Latest / CareTalk: Healthcare. Unfiltered. / Corporate Concentration Is Breaking Healthcare w/ Dr. John McDonough, Author, America's Wrong Turn

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Corporate Concentration Is Breaking Healthcare w/ Dr. John McDonough, Author, America's Wrong Turn · CareTalk: Healthcare. Unfiltered.

• 0:00
  SPEAKER_00: U.S.
• 0:00
  SPEAKER_00: healthcare spending broke away from the rest of the developed world in the early 1980s and it's really never come back.
• 0:06
  SPEAKER_00: And today's guest has worked hard to figure out why.
• 0:09
  SPEAKER_00: He concludes that this was no accident.
• 0:11
  SPEAKER_00: Rather, it was ideology.
• 0:14
  SPEAKER_00: John McDonough is professor of practice at the Harvard T.H.
• 0:17
  SPEAKER_00: Chan School of Public Health.
• 0:19
  SPEAKER_00: He helped shape the Affordable Care Act from the Senate Help Committee, and he worked on Massachusetts landmark reform before that.
• 0:25
  SPEAKER_00: His new book, America's Wrong Turn: U.S.
• 0:28
  SPEAKER_00: Healthcare in the Neoliberal Era, is available now.
• 0:38
  SPEAKER_00: Welcome to CareTalk, America's home for incisive debate about healthcare business and policy.
• 0:44
  SPEAKER_00: I'm David Williams, president of Health Business Group.
• 0:47
  SPEAKER_01: And I'm John Driscoll, the Chairman of the UConn Health System.
• 0:50
  SPEAKER_00: Well, John, welcome to CareTalk.
• 0:52
  SPEAKER_00: Thank you.
• 0:53
  SPEAKER_02: It's a pleasure and an honor to be here with both of you, David and John.
• 0:57
  SPEAKER_00: So let's talk about the early 1980s.
• 1:00
  SPEAKER_00: What happened to U.S.
• 1:02
  SPEAKER_00: healthcare spending around that time?
• 1:04
  SPEAKER_00: You say that's a question that you kept getting asked.
• 1:07
  SPEAKER_00: So I want to know who's asking and what's the answer that you settled on.
• 1:12
  SPEAKER_02: So I started teaching full-time at the Harvard Chan School of Public Health in 2011.
• 1:18
  SPEAKER_02: Started teaching regular Masters of Public Health students, young professionals, and older professionals in executive education.
• 1:26
  SPEAKER_02: And I would talk about the U.S.
• 1:27
  SPEAKER_02: healthcare system and show this chart from the Commonwealth Fund that showed U.S.
• 1:34
  SPEAKER_02: spending on health care as a percent of gross domestic product in comparison with 10, 11, or 12 other advanced nations, Germany, France, Japan, South Korea, you name it.
• 1:48
  SPEAKER_02: And interesting, you go back to 1980 and you look at the chart, and the U.S.
• 1:53
  SPEAKER_02: was the high spender then.
• 1:55
  SPEAKER_02: However, it was very much in the pack.
• 1:58
  SPEAKER_02: It was tightly bound, and there wasn't that much difference between number one and number 11.
• 2:03
  SPEAKER_02: And then you look at the chart and you see around 1982, 83, something happened.
• 2:10
  SPEAKER_02: And we jackrabbited out of the pack.
• 2:13
  SPEAKER_02: And it's been up, up and away in the 45 years after that.
• 2:20
  SPEAKER_02: And so people would ask me what the heck happened in the early 1980s.
• 2:24
  SPEAKER_02: And I had hypotheses, but I didn't have a hard answer.
• 2:28
  SPEAKER_02: Maybe it was managed care and HMOs, maybe it was Medicare prospective payment, maybe it was Reaganomics.
• 2:37
  SPEAKER_02: And it wasn't until later, after I kept getting asked and started to do some searching, that I started to look at this political economic revolution that happened in the United States starting in the late 70s and into the 1980s, that some people, and I use the word too, called neoliberalism, which Naomi Oreskes at Harvard undergrad calls it free market fundamentalism.
