Another great article, Katy. Like Tiffany, above, I’m pro the reconciliation package you suggested. How can I or any of us help? What ‘weak spots’ can we lean on?
Thanks Marion! I think the key here is to press any congressional and WH contacts to not give up the fight. The key here will be encouraging the president to lean into the arguments I'll be making next week on the pro-life issues.
Really appreciated this primer on the process + players and your attempt to separate “headline heat” from what’s actually moving behind the scenes!
I always come back to a few practical tests that distinguish reform-as-theater from reform-that-changes outcomes:
1. Does it reduce friction at the bedside? (prior auth/admin load, opaque formularies, endless “middleman” complexity) That’s not just clinician burnout, but it’s delayed care, fragmented follow-up, and lower-quality chronic disease control.
2. Does it strengthen primary care and prevention (time, continuity, access) rather than just reshuffling who pays the bill? The highest-ROI reforms usually look boring: fewer barriers, better longitudinal care, smarter incentives.
3. Does it protect the medically vulnerable during the transition? In real life, “choice” only works if people can still access essential meds, specialty care, and catastrophic coverage without a financial cliff.
Curious how you’re thinking about success metrics for whatever emerges (e.g., admin burden, time-to-treatment for key conditions, preventable admissions, and patient out-of-pocket predictability) because those are the numbers that patients (and clinicians) will actually feel.
Yes, I believe that a transition will increase the availability of more affordable catastrophic coverage (to help those who have no coverage at all but don’t qualify for subsidies or enough subsidies), as well as encourage direct primary care and other direct pay arrangements. But this solution is just financing. On the employer side it will scale cash pay for innovative employers first and then more broadly in the self-funded market. This isn’t the end all. It doesn’t fix everything by any means, certainly not clinically. But it enables the type of competition that will re-establish some fiduciary opportunities that can lower costs.
The reconciliation package you're describing would actually shift power back to patients and employers. It has to happen!
Amen sister! From your mouth to God’s ears!
🙏🙏🙏
Love the audio! So much better than the AI version. The passion and intentionality really shine through!
Thanks so much Devin!! It's actually so fun to do it. I always think about you guys out there in Substackistan when I'm recording :)
Another great article, Katy. Like Tiffany, above, I’m pro the reconciliation package you suggested. How can I or any of us help? What ‘weak spots’ can we lean on?
Thanks Marion! I think the key here is to press any congressional and WH contacts to not give up the fight. The key here will be encouraging the president to lean into the arguments I'll be making next week on the pro-life issues.
Really appreciated this primer on the process + players and your attempt to separate “headline heat” from what’s actually moving behind the scenes!
I always come back to a few practical tests that distinguish reform-as-theater from reform-that-changes outcomes:
1. Does it reduce friction at the bedside? (prior auth/admin load, opaque formularies, endless “middleman” complexity) That’s not just clinician burnout, but it’s delayed care, fragmented follow-up, and lower-quality chronic disease control.
2. Does it strengthen primary care and prevention (time, continuity, access) rather than just reshuffling who pays the bill? The highest-ROI reforms usually look boring: fewer barriers, better longitudinal care, smarter incentives.
3. Does it protect the medically vulnerable during the transition? In real life, “choice” only works if people can still access essential meds, specialty care, and catastrophic coverage without a financial cliff.
Curious how you’re thinking about success metrics for whatever emerges (e.g., admin burden, time-to-treatment for key conditions, preventable admissions, and patient out-of-pocket predictability) because those are the numbers that patients (and clinicians) will actually feel.
Yes, I believe that a transition will increase the availability of more affordable catastrophic coverage (to help those who have no coverage at all but don’t qualify for subsidies or enough subsidies), as well as encourage direct primary care and other direct pay arrangements. But this solution is just financing. On the employer side it will scale cash pay for innovative employers first and then more broadly in the self-funded market. This isn’t the end all. It doesn’t fix everything by any means, certainly not clinically. But it enables the type of competition that will re-establish some fiduciary opportunities that can lower costs.
Appreciate your perspective, Katy. It's always interesting to know how the sausage is made (or not made).
You and I have different views (probably due to different life experiences), but it's all about finding common ground.
Yes indeed, and there's a whole lot we DO agree on! Appreciate you!
You get it. 100% these policies would be far more transformative than anything we do in the ACA market. Fingers crossed!