Organization Chart For The Agency For Healthcare Research And: Fill & Download for Free

Here is a list of things that would have been very appropriate and intelligent things to do in response to Covid-19, none of which the Trump Administration did.Years before the virus hits, you expand funding for the CDC and NIH (Trump proposed cutting funding and unbelievably, his 2021 budget for both cut CDC and NIH). You absolutely do NOT eliminate the pandemic team within the CDC (like Trump did). You absolutely do NOT keep the pandemic management roles in DHS empty and unfilled (like Trump did). Ideally you have a senior person in DHS who has a strong infectious disease background because there is only going to be greater risk of pandemics now and in the future because of climate change.Did I mention climate change? You put the force of the USG behind efforts to study climate change and its’ impacts. You don’t ban USG research in to it. You don’t unfund or cut offices that do that work. You don’t prevent USG researchers from going to conferences that study climate change and its’ impact. Here’s a reality check for climate change skeptics and deniers: among people who research climate change in great detail, pandemics are a BFD, something that there is a lot of work on. Seriously—there is tremendous amounts of pandemic research and analysis that is occurring through the climate change lens/perspective.You know all of those rules that the Trump Administration has reversed or not enforced dealing with game hunting and cracking down on trafficking of endangered species? Well, it appears the vector location where the Covid-19 virus appeared to emerge is a wildlife market in Wuhan. Yeah, people are pointing at bats—but that’s simplistic. How bats get involved is they poop—and other animals eat it. Or the bat eats a bug (like a mosquito) that sucked some blood off of a creature. Ladies and Gentleman, let me introduce you to the Pangolin. Very endangered, it has a coronavirus internal to most Pangolins that is almost a dead ringer to what is hitting humans now—except it has mutated a bit. And Pangolins (especially from Africa) are very popular in China. Did pangolins spread the China coronavirus to people? I think when all is said and done with this virus in 2–3 years, we’ll likely conclude that Covid-19 did NOT come directly from the pangolin. But they played a role. That’s why the flu stations are in China. Yes, the season starts in that part of the world. But they have so much mixed use farms (ducks and pigs together, eat each other’s scat, viruses intermix, end up in bats or birds and so China is the birthplace for most modern new flu strains—that’s why the Swine flu scare to come out of Mexico was unexpected).Healthcare—woah, this is a biggie. As in: expand the number of people in the US who have healthcare (so they have access to it—and no, I don’t mean “they can always go to the ER!”). What happens with more people getting health insurance? Fewer smokers, more early screening, access to testing, more preventative care, and when people get it (and most cases will be mild) they’ll get better advice on how to avoid spreading it (which increases the chances that you stay healthy). The Trump administration has gone in the complete opposite direction, seeking to kneecap Obamacare, has a court case right now up on appeal that would wipe out Obamacare (doing this in the middle of a pandemic—that’s a perfect storm folks—a fricking perfect storm from an epidemiological or public health perspective).Supplies. If you’re smart, and you realize that because every day the world is getting smaller (more global, more migration, more business travel) combined with climate change produces warmer climates and more extreme weather, you start preparing for pandemics more than we currently were. You have a larger supply of gloves and masks for medical workers and first responders. A larger supply of Tamiflu (and anti-viral) as well as antibiotics (because you don’t know what is going to emerge). You do “what if” scenarios that you war game out with key leaders in industry and government: what would it take to ramp up production of antibiotic X in 2 weeks? What if we had to quarantine a couple of cruise ships? What if a military unit overseas became infected with something communicable? What if the next flu season was a killer? You can’t plan for everything or even most things—but you don’t have to. You work out—how do we handle a pandemic? FEMA does this sh*t all the time with hurricanes and natural disasters—talk to anyone at the state or federal level who does emergency preparedness and they’ll tell you that if you prepare for 3–4 scenarios it enhances your ability to deal with all of them because you get supplies pre-positioned, you get light on your feet organizationally, you develop an emergency response capability. Good lord—look at the fricking Trump Administration—inept at anticipating and then quickly responding to Maria and the other hurricanes that hit Puerto Rico and the USVI. My point is not that they were delayed specifically in preparing for Covid-19, it’s that they don’t prepare for and handle crises well in general. Talk to anyone in disaster