• 3:05
  SPEAKER_02: It's a belief that the necessity for government is to step as far back as possible to just manage the economy and stay the heck out of everything else to let the free market unleash itself.
• 3:22
  SPEAKER_02: And its proponents were people like Milton Friedman, the first w American winner of the Nobel Prize for Economics, Robert Bork, James Buchanan, a whole set of people, a lot of whom came out of the University of Chicago Economics Department going back to the 30s and 40s.
• 3:43
  SPEAKER_02: And it was also a global movement as well.
• 3:46
  SPEAKER_02: Countries like Margaret Thatcher in Great Britain, Deng Xiaoping in China, Gerhard Schroeder in Germany.
• 3:53
  SPEAKER_02: These were people who adopted these ideas and folded them into their government.
• 3:58
  SPEAKER_02: And when Ronald Reagan became president, he was quite familiar with this whole line of thinking.
• 4:05
  SPEAKER_02: And Milton Friedman was one of his chief economic advisors, as well as a lot of other people, and they began step by step to implement the neoliberal agenda across the economy.
• 4:19
  SPEAKER_02: They were not aiming at medical care.
• 4:22
  SPEAKER_02: They were not aiming at health care to be a target.
• 4:27
  SPEAKER_02: But it's hard to do it without bringing that in.
• 4:31
  SPEAKER_01: But I think maybe maybe step back.
• 4:32
  SPEAKER_01: Most people wouldn't even think of the health care part of the economy as a marketplace or a part of the economy.
• 4:41
  SPEAKER_01: What changed in the relationship between doctors and hospitals and patients and insurance that made that economic theory relevant to health care?
• 4:54
  SPEAKER_02: I would say, first of all, people have always been upset about the high cost of medical care.
• 5:00
  SPEAKER_02: You can go back to the 1920s and 30s and see a lot of anger about that, about just how difficult.
• 5:06
  SPEAKER_02: But particularly in 1965, when we created Medicare and Medicaid.
• 5:12
  SPEAKER_02: And although these was this was so-called government-run health care, it actually brought in the private sector into the medical care space, and particularly corporations and for-profit corporations, in a way that we really hadn't seen before.
• 5:30
  SPEAKER_02: And the momentum picked up.
• 5:33
  SPEAKER_02: And then with the neoliberal ideas going forward, the notion was, and by the way, this was a rich debate in the 1970s.
• 5:43
  SPEAKER_02: In the 1970s, there was a heavy debate in the United States between government-led health planning versus a free market solution.
• 5:53
  SPEAKER_02: And both sides went at it, and for a while it looked like the planning effort was winning.
• 5:59
  SPEAKER_02: But then in the second half of the 1970s, the market hypothesis really found its wings and really started to take off.
• 6:09
  SPEAKER_02: And then the Reagan administration really institutionalized it and embedded it in the framework of government in many, many ways, not so much in statute or regulation, but in practices, particularly around antitrust and consolidation, that is a major driver of health care inflation even today.
• 6:30
  SPEAKER_00: So just going back to that pre-1980 era and even Medicare and Medicaid in the in the middle of it in 65 or so, so from 33 to 80, you frame that as an era when things were working decently well, and that's even though in the Truman administration was a big push, I think, for national health plan that never came to pass.
• 6:50
  SPEAKER_00: So uh what what was working well during this?
• 6:54
  SPEAKER_02: Well so one of the one of the frameworks that is central to my book are the ideas of a political scientist from Yale named Stephen Skaronik.
• 7:04
  SPEAKER_02: You know, when we think about eras in American political history, we tend to look at individual presidents.
• 7:10
  SPEAKER_02: So there was an LBJ era, there was a Nixon era, there was an Obama era.
• 7:17
  SPEAKER_02: And what Scheronik says is that there are larger politico-economic eras that extend for decades, and he counts five of them.
• 7:27
  SPEAKER_02: And the two most important for this discussion is the New Deal era that started with FDR in 1933 and actually went on long after his death, up until 1980.
• 7:40
  SPEAKER_02: And when Reagan got elected, many commentators said, hey, everybody, this is the end of the New Deal era.
