A blog covering the health/care ecosystem and people.

Financial Experience (let’s call it FX) is the next big thing in the world of patient experience and health care. Patients, as health consumers, have taken on more of the financial risk for health care payments. The growth of high-deductible health plans as well as people paying more out-of-pocket exposes patients’ wallets in ways that implore the health care industry to serve up a better retail experience for patients. But that just isn’t happening. One of the challenges has been price transparency, which is the central premise of this weekend’s New York Times research-rich article by reporters Sarah Kliff and

There is one health care public policy issue that unites U.S. voters across political party: that is the consumer-facing costs of prescription drugs. With the price of medicines in politicians’ and health citizens’ cross-hairs, the pharmaceutical and biotech industries have responded in many ways to the Rx pricing critiques from consumers (via, for example, Consumer Reports/Consumers Union and AARP), hospitals (through the American Hospital Association), and insurance companies (from AHIP, America’s Health Insurance Plans). The latest poll from the University of Chicago/Harris Public Policy and the Associate Press-NORC Center for Public Affairs Research quantifies the issue cross-party, finding that 74%

As connected devices proliferate within health care enterprises and across the health care ecosystem, cybersecurity risks abound. During the first year of the COVID-19 pandemic, the health care sector was profoundly affected by cyber-attacks on connected devices, we learn in the report, Rise of the Machines 2021: State of Connected Devices – IT, IoT, IoMT and OT from Ordr. For this annual report, Ordr analyzed security risks across over 500 deployments in healthcare, life sciences, retail, and manufacturing sectors for the 12 months June 2020 through June 2021. In health care, outdated operating systems present some of the greatest risks:

The COVID-19 pandemic digitally transformed most people living in the U.S., re-shaping consumers to work from home when possible, go to school there, and buy all manners of goods and services via ecommerce. In March 2021, Zoom conducted research into the question, “how virtual do we want our future to be?” posing that to thousands of citizens living in 10 countries including the U.S. As the first chart from the study illustrates, most people in America expect hybrid lifestyles, from fitness and retail to entertainment and education. And 7 in 10 U.S. health citizens want their health care to be

Simply put, is the equation, “Spend more, get less” a sustainable business model? Of course not. But that’s the simple math on U.S. health care spending and what comes from it, according to Mirror, Mirror 2021: Reflecting Poorly, a perennial report from The Commonwealth Fund that compares health system performance across eleven developed countries. The first table details the metrics that the Fund compares across the eleven peer nations, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. The metrics compared were access to care, care process, administrative efficiency, equity,

“You can trust us to help you find the right Medicare coverage for you and your lifestyle,” the tagline reads. What kind of organization would be behind this campaign: a healthcare navigator company, an insurance company, or a social services agency? In fact, it’s a grocery store called Hy-Vee, which launched the “Medicare Aisle” to help consumers living in the eight states in which the chain’s 240+ stores operate to sort through the daunting labyrinth of Medicare choices. “Hy-Vee is a trusted leader in the health and wellness space, and as a retail and specialty pharmacy provider, we are deeply

When we say the word “pharmacy,” we might picture the Main Street brick-and-mortar chain drugstore that dispenses medicines from behind the counter in the far back of the building, and sweet and salty snacks at the front by the cashier. In fact, “pharmacy” is the jumping off point for the expanding and increasingly beloved retail health ecosystem, J.D. Power found in the company’s latest 2021 U.S. Pharmacy Study. Each year, J.D. Power assesses consumers’ perceptions of pharmacies by category, including those retail chains along with supermarket operated, mass merchants, and mail order channels. This is the 13th year of the

There is no doubt that the COVID-19 pandemic motivated health care providers, payers, and patients to adopt digital tools and contact-less services, allowing people to deliver and receive medical care. Still, 18 months into the pandemic, now endemic and in its fourth wave of cases spiking around the world and in many parts of the U.S., some aspects of “digital transformation” seem not to have fully transformed American healthcare, we learn in HIMSS’s annual 2021 State of Healthcare Report. HIMSS collaborated with the organizations Trust  Accenture, The Chartix Group, and ZS on this year’s research. Nine in ten clinicians have recommended

