Goodbye, 2020. Hello, 2030.

2020 is almost over; thank goodness.  It has been one of the strangest, and longest, years most of us have ever endured.  We’ve all probably known someone who contracted COVID-19; many of us have had lost loved ones from it.  Most of us have had to make drastic changes to our lives – masks, social distancing, limits on family visits, eating out, concerts, or trips among them.  No, 2020 can’t get over fast enough.

I was struck, though, by a quote I recently read.  Loren Padelford, a vice-president at Shopify, told The Wall Street Journal: “Covid has acted like a time machine: it brought 2030 to 2020.” 

Gosh, I hope not.

Credit: Getty Images

Mr. Padelford went on to explain: “All those trends, where organizations thought they had more time, got rapidly accelerated.” These trends include the shift from physical to online, further decline of cash, and work from home/remote learning.  Individuals/families without broadband are being left behind; companies not investing in IT and logistics may not be here in 2030.  Healthcare has not been exempt from these trends.

The pandemic has illustrated both the great strengths and the great weaknesses of the U.S. healthcare system.  Among the strengths are the courage and professionalism of our health care workers, the innovation that has delivered several vaccines within a matter of months, and the ability to adapt to an existing but underutilized mode of care in telemedicine. 

Among the weaknesses, of course, are the lack of planning and coordination that has doomed testing, contact testing, and supply of personal protective equipment; the patchwork quilt of insurance coverage that has left even more without coverage (e.g., due to loss of job based coverage and/or lack of Medicaid expansion); the refusal of many to act in their own best health interests, such as not wearing masks or taking vaccines. 

Credit: Mark Felix/Getty Images

Legislators/regulators may be taking bold actions like throwing money at healthcare organizations, vowing that the COVID testing and vaccines are “free,” and loosening restrictions on telemedicine, but the underlying disfunction in our healthcare system has never been more visible.  We don’t test enough or fast enough.  We have sick people on gurneys in gift shops, we have dead people in refrigerator trucks, and we still have people crushed by their healthcare bills.

Please, don’t let this be a picture of 2030.

2030 is a decade, three Presidential administrations, six Congresses, and hundreds of state/local governments away, so it’s hard to predict what healthcare might look like then.  Some think our current crisis is the perfect opportunity to take big, bold political action on healthcare, and it should be, but I must admit I’m dubious we’ll take it.

Instead, I’ll offer a few more measured – but important -- hopes for 2030:

Ensure a floor of coverage: ACA was supposed to achieve this, but a Supreme Court ruling and a number of ideological states kept it from happening.  I don’t know if we’ll ever get to true universal coverage, be that “Medicare For All or something else, but we should at least be able to ensure that cost is not a barrier to coverage for anyone, especially for the poorest among us.  Maybe we should shoot for “Medicaid For All” and let those who choose “buy up.”

Claire DeRosa/Wisconsin Watch

Ensure a ceiling for spending: Again, ACA addressed this, with out-of-pocket maximums and cost-sharing reductions, but too many people still end up spending too much of their money on healthcare (think about surprise bills or non-covered services).  A healthcare system that drives people into bankruptcy and/or takes them to court for services they cannot afford is just indefensible.  We should stop defending it.

Oriented around virtual care: Telehealth/telemedicine/virtual care has been around for at least two decades, but barely was a ripple in the healthcare system until COVID-19 sparked it into prominence.  However, right now it still is being bolted on to our system, rather than being truly integrated, and those bolts aren’t even all that strong.  By 2030, virtual care – in whatever form it may take by then (think AI/holograms/etc.) should be part and parcel of all health care, the first point-of-contact for most needs. 

Quality first: We talk about quality in healthcare, but we don’t really know what it is, much less measure it.  Our various attempts at payment reform have failed either to improve quality or to control costs, and will continue to do so as long as there is not agreement on the quality that is delivered for those payments.  In a world of continuous monitoring, there’s no reason for us not to know which patients got how much better through what interventions from which health care professionals.  That information would allow us to tie reimbursement appropriately to quality of care/outcomes.

Big picture: In the big picture, health is not just connected to medical care but also to vision and dental care.  In the big picture, health is not just connected to care but also to lifestyle and environment (SDoH).  In the big picture, our microbiome is integral to “us” and to our health.  But most of our healthcare system and our solutions to improving it focus mainly on the smaller, medical picture.  That it so 19^th century of us, yet 2030 brings us almost a third into the 21st century.  We need to think much, much bigger – starting now.