• 7:46
  SPEAKER_02: And they were right.
• 7:48
  SPEAKER_02: And it was succeeded by Reagan.
• 7:50
  SPEAKER_02: I didn't understand.
• 7:52
  SPEAKER_02: I was 27 when Reagan got elected.
• 7:55
  SPEAKER_02: And I didn't believe he was the start of anything substantive.
• 7:59
  SPEAKER_02: I kind of thought he was a little bit of a joke.
• 8:02
  SPEAKER_02: But it turns out he got re-elected in 1984, winning 49 of the 50 states.
• 8:09
  SPEAKER_02: And his influence, his ideas, borrowed from Friedman and other people, were of fundamental importance in terms of what followed really for a 40-year period, 1980 to 2020, which I refer to as the neoliberal era, when it was free market fundamental principles, including during President Clinton and President Obama, believe it or not, that guided the direction of society.
• 8:40
  SPEAKER_02: And so the belief was in that period for many, many people, what's wrong with medical care and health care in the United States?
• 8:47
  SPEAKER_02: And the answer was that we don't have enough of a free market.
• 8:51
  SPEAKER_02: And if we can just unleash the free market more, then all of these problems of cost and access would just disappear on their own.
• 9:00
  SPEAKER_02: And that was a firmly held belief by lots of different people.
• 9:04
  SPEAKER_02: In fact, you still hear many Republican office holders say the same line today.
• 9:10
  SPEAKER_01: But if you kind of look at the big drivers, John, you look at pharma pharma, large farm manufacturers continuing to jack up rates, extend their patents through litigation, game the system, which has gone from probably in that in the period you start at 4%, 5% of total medical costs, down at probably 24%.
• 9:36
  SPEAKER_01: You look at physician compensation across the board, government and not, at a substantial premium to any of the international comps, and you look at the rapid application and adoption of extremely expensive technology as opposed to investment in primary care.
• 9:56
  SPEAKER_01: I don't think those are those don't sound like uh Milton Friedman's problem.
• 10:02
  SPEAKER_01: It almost seems like, for example, with the government, we didn't negotiate prices, which it would be a private sector response.
• 10:09
  SPEAKER_01: Same thing with physician compensation.
• 10:12
  SPEAKER_01: And I I don't really have a I don't think there's ideology associated with the innovation other than the fact that it allows you to embed higher cost things in what you I mean isn't this really about what government supports an investments in and whether it actually plays a role rather than a private sector a private sector ideology?
• 10:34
  SPEAKER_01: Because I'm taken with your point on the rest of the economy, but gosh, it doesn't seem like in that period government played the role that as a purchaser in any rational market fashion.
• 10:48
  SPEAKER_02: So let me give an example in the breadcrumb trail to it.
• 10:52
  SPEAKER_02: And the best example, and it's only one of many, but it's one of the most important ones, is the area of antitrust and monopoly and corporate consolidation.
• 11:02
  SPEAKER_02: So we started in the United States with government intervention to prevent consolidation in 1890 with the Sherman Antitrust Act.
• 11:12
  SPEAKER_02: And changes, additions, moderate modifications, um, but roughly the same idea that we need to prevent huge amounts of concentration when they are tied to companies just eating up and devouring others.
• 11:28
  SPEAKER_02: And in the 1960s and 70s, the neoliberals, led particularly by one of their more uh uh noteworthy adherents, a guy by the name of Robert Bork, B-O-R-K, he advanced the idea that we've been doing antitrust all wrong.
• 11:49
  SPEAKER_02: He put it in a book.
• 11:50
  SPEAKER_02: He called the book the antitrust paradox, came out in 1978.
• 11:57
  SPEAKER_02: And basically what he said was that big is not necessarily bad.
• 12:02
  SPEAKER_02: If a company's big, it probably deserves to be big because it's got something good going on.
• 12:08
  SPEAKER_02: And the test should be when companies want to combine, merge, whatever, get bought out.
• 12:15
  SPEAKER_02: If the merging parties can say that consumers will get lower prices as a result, then it should be green light to merge as much and as often as you want, as long as you can show that.