The level of medical debt in America exceeded debt of other types in 2020. Furthermore, the flow of medical debt was greater among health citizens living in states that did not expand Medicaid as part of the Affordable Care Act, compared with patients who reside in Medicaid expansion states, according to an original research essay, Medical Debt in the US, 2009-2020 published in JAMA on 20 July 2021. The first line chart illustrates the trends in medical debt in collections by state expansion of Medicaid, with the bottom darkest line representing debt in collections in Medicaid expansion states from the

Cain Brothers is a 100+ year old financial services firm with a strong health care experience, now part of KeyBanc. A recent “House Calls” memo and podcast from two company analysts detailed the state of Medicaid, Motherhood and America’s Future: Giving Birth to Better Maternity Outcomes. Christian Pesci and David Johnson’s in-depth discussion detailed their bottom-line that, “maternity care in the U.S. is in crisis but poised for rapid evolution…(recognizing) that an uncoordinated system with misaligned incentives harms too many individuals, families, and communities.” They lay out the crisis as follows: Medicaid funds nearly one-half of births in the U.S.

“Self-care” took on new meaning and personal work-flows for people living in and through the coronavirus pandemic in the U.S. Acosta, the retail market research pro’s, updated our understanding consumers evolving as COVID-19 Has Elevated the Health and Wellness Trends of the Recent Years, results of a survey conducted among in May 2021. In the U.S., consumers’ take on self-care has most to do with healthy eating and nutrition (for 1 in 2 people), getting regular medical checkups (for 42%), taking exercise, relaxing, using vitamins and supplements, and getting good sleep. Healthy relationships are an integral part of self-care for

The ultimate health and wellbeing of an adult depends on the factors that shape us when we are children. A new, deep report from the OECD, Measuring What Matters for Child Well-being and Policies, spells out the many domains of experience that, together, bolster our whole health as we grow from child to adult. The first chart presents the OECD’s framework for measuring child well-being, calling out the nature of being “aspirational.” This re-look at children’s health data is aspirational because it is laying out how to best measure child well-being to set the bar higher for doing so. It addresses

The FDA’s approval of the first therapy to treat Alzheimer’s Disease in over twenty years brought attention to a not-yet-convened debate of U.S. health care costs and spending, innovation, and return-on-the-investment (as well as “for whom” do the returns accrue). In my latest post for Medecision, I explore different angles on the Aduhelm and Alzheimer’s discussion, covering: The macro- and micro-economics of Alzheimer’s and the $56,000 list price for the drug The FDA regulatory process and aftermath U.S. consumers’ bipartisan support for drug price regulation through Medicare negotiation and private/commercial sector adoption Congressional legislation addressing the price of medicines in

COVID-19 reshaped people around the world, one-half of whom are re-defining their personal purpose and life-goals. This sense of purpose extends to peoples’ willingness to buy or patronize companies who do not meet their needs for health, safety, sustainability and trust. For example, two in three of these people would switch travel brands if they felt health and safety weren’t up to par, discovered in Life Reimagined – Mapping the motivations that matter for today’s consumers, from Accenture’s Voices of Change series. In May 2021, Accenture polled over 25,000 consumers globally, in 22 countries, and found that one-half of people

Getting totally rid of the coronavirus isn’t likely, so we humans must accept the fact that SARS-CoV-2 will be endemic. The economic and healthcare system impacts of this were explored in the Post-Covid Healthcare Landscape, delivered by Fitch Solutions’ Jamie Davies and Beau Noafshar, leaders in the Pharmaceuticals, Healthcare, and Medical Devices groups. I welcomed the opportunity to learn from this team’s approach in weaving together the dynamic issues that help us to plan for the long-tail of COVID-19 and its impact on the economy and prospects for the health care industry and health citizens. The first graph illustrates the

One in two people in the U.S. with employer-sponsored health insurance worry that a major health event in their household could lead to bankruptcy, according to research gathered by West Health and Gallup in Business Speaks: The Future of Employer-Sponsored Insurance. Gallup and West Health presented their study in a webinar earlier this week; in today’s post, I feature a few key data points that particularly resonate as I celebrate/appreciate yesterday’s U.S. Supreme Court’s ruling on the Affordable Care Act (i.e., California v. Texas) combined with a new study published in JAMA Network Open, discussed below the digital fold in

