Healthcare “Consumerization” through 2030

We say healthcare is getting more “consumer” — here’s how I think that plays out in the real world, not just amongst VC-backed startups.

Shifts in Consciousness Driving Most of These Trends:

1. 100M+ Americans (and growing) turn to other options as they increasingly realize their health insurance is essentially just catastrophic coverage for them and their families.

2. We’ll move to a bi-modal world where most Americans are just paying for access, and the rare lucky few are searching for quality (i.e., those with rich commercial insurance or Medicare is paying).

General Trends:

3. “Ambulatory first, Ambulance last. Ambulatory get capitalism injected into it.” — Balaji

4. Rise of private pay, out of pocket economy ($500B in 2021 → $800B by 2026)

Care shifts by Income:

5. Lower and Middle-Income America pay for access, while Elites pay for “quality” (i.e., Brand).

6. Dramatic increase in medical tourism, especially for the working Lower and Middle-Income (e.g., busloads of people down to Mexico for pills and surgeries).

7. Billionaires continue to step into healthcare. Cuban is the latest example, but anyone rich enough to see margin as opportunity for innovation will make purchases. Smaller hospitals will get bought.

8. Rise of prosthetics — eyes and feet — for folks for whom it’s too late for diabetes. It will become normal at some point and fashion industry will take advantage of this trend…

9. …on the opposite side of the spectrum, there will be a rise in “preventative” and cosmetic surgeries for the rich. “Preventative” examples include double mastectomy even if not needed, or veneers.

10. Cosmetic surgeries will only continue to increase, but now at a faster rate as the trans-humanism movement picks up steam and body augmentation becomes normal.

Insurance Changes:

11. Rise of true “capitalist” health plans for the wealthy. Apple or Other to release an insurance-esque product as the “ultimate subscription” (credit Stuart Blitz for that quote). Increase in concierge care for the wealthy (e.g., Solis Care competitors and hospital-based concierge programs pop up more).

12. Dramatic rise of indemnity and catastrophic plans purchases. Why purchase regular insurance when it does so little for you and there’s no mandate? (Not in most States).

13. Direct-pay networks emerge to surface diagnostic/therapies that have lacked Payer reimbursement.

Government action:

14. Medicare Trust Fund will remain fully funded likely through debt.

15. At some point after 2025, a Republican Congress/President will repeal the Enhanced Subsidies and temporarily collapse the ACA market.

16. Increase in Medicaid applications but decrease in % of accepted enrollees. People will only be able to hide their income more easily, and most States will become poorer relative to the # that need their help.

17. Gradual increase in price transparency regulation and enforcement; yet true market clearing price for services/procedures is still rare/regional, and mostly between certain big Payers and Hospitals.

Hospitals:

18. Shift of net dollars out of physical big box hospitals. Anyone that must wildly guess how much they going to pay in the hospital will avoid that care setting if possible.

a. Example: Increase in % of births that take place outside of a hospital. Birthing centers and alternative options quickly gain in popularity.

19. Hospital’s payer mix becomes more Medicare/Medicaid by volume of patients and Commercial/Direct Pay by dollar amount. Rise of Cash-Pay and “Direct Pay Discounts” at hospitals to reduce AR issues.

20. Tier 2/3 hospitals become the first True Adopters for AI in Medicine — not because they are more tech savvy, but because it’s cheaper than doctors. Academic Medical Centers and other Tier 1s will avoid True Implementation for as long as they can, but they’ll continue to pump out the research around it.

21. Hospitals begin to rent out space to private practice, shopping areas, multi-use zones, etc. because they need the cash flow.

22. Increase in State/Federal bailouts of hospitals, especially in more rural areas.

23. Consolidation continues, with Private Equity playing an increased role. As many hospitals continue to go out of business or opt for sale, PE is there to swoop up “under-performing assets”, especially rural hospitals that are the only games in town.

New Access channel / Lack of affordable options for consumers forces “innovation” in unlikely areas:

24. Cash-pay networks become normal. Not just for providers, but for Consumers looking to access care — it will become normal to purchase a membership to a discount network, esp. for a single care vertical.

25. Black market for Rx will continue to skyrocket.

26. Less regulated places in the industry start to blur the lines on their functionality (e.g., dietary supplements continue to become stronger/more impactful).

Employers:

27. The damn will break — SMBs can no longer stomach healthcare costs and healthcare won’t be a key retention tool in this category of company. There will be enough alternative healthcare options, and employees will favor flexibility of workplace/locations, pay, hours, etc. and begin to understand that anything other than bare minimum healthcare is a perk.

28. Companies trying to attract talent using healthcare will have two ways to use healthcare as a carrot: (1) We pay for everything (already exists today, see: Mckinsey), or (2) We don’t pay for much, but you’ll know the price for most stuff before you pay. Many more companies will be able to offer #2 than #1.

Talent:

29. NPs/PAs/Etc. will moonlight for cash in their communities. While they’ll still fear losing their license, they’ll be able to make so much money and it’ll become normal amongst their friends at work. They are so squeezed for cash they’ll keep doing it.

30. Rise of unionization in healthcare. Covid exacerbated the gap between Haves and Have Nots in our corrupted healthcare system, a gap which will only get worse.

Not actual predictions because they’re unlikely, but if they were to happen it would be a massive unlock for the Healthcare Consumer:

31. HSAs get further “unlocked”. Many ideas but some examples include: De-coupled from high deductible health plan enrollment, allowing Medicare Part A enrollees to contribute, an ecosystem emerges to help people spend their HSA money.

32. Partnerships between local banks and hospitals (or a fintech play), whereby if the hospital knows you can pay for something, they will charge you less because they’d rather have the guaranteed payment at a lower amount than bill you the highest amount they can and hope it gets paid.