The future is uncertain—even with 2020 vision. Jane Sarasohn-Kahn shares key uncertainties about politics, economics, technology and social factors that healthcare stakeholders should keep in mind when planning for the new year.
By Jane Sarasohn-Kahn, MA, MHSA
When we think of 20/20 vision, we think of perfect foresight. But making predictions about the future of U.S. healthcare in 2020 and planning for the new year isn’t easy with even the sharpest vision.
In my scenario planning work, which we do to hedge against uncertainties and manage risks, we identify the key forces that shape the markets we serve. After this period of risk planning, we sort these factors into what we know (the certainties), what we don’t know (the uncertainties) and the wild cards—the possible events that can blow our assumptions apart and derail the best-laid plans. The major categories that these forces cover include politics, technology, economics and society.
Here are some key uncertainties that Medecision stakeholders should bear in mind when ideating, planning and implementing new services in 2020.
In 2020, politics will play a big role for Medecision stakeholders at both the federal and state levels, as well as in local and metro markets for more granular issues. The biggest uncertainty in national politics will be the presidential election in November 2020. Healthcare is one of the top voting issues for millions of U.S. voters, which we saw in both the 2018 midterm elections and in the 2019 state run-offs. President Trump’s 2016 promise to “repeal and replace” the Affordable Care Act (ACA) did not manifest when he took office, even with a Republican majority in both the House and Senate. While certain provisions have eroded, the ACA remains in place—battered and slimmed down, but a legislative survivor nonetheless. The health reform visions of Democratic presidential contenders range from single-payer plans to aiming for universal healthcare through “Medicare for All … Who Want It,” bolstering the ACA with a public option. That could be accomplished through the federal Medicare program, expanding Medicaid programs at the state level or something entirely new.
At the state level, we could see further Medicaid expansions depending on the senatorial election outcomes in Puerto Rico and eleven states: Delaware, Indiana, Missouri, Montana, New Hampshire, North Carolina, North Dakota, Utah, Vermont, Washington and West Virginia. In addition, we should be mindful of specific legislative and regulatory issues that can shape healthcare at the local and regional level: These include, but aren’t limited to, certificate of needs (CON) laws, value-based purchasing initiatives, rural health programs, education, criminal justice reform and technology.
Broadband connectivity underpins a productive economy. In the U.S., telecom gaps remain that compromise not only the healthcare micro economy, but also the nation’s macro economy. The FCC broadband map illustrates areas of gaps, and discussions have been underway inside the Beltway to address deficiencies within the national telecom infrastructure. But the promise of telehealth and expanding access to care doesn’t help healthcare providers and patients who need that access now. Another technology uncertainty in 2020 will be privacy: With California’s Consumer Privacy Act (CCPA) implemented as of January 1, 2020, will that state’s approach to privacy for residents be a model for other states to follow?
And more broadly speaking, will Congress take a national view on privacy in 2020? The latter is unlikely in this election year as other priorities will likely take precedence, but individual members of Congress have targeted big tech and privacy in hearings. We find greater attention (and “teeth”) being exacted on big tech and privacy in the European Union (EU), which has had the force of the General Data Protection Regulation (GDPR) for an opt-in approach to personal data sharing versus the U.S.’s opt-out paradigm. Finally, with EHRs fully implemented in hospitals and physician offices, will healthcare providers take the opportunity to leverage digital data to improve healthcare delivery and patient outcomes?
With some early wins using artificial intelligence (AI), we can expect more adoption of data analytics in healthcare as greater evidence mounts for its utility. The news that Google’s AI may identify breast cancer more adeptly than humans will certainly provoke and inform this conversation.
Here, we segment the national economy—the growth of the GDP, employment statistics and job growth—from the healthcare economy. They are intimately related, to be sure: Healthcare represents nearly one-fifth of the U.S. GDP, and the same for American household spending. On the job front, the U.S. is nearly at full-employment, which is the glass-half-full interpretation of the November 2019 statistic of 3.5% unemployment. On the glass-half-empty side, though, wage growth continues to stagnate given its flat-to-declining trend for more than a decade. The divide between wealthy and lower-income Americans has also widened, represented by an increasing Gini-coefficient (a measure of statistical dispersion that represents the wealth distribution of a nation’s residents) documented by the St. Louis Federal Reserve. Economists are split on whether a recession is probable in 2020, with a greater likelihood of economic softening occurring in 2021—just after the U.S. presidential election.
The healthcare economy—ever-expanding in terms of both spending and jobs—will be challenged by more attention to value and outcomes. This transition requires doing more with less, and should foster greater adoption of telehealth and virtual care workflows that treat patients in lower-cost settings. More employers have added telehealth to their employee benefit package to better manage healthcare costs. At the same time, employer-based health plans have also shifted more costs to employees, which has resulted in self-rationing among workers with high-deductible health plans who may choose to delay care. Delaying care is a new normal for people covered by health insurance, where cost can be a barrier to medical services or filling prescriptions. “Financial toxicity” will remain a feature in U.S. healthcare in 2020, needing more artfully designed health plans that serve true value-based care devoted to delivering holistic patient outcomes.
Health is social: Our social networks, offline and on, influence our health, as we’ve learned from Christakis and Fowler’s research revealed in their book, Connected, along with others’ work in this field. More health plans and providers recognize the health risk factor of social isolation and loneliness; for example, Cigna’s U.S. Loneliness Index has been tracking this as an epidemic threat to American public health. Anne Case and Angus Deaton’s book, Deaths of Despair and the Future of Capitalism (due out in March 2020) weaves the Princeton researchers’ authoritative research into the tragic rise of deaths by suicide, drug overdose and alcoholism in the U.S. Their work has focused on key social determinants contributing to rising mortality rates among a cohort of people, pointing to education, income disparities and growing healthcare costs underpinning this uniquely American tragedy.
Healthcare providers, plans and payers have started to embrace social determinants of health (SDOH) in creative ways to help address individuals’ lack of access to healthy food, housing and transportation. We’ll continue to see more SDOH initiatives as the healthcare ecosystem wrestles with and tackles what used to be seen as public health and national infrastructure spending for the country’s citizens.
In this year of uncertainty, one thing is certain: It will take our village of liberators to address the biggest challenges facing our healthcare community.
I wish the Medecision community a healthy, productive, inspiring and peaceful New Year.