Latest / Yaron Brook Show / Conversation with Jared Rhoads, Reinier Schuur, Colleen Smith - Health Care in US | Yaron Brook Show

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Conversation with Jared Rhoads, Reinier Schuur, Colleen Smith - Health Care in US | Yaron Brook Show · Yaron Brook Show

0:02
Speaker 1: A lot of fundamental principles of edom while self.
0:08
Speaker 2: Interest and an individual watch.
0:14
Speaker 1: This is the show, all right, everybody welcome tore one
0:21
Speaker 1: book show on this Monday, January nineteenth. It stopped there
0:26
Speaker 1: in the middle. Music didn't go all the way through.
0:28
Speaker 1: All right anyway, Uh, welcome. We have a real treat today.
0:34
Speaker 1: We've got three experts in the field of healthcare that
0:38
Speaker 1: we're gonna be talking to about American healthcare system. I'm
0:44
Speaker 1: gonna I'm gonna pass it on to Ray, who I
0:46
Speaker 1: think right those of your regular watches are no way
0:51
Speaker 1: because he's been on the show before. I's gonna explain
0:54
Speaker 1: a little bit about Ray was the executive director of AFKHAM.
0:59
Speaker 1: But this means some changes, and so he's going to
1:02
Speaker 1: fill us in on those changes and then and then
1:06
Speaker 1: we're going to get into the real healthcare discussion. Go ahead.
1:09
Speaker 1: We thanks Ron.
1:10
Speaker 3: We're very excited to be here. As some of your
1:13
Speaker 3: audience members might remember, a few years ago, I organized
1:17
Speaker 3: the conference on health policy called Desocializing American Medicine. Amish
1:25
Speaker 3: came on your show with Greg to help promote it.
1:28
Speaker 3: I recommend that your listeners go to the Salem Center
1:33
Speaker 3: for Public policy website to check it out. We still
1:35
Speaker 3: have those talks on the Americans for Free Choice Medicine
1:39
Speaker 3: website are great talks. But it was under that context
1:43
Speaker 3: that I got to know Colleen and Jared. We knew
1:47
Speaker 3: each other before, we were on an email list together.
1:51
Speaker 3: That's the first time I got to actually know them.
1:53
Speaker 3: Jared Rhodes teaches health policy at Dartmouth. Colleen Smith is
1:59
Speaker 3: an emergency doctor in New York City. And it was
2:02
Speaker 3: a great conference. But after the conference we all kind
2:05
Speaker 3: of went our separate ways. Colin went back to full
2:09
Speaker 3: time medical practice. Jared at that point did start the
2:15
Speaker 3: Center for Modern Health, and we'll get more to that later,
2:19
Speaker 3: but at that point, Jared's vision for that was more
2:22
Speaker 3: of a for profit program to help train people in
2:27
Speaker 3: health policy, which I was super excited about. I was
2:30
Speaker 3: looking forward to benefiting from that myself, and and of
2:34
Speaker 3: course I first was in the process of finishing my
2:40
Speaker 3: PhD and taking over Americas for Free Choice in Medicine,
2:44
Speaker 3: and that, of course was very exciting. But I got
2:47
Speaker 3: to tell you, it's very hard running a think tank.
2:50
Speaker 3: And it's one thing. Yeah, and it's one thing to
2:55
Speaker 3: run it, but it's it's another thing to actually make
2:57
Speaker 3: an impact and make it grow. And of course I
3:01
Speaker 3: was getting all sorts of support. I was getting training
3:05
Speaker 3: from Aari Casper, Sofarlu was helping me out of my work.
3:12
Speaker 3: The board of AFCAM was helping me run the organization.