planning for organizations and they’ll tell you it all starts with what you do before the crisis ever hits. Oh, and btw, you don’t respond to pandemic risks by slicing funding from one concern to get money for another (I’m talking about Congress cutting Ebola funding to address Zika over the wishes of the Obama Administration—that’s just bassackwards!).Now everything I’ve listed so far is stuff you do BEFORE anyone in the administration even knows how to spell “coronavirus” let alone knowing Wuhan has a crisis. This is all pandemic-101 stuff. And the Trump Administration flunked all of it—every single thing I’ve mentioned.Now let’s talk about what happens when one of the CDC flu spotting stations in China gets a report from a doctor (let’s call him….Li Wenliang) complaining that the government won’t listen to him about this new type of flu. Let me eliminate the suspense and just tell you that everything I’m about to list about what you do once you get a hint this is happening—is stuff the Trump Administration has done poorly on.6. You don’t cut off access to China—you rush people in. You get additional CDC and NIH talent in China. This isn’t a variation on the normal flu. China is the hothouse for this stuff—the flu season starts with them, that’s why CDC has flu spotting stations there—to get a jump on the flu and begin development of a flu shot early. Except this isn’t influenza. But with teams on the ground quickly, getting samples, observing what the Chinese are going, trying to nail down this bad boy as quickly as possible—that is what you do as soon as you hear a unsubstantiated rumor coming out of Asia. Ditto with Iran (more on this later). Ditto with Italy. It’s critical to get a reliable test nailed down and then start testing like crazy. Why? Because the first most critical step in dealing with pandemics before they become a pandemic is: INFORMATION. We were late on this. The USG didn’t get started on a test until late (we were relying on China, rather than pushing our people out in to the field we were cutting off access) and then when we got a test we only tested people returning from China. Information tells you what kind of beast you’re dealing with, how to deal with it, how widespread it likely is, who’s must vulnerable. It all starts with information and that only happens if, at the first hint of a problem, you push people in to the infected areas rather than cutting them off.7. Set up a task force to coordinate the gathering and sharing of the research from the field plus interact with various agencies (DoD, DHS, CDC, NIH, CIA, DoS, USAID, FBI, Customs, TSA, FDA, USAMRID, US Surgeon General—who has been invisible through all this mess by the way—and I’m sure I’ve left about 12–15 other offices or agencies off the list) to coordinate who is doing what, what supplies are being acquired, begin briefing states and governors and their health directors. This action should have started within a week of the first cases coming out of Wuhan. And the head of this task force should be a research or medical professional. Fauci is a good person to go with—he’s fought this fight before and has bi-partisan credibility. The head of the Center for the National Center for Immunization and Respiratory Diseases (Nancy Messionier) would also be a great choice. I’d probably avoid the head of USAMRID (Col. Darrin Cox) because he’s active duty US military that would feed wild conspiracy rumors that this is somehow a Chinese/American/Israeli bioweapon. But Carl Shaia who retired there back in the Fall was the former Director of Administration (but is now a civilian) and he’d do a bang-up job managing a task force of a lot of government people dealing with complex, unplanned health and medical issues—if you felt like you didn’t want to pull Fauci or Messionier from their organizations (because their supervision of their work was too vital) than Shaia could be a good option. If the head of DHS or HHS was someone with public healthcare expertise then they’d be a fallback option. We don’t currently have an actual DHS head (that position is vacant) and the acting person (formerly of TSA) Chad Wolf has no background in this issue. Alex Azar (HHS) is a lawyer and worked in healthcare organizations but frankly wouldn’t be a strong choice in terms of knowing the public healthcare players. Picking Mike Pence is a poor choice. He double-screwed up the HIV mini-epidemic in Indiana (first cutting support for PP, then refusing to follow the data and wouldn’t do a needle exchange until the cases had exploded). Pence isn’t the worst choice—as a governor he’s got background in dealing with emergencies (in his case: floods and tornados) so that’s a positive plus he’s pretty high up. Still, with a little bit of research (ie: 4 hours) I could give you about 200 names of people who would be a better choice than Pence.8. What Donald Trump says. Now if you really want to know the optimal approach here, it would be that Donald Trump never says or tweets anything about Covid-19 or the Coronavirus at all—when asked about it he refers to the head of the taskforce and then shuts up. That would be optimal. But if we can’t have that, then it would be that he says NOTHING