Wherever you live in the world touched by the coronavirus pandemic, you felt (and were) stress-tested. Both you were, and your home was as well. In this year’s 2021 annual report by Deloitte into Connectivity & Mobile Trends, their report details How the pandemic has stress-tested the crowded digital home. This analysis was done, as it is every year, by the Deloitte Center for Technology, Media & Telecommunications. Deloitte’s Center commissioned an online survey among 2,009 U.S. consumers to gauge five generations of peoples’ perspectives on connected life in the context of COVID. The report covers the various life-flows of

The pandemic ushered in millions of peoples’ first digital health experiences, many of which will persist according to the 23rd Annual U.S. Consumer Technology Ownership & Market Potential Study, published by the Consumer Technology Association. CTA conducted an online survey among 2,409 U.S. adult 18 and over in April 2021 to gather data for this annual report. To ensure a fair sample, CTA drew three datasets for the general population along with an Hispanic oversample and an oversample for people 65 years of age and older. The study looked at 83 consumer technology products and sub-categories, including many directly related

Two studies published in May 2021 illustrate the value and importance of telehealth to patients in 2020, and a disconnect among many C-level executives working in hospitals, academic medical centers, and other care provider organizations. Together, the two reports from J.D. Power and BDO illustrate some mis-alignment between the demand and supply side of telehealth. On the consumer demand side, patients’ growing use of telehealth in the COVID-19 pandemic along with more frequent digital contacts with health plans bolstered member satisfaction, discovered by the J.D. Power 2021 U.S. Commercial Member Health Plan Study. J.D. Power has conducted the U.S. Commercial

The good news for health care costs for a family of four in America is that they fell, for the first time in like, ever, in 2020. But like a déjà vu all over again, annual health care costs for a family of four enrolled in a PPO will climb to over $28,000 in 2021, based on the latest 2021 Milliman Medical Index (MMI). The first chart shows how health care costs declined in our Year of COVID, 2020, by over $1,000 for that hypothetical U.S. family. But costs rise with a statistical vengeance this year, by nearly $2,200 per family–about

The emergence of the COVID-19 vaccine “infodemic” has slowed the ability for nations around the world to emerge out of the public health crisis. Growing cynicism among some health citizens facing the politicization of public health tactics like vaccines and facial masks is what we’re talking about. At the root is peoples’ lack of trust across a range of information providers, including government, media, business, and even peers. The 2021 Edelman Trust Barometer spotlighted the infodemic and eroding trust in the U.S. in the voices of public health, the public sector, and media. This is a global challenge as well,

You’re stressed, I’m stressed; most of us have felt stress in the COVID-19 era which began in the U.S. in the first quarter of 2020. Nearly eighteen months later, a 2021 Edelman Trust Barometer update finds that consumers’ trust in the health care industry is under stress, too — in the U.S. and around the world. The first chart from the Edelman health care update demonstrates that in most countries polled, health citizens’ trust in health care was buoyed in the first five months of 2020 (January through May): up 18 points in the U.S., 14 points in Canada and

The hearts and minds of nurses are fertile and inspirational sources and engines for health care innovation. This past weekend, and for the second time, I had the privilege and opportunity to be a panelist for the perennial hackathon meet-up of Nurse Hack 4 Health, sponsored by Microsoft, Johnson & Johnson, Sonsiel, and DevUp. This round, the hackathon attracted hundreds of nurses from at least 20 countries and 30 U.S. states. Even a few students attended, a growing trend as academia recognizes the shortage of workers trained to solve thorny problems of the world. In health care, right here, right

“Compare digital health to airlines, cruise lines, and other industries” and the sector looks quite privileged, opined Matthew Holt in a discussion on a study diving deeply into the State of Digital Health, conducted by Catalyst @ Health 2.0 and sponsored by WIPFLI.. The research was conducted among 335 respondents, which included 182 digital health companies polled between November 2020 and March 2021. Digital health companies represented 60% of the sample, the other 40% of which were consulting firms, subsidiaries of providers/payers/life science companies and tech corporations, and investors. As Matthew called out, the digital health sector has a relatively