3:14
Speaker 3: But at the end of the day, I was the
3:16
Speaker 3: main person producing its content. And it is a pretty lonely,
3:23
Speaker 3: pretty difficult thing to have an impact on health policy
3:26
Speaker 3: as a kind of one person think tag, if there's
3:29
Speaker 3: only one person really creating the content. So I knew
3:32
Speaker 3: early on that to really have an impact, I would
3:37
Speaker 3: need to grow some kind of team around me that
3:42
Speaker 3: would help me, make me be more productive, and I
3:45
Speaker 3: can help them be more productive, because essentially we need
3:48
Speaker 3: more people writing and health policy. It's also a volume
3:52
Speaker 3: question of having an impact, and so I always had
3:57
Speaker 3: that in mind. And then at some point, miss and
4:00
Speaker 3: I came onto your show almost exactly a year ago
4:06
Speaker 3: from now to promote Americas for Free Choice in medicine.
4:10
Speaker 3: What we were planning to do, and probably the best
4:12
Speaker 3: thing to come out of that show is that it
4:16
Speaker 3: somehow reached Colleen at that point reached back out to
4:21
Speaker 3: me and told me, Hey, Ray, I'd like to write
4:25
Speaker 3: on health policy and speak out on health policy. And
4:29
Speaker 3: I was like, great, let's work together. And from there,
4:33
Speaker 3: like I mean, we were exchanging drafts and we launched
4:36
Speaker 3: our podcasts. I probably learned more from that period than
4:45
Speaker 3: the two years before in terms of just back and
4:48
Speaker 3: forth preparing for podcasts, going through drafts. It was a
4:53
Speaker 3: real learning moment for me, and I could really see
4:55
Speaker 3: the potential that if we just grow as things and
5:01
Speaker 3: we'll be able to kind of reach the volume that
5:03
Speaker 3: we need in terms of producing content and then also
5:07
Speaker 3: just obviously raising enough money to make it worth our
5:13
Speaker 3: while to actually make a living out of this. And
5:17
Speaker 3: around that time, I actually reached back out to Jared
5:20
Speaker 3: because I wanted to have him on for our podcast,
5:24
Speaker 3: and Jarrett at that point was starting to shift the
5:28
Speaker 3: Center for Modern Health into more of a nonprofit think
5:34
Speaker 3: tank model as well, and so we've we had Jared
5:37
Speaker 3: on for a few episodes and those were great, Like
5:41
Speaker 3: our leadership went way up, still way too little from
5:44
Speaker 3: what our ambitions were, but it was a proof of
5:45
Speaker 3: concept that, like, we're a great team. And at some
5:50
Speaker 3: point we just started asking ourselves, well, why have two
5:55
Speaker 3: separate think tanks, Like why not just work together. And
6:00
Speaker 3: from there it became pretty obvious to me that it
6:02
Speaker 3: made more sense for Colleen and I to join Jared's
6:06
Speaker 3: think tank. The board for Americas for Free Choice and Medicine.
6:12
Speaker 3: They're either in retirement or nearing retirements, and Jared had
6:17
Speaker 3: already set up his own board with new board members,
6:20
Speaker 3: So rather than having two separate organizations, we just knew
6:23
Speaker 3: that it made sense for us to join Jared's organization.
6:27
Speaker 3: Now what that does mean is that Americas for Free
6:30
Speaker 3: Choice in Medicine will be closing. But the way that
6:33
Speaker 3: I see it is that what Colleen and I have
6:36
Speaker 3: managed to build over the year with Jared's help at
6:39
Speaker 3: Afkhaan like our our podcast will continue under the Center
6:45
Speaker 3: for Modern Health, and we're just brimming with ideas and
6:50
Speaker 3: and and it's we have a lot of work ahead
6:55
Speaker 3: of us, and I'm just really excited about that.
6:58
Speaker 1: Good should you maybe take it? Tell us a little
7:01
Speaker 1: bit about Center of Modern Health? What inspired you to
7:05
Speaker 1: start it and and what are you guys doing at
7:08
Speaker 1: this point? What are the plans?