in any media form without clearing it first with a senior healthcare SME (subject matter expert). This post is already too long for me to list all the things he’s said so far that are dumb or false: the virus would go away in April because of temperatures (tell that to Singapore, plus there is a new paper out of the Harvard epidemiology Dept. that says this virus doesn’t seem be affected by warmer temps), that the WHO death rate was wrong (not what he should have said), that Democrats are trying to make this a scare tactic to win the election, that there was nothing to worry about. Donald Trump has added probably not one piece of value to this whole issue—just confusion or wrong information plus delays. I mean, suggesting we should seal the border with Mexico: they have 5 cases as of yesterday and 3 of them came from exposure to foreigners (Italy and America)—I think Mexico might want to seal their border for protection from the US! If you could cut him out of the picture and he’d tolerate that from Day One, things would be so much better now.9. Policy on cruise ships: have one. Right now the US does not and is scrambling. Think about that—there have already been a couple of cases of passengers on cruise ships with Covid-19 signs, why hasn’t the US developed a policy for what to do other than tell the ship to stay offshore? We knew this was an issue a month ago and we’ve got ships off the US coast that we’re trying to figure out what to do because there is no policy in-place. This is exactly what the USG is supposed to do—establish policies. And I said cruise ships because that’s an immediate issue. Someone is going to have a 14 hour plane flight and in the middle of the flight (with air being circulated through the cabin) it will be clear that a passenger is sick with the coronavirus—so what’s the procedure? Have them disembark and stand in line at a crowded customs and immigration portal with hundreds of other incoming passengers? Every single US airport that has an international terminal needs to be setting up infrastructure and implementing USG policy (except there is none) besides setting up hand sanitizer and putting out more tissue dispensers.10. Establish and follow basic risk protocols for individuals who are exposed or possibly exposed re-entering the country. The healthcare workers who met the plane load of sick and at-risk Americans returning to the US—none of them had any kind of protection or established procedure for processing those individuals. WTF? This sounds like an isolated example. There will be hundreds of thousands of Americans seeking to return back to the US from overseas. Students, business professionals, tourists, retirees, military, diplomats, USG workers, professors. You need a basic protocol for screening and handling them (and it’s not all the same—it will vary with the country they’re coming from, if they’ve been tested, if they have obvious signs, if they’d had contact). That doesn’t exist right now.11. Information is critical at times like this—to avoid panic. You don’t want to downplay it all, you need to be open and honest but put things in perspective. So for instance, people need to be told that you should not be wearing a mask unless you’re sick (wearing a mask INCREASES the likelihood you get infection if you’re exposed to someone) unless you change your mask every hour (or every encounter). In the effort to downplay the spread and infection, there is very little (okay, none) Federal govt. resources talking publicly about “let’s talk through planning for if schools in most of the country shut down for a month—can we get all businesses to give people temporary family leave?” Local governments are working on this (kudos to them) but they’re often having to do this in the dark. The Feds should be driving this and be pre-eminent. What Jay Inslee (gov. of Washington State) had to tell Pence is sad, just appalling but that’s a reflection on the Federal coordination effort to-date. So information not only about “this is what we know, this is what we don’t know, here’s what you should be doing know, here’s what you should plan for just in-case” is critical and it’s not happening. That’s not really happening publicly driven by the Feds, it’s very piecemeal and fragments. Look at the comments from Carson (HUD). He shouldn’t be in the public eye on this except the Trump information shortage/gap has people hungry for information and since he was a surgeon, he got approached by media. So he was asked about the Trump policy on the cruise ship approaching the US and he said it was finalized but it wasn’t going to be revealed yet. Then he said it was formulated but some details were being worked out. Then he said there were no plans as of yet. This is from one senior Administration official within one 24 hour period who shouldn’t even be talking about cruise ships. And this happens because there is no coordination or reliable information source on this issue at the moment. So people are going all over the place seeking information.12. There are a gazillion specialty situations that need to be addressed by government. If you’ve got a kid overseas in an exchange program (say—studying art in Milan, or teaching