• 12:29
  SPEAKER_02: And that was in the first years of the Reagan administration.
• 12:34
  SPEAKER_02: That became their gospel so much so that there are these important, it's not a law, it's not a regulation, important guidelines from the Justice Department and the Federal Trade Commission called the antitrust guidelines.
• 12:48
  SPEAKER_02: And they get redone on a regular basis, but in the early 80s, the Reagan people redid them to incorporate and ingrain the consumer welfare hypothesis into the practice.
• 13:03
  SPEAKER_02: And this is what goes to every federal judge, every federal prosecutor.
• 13:08
  SPEAKER_02: If you've got an antitrust case coming up, here's what you need to understand.
• 13:14
  SPEAKER_02: And so that became the practice.
• 13:16
  SPEAKER_02: And so starting in the 1980s, we went into hibernation as a nation around antitrust.
• 13:24
  SPEAKER_02: And it particularly impacted health care and the medical care industry.
• 13:29
  SPEAKER_02: For example, today, about 90 percent of U.S.
• 13:34
  SPEAKER_02: counties all over the nation are considered for acute care hospitals highly concentrated, the highest rate you can get under the established index to measure corporate concentration.
• 13:48
  SPEAKER_02: Physician specialization, over 65 percent.
• 13:52
  SPEAKER_02: Health insurance companies, over 75 percent, highly concentrated.
• 13:58
  SPEAKER_02: Uh you have uh suppliers of uh diabetic uh uh uh uh therapies, and 90 percent of the market is controlled by just two companies.
• 14:10
  SPEAKER_02: This is all across American society and all across the medical system, so much so that uh Phil Longwell, who represents the uh the Antitrust Institute, he says that if you want to understand why health care costs so much, the answer in the U.S., the answer begins and ends with corporate concentration and monopoly.
• 14:33
  SPEAKER_02: And that is straight out of the neoliberal playbook.
• 14:37
  SPEAKER_02: That's where it came from.
• 14:38
  SPEAKER_00: So, John, we met about, I think, a little over 20 years ago when you're running Healthcare for All.
• 14:44
  SPEAKER_00: And this is just before the Massachusetts bill, not called Romney Care by Romney, but anyway, Romney Care, which you worked on, and then working with the Senate Health Committee on the Affordable Care Act.
• 14:55
  SPEAKER_00: And both of these, I think, in the way you're describing it, may be considered in the neoliberal approach.
• 15:01
  SPEAKER_00: And I'm wondering how you looked at that at the time, and then sort of looking back as people were starting to ask you about the 80s, did your view of those bills and your role in it a change as a result of the research for this book?
• 15:14
  SPEAKER_02: Aaron Powell So I I can tell you, um, being central to the Massachusetts reform in 2006 and being deeply engaged as a Senate staffer in the ACA, that the term neoliberalism, to my recollection, never came up.
• 15:32
  SPEAKER_02: You know, there were the people out there arguing for Medicare for all, um, but we all knew whether we liked that idea or not, and a lot of us did, myself included, that it was simply a no-go politically, that if we pushed ourselves for single payer, we would have fallen off a cliff, nothing would have happened, and we would have completely humiliated the Democrat majorities in the House and the Senate.
• 15:59
  SPEAKER_02: And so we went with the notion of the public-private partnership, whereas basically a model where people get private insurance.
• 16:08
  SPEAKER_02: And there was a push by advocates to create a so-called public option, which would have been a Medicare fee-for-service-like option.
• 16:18
  SPEAKER_02: We had well over 50 Democratic senators who were for it.
• 16:22
  SPEAKER_02: We had two in particular, Joe Lieberman from Connecticut and Ben Nelson from Nebraska, but they were not the only two.
• 16:30
  SPEAKER_02: They were just the two who were outspoken who said, if this bill contains a public option, we're voting no.
• 16:37
  SPEAKER_02: And so we could see how, regardless of where you come from, including up to Barack Obama, he said, you know, if we were designing the system all over again, we would start with a single payer.
• 16:49
  SPEAKER_02: But the Times did not permit that level of commitment.
• 16:55
  SPEAKER_02: It wasn't there from the public.
• 16:58
  SPEAKER_02: In fact, what we saw was the emergence of a resistance in the Tea Party that came out right away that pushed back against the whole thing.
• 17:07
  SPEAKER_02: I I say to people, I say, I think that the Affordable Care Act was absolutely not the best law that could have been written, and it's probably close to the best law that could have been passed in 2010.
• 17:20
  SPEAKER_01: I want to dig back into John.
• 17:23
  SPEAKER_01: If you right now Medicare for All is is back.
• 17:27
  SPEAKER_01: There's this big Yale study which says we're going to save a trillion dollars without pointing out to that hospitals and doctors and all of the people who and pharmacies will have to accept Medicare rates when actually on a blended basis they're getting paid a ton more.
• 17:47
  SPEAKER_01: That's before you even get into people having to give up their private insurance.
• 17:52
  SPEAKER_01: I I just think I I don't know.
• 17:54
  SPEAKER_01: It would be interesting to hear your thoughts on that.
• 17:56
  SPEAKER_01: I'm sure you've looked at that proposal.
• 17:59
  SPEAKER_01: You know, if you assume everyone cuts their costs, it's remarkable how easy it is to save money.
• 18:04
  SPEAKER_01: But having lived in this it as a as a as a as a leader, legislator, and negotiator with all these constituencies, do you really think that doctors, hospitals are gonna and and and device manufacturers and big pharma are gonna cut their prices and just live on Medicare rates?
• 18:23
  SPEAKER_01: Or do you think that might create a little bit of trouble?
• 18:27
  SPEAKER_02: Oh, I think it would create enormous trouble.
• 18:30
  SPEAKER_02: Um, we've had three states since the 1990s where citizens have mobilized to put a version of Medicare for All on the state ballot.
• 18:42
  SPEAKER_02: And not as an advisory, do you like this or not, but as a binding new law in the state to push.
• 18:50
  SPEAKER_02: In each one of those states, when the polls started evaluating uh support for it was sky high, very popular.
• 19:00
  SPEAKER_02: Lots of people said yes, that's the way to go.
• 19:03
  SPEAKER_02: And by the time it ended, in uh in California in 1994, it got 26 percent yes.
• 19:11
  SPEAKER_02: In Oregon in 2002, it got twenty focent yes.
• 19:18
  SPEAKER_02: And in Colorado, in 2016, it got 20 percent yes.
• 19:24
  SPEAKER_02: And so there is this difficulty in terms of how it gets translated, the money that comes out immediately to scare people about it, about the realities, that makes it one of the toughest political challenges I can imagine out there to do.
• 19:44
  SPEAKER_02: It's very hard to do.
• 19:45
  SPEAKER_02: And you're right, uh there there are in fact lots of hospital leaders and physicians and physician leaders who say they would uh do it.
• 19:55
  SPEAKER_02: I'll I'll mention one in particular, Eric Dixon, who runs uh the UMass Memorial Healthcare System in central Massachusetts.
• 20:03
  SPEAKER_02: He says he's run the numbers, and he would do equally well under a single payer in Medicare rates than uh than uh keeping the current system, and he thinks it would be great.
• 20:16
  SPEAKER_02: But that's certainly not the case with most of the hospital leaders and with many, many of the physicians.
• 20:23
  SPEAKER_02: It's hard to imagine when they actually look at the numbers that they will, you know, they will say, yes, I'm all in favor of the idea, but somehow between the idea and what you're presenting now, it's gotten all screwed up, and I can't support that.
• 20:37
  SPEAKER_01: Medicare rates for you, but private rates for me.
• 20:39
  SPEAKER_01: I mean it's a the downstream I I just think it's a little bit of a cutesy analysis that we assume everybody takes a pay cut.
• 20:47
  SPEAKER_01: We're shocked that they're and surprised that there is savings.
• 20:50
  SPEAKER_01: But didn't Vermont actually try a version of this as well?
• 20:53
  SPEAKER_02: Yes, Vermont in 2010.
• 20:56
  SPEAKER_02: The new governor, Peter Schumlin, in his campaign said, if I'm elected governor, we will pass in the legislature and implement a single payer system by 2014.