7:10
Speaker 4: Yeah, sure, so you know we are we're health policy
7:14
Speaker 4: thing tank, and I think one of the things that
7:17
Speaker 4: you know sets us apart a little bit is that
7:19
Speaker 4: even just the starting point is sort of health focused. Uh,
7:23
Speaker 4: I mean that sounds maybe silly to say, but but
7:27
Speaker 4: it's it's really it's about a new vision of health
7:29
Speaker 4: really as this thing that people positively pursue. I mean
7:34
Speaker 4: that is a you know that what other kind of
7:37
Speaker 4: value pursuit really you know, can rank much higher than that, right,
7:40
Speaker 4: And so from from that kind of starting point viewing
7:43
Speaker 4: health as this important thing that people ought to be pursuing,
7:47
Speaker 4: people who are involved in the production of it, So
7:49
Speaker 4: all the professionals, all the business people, all the clinicians,
7:52
Speaker 4: et cetera, they should be you know, thinking about this
7:55
Speaker 4: as a as a positive pursuit as well. And all
7:57
Speaker 4: that kind of stands in contrast to maybe an idea
8:00
Speaker 4: of health being something that is given to you or
8:03
Speaker 4: done to you, or like something that you're just kind
8:05
Speaker 4: of born with or something like that. And so that
8:08
Speaker 4: that's kind of like a starting point of that of
8:12
Speaker 4: that vision. Where we go from there, of course, is
8:15
Speaker 4: like asking the question, well, what is what kind of
8:18
Speaker 4: social system is going to you know, allow people to
8:21
Speaker 4: positively pursue their health as they see fit in their context,
8:25
Speaker 4: and according to what's important to them and and what
8:28
Speaker 4: is you know, according to their own maybe constraints even
8:30
Speaker 4: as well. And that's of course leads us to you know,
8:34
Speaker 4: freedom being the thing that makes that happen to to
8:37
Speaker 4: really bring him around a kind of way to thrive
8:41
Speaker 4: freedom free markets as well. And so I think and
8:45
Speaker 4: I think that is kind of interesting because you know,
8:48
Speaker 4: it's it's not that we're we're we're approaching this from
8:51
Speaker 4: the idea straight off that oh, you know, everybody everybody's
8:55
Speaker 4: frustrated with government, where everybody's frusture with healthcare, government is
8:59
Speaker 4: the problem. Therefore, let's just launch in with you know,
9:02
Speaker 4: here's a bunch of free market ideas. You know, I mean,
9:05
Speaker 4: I mean, there's a there's a sense in which that's
9:06
Speaker 4: all true, but it's it's kind of nice to have
9:10
Speaker 4: a more like health kind of focused vision from from
9:14
Speaker 4: the get go. I'll say more two about just kind
9:19
Speaker 4: of how this plays out when you when you talk
9:21
Speaker 4: to people.
9:22
Speaker 2: You know, when you when you when you.
9:24
Speaker 4: Have conversations about people, it does change the conversation because
9:27
Speaker 4: you can say, like to people, you know, what what
9:30
Speaker 4: kind of vision do you have for health? What what
9:33
Speaker 4: kind of approach do you would you want for your
9:37
Speaker 4: own health and for you know, for for the healthier family,
9:39
Speaker 4: et cetera, and your loved ones, and and then you
9:43
Speaker 4: can ask them like, well, what, uh, you know, you know,
9:45
Speaker 4: do you would you would you want a system in
9:48
Speaker 4: which you can pursue your health as you see fit
9:52
Speaker 4: and you know, and and and be free to do
9:53
Speaker 4: this and try that, et cetera.
9:56
Speaker 2: And you can kind of.
9:56
Speaker 4: Get people along that that way first, you know, before
10:00
Speaker 4: you even bring in something like free markets, which you
10:02
Speaker 4: know can be like a turn off first depending on
10:05
Speaker 4: who you're talking to. And so it's it's it's kind
10:08
Speaker 4: of a way of kind of connecting with people, even
10:11
Speaker 4: getting people to think about themselves.
10:14
Speaker 2: Which which I think is a you know, a.