English in Beijing), can they come back home? Or what if they wait till the end of the semester? What about US military? What about large crowds at sporting events—any policy or recommendations regarding those? I bet every police officer out there is now wondering “hmmm….how does this affect me and possible infected people or areas?” Could you imagine medical professionals or first responders refusing to go out in the field if we have a shortage of gloves and masks? Certain industries (any place like Orlando that does a lot of conventions), cruise ships, airlines, travel, tourism, caterers, restaurants—they’re likely dealing with tremendous business crashes right now or in the near future. Saying “we’ll give you a tax break” is a crappy answer—that’s not what they need right now. Their immediate concern is about safety and a tax break doesn’t address that. They need to be given some direction on what to expect, how the USG is going to intervene, if there will be tests set up when people board/deplane/disembark. These are issues that industry can’t solve or fix and a tax break is irrelevant to. And we aren’t even talking about jobs like TSA that involve touching a lots of things. The latest word I’ve heard is that Covid-19 can live for up to a week on a surface. So any high-traffic screening personnel would be a great risk-2,000 people could come through your shift and it only takes one to pass on something (because of a suitcase they brought from home where an asymptomatic individual—not the traveler—coughed on it).13. This is related to #11 but you need to balance the panic and the information. You should not be trying to “spin” this event or push good news. Right now, the Trump Administration has tried hard to downplay this and say it is something that will go away quickly with little pain. Meanwhile the markets are taking deep dives, Italy is quarantining 15 million people, and the Fed issues an unprecedented emergency rate cut while the President is saying “no biggie.” Let me let you in on something: our numbers on infections in the US are bogus. We’ve mostly been testing only people who were traveling overseas or those immediately next to someone who’s infected. Partially that was lack of planning, partially that was a lack of test availability. Once we expand the number of tests, you’re going to see the number of people with a “positive” result (meaning: they got it or have antibodies so were exposed and may be a carrier) to probably go up 5X the current number (if not higher). That’s to be expected—we had artificially low numbers previously. But to fearful members of the public, it will seem like their government was lying to them or that all of sudden the virus has gotten really bad when it hit the US (neither case was true). That’s why the mis-statements by the Trump Administration and the efforts to downplay this sucker are just stupid, stupid, stupid. You’ve got a balancing act—it’s tough—but it’s critical. You’ve got to level with people, talk about what we know, what we don’t know, talk a little about an unknown future. When you try to downplay or minimize the bad news, and then you suddenly get a bunch of bad news, you lose your credibility. You don’t just look bad, instead you become the bad guy.14. Protecting Asians and Immigrants. The Trump Administration is probably the least credible and competent governmental entity to engage in this. You’re already seeing individuals verbally or physically attacking Asians. People who are 2nd generation US and from Japan or the Philippines are being told to go back to China. After 9–11, George W. Bush gave a very powerful speech where he said we were all Americans, we couldn’t turn on each other, that it should still be safe for someone wearing a hijab to go to a mosque, and it was shameful for us to betray our values by turning on minorities. At a time when there are a ton of rumors, lots of fear, it’s important for our government to do something that they’re very capable of doing—standing up for targeted minorities and letting people know “hey, they’re not the danger here.” Seriously—this is a “no-brainer” kind of action because the USG is well positioned to deal with it, can do it RIGHT NOW, and variations of this come up whenever there is a terrorist attack, a pandemic, a violent crime or something that stereotypes a specific group. And it doesn’t require scientists coming up with a new vaccine or some medical advance. it’s about USG leadership saying “hey—no scapegoating, we’re all in this together, don’t turn on each other.” Has anyone seen anything from Trump or Pence or any senior USG official addressing this issue? I haven’t.15. Do not rely on information from Xi. China has not handled it well, they were initially in denial. Xi basically told Trump “nothing to worry about, it’s going to go away” and then Trump came out with his “it will disappear in April” statement. Let healthcare professionals talk to their foreign counterparts—they’ll be able to decipher what is bullish*t and what is truth.16. South Korea: we should have teams over there right now looking at what they’re doing. ROK isn’t perfect but they’re a great example of getting it “mostly” right. They’ve got