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December has been the worst month of the pandemic in the U.S.  Many experts think that the worst is yet to come, despite vaccinations beginning.  2020 may be ending but what has happened in 2020 is going to have a long and very unpleasant tail. 

2020 is a decade after ACA passed, and, let’s be clear, our healthcare is much better for it.  But if 2030 doesn’t find us with significantly more improvements than the 2010’s brought us, well, expect many more bad years like 2020. 

We can muddle through another decade of incremental improvements in our healthcare system.  We can lurch from crisis to crisis, addressing each without tacking the underlying weaknesses that allow them to become crises.  We can continue to astonish the world with our profligate spending and very mediocre outcomes. 

Me, I’m hoping 2030 will astonish us by how far we’ll have come.

No Names, Please

Feeling good about your holiday spending?  You’ve made it through most of this mostly horrible 2020, maybe lost a job or even a loved one, but still probably found a way to buy presents for your loved ones and maybe even to give some money to charity.  Indeed, charitable giving was up 7.5% for the first half of 2020, despite the economic headwinds.

Then there’s MacKenzie Scott.

NY Post photo composite/Mike Guillen

Ms. Scott, as you may recall, is the former wife of Amazon founder/CEO Jeff Bezos.  She got Amazon stock worth some $38b in their 2019 divorce, which is now estimated to be worth around $62b.  She just gave away $4.2b – and that’s on top of $1.7b she gave away in July. 

In case your math skills are impaired, that’s $6b in six months, which Melissa Berman, chief executive officer of Rockefeller Philanthropy Advisors told Bloomberg: “has to be one of the biggest annual distributions by a living individual.”   Ms. Scott has vowed: “I will keep at it until the safe is empty.”

Kenzie Bryant, writing in Vanity Fair, marveled: “It gives a whole new meaning to “fuck-you money.” 

Private foundations are required to distribute at least 5% of their endowments each year; Ms. Scott not only has given away 10% of her net worth this year alone, but she hasn’t even used a foundation to do so.  As The New York Times reported: “Ms. Scott’s operation has no known address — or even website. She refers to a “team of advisers” rather than a large dedicated staff.”

She doesn’t make recipients plead for money through grant applications.  She doesn’t specify how the money is to be used, or require reports on how it is spent.  She doesn’t expect her name on anything.  She doesn’t even make public how much she is giving each recipient (although some choose to do so).

NYT says:

Ms. Scott has turned traditional philanthropy on its head…By disbursing her money quickly and without much hoopla, Ms. Scott has pushed the focus away from the giver and onto the nonprofits she is trying to help.

Ms. Scott’s Medium post outlined her goals for the giving: “special attention to those operating in communities facing high projected food insecurity, high measures of racial inequity, high local  poverty rates, and low access to philanthropic capital.”  Easterseals, food banks, Goodwill, Meals-on-Wheels, United Way, and YMCAs accounted for a large number of recipients.  She’s guided by “a conviction that people who have experience with inequities are the ones best equipped to design solutions.”

In all, Ms. Scott and her team analyzed nearly 6,500 organizations and made grants to 384, in all 50 states, Washington D.C., and Puerto Rico. 

The Washington Post did its own calculation and estimate that at least $800 million of her donations went to higher education institutions, especially those serving people of color: “$147 million went to Hispanic-serving institutions, $5 million to tribal colleges and $560 million to historically Black colleges and universities. In addition, a total of $130 million went to five other public colleges in Florida, Washington state, Nebraska and Kentucky.” 

Rob Reich, co-director of the Center on Philanthropy and Civil Society at Stanford, told NYT: “She’s moved extraordinary sums out the door, quickly, in an anti-paternalistic way.”  Debra Mesch, a professor at the Women’s Philanthropy Institute at Indiana University added:

If you look at the motivations for the way women engage in philanthropy versus the ways that men engage in philanthropy, there’s much more ego involved in the man, it’s much more transactional, it’s much more status driven. Women don’t like to splash their names on buildings, in general.

Take that, Mark Zuckerberg (or, rather, take this).   

The New York Post put the difference with typical bluntness:

While all the tech bros fight over colonizing space and California tax codes, banding together for the only thing they really care about — fending off anti-trust legislators — Scott makes them all look like stingy, greedy incels without a shred of compassion for those ruined by COVID-19. 

Healthcare likes to splash donors’ names on buildings.  Healthcare organization, especially hospitals, like to get big donors on their boards as a reward for, or incentive to get, donations.  Look at the nearest big hospital.  Chances are there are wings, departments, even buildings with big donors' names on them.  Maybe there’s a brick or a plaque with your name on it to commemorate a smaller donation too.  Medical schools have followed suit. 

Lately, hospitals have made targeted efforts to solicit patients for donations.  In 2019, NYT reported:

Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations.

Credit: Maria Fabrizio for KHN

“Nightly wealthy screenings.”  That should make us all shudder.  Hospitals do this despite the fact that patients generally look down upon the practice, with most fearing it might interfere with the patient-physician relationship.  They’re probably right.

It’s easy to do those kinds of donations: we sympathize with the hard-working hospital staff, we can tell if the buildings look modern or run-down, and chances are we or someone we know has used that hospital.  Making a donation is an easy way to seem like we’re making a difference; the bigger the donation, the bigger the difference.

And maybe we’ll get our name on something.

That’s not a way to run a healthcare system – or a society.  Ideally, our taxes would help assure that we all have access to enough food, safe housing, good education, clean air and water, reliable infrastructure, decent paying jobs, and quality healthcare – all at affordable levels.  To the extent that our taxes don’t prove sufficient, those of us with some extra left over can help fund organizations that try to make things better for those who are less well off.

Ms. Scott pleaded:

If you’re craving a way to use your time, voice, or money to help others at the end of this difficult year, I highly recommend a gift to one of the thousands of organizations doing remarkable work all across the country. Every one of them could benefit from more resources to share with the communities they’re serving. And the hope you feed with your gift is likely to feed your own.

There are a lot of unmet needs in our society, especially during this pandemic.  Ms. Scott is showing us that we can do something about them.  We shouldn’t just admire her; we should try to emulate her, especially (but not only) anyone with a few billion dollars.

Streaming, Baby Yoda, and Healthcare

I’ve never seen The Mandalorian.  I don’t have Disney+.  But I know who Baby Yoda is, and I’m pretty sure Disney is counting on that.  Hollywood, in case you haven’t been paying attention, is going through some radical changes.  There may be some lessons for healthcare in them. 

Credit: Mike Raab

2020 has been the year of streaming.  Moviegoing isn’t entirely dead in the pandemic, but it may be on life support, with major chains like Regal and AMC barely staying out of bankruptcy.  “Yes, there is pent-up demand to see movies in a theater,” Hollywood insider Peter Chernin told The New York Times.   “But people change their habits.”

Indeed, they do.  A new Press Ganey survey found that telemedicine visits shot to 37% of all visits in May, then settled down to around 15% – far above less than 1% pre-COVID-19.  Habits do, indeed, change, even in healthcare. 

Hollywood has made some startling announcements in the past few weeks that illustrate how swiftly changes are coming to the entertainment industry:

Disney: Disney expects to have 100 new titles – TV shows or movies – each year for the next few years.  Disney chairman Bob Iger noted modestly: “The pipeline of original content we’re making is much more robust than originally anticipated.”  Of particular note, though, CEO Bob Chapek said, “Of the 100 new titles announced today, 80 percent of them will go to Disney Plus.” 

NYT characterized the move as: “Here is a 97-year-old company making a jump to direct-to-consumer hyperspace.”  (If you don’t get the reference, you probably didn’t get the Baby Yoda one either). 

The strategy appears to be working.  Disney said that its year-old Disney+ streaming service already has 87 million subscribers; it had originally projected to reach this number by 2024.  Now it expects to reach 260m subscribers by 2024.  And those numbers do not include Disney services Hulu (39m) and ESPN+ (12m).  Collectively, Disney now expects up to 350m subscribers by 2024. 

Warner Bros: Although Disney expects some of its movies to still have theatrical runs prior to streaming, Warner Bros announced in early December that all of its 2021 releases will be available for streaming on its HBO Max service upon release, rather than after the “traditional” 90+ day wait (outside the U.S., where HBO Max is not yet available, the movies will still be in theaters first).  It had previously announced that its big 2020 release – Wonder Woman 1984 – would be released this way.  Shares of major theater chains dropped precipitously after the latest announcement.

Credit: CNN

“We see an opportunity to do something firmly focused on the fans, which is to provide choice,” WarnerMedia CEO Jason Kilar wrote.  That’s all well and good, but it’s worth noting that Warner Bros is owned by AT&T, and AT&T views this strategy as a way to instill more loyalty to its wireless services, even at the potential cost to theater revenues.

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If you’re worried about the original streaming service – Netflix – don’t be.  Although its growth has slowed, that’s partly because it already has close to 200m subscribers worldwide.  Its stock is up over 50% YTD, and even the announcements from Disney and Warner didn’t seem to shake that.  Similarly, Amazon Prime has over 150m video users, more than half of them in the U.S., and continues to invest heavily in new streaming content.

It’s a new world for Hollywood.  Brooks Barnes, NYT entertainment reporter, wrote: “one Warner Bros. executive told me that “the town” felt like a dismantled movie set: The gleaming false fronts had been hauled away to reveal mere mortals wandering around in a mess.”  Another Hollywood insider told him: “I see this as a time of opportunity.  Sometimes you have to take it down to the studs and build something new.”

Healthcare’s “false fronts” have been torn down too.  We’ve exposed our glaring lack of public health infrastructure, our inability to generate enough PPE, our testing has been abysmal, and now our hospitals, particularly our ICUs, are overflowing.  We’re used to handling expected elective surgeries and even “normal” emergencies, but were caught flat-footed by a pandemic. 

 If ever there was a time to take healthcare “down to the studs and build something new,” this is it. 

We brag about the increases in telemedicine, but we should note the CMS rules that have expanded its use are only temporary.  We haven’t addressed the inter-state licensing issues.  We’re not even doing telehealth visits all that well; the Press Ganey survey concluded: “The bad news is that patients clearly feel that the process of telemedicine (logistical things like ease of scheduling and making audio/video connections) falls short.” 

We’ve seen dramatic declines not just in office visits but also in use of preventive services and screenings, elective surgeries, emergency room visits, even heart attacks.  We just don’t know if these declines are good or bad.  Researchers Allison H. Stokes, PhD, and Jodi B. Segal, MD, suggest in Health Affairs: “We see a unique methodological opportunity to evaluate the harms of low-value care.”  Another researcher, Dr. H. Gilbert Welsh agrees, telling NYT: “We are in the midst of an unprecedented natural experiment that gives us an opportunity to determine the effect of a substantial decline in medical care utilization.” 

But will we take advantage of that opportunity, or will we just go back to our old ways once the vaccines work their magic? 

E.g., will healthcare just expect patients to go back to the theater?  Or will major healthcare companies bet big on the future: “streaming” (aka telehealth) as the main consumer point-of-contact, with patient convenience as a main driver?  Where digital is the norm? 

Disney’s physical locations – its theme parks – are hemorrhaging money, and Warner Bros has suffered dramatic declines from theater revenues, but both are betting big on their virtual strategies – and the markets are rewarding them.  Warner says its announcement is only a strategy for 2021, but, as NYT put it:

It will be almost impossible to go back, and it may force other studios to abandon the old model. Fans trained to expect immediate gratification will not be eager to return to the days of giving theaters an exclusive period to play movies.

We shouldn’t expect patients to go back to the “old” healthcare system either. 

I’m not expecting healthcare to have a Baby Yoda caliber idea, but it can certainly do better than its current Jar Jar Binks strategies.   

This Is Your Brain on Microwaves

Those of us of a certain age well remember the 1987 ad campaign from the Partnership for a Drug-Free America.  It equated frying an egg to what drugs did to our brains.  The ad certainly impacted awareness, but it is less clear that it impacted drug use or, for that matter, that it actually was like what drugs did to our brains.

Well, it turns out that there is something that can scramble our brains, but it’s microwaves, and it appears that “malevolent actors” are using them to do just that.  We’re now in the age of “directed, pulsed radiofrequency energy.” 

There were reports coming out of Havana in 2016 of State Department employees complaining of mysterious symptoms, including dizziness, fatigue, headaches, memory loss, balance issues, and hearing loss.  Over the next couple years there were more reports, in Cuba and in other countries, including China and Russia, with CIA officers also seemed to be common targets.  It has been labeled "the Havana syndrome."

Illustration by Bianca Bagnarelli for The New Yorker

Now the National Academies of Science, Engineering and Medicine has issued a report concluding that the directed, pulsed microwave bursts were “the most plausible mechanism” to explain what happened.  They evaluated but ruled out other mechanisms, such as background microwaves, chemical agents, infectious diseases, and even “psychological issues.” 

As least 44 people from Cuba and 15 from China were treated at Center for Brain Injury and Repair at the University of Pennsylvania, with more believed to have been treated elsewhere.  No one could pin down exactly what was happening. 

Committee chairman David Relman, a professor of medicine at Stanford University, said:

The committee found these cases quite concerning, in part because of the plausible role of directed, pulsed radiofrequency energy as a mechanism, but also because of the significant suffering and debility that has occurred in some of these individuals.  We as a nation need to address these specific cases as well as the possibility of future cases with a concerted, coordinated, and comprehensive approach.

MRI showed brain differences in microwave victims. Credit: JAMA Network

One thing in particular that concerned the Committee was the presence of persistent symptoms in many victims – “persistent postural-perceptual dizziness (PPPD), a functional (not psychiatric) vestibular disorder that may be triggered by vestibular, neurologic, other medical and psychological conditions and may explain some chronic signs and symptoms in some patients.”  I.e., not only can you be impacted by such an attack, but the impairment can last an indefinite time. 

Many have suspected Russia as a likely culprit, and, indeed, the committee noted Russian research that dates back several decades.  Dr. Relman told Andrea Mitchell of NBC News:

What we found was that there is a literature that describes health effects of a particular form of microwave energy, which is pulsed and directed.  And that literature now goes back a number of decades, and was published largely by the former Soviet Union. That literature does mimic and is consistent with a number of the clinical findings that we noted.

The committee suggested that further studies “be undertaken by subject-matter experts with proper clearance, including those who work outside the U.S. government, with full access to all relevant information” – suggesting they suspected there was classified information they did not have access to. 

The State Department, which requested the report but which only allowed the release after NBC News and The New York Times obtained it, was diplomatic in its response: “We are pleased this report is now out and can add to the data and analyses that may help us come to an eventual conclusion as to what transpired…The investigation is ongoing, and each possible cause remains speculative.” 

Dr. Relman seems to have fewer doubts, telling NPR: "What we can say is that something real and significant clinically happened to these people.  At least some, if not many, of the signs and symptoms that were reported in these patients can be explained by this particular form of microwave radiation.” 

The committee looked ahead and:

…was concerned about the possibility of future new cases among DOS [Department of State] or other U.S. government employees working overseas, either similar or dissimilar to these, and the ability of the U.S. government to recognize and respond to these cases in a coordinated and effective manner. The next event may be even more dispersed in time and place, and even more difficult to recognize quickly.

Somewhat disappointingly, most of the committee’s recommendations revolved around more data collection and analysis, and, when necessary, being prepared to “activate the necessary response” -- whatever that might be.   

Lest anyone think this is only an issue for diplomats or other people Russia might target, a few weeks ago there were reports that Chinese troops were turning “the mountain tops into a microwave oven,” according to The Times, in order to force Indian troops to retreat during a border dispute.  “In 15 minutes, those occupying the hilltops all began to vomit,” a Chinese professor said.  “They couldn’t stand up, so they fled.”

Curiously, Indian defense officials call the report “FAKE.”  One Indian official explained that the attacks are impractical in that situation and the symptoms are not consistent with what is known about such weapons, especially the nausea.  Technology journalist David Hambling tends to agree, but notes:

However, it is possible that China has a microwave weapon based on a different physical principle, perhaps something like the Electromagnetic Personnel Interdiction Control (EPIC) device researched by the Pentagon in the early 2000s.

One thing is clear: it’s pretty scary to think about a weapon that you’re not quite sure you’re being attacked by, from where, against which you don’t have any defense, and that can cause lasting physical and mental damage.  The committee report warned:

…the mere consideration of such a scenario raises grave concerns about a world with disinhibited malevolent actors and new tools for causing harm to others, as if the U.S. government does not have its hands full already with naturally occurring threats.

Mr. Hambling believes: “Grey zone warfare, in which conflict remains just under the level of shooting war, is a feature of the 21^st century. The Chinese may now think they have the weapon to win it.”  And they may not be the only ones. 

Imagine if terrorists got their hands on these weapons.  Or militia groups.  Or police departments using them to quell protests.  I don’t know about you, but I’m thinking maybe those people with tinfoil hats might be on to something.