10:16
Speaker 4: Kind of a key strategy about that, right and obviously
10:19
Speaker 4: a good fit for this show, right, you know, think
10:21
Speaker 4: think about get them to think about themselves and their
10:23
Speaker 4: own values and their own family first, and then you know,
10:26
Speaker 4: later on if if if the conversation goes as it
10:29
Speaker 4: often does, you know, to like, well what about the poor,
10:31
Speaker 4: what about the what about my uncle's neighbor who had
10:34
Speaker 4: this rare condition? And you know, we can treat those
10:36
Speaker 4: as edge cases. And you know, we can find ways
10:40
Speaker 4: to to get there. But but let's let's start with
10:43
Speaker 4: the sort of main point and the what's the what
10:46
Speaker 4: what's the experience of the most people? And and and
10:50
Speaker 4: and and what's that vision of like freedom first and all?
10:53
Speaker 4: And then we you know, we we work towards the
10:56
Speaker 4: kinds of ideas that you know how this plays out
10:59
Speaker 4: in Paul see Sure.
11:01
Speaker 1: So Colleen, you're an emergency medicine physician, which, as now
11:06
Speaker 1: that I've watched Pitch, I have a huge the pit
11:09
Speaker 1: the show. I have a huge admiration ful. My dad
11:12
Speaker 1: was a doctors. I've been around doctors all my life,
11:14
Speaker 1: but that show kind of conquatizes the intensity of it
11:18
Speaker 1: in a way that I haven't seen before. So that
11:23
Speaker 1: seems like more than a full time job. What made
11:27
Speaker 1: you decide to get involved in the policy side, and
11:31
Speaker 1: how do you see your role in kind of the
11:36
Speaker 1: this this new think tank, well this existing thing tank,
11:39
Speaker 1: expanding thing tank.
11:41
Speaker 5: Yeah, I mean so I think if you start kind
11:43
Speaker 5: of with what Jared said, a lot of that comes
11:45
Speaker 5: from the perspective of the consumer or the patient, right,
11:48
Speaker 5: how do you want your healthcare to be? But but
11:51
Speaker 5: doctors also right now, and nurses and other healthcare providers
11:55
Speaker 5: are in this place where we also none of us
11:59
Speaker 5: are happy with the way that healthcare is being provided.
12:01
Speaker 5: We're not happy with our role in it. We're not
12:03
Speaker 5: happy with the way that we feel like we're quote
12:05
Speaker 5: unquote treated. We're not happy with our inability to have
12:10
Speaker 5: the freedom to create the kind of health the kind
12:14
Speaker 5: of patient doctor experience that we would like to be
12:17
Speaker 5: having with the people that we take care of, and
12:20
Speaker 5: we're really not free to do it to create that.
12:23
Speaker 5: And so, you know, I think one major impetus for
12:29
Speaker 5: me to join Ray and Jared in this is that
12:32
Speaker 5: we also need to be talking about what does freedom
12:35
Speaker 5: look like on the consumer side as well, what does
12:38
Speaker 5: freedom look like to trade to create new versions of healthcare,
12:42
Speaker 5: new versions of ways to pay for health care. And
12:47
Speaker 5: I so, so that's one major reason why I'm involved
12:50
Speaker 5: in it. The other big reason, though, is, you know,
12:53
Speaker 5: I'm in New York City, which is pretty overwhelmingly liberal,
12:58
Speaker 5: kind of left leaning liberal, and I have for years
13:06
Speaker 5: fought back against the assumption that everyone around me, makes,
13:10
Speaker 5: all of my colleagues make that everyone thinks we should
13:13
Speaker 5: just be single pair like a single pair system, or
13:17
Speaker 5: everyone thinks we should just you know, pay for everything.
13:20
Speaker 1: Or.
13:22
Speaker 5: With just saying yeah, I don't agree with that, or
13:24
Speaker 5: refusing to sign the petition. But I'm starting to realize
13:28
Speaker 5: because I'm also a teacher, I have a lot of
13:30
Speaker 5: residents who I teach. I work at a couple of
13:36
Speaker 5: a couple of the hospitals I work at are mostly
13:38
Speaker 5: resident run hospitals, and the residents are drawn to the
13:42
Speaker 5: to New York City because it's a place where medicine
13:45
Speaker 5: is difficult, and so they learn to be really good
13:49
Speaker 5: doctors like the doctors on the pit. But also they're
13:53
Speaker 5: coming from all walks of life and all backgrounds, and
13:56
Speaker 5: they come to New York City and they feel like
13:58
Speaker 5: they can't speak out about what their values and ideas are.