drive-in stations for quick tests to see if you’re contagious or not. From the git-go they were testing far more people than just international travelers—making us look like idiots. South Korea hasn’t been perfect but they’ve been pretty darn good. I bet that right now, we’re so focused on the US that any potential lessons or tips we might gain from ROK are going to be ignored until this thing plays itself out and a year or so from now we’re doing a “hot wash” and go “gee, wouldn’t it have been smart if we’d implemented this thing they tried in South Korea?”17. Do not, do not, use the Coronavirus as an excuse to implement other policies you have. The Trump Administration has already tightened immigration rules with Iran (actually, we should be sending CDC teams there to see what we can learn and also identify if it’s the same strain). Trump has talked about closing the border with Mexico (but not Canada which has far more cases—although a significant number came from exposure to Americans—sorry Canada!). Do you hear any talk of closing immigration with Italy (which is attempting to quarantine 15 million of its’ citizens)? Nope, neither have I. You see, the problem when you do stunts like this (sneak in another policy using the rationale of it’s dealing with Covid-19) is it ends up hurting your credibility and perceived confidence across the board. If shutting down borders is “the answer” then why shut off a border with Mexico but not Canada? If shutting down borders is “the answer” then why allow trucks full of auto parts from Mexico to still come in to the US (answer: it would shut down nearly all US auto manufacturing plants and immediately lead to a recession plus kill Trump in a bunch of battleground states like Michigan that he needs to win).18. This last piece is tough to do but it’s now essential: we need to flatten the curve and expand capacity ASAP. Let me explain the concept: the US healthcare system is near capacity. We don’t have a lot of empty beds. We have fewer doctors (especially in rural areas) per capita then places like Italy. Our ICU’s are maxed out mostly (in part due to a very bad flu season). A massive influx of new Covid-19 cases is a healthcare disaster. It doesn’t matter if the case mortality rate for infections is only 1% (or .2%) rather than 3.5%. You end up with not enough ventilators, not enough ICU beds, not enough healthcare providers. And while the extreme Covid-19 cases (about 4–10% of those infected) are in ICUs, other patients are either underserved or don’t get help. Seriously folks, with every epidemic the public healthcare data shows an increase in mortality for healthcare issues not related to the pandemic. So if you’re a healthcare administrator, you should be doing whatever you can to add beds, bring people out of retirement, add interns or admin support to free up nurses from work that someone without a degree can do. In terms of the Trump administration (ie: this question), they should be pushing all strategies to add capacity. And we (as an administration) should be looking at ways to “flatten the curve” by reducing the speed of infection. This chart is from Vox and Christina Animashaun and it illustrates why Covid-19 is got a lot of public healthcare folks alarmed, why you’re seeing so many Universities and localities canceling events and what the Federal Government needs to be focusing on much more than it currently is.I’m sure I’m leaving out a couple of other things but this post is long enough as is. Quite simply, the Trump Administration has done a terrible job preparing for a pandemic and then responding to the initial news and then acting when it hit the US.Let me say one last thing here: some people will write this post off as being “anti-Trump.” Preparing for disasters (diseases, natural emergencies, energy blackouts, rioting, etc.) is a special kind of challenge. We have professionals who do this stuff for a living. It absolutely infuriates me when we violate some of the most basic rules of disaster planning and emergency management—whether it’s with storms or pandemics. If this post comes off as “anti-Trump” it’s only because the Administration has badly bungled their response to the coronavirus. We had a reasonable shot at containing this sucker. No longer.

The truth is that no single system will help in a country that intentionally explodes the cost of its healthcare.Currently, our health expenditure, per person, in this country is far greater than any other. Sometimes double the cost of a few and triple the cost of others.We should go over why this cost is as high as it is. We see these outrageous costs all the time, but we rarely get a glimpse at how this cost is even calculated. For the cost associated with these expenditures, the transaction tells us that somebody on the other side is receiving payment.Health system:A health system, also sometimes referred to as health care system or healthcare system is the organization of people, institutions, and resources that deliver health care services to populations in need.We can be a bit more specific: A healthcare system is just an entity that meets the health needs of a population. The World Health Organization says that a health care system requires a “financing mechanism, a well-trained and adequately paid workforce, reliable information on which to base decisions and policies, and well maintained health facilities to deliver quality medicines and technologies.”Let’s dig deeper into how the mechanism of our health system works.A manufacturer will make the product. That product will be purchased by a wholesaler. That wholesaler will aid in distributing that product. Pharmacies will purchase that product from a wholesaler. The pharmacy will distribute that product to the actual patient.But there’s more.We have payers, who we all recognize as our insurance companies. They pay for that medication that comes through the supply chain. There are also PBMs, or pharmacy benefit managers. These people are the mediators to discuss optimal pricing valuation.Of course, there are also hospitals and their networks that fit into this scheme along the way, too.For every $100 you spend in a retail pharmacy, a study at USC found that approximately $41 goes to these intermediaries in the supply chain. Those are the entities essentially invisible between the people who make the drug and the people who sell it to you physically.An important note is that we don’t have a single metric to gauge exploded costs of the current health system we have in place.How much hospitals are charging for services?How hospitals are coming up with the costs for their services?What the actual cost is of producing the drug?What the payer is actually paying for?How the PBMs work?How all of this comes together in a concise and organized and cost-effective manner?We do, however, get a glimpse of profit margins in each step of the system.If we take a look at Amgen’s last annual report, which is a manufacturer in our supply chain, we see the following:On total revenues of around $23.4 billion, they managed to profit nearly $8 billion.So, I wanted to look more into the drugs and the margins that each of the drugs make them.But I can’t. They give me this instead—a chart of how much they get in sales and the difference in sales year over year. That’s a funny way of showing investors how great your business is. I would think a fundamental way to show business strength is to display the margin you make on the drugs you are producing. There is no information on any of its 160 pages of documentation to tell you the relationship between each of the individual drugs and their profit margin.Charts like these only signal to me the desperate need for transparency in the health system in America. And we are only on the first step of our supply chain.As much as I want to rag on manufacturers and their stealthy annual write-up habits, they’re a necessary cog in the welfare and health of our society.We need research and we need the production of medication to help people live well.These drugs inevitably go to pharmacies. One of the largest pharmacies in the world is CVS. Most people are familiar with this place.Here is a snippet of their latest annual report.The largest revenue stream by far is their pharmacy. Nearly $150 billion came through that business segment. It’s nearly double their retail segment. With their Health Care Benefits program, which is their insurance segment (a payer), they eclipse more than $200 billion in revenue just from the health system alone.Notice I’m not talking about profit numbers at this point. The reason that profit becomes irrelevant is that the flooded system of multiple stops in the supply makes it hard to track who is getting what. Whenever we want to look at specific margins, we note that, like Amgen, it’s hidden or vaguely stated.We do know that ultimately somebody on one side is paying for it. We also know bottom-line profit figures. But those figures alone aren’t enough.HCA Healthcare is one of the largest private hospital chains in the United States. They offer everything from services from professionals, from nurses, to access to medication and beds and testing you’d otherwise need to maintain your health.Below, I am showing, via their 2019 annual report, what percentage they get paid from each relative agency.Approximately half of the revenue for the $40 billion this hospital made in revenue came from taxpayer dollars.That’s Medicare and Medicaid. While I don’t get a good definition for what managed care and insurers means, I’m led to believe that it is completely private health insurance. I’m also led to believe that it doesn’t matter, as a hospital is technically the last leg of the supply in our traditional health supply chain.Here is a good example I experienced of what happens to the last leg: They get all the added-on cost of an inefficient system. I took my mom to the emergency about two weeks ago. I was 99% sure she had cellulitis, a staph infection. We were both sure that she needed antibiotics. It should have taken about an hour, maybe less. The hospital decided to keep her for overnight stay. They gave her IV fluid and antibiotics. They even had her get an MRI. The next day, the swelling in her hand was gone.However, we got a bill recently that amounted to the following:$20,000 in total. For an overnight stay and IV.While most studies prove that the efficacy does not improve with IV fluid over oral antibiotic, my argument doesn’t concern that arena. My focus is on the added-on cost of the entire supply chain in a single picture.You see the total picture of many systems coming together to form a consolidated total.The New York Times estimated in an article that IV fluid costs anywhere from 44 cents to a dollar. Patients were charged anywhere from $500 to $800 for a bag of, essentially, distilled water.It’s not new that aggressive, immature, and blatant overcharging exists. It very well does exist. It thrives on that aggressive overcharging and price gouging, in fact.The question ends up, however: Who pays for the final line item that you see in the supply chain?This is the most important factor in this entire mess of a system.We have nurses and doctors who want to provide healthcare. These are people who want to help those in need. However, they're stuck in a web of services they can’t control the pricing of. In the end, they enter codes through a hospital computer and ship those codes off.Those codes end up being bills for the patients.One of the craziest elements in this current Coronavirus pandemic is that the people who do survive are going to have insurmountable debts. If my mom’s $20,000 overnight stay at a hospital is any indication, those who needed ventilators to breathe are going to have a much harder time breathing once the bill delivers.Here was the title of a CNN article I read the other day:A nurse revealed the tragic last words of his coronavirus patient: ‘Who’s going to pay for it?’The sum total of that supply chain cost isn’t exactly the patient, either.It’s you and me. We can talk about all the different cogs in the machine, but the bottom line is that somebody needs to pay for it.We don’t need Medicare for All to understand that we already have Medicare for All today. Except, it isn’t Medicare for All, it’s Medicare for Corporate America. We aren’t using the system as intended. Its main function is to provide health and welfare for the people of our country.The system is functioning, instead, at the behalf of every player in that chain, from the manufacturer, to the distributor, to the payer, to the pharmacy, and finally to the person who actually needs it.That first graph in this entire piece illustrates all of it succinctly: We pay more and we are still dying earlier than our neighbors. It doesn’t take a mathematician to figure out that the little profits each agent pulls from the supply chain eventually comes out of the taxpayer’s wallet.The system of Medicare for All already exists. It’s just insanely distorted and ripped apart at the seams. It makes no sense that people like Sam Hazen, the CEO of HCA Healthcare, make $27 million in compensation in a single year. He made almost 500 times the median employee’s salary at his hospitals (his median salaried employees being nurses). That money he gets paid is a collection of so much Medicare and Medicaid that gets directly or indirectly fed into his network of hospitals.The business model can’t fail because it is designed to grow as large as it needs to.We already have public healthcare. When we tell people that nationalizing healthcare is probably a good idea, most people think about socialism. What we have is already socialism—except, it’s exploited solely for the elite and rich.

I'll let the "smart people" part of the question slide as it's pretty condescending to question if there are a lot of smart people in a major US city. There are.But do the smart people have an interest in being entrepreneurs? Do the smart people have the skill sets to be successful entrepreneurs? Is there enough infrastructure in place to support the entrepreneurs?Rather than focus just on Cleveland I'll expand my question to Ohio in general. There are smart people in Cleveland, Columbus, Cincinnati, Toledo and places in between.It's paragraph four and now I will belatedly answer the question. Yes, Cleveland has enough smart entrepreneurial minded people to sustain robust early stage investment. I sidestepped the specific focus on 500 startups to broaden the question.500 startups has a "spray and pray" model of investment. I'm not being critical but I think that's a good description. I don't think the entrepreneurial ecosystem in Cleveland is mature enough to support 500 investments in short order but perhaps it does. It definitely can support investment from more traditional concentrated early stage investors and I think that these investors are the best current match as they have smaller portfolios and are able to be more hands on investors. With a lot of first time entrepreneurs, Cleveland needs hands on investors at this point.I think Ohio is relatively unique due to the level of State support for entrepreneurship which is why my answer focuses on Cleveland rather than generalizing to cities like Cleveland. Ohio created the Ohio Third Frontier program ("OTF) in 2002 and the Ohio Capital Fund in 2005 to help build and support an entrepreneurial ecosystem.OTF, now a $2.1 billion program, was created to support entrepreneurship beginning at the ideation stage through the seed (now seed+) stage of investment. OTF invested at the idea stage by funding University and corporate research and development projects. OTF support seed stage investment by funding seed stage organization across the state. These organizations included business incubators and accelerators, Y-Combinator type organizations and organized Angel group funds. In each instance, the State required private funding alongside the State to provide local validation and support.The chart below shows many of the organizations supported by the state at the pre-seed/seed level.The State also funded entrepreneurial support dollars for business accelerators across the State so that they would have the capacity to not only invest but advise companies whether they received investment or not. Notably there are many other organizations that have sprung up in addition to the ones listed on the chart that haven't received State support but were enable by the State priming the pump of entrepreneurial activity.At the commercialization stage, in general, the state invested in pre-seed accelerators that provide services and funds to fledgling companies. The State also backed the formation funds backed by organized Angel groups across the State. The Angel funds invested in the best pre-seed opportunities coming out of the accelerators. Other organizations came into play as well but the two drivers were the accelerators formed across the state and the robust angel groups that were formed as well.By investing at the idea/pre-seed/seed stages, Ohio smartly built a pipeline of opportunities that could advance to Series A investment. Ohio's Development Services Agency reports that over 1,200 companies had received pre-seed services with 474 of these companies receiving investment through September, 2015[1] .Notably, when you are dealing with companies outside silicon valley you must focus on the regional strengths which includes healthcare in Ohio with major research institutions such as the Cleveland Clinic and Ohio State. IT is still the largest area of investment but nearly one-third of the companies receiving funding through OTF were in the healthcare space.After the State sets a foundation at the idea/pre-seed/seed stage, it's time for venture capital. This is where the Ohio Capital Fund ("OCF") comes into play. OCF was established to invest into early stage VC funds to attract more venture capital investment to the budding Ohio companies. The OCF, used contingent tax credits from the State as collateral to raise $150 million to commit to venture capital funds with the condition that the VC funds receiving investment commit to invest capital in Ohio early stage companies. The results are pretty compelling with 30 funds receiving investment and those funds investing 2.2x the amount Ohio had invested in these funds. In total 81 companies had received investment of $265 million from the OCF funds and these companies raised an additional $777 million from other investors mostly in later rounds of investment. So, these 81 companies raised over $1 billion of investment, nearly 9 times the investment by OCF into the VC funds.You can clearly see the investment funnel in these metrics: 1,200+ companies receive services of which 474 receive seed/pre-seed investment of which 81 receive venture investment from OCF backed VC funds. Companies also received investment from non-VC backed funds.I lay out all of this detail to show how, with State or federal support, you can manufacture an entrepreneurial economy. A lot of smart people want to be entrepreneurs but don't know how and don't have access to the earliest stage risk capital to make it happen. When that capital and educational resources/help show up, the floodgates open.The results of these activities take a decade or more to bear fruit but Ohio is seeing the results. Looking at the OCF company microcosm, just last year one company was sold in a major transaction to Oracle, another to Medtronic and another company completed an IPO. This is in addition to many other success stories and many companies that are still maturing.So my answer is that yes, Cleveland and cities like it have the potential to generate a lot of entrepreneurial companies that could be venture backed. In Ohio alone over $1 billion of venture capital has been invested in companies across the State since the OTF and OCF programs were put in place. The 500 Startups model might not be the best fit as these immature ecosystems need concentrated hands on investors to help the many first time entrepreneurs.But, and a huge but, these cities need some help in getting the top of the funnel created in order to build a critical mass of opportunities that will interest VC investors. State or Federal money is necessary to kick-start these geographies but states like Ohio and Pennsylvania and others can point to a great payback if the State invests some money to build the foundation for a blossoming entrepreneurial ecosystem.Thanks for the A2A.______________________________________Ohio Third Frontier December, 2015 meeting slides: https://development.ohio.gov/files/otf/December%2017%202015%20Commission%20and%20Advisory%20Board%20Presentation.pdf Footnotes[1] https://development.ohio.gov/files/otf/09.16.2015%20otf%20retreat.pdf