• 21:08
  SPEAKER_02: And he got elected, and the legislature passed a law to put it in motion.
• 21:13
  SPEAKER_02: They created the Green Mountain Board to come up with the plan.
• 21:17
  SPEAKER_02: And people kept saying, okay, where's the financing?
• 21:21
  SPEAKER_02: How are you gonna pay for this?
• 21:22
  SPEAKER_02: Where's the money gonna come from?
• 21:24
  SPEAKER_02: And by the end of 2014, Governor Schumlin had to publicly throw in the towel and say, we have run the numbers, we've talked to D.C., we have things that happened.
• 21:36
  SPEAKER_02: So, for example, um, they found that their uh their their um the actual amount that people were paying was about, on average, in for their insurance, 65 percent of actuarial value was what was being paid, which is how much you pay in premiums versus the cost sharing.
• 21:58
  SPEAKER_02: So a ton of cost of the Cost sharing even back then, about more than 10 years ago.
• 22:04
  SPEAKER_02: And so they had to then incorporate into their design, bringing everybody in the state up to a 95% actuarial value level.
• 22:14
  SPEAKER_02: And that with other things, including having to cover people from out of state.
• 22:19
  SPEAKER_02: And the numbers just could not work.
• 22:21
  SPEAKER_02: And they were looking at a financial catastrophe.
• 22:24
  SPEAKER_02: And Shumlin, much to his chagrin, embarrassment, and regret, had to say, listen, we gave it the full try.
• 22:32
  SPEAKER_02: We went the absolute length that we could, and we couldn't make the numbers work.
• 22:37
  SPEAKER_02: And so that again is an important lesson.
• 22:40
  SPEAKER_02: We looked at Vermont, we said, hey, it's a tiny little state.
• 22:44
  SPEAKER_02: If there's a state to use as a laboratory, it doesn't have greatly porous borders, but boy, they were a lot more porous than they realized at the time.
• 22:52
  SPEAKER_02: And they couldn't make it work.
• 22:54
  SPEAKER_02: So you add to California, Oregon, and Colorado, Vermont as well, and you have four states that really went at it and tried to do it and ultimately couldn't make it work.
• 23:06
  SPEAKER_00: So four lovely states.
• 23:22
  SPEAKER_00: And they are high salary countries in general, at least Switzerland is, but they still manage to get to universal coverage and lower a lot lower cost than we have here.
• 23:31
  SPEAKER_00: What can we learn from what's happening in those places now?
• 23:36
  SPEAKER_02: So that is one of the real anomalies.
• 23:39
  SPEAKER_02: We spend by far the most.
• 23:41
  SPEAKER_02: We spend about half more as much more than the average advanced country in terms of our total health care spend.
• 23:50
  SPEAKER_02: So we are way up number one.
• 23:52
  SPEAKER_02: Nobody's even close to us.
• 23:54
  SPEAKER_02: Switzerland is probably the closest.
• 23:57
  SPEAKER_02: And looking at that, and then looking at every one of those other countries we measure ourselves against, we right now cover about 92% of Americans with health insurance, one way or another.
• 24:10
  SPEAKER_02: All of those other nations, all of them are at either 99 to 100 percent coverage.
• 24:16
  SPEAKER_02: And it doesn't matter whether they are single payer, unitary government payment, or whether they are like Netherlands, like Germany, like Switzerland, multipayers that involve the private sector.
• 24:29
  SPEAKER_02: They've just set up their structure so that everybody's in and nobody's left outside.
• 24:36
  SPEAKER_02: And that is such an important lesson in terms of trying to make a system work.
• 24:41
  SPEAKER_02: We got in the ACA, we got coverage.
• 24:44
  SPEAKER_02: Uninsurance dropped from about 16%.
• 24:48
  SPEAKER_02: We got it down to about 7.5% under Biden.
• 24:52
  SPEAKER_02: And now under Trump it's going back up again.
• 24:55
  SPEAKER_02: We don't know how much, but it's going to be bad when we see the numbers.
• 24:58
  SPEAKER_00: I know the book uh you know doesn't come up right up to the present moment, and things change fairly quickly.
• 25:05
  SPEAKER_00: Can you say a word or two about the second Trump term and Medicaid work requirements, big, beautiful bill, and how how that fits into your overall arc?
• 25:19
  SPEAKER_02: Aaron Powell So you may recall Trump 1 came in in 2017 with its ultimate top-level objective of completely repealing the Affordable Care Act and replacing it with something that Republicans were never able to flesh out and meaningfully identify, and they lost it, and they ended up getting very little done on health policy in that first term.
• 25:46
  SPEAKER_02: So you may recall in the campaign in 2024, President Trump repeatedly said, I'm not gonna touch Medicare, I'm not gonna touch Medicaid, I'm not gonna touch the ACA.
• 25:56
  SPEAKER_02: Well, he's touching all three, particularly Medicaid and the Affordable Care Act exchanges in ways that are gonna be driving up on insurance by millions of people, and we'll see those numbers over the next two years, how bad it's gonna get.
• 26:13
  SPEAKER_02: So that's a major step backwards.
• 26:17
  SPEAKER_02: And so it appears that the Trump administration has understood that they can't go after the ACA as a total repeal effort, but they can go at it and undermine it in ways that will significantly weaken it.
• 26:34
  SPEAKER_02: So refusing to extend the enhanced subsidies that were implemented under the Biden administration that really made the exchange coverage a major success in terms of people coming in.
• 26:49
  SPEAKER_02: Imposing work requirements on Medicaid programs for the 40 states that have expanded coverage in a way that will not punish people not for working, but will punish people because of the bureaucratic paperwork requirements that people will not be able to navigate.
• 27:08
  SPEAKER_02: And that's not an accident.
• 27:10
  SPEAKER_02: That is by design.
• 27:12
  SPEAKER_02: We know that's what happened.
• 27:13
  SPEAKER_02: We saw it happen in Arkansas when they tried it in 2018.
• 27:17
  SPEAKER_02: So there's a lot of damage coming.
• 27:19
  SPEAKER_02: There's been immense damage done to the research and innovation discovery pipeline.
• 27:27
  SPEAKER_02: Uh, the medical uh uh research and innovation has been deeply injured in terms of what's been done to the National Institutes of Health, to the uh CDC, and to other parts of this system.
• 27:42
  SPEAKER_02: I we see it here at the uh at the Harvard Chan School and across Harvard University, but it's going on all over the country, and it's just tragic.
• 27:52
  SPEAKER_01: So, John, putting back your policy in political hats equally, you're now responsible for the health care part of Project 2030 for the Democrats.
• 28:04
  SPEAKER_01: What are the top two things that the Democrats should be advocating for in the current environment where too few people are getting the care they need and too many people are paying too much?
• 28:16
  SPEAKER_02: So I think just for a slight correction, Project 2029.
• 28:22
  SPEAKER_02: 2029, yes, after the 28 elections.
• 28:25
  SPEAKER_02: So there's going to be an immense amount of repair work to be done for what has been lost with the elimination of USAID, for example, and the on the global health, the infectious disease front, rebuilding the Centers for Disease Control and Prevention.
• 28:43
  SPEAKER_02: But I think that most people who are working on this, and by the way, there are a lot of people right now thinking about where are we going to go in the future when the Trump administration heads off into the sunset?
• 28:56
  SPEAKER_02: And the belief is it's not about going backwards, it's about creating a different future where there's a little bit of a starting over.
• 29:07
  SPEAKER_02: What do we need in terms of the Medicaid program?
• 29:11
  SPEAKER_02: And what do we need in terms of Medicare, ACA coverage, but also, you know, some of the most extreme cost problems right now come from the world of employer-sponsored insurance, um, from the coverage that's offered through people's workplaces.
• 29:28
  SPEAKER_02: When people look at it and Medicare is at 100%, a lot of the coverage provided by employers, their hospital bills come to be two and three times as high as what Medicare pays.
• 29:44
  SPEAKER_02: Medicaid is even less than that.
• 29:46
  SPEAKER_02: And that is a serious catastrophic problem in terms of the future of employer-sponsored health insurance.
• 29:56
  SPEAKER_02: And so there's got to be some holistic thinking.
• 30:00
  SPEAKER_02: To me, the original sin to talk in Roman Catholic terms, sorry about that, but the original sin of the U.S.
• 30:08
  SPEAKER_02: healthcare system is its fragmentation.
• 30:11
  SPEAKER_02: How we created employer-based coverage and then individual coverage and then Medicare and Medicaid and Indian Health Service and Veterans Care and so many different varieties within each, so that system-wide solutions are so much more difficult than in any other advanced nation where even if you have a multipayer system like in Germany or Netherlands or Switzerland, they all operate under the same set of rules.
• 30:45
  SPEAKER_02: And so you're able to turn the knobs up and down to affect the whole population and then not create this cost shifting by, you know, employer coverage is getting squeezed.
• 30:57
  SPEAKER_01: Ultimately, the policymakers have had it figured out for a while, but the politics, to your point, is crap in terms of really breaking through.
• 31:05
  SPEAKER_01: People want more, don't want to pay for it, they're getting less and paying too much for it.
• 31:11
  SPEAKER_01: What are the best ideas?
• 31:12
  SPEAKER_01: I mean, you you've been in the midst of some of the most interesting conversations on those trade-offs.
• 31:18
  SPEAKER_01: And we've got to come up with something that's gonna break through to the public.
• 31:22
  SPEAKER_02: Yeah.
• 31:22
  SPEAKER_02: So there's a lot of interesting ideas.
• 31:24
  SPEAKER_02: There's a lot of discussion about the public option, bringing that in, putting that into the marketplace, opening it up to employers.
• 31:33
  SPEAKER_02: There's a lot of conversation, interesting conversation on both sides about this innovation that actually came out of the Trump administration, started with Obama, but Trump put it forward called ICRA, a terrible acronym, individual coverage, health reimbursement arrangements, just an awful name.
• 31:53
  SPEAKER_02: Um, but it is a way to provide an escape valve for employers who are just fed up with their inability to negotiate effectively with insurance companies and the other intermediaries.
• 32:10
  SPEAKER_02: So that's an interesting piece.
• 32:12
  SPEAKER_02: Um there's talk of a different model in terms of the Medicare program.
• 32:19
  SPEAKER_02: How do we deal with the reality that Medicare Advantage, which was created going back to the 70s because it was supposed to be more affordable and provide better care, now costs substantially more than traditional Medicare fee for service, even though it's capitated, which I was brought up to believe would be the salvation of everything.
• 32:42
  SPEAKER_02: And now we see the capitation.
• 32:46
  SPEAKER_02: Let's keep the language clean.
• 32:48
  SPEAKER_02: Sorry about that.
• 32:49
  SPEAKER_00: Yeah.
• 32:49
  SPEAKER_00: Very good.
• 32:50
  SPEAKER_00: Well, I think we're gonna have to cut it off there and have you back again, uh, John, once we uh once think maybe after the midterms.
• 32:57
  SPEAKER_00: Uh what I'll say is now that's it for another episode of CareTalk.
• 33:00
  SPEAKER_00: Our guest today has been John McDonough.
• 33:02
  SPEAKER_00: He's professor of practice at the Harvard T.H.
• 33:04
  SPEAKER_00: Chan School of Public Health.
• 33:06
  SPEAKER_00: He's author of America's Wrong Turn, U.S.
• 33:09
  SPEAKER_00: Healthcare in the Neoliberal Era.
• 33:11
  SPEAKER_00: I'm David Williams, president of Health Business Group.
• 33:14
  SPEAKER_01: And I'm John Driscoll, the chairman of the UConn Health System.
• 33:17
  SPEAKER_01: If you like what you heard or you didn't, we'd love you to subscribe on your favorite service.
• 33:20
  SPEAKER_01: And John, thank you so much for this thought-provoking discussion.
• 33:24
  SPEAKER_01: Pleasure to be with you.
• 33:24
  SPEAKER_01: Thank you for the opportunity.