14:03
Speaker 5: And so there's a sense in which I felt that
14:07
Speaker 5: I need to, for me, wrestle with many of these
14:12
Speaker 5: ideas and and be better at saying what I think
14:16
Speaker 5: and why I think it, and why I believe it
14:18
Speaker 5: and where it comes from. And also, as kind of
14:22
Speaker 5: a corollary of that, help make it acceptable for residents
14:26
Speaker 5: and learners and other doctors to feel that they can
14:28
Speaker 5: speak out and say this is not the way that
14:32
Speaker 5: we want to just allow medicine to roll down the
14:34
Speaker 5: slippery slope into a single payer system.
14:38
Speaker 1: What's been the response from your students, so from your
14:42
Speaker 1: colleagues to some of the things you published.
14:45
Speaker 5: So I haven't I haven't, you know, gone all out
14:49
Speaker 5: and put it in everyone's face. But I have been
14:52
Speaker 5: found by some of them. I've started writing on substack,
14:58
Speaker 5: so it's been mixed. I've found that several of them
15:01
Speaker 5: have said, oh, I agree with this, and I've just
15:03
Speaker 5: been quiet about it. Maybe they don't agree all the way,
15:07
Speaker 5: but they at least agree a little bit. A lot
15:11
Speaker 5: of them are sort of a liber a little bit
15:14
Speaker 5: more libertarian, but there's some allieship there, so there's something
15:18
Speaker 5: to build on, I think, And you know, others have
15:23
Speaker 5: been surprised, but but they've come at me with the
15:26
Speaker 5: sort of things that that Jared mentioned before. Well, what
15:29
Speaker 5: do we do about the poor? What about all the
15:32
Speaker 5: immigrants in in in our you know, in our city,
15:36
Speaker 5: because we're in New York City, which has a lot
15:38
Speaker 5: of immigrants. What about emergencies. I've definitely had doctors say
15:43
Speaker 5: to me, I can't believe that an emergency medicine doctor
15:46
Speaker 5: is against is against a single payer system. What are
15:50
Speaker 5: you going to do when somebody shows up in the
15:52
Speaker 5: emergency department having a heart attack? Are you going to
15:55
Speaker 5: stop and say pay me first? And I think this
15:57
Speaker 5: is again this is sort of an edge case. I
16:00
Speaker 5: don't have the total answer to that. I think, obviously
16:04
Speaker 5: I'm not going to stop and say pay me first.
16:07
Speaker 5: But that also doesn't mean that we shouldn't have some
16:10
Speaker 5: sort of system set up where people expect to have
16:14
Speaker 5: to eventually pay that bill.
16:17
Speaker 1: Yeah, and I think hospitals have always had in a
16:21
Speaker 1: days of private medicine, you know, charity, charity, you know,
16:25
Speaker 1: funds to exactly cover with these kind of emergencies.
16:28
Speaker 5: Well, I think we suffer from a lack of creativity
16:31
Speaker 5: in a way because we have what we have, and
16:33
Speaker 5: people struggle to imagine anything different. So it's hard for
16:38
Speaker 5: them to imagine, Oh, if we didn't have the government
16:41
Speaker 5: paying for everything, we could have some other option. If
16:45
Speaker 5: we didn't have health and so called health insurance that
16:50
Speaker 5: pays for everything, we might be able to have a
16:54
Speaker 5: less expensive way to pay for other things if we
16:56
Speaker 5: you know it. Just I think there's this kind of
16:59
Speaker 5: strung to get past the idea that we could have
17:05
Speaker 5: mechanisms for paying for our health care that even I
17:08
Speaker 5: can't imagine.
