can use based on the high average cost of Medicare in every county.

When the plans discount and reduce their capitation levels by 10 to 20 percent in their annual bids in every county in the country today from the high cost of bad care in fee-for-service Medicare today, then the functional and mathematical reality is that there’s absolutely nothing to be gained by the plans from upcoding any numbers even if they choose to do it, and had the tools to achieve that goal, because the capitation opportunities already exceed the payment levels that the plans can use without creating excessive profits under the law.

However — that isn’t what many people believe. The Medicare Advantage critics believe and continue to say with conviction that risk skimming happens and upcoding exists, and they say consistently that the upcoding impact currently costs about 9 percent in the cash flow of Medicare. They say the country can’t count on or celebrate what appear to be major savings from the Medicare Advantage prices, bids, better benefits, and county-by-county surpluses because everything is so distorted by the cloud created by that 9 percent that we can’t trust any numbers about Medicare Advantage.

The fake news and the intentional and deceptive voodoo economics created by those numbers are actually believed by too many people — and the upcoding attackers and attacks change people’s behaviors in some damaging ways. That accusation has a number of strong followers — and that accusation makes the 40 percent difference in the death rates seem somehow irrelevant to too many people, because people think that the plans might be paid wrongly and they believe that payment flaw somehow offsets more than 40 percent fewer deaths.

George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14.

Telehealth addiction treatment clinic Boulder Care just closed a $36 million Series B. I’ve got Founder & CEO Stephanie Strong here to talk about the virtual care company’s medication-assisted approach to opioid and alcohol use disorder treatment, and its growing-bigger-by-the-day presence in the Medicaid market.

In fact, more than 95% of Boulder Care’s revenue comes in from Managed Medicaid plans, and this focus on making medications like Suboxone accessible to traditionally marginalized patients is not only better for patients (drugs like these can cut all-cause mortality rate by half or more) but also compelling for payers. Stephanie says patients suffering from opioid addiction who go untreated are 550% more expensive to the plan than those who are not, and these types of medications facilitate recovery by making it bearable, blocking withdrawal symptoms.

We get into the details behind Boulder Care’s approach, which includes a number of wrap-around support services, including those provided by the startup’s care delivery team that is set to grow as a result of this Series B funding. And speaking of scaling… Does Stephanie have any concerns about challenges that Boulder Care might face prescribing-and-managing controlled substances as a result of the scrutiny created by Cerebral’s bad behavior? Any additional concerns about changes to the clinic’s telehealth practices when the Covid19 public health emergency comes to an end? And…what about competition in this space?? Particularly as similar-looking Bicycle Health announced its $50 million Series B just days earlier? A great inside look at how virtual care is changing the specialized mental health care space.

BY MIKE MAGEE

“As I’ve said before, I believe Dr. Ladapo is an anti-science quack who doesn’t belong anywhere near our state’s Surgeon General office, let alone running it. But now that he’s been confirmed, it’s my sincere hope that he and Governor DeSantis choose to focus on saving lives and preventing unnecessary illness instead of continuing their absurd promotion of conspiracy theories and opposition to proven public health measures — but I’m not going to hold my breath.”

If you identified these as the words of the former governor, and now Congressman Charlie Crisp, currently running to retake the office he once held, you’d be wrong. These are the words of another state Democrat who is running a distant 2nd in the Democratic primary battle set for this summer.

Her name is Nikki Fried, Florida’s Agricultural Commissioner, and the only Democrat in his Cabinet. This is not the first time she’s tangled with DeSantis over Joseph Ladapo. She vigorously opposed his nomination in October, 2021, citing among other deficits promoting Covid misinformation, discriminating against Black farmers, and refusing to wear a mask at the request of State Senator Tina Policy who was undergoing chemotherapy for breast cancer.

By all accounts, the health department that Dr. Ladapo is supposed to be surgeon generaling is a mess. An investigative report in this week’s Tampa Bay News, found that in the past seven months as Covid variant cases topped 80,000 per week in the state, public health officials failed to report back positive tests to nearly a quarter of those infected, and failed to include 3,000 cases of COVID-19 deaths in the states mortality stats. During this same period, Ladapo, who earned his reputation for incompetence as a Trump sycophant, recommended that the state’s health departments cease all COVID contact tracing.

It would be comforting to imagine that politically motivated medical malfeasance is restricted to this one state, but a comprehensive article published this week in the BMJ, tracking U.S. health data from 2001 to 2019, finds that politics does indeed affect your health.

In a prior study published in JAMA the authors had established that there was a growing gap in morbidity and mortality between rural and urban areas in the U.S. As a follow-up, the lead author decided to explore whether county level political leadership affiliation positively correlated with poor medical outcomes.

In an article this week, the author, Haider J. Warraich, an assistant professor at Harvard Medical School, stated, “Regardless of whether we looked at urban or rural areas, people living in areas with Republican political preferences were more likely to die prematurely than those in areas with Democratic political preferences. There was no single cause of death driving this lethal wedge: The death rate due to all 10 of the most common causes of death has widened between Republican and Democratic areas… Based on statistical testing, the gap in mortality appeared to particularly widen after 2008, which corresponds to the passage of the Affordable Care Act in 2010, a major part of which was Medicaid expansion.”

As expected, the poorest performing areas coincided with those under the control of Republican governors who refused to accept federally subsidized expansion of Medicaid services for their citizens.

While DeSantis and his fellow governors fan the flames of “replacement theory” and gratefully accept the unwavering support of the Trump base, they may want to focus on this surprise finding in the BMJ data – The “fourfold growth in the gap in death rates between white residents of Democratic and Republican areas seems to be driving most of the overall expanding chasm between Democratic and Republican areas.”

In 2005, I gave a speech at the Library of Congress that caused a stir. Its title was “Health is Political.” Dr. Warraich’s work adds concrete data in support of the argument. As he recently wrote, “In an ideal world, public health would be independent of politics. Yet recent events in the U.S., such as the Supreme Court’s impending repeal of Roe v. Wade, the spike in gun violence across the country, and the stark partisan divide on the response to the Covid-19 pandemic, are putting public health on a collision course with politics. Although this may seem like a new phenomenon, American politics has been creating a deep fissure in the health of Americans over the past two decades.”

Mike Magee M.D. is a Medical Historian and the author of “CODE BLUE: Inside the Medical-Industrial Complex.”

BY ROSEMARIE DAY

When the Affordable Care Act (ACA) was signed into law twelve years ago today, Joe Biden called it “a big f-ing deal.”  Little did he, or anyone else at that time, realize how big of a deal it was. Just ten years later, America was engulfed in a global pandemic, the magnitude of which hadn’t been seen in a century. Two years after that, the numbers are chilling: over 79 million people were infected, at least 878,613 were hospitalized, and 971,968 have died.

As bad as these numbers are, things would have been much worse if the ACA hadn’t come to pass. The ACA created an essential safety net that protected us from even more devastation. Covering over 20 million more people, it is the single largest health care program created since the passage of Medicare and Medicaid in 1965. Thanks to the ACA:

• The estimated 9.6 million people who lost their jobs during the pandemic didn’t have to worry as much about finding health care coverage if they got sick from Covid (or anything else) – they could shop for subsidized insurance on the public exchanges or apply for Medicaid. This helped millions of people to stay covered, which saved thousands of lives. In fact, the overall rate of uninsured people has not increased significantly during the pandemic, thanks to the safety net of these public health care programs.

• The 79 million people who got Covid didn’t have to worry about whether their infection’s aftermath would result in acquiring a pre-existing condition that would prohibit them from buying health insurance in the future (if they couldn’t get coverage through their jobs).

• Those who were burnt out from the pandemic and joined the Great Resignation did not have to worry that they would be locked out of health insurance coverage while they took a break or looked for a new job. According to the Harvard Business Review, resignation rates are highest among mid-career employees (those between 30 and 45 years old), a stage of life when health insurance is critical, given the formation of families and the emerging health issues that come with age. 

The ACA’s remarkable safety net framework made it far easier for policy makers to deploy federal funds during this unprecedented emergency. The American Rescue Plan Act , a $1.9 trillion coronavirus relief bill signed by President Biden on March 11, 2021, included provisions that built on the ACA, including more generous premium tax credit subsidies. Its predecessor, the Families First Coronavirus Response Act (FFCRA) of 2020 enhanced Medicaid funding and required states to provide continuous Medicaid coverage.

• For working- and middle-class people, the health insurance exchanges (both state and federal) provided one-stop shopping with enhanced federal subsidies which made health insurance more accessible for people who lost their employer-sponsored insurance. Many Americans who needed health insurance turned to the ACA marketplaces to find a plan. Amid the recent surge in resignations, the Biden administration announced that sign ups hit an all-time high of 14.5 million when open enrollment ended in January 2022.

• For lower income people, the Medicaid program was there, stronger than ever, thanks to 38 states opting into the ACA’s expansion of the program. An increased federal matching contribution helped states to finance Medicaid enrollment during the worst of the economic downturn and prevented Medicaid disenrollments.

• Additional benefits from these measures included reducing health disparities, ensuring mental health coverage, and helping new moms with more robust coverage.

Despite the ACA’s strong foundation and the many good things worth celebrating on its twelfth anniversary, there are difficulties ahead. The expanded premium subsidies and enhanced Medicaid funding are only temporary – both are set to expire this year. With that will come a loss of insurance coverage as people struggle to afford what’s on offer. On top of this, the public health emergency will be unwinding which will bring continuous Medicaid coverage to an end. And there are still too many uninsured people in this country (27.4 million). Retaining the expanded ACA benefits and finding other ways to build upon the ACA’s foundation are critical issues for the mid-term elections this fall.  

A recent study shows that support for the ACA and universal health care has increased during the pandemic. We shouldn’t “let a good crisis go to waste.” We need to make our voices heard and commit to building the future. We’ve had to expend far too much energy over the past decade defending the ACA and protecting it from repeal. The pain we’ve endured during this pandemic should not be for naught. Now is the time to assume an expansive posture of building toward universal health care. Retaining the expanded ACA benefits is an important incremental step. As difficult as the pandemic has been, it is providing a once-in-a-century opportunity to address America’s unfinished business in health care. The ACA is an excellent foundation. Let’s build on that so that we have a lasting cause for celebration.

Rosemarie Day is the Founder & CEO of Day Health Strategies and author of Marching Toward Coverage:  How Women Can Lead the Fight for Universal Healthcare (Beacon Press, 2020).  Follow her on Twitter:  @Rosemarie_Day1

Two experts in mental health care for the Medicaid market stop by to help us get smart on the challenges facing patients and providers alike in this critical area of care. It’s not just the payment model that is different; stigma is different, patients are more racially and culturally diverse than those in commercial plans, support systems vary, and even the normalization of seeking mental health care manifests itself differently when it’s individually-driven as opposed to part of an “employer group.”

Anna Lindow, CEO of digital-first mental health startup Brave Health, and Vik Bakhru, Chief Health Officer of new managed Medicaid plan Circulo (the one built on Olive’s health tech platform) share what they know about this patient population, including what they are learning via the partnership they share to provide Brave Health’s services to Circulo’s members in Columbus, Ohio and Albany, New York.

The top of this conversation starts with the trend-talk and identification of the key issues facing Medicaid mental health care, then we get into some updates from Brave and Circulo, including how Circulo is examining “what it means to be a payer of care” and looking to innovate just one-year after launch.