To pay for health care expenses, the average nest-egg required for a couple retiring in the U.S. in 2021 will be $300,000 according to the 20th annual Fidelity Investments Retiree Health Care Cost Estimate. I’ve tracked this survey for over a decade here on Health Populi, and updated the annual chart shown here to reflect a $40,000 increase in retiree costs since 2016. While the rate of increase year-on-year since then has slowed, the $300,000 price-tag for retiree health care costs is a huge number few Americans have saved for. That $300K splits up unequally for an opposite-gender couple (in

The pandemic accelerated many Very Big Deals in digital health venture capital investment, mergers and acquisitions, and the re-emergence of SPACs in health care. A closer look at this activity points to a key trend that will persist post-pandemic: that telehealth and the broader theme of virtual care is re-shaping how health care is delivered. This graphic comes out of my current thinking about telehealth across the continuum of care. Before the pandemic, the dominant work-flow for telemedicine was for triage, primary care and pediatrics (think: your child registers a 105-degree fever on a Saturday night and the pediatrician’s office

Spending on medicines, globally, will rebound this year and rise above pre-pandemic levels through 2025. Between 2021 and 2025, the annual growth global growth rate for prescription drugs spending is expected to range from 3% to 6%, a $1.6 trillion bill for the worlds’s total Rx medicines market. That relatively low single-digit growth rate is tempered by savings from biosimilars and the loss of brand exclusivity (that is, more generics coming to market). On the faster-growth side, we can expect two big therapeutic areas to drive spending upward: oncology and immunology, projected to expand by 9% to 12% each year

In April 2020, the U.S. Centers for Disease Control issued a report featuring evidence that in the month of March 2020, the coronavirus pandemic was not an equal-opportunity killer. Within just a couple of months of COVID-19 emerging in America, it became clear that health disparities were evident in outcomes due to complications from the coronavirus. An update from that early look at differences in COVID-19 diagnoses and mortality rates was published in Health Disparities by Race and Ethnicity During the COVID-19 Pandemic: Current Evidence and Policy Approaches, In this report, the Assistant Secretary for Planning and Evaluation, part of

As the COVID-19 expanded peoples’ consciousness about infectious disease and opportunities to keep a tricky virus at bay, consumers grew new muscles about public and individual wellness…now, “more invested in achieving it,” according to In Health We Trust, a survey report from Healthline Media. To gauge Americans changing perspectives on personal health, HealthLine conducted surveys among 1,533 U.S. consumers age 18 and over in February 2020 (just about the time the coronavirus pandemic was emerging in the U.S.) and 1,577 consumers in December 2020. One of the subtle shifts in health care consumerism concerns cost, which before the pandemic has

In the summer of 2020, four months into the pandemic, one-half of people living in the U.S. felt worry or stress related to the coronavirus that had a negative impact on their mental health. Over a year into the COVID-19 in America, nearly one-half of people still have negative mental health impacts due to the coronavirus, based on research from the Kaiser Family Foundation (KFF) published in their April 2021 update on the mental health impact of the COVID-19 pandemic. Note the line in the bar chart from the study has flat-lined and settled at just about 50% of U.S.

The United States has among the highest per capita incomes in the world. The U.S. also has sustained among the highest death rates per 100,000 people due to COVID-19, based on epidemiological data from the World Health Organization’s March 28, 2021, update. Higher incomes won’t prevent a person from death-by-coronavirus, but risks for the social determinants of health — exacerbated by income inequality — will and do. I have the good fortune of access to a study group paper shared by Paul Sheard, Research Fellow at the Mossaver-Rahmani Center for Business and Government at the Harvard Kennedy School. In reviewing

The coronavirus pandemic exposed weaknesses in the U.S. health care system that existed before the public health crisis. What lessons can be learned from the COVID-19 stress-test to build American health care back better? The National Academy of Medicine is publishing nine reports addressing health stakeholder segments impacted and re-shaped by COVID-19 — for public health, quality and safety, health care payers, clinicians, research, patients-families-communities, health product manufacturers, digital health, and care systems. The report on health care systems and providers was released this week:  COVID-19 Impact Assessment: Lessons Learned and Compelling Needs was authored by experts on the front-line

Investments in the digital health sector have fast-grown in the past decade, reaching $14bn in 2020 based on Rock Health’s latest read on the market. The COVID-19 pandemic accelerated the field across many industry segments. With such turbocharged growth on the supply side, Beazley, experts in specialty insurance, explores the risks of digital health and wellness in a new report, Digital health, telehealth and wellness: Attitudes to risk and insurance. With great potential for both innovation and reward comes great risks: Beazley points to the facts that, over two-thirds of digital health companies lack insurance coverage for medical malpractice for

COVID-19 ushered in the era of our homes as safe havens for work, shopping, education, fitness-awaking, bread-baking, and health-making. In my latest essay written for Medecision, I weave together new and important data and evidence supporting the basic social determinant of health — shelter, housing, home — and some innovations supporting housing-as-medicine from CVS Health, UnitedHealth Group, AHIP, Brookings Institution, the Urban Land Institute, and other stakeholders learning how housing underpins our health — physical, mental, financial. Read about a wonderful development from Communidad Partners, working with the Veritas Impact Partners group, channeling telehealth to housing programs serving residents with

Springtime is finally emerging on the east coast of the U.S. and my local CSA farm is on my mind. It’s timely, then, to re-visit a research paper on subsidizing fruits and vegetables from a March 2019 issue of PLOS as an introduction to a new initiative growing out of The Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) on produce prescriptions. Timely, too, that Chef José Andrés has been called to President Biden’s White House to help address food security in America. First, let’s look at the research in PLOS: Cost-effectiveness of financial incentives for

In 2021, racial and ethnic disparities in healthcare are a top patient safety issue, according to ECRI’s annual list of major concerns facing healthcare consumers’ risks to adverse events that can harm them. ECRI has published their annual Top 10 list since 2018, when the list featured diagnostic errors, o behavioral health needs in acute care settings, and patient engagement and health literacy — all of which play into this year’s #1 issue, racial and ethnic disparities in health care. In fact, among the risks in this year’s Top Ten list, eight were accelerated and highlighted by the COVID-19 pandemic

A Year into our collective coronavirus experience, Americans remain stressed, with physical health taking a back seat to our daily grinds based on the 2021 Stress in America survey from the American Psychological Association (APA). The APA has been updating us on U.S.-stress for several years, and more frequently since the start of the COVID-19 pandemic at the start of 2020. In their latest report, APA updates their previous profiles of Americans’ stress looking into different demographic groups and coping mechanisms. The topline, across all adults living in America, is that one-half have delayed or cancelled health care services. One-half has

“So close and yet so far” feels like the right phrase to use a year after the World Health Organization used the “P-word,” “pandemic,” to describe the coronavirus’s impact on public health, globally. One year and over 550,000 COVID-related deaths in the U.S. later, we face a New Reality that Dr. Michael Osterholm and I are brainstorming today at the 2021 South-by-Southwest Festival. Usually held live and very up-close-and-personally crowded in Austin, Texas, this year we are all virtual — including the film, music, and interactive festivals alike. While I regret to not be in the same room as Dr.

With a vaccine supply proliferating in the U.S. and more health citizens getting their first jabs, there’s growing optimism in America looking to the next-normal by, perhaps, July 4th holiday weekend as President Biden reads the pandemic tea leaves. But that won’t mean Americans will be ready to return to pre-pandemic health care visits to hospital and doctor’s offices. Now that hygiene protocols are well-established in health care providers’ settings, at least two other major consumer barriers to seeking care must be addressed: cost and access. The latest (March 2021) Kaiser Family Foundation Tracking Poll learned that at least one

2021 is the 20th anniversary of the University of Michigan Center for Value-Based Insurance Design (V-BID). On March 10th, V-BID held its annual Summit, celebrating the Center’s 20 years of innovation and scholarship. The Center is led by Dr. Mark Fendrick, and has an active and innovative advisory board. [Note: I may be biased as a University of Michigan graduate of both the School of Public Health and Rackham School of Graduate Studies in Economics].   Some of the most important areas of the Center’s impact include initiatives addressing low-value care, waste in U.S. health care, patient assistance programs, Medicare

A major side-effect of the coronavirus pandemic in 2020 was its impact on the national U.S. economy, jobs, and peoples’ household finances — in particular, medical spending. In 2021, patients-as-health-consumers seek lower health care and prescription drug costs coupled with higher quality care, discovered by the patient advocacy coalition, Consumers for Quality Care. This broad-spanning patient coalition includes the AIMED Alliance, Autism Speaks, the Black AIDS Institute, Black Women’s Health Initiative, Center Forward, Consumer Action. Fair Foundation, First Focus, Global Liver Institute, Hydrocephalus Association, LULAC, MANA (a Latina advocacy organization), Myositis Association, National Consumers League, National Health IT Collaborative, National Hispanic

The coronavirus pandemic accelerated digital transformation of organizations, including health care providers. But another patient side-effect of COVID-19 has been the digital transformation of many patients, documented by data gathered by Rock Health and Stanford Center for Digital Health and analyzed in their latest report explaining how the public health crisis accelerated digital health “beyond its years,” noted in the title of the report. Rock Health and Stanford commissioned an online survey among 7,980 U.S. adults from early September to early October 2020 to gauge peoples’ interest in and utilization of digital health tools and telehealth. Rock Health has conducted a consumer digital

Consumers favorite brands in 2021 are baked with health, from medical care through to the social determinants that make our wellness and mental health better, based on the 2021 Prophet Brand Relevance Index. The top ten brands in 2021 are Apple (the top brand for the sixth year in a row), Peloton, KitchenAid, Mayo Clinic, LEGO, Costco, Honda, Johns Hopkins Medicine, PlayStation, and Amazon. In this year’s study, Prophet remarked that, “Almost overnight, they’ve [consumers] reconsidered beloved names like Disney, making room for brands that serve them better…As they weather some bleak moments, consumers want brands that will commit to

The more health consumers use health and wellness services at retail, the greater their satisfaction and brand-love, according to a new report from J.D. Power. J.D. Power found that peoples’ Net Promoter Scores were higher among those folks who used at least one health and wellness service at a brick-and-mortar pharmacy, shown in the first chart. That NPS-delta was 15 points between consumers who used no services (rating an NPS of 55) versus people using at least 2 services (awarding an NPS score of 70). Consumers using more health and wellness services also spent more money at the drug store, a

Some people remark about 2020 being a “lost year” in the wake of the coronavirus pandemic. That happens to be a true statement, sadly not in jest: in the U.S., life expectancy at birth fell by one full year over the first half of 2020 compared with 2019, to 77.8 years. In 2019, life expectancy at birth was 78.8  years, according to data shared by the National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention (CDC). Life expectancy at birth declined for both females and males, shown in the first chart. The differences between

By the autumn of 2020, U.S. physicians grew concerned that patients who were avoiding visits to doctor’s offices were missing care for chronic conditions, discussed in in Delayed and Forgone Health Care for Nonelderly Adults during the COVID-19 Pandemic from the Urban Institute. More than three-fourths of people who delayed or forewent care had at least one chronic health condition. The pandemic may have led to excess deaths from diabetes, dementia, hypertension, heart disease, and stroke, as well as record drug overdoses in the 12 months ending in May 2020. In their JAMA editorial on these data, Dr. Bauchner and

Seven in 10 U.S. adults are willing to be vaccinated, and they’re not happy about the process in getting their jab, according to Gallup’s poll taken in the last week of January 2021. The proportion of Americans willing to receive a COVID-19 vaccine has steadily grown since October 2020, which fell to a mere 50% of folks keen to get the shot. That percentage has risen to 71% as of February 1 2021, as the first line chart shows the reversal in public embrace for vaccination against the coronavirus. Now that most people in the U.S. welcome the opportunity to

At the start of CES 2021, I had the opportunity to catch up with Karsten Russell-Wood, Portfolio Marketing Leader, Post Acute & Home, Connected Care at Philips. We brainstormed just as CES 2021 was going to “open,” virtually, for the consumer electronics conference’s first all-virtual meeting. Philips, a longtime major exhibitor at CES, created an entirely new online experience for the CES attendees – a sort of virtual gallery of different exhibits that are accessed from a single point in a “room” with various entry points. One of the company’s key messages for CES 2021 was health care delivered outside

Nearly a year into the COVID-19 pandemic, the same percent of Americans say strengthening the U.S. economy and dealing with the coronavirus outbreak should be a top priority for President Biden and Congress to address this year, according to data from the Pew Research Center collected during the second week of January 2021. Two-thirds of people in the U.S. also want government leaders to prioritize improving the employment situation, defending against terrorism, and improving the political system, the study learned. At Americans’ low end of the priority list for the President and Congress are dealing with global trade, improving transportation,