17:09
Speaker 3: Now, so Jo tell us, oh, yes, like like because
17:16
Speaker 3: I wanted to tie in what Jared was explaining about
17:19
Speaker 3: the Center for Modern Health and and Colleen's own story.
17:23
Speaker 3: I think what that points to is that they're deeper.
17:27
Speaker 1: Uh.
17:28
Speaker 3: I mean, obviously philosophical views at play here, but there's
17:31
Speaker 3: also a certain kind of culture around medicine. Are kind
17:35
Speaker 3: of cultural expectations, doctor's view of themselves, the view of
17:40
Speaker 3: patients of themselves of what it would mean to actually
17:44
Speaker 3: have a free market in medicine, and this imagining then
17:48
Speaker 3: like well, like well, so like it's like burger king,
17:49
Speaker 3: you can just have it your ways, like no, Like
17:51
Speaker 3: it's a new kind of thing that we have to
17:54
Speaker 3: think of, and like that's what then also justifies and
17:58
Speaker 3: motivates the advocacy for free markets is making possible those
18:02
Speaker 3: new kinds of values. And in a case of I'm Colleen,
18:07
Speaker 3: I think her superpower here as a doctor is that
18:13
Speaker 3: she can show to other doctors what it means to
18:17
Speaker 3: accept that new kind of vision of yourself as a
18:19
Speaker 3: doctor where you don't have to feel conflicted that you
18:24
Speaker 3: want to heal people, but you want to make a
18:26
Speaker 3: good living out of it. And it's like not like
18:28
Speaker 3: these kind of like two souls that like you have
18:30
Speaker 3: that are competing with each other that you have to
18:32
Speaker 3: kind of like mesh together. Is that No, Like you
18:35
Speaker 3: should be rewarded for healing and saving people's lives and
18:40
Speaker 3: thinking about that in a monetary way isn't like some
18:43
Speaker 3: necessary evil. It's actually a way that that kind of
18:46
Speaker 3: mindset helps you be more innovative and and and do
18:49
Speaker 3: it in new and better ways. And that that's kind
18:53
Speaker 3: of like the vision that we're trying to sell with
18:55
Speaker 3: the Center of Modern Health, and that we think is
18:57
Speaker 3: also missing from like the health policy debate, including from
19:01
Speaker 3: people who advocate for free markets, right, like Jared said
19:06
Speaker 3: that very often it's motivated as kind of like, well,
19:09
Speaker 3: we need free markets because the government sucks, right, But like, no,
19:12
Speaker 3: we want free markets because we want a new kind
19:15
Speaker 3: of relationship between doctors and patients and a new kind
19:19
Speaker 3: of pursuit of health. And that's what freedom, Why we
19:22
Speaker 3: need freedom.
19:24
Speaker 1: So Jo tell us a little bit about what you
19:27
Speaker 1: foresee as kind of the programs that the did you
19:30
Speaker 1: guys will engage in in order to get this kind
19:33
Speaker 1: of these ideas out there into the into the culture,
19:36
Speaker 1: right absolutely.
19:37
Speaker 4: So the focus for the moment is we're doing a
19:40
Speaker 4: lot of writing. We're doing a lot of writing, putting
19:42
Speaker 4: out articles. We've got the podcasts that we're continuing. So
19:46
Speaker 4: the podcast that that race started with with a FCM
19:50
Speaker 4: is we'll be.
19:51
Speaker 2: Adding episodes to that.
19:55
Speaker 4: So generating the content, doing the thinking that kind of
19:57
Speaker 4: goes goes around shaping the view and and and figuring out.
20:01
Speaker 2: The optimal ways of expressing it.
20:04
Speaker 4: And you know, there's a little bit of trial and
20:06
Speaker 4: error and and and some some empirical you know, component
20:10
Speaker 4: to to figuring out what kind of message works for
20:12
Speaker 4: the right particular kinds of audiences.
20:14
Speaker 2: Right.
20:14
Speaker 4: I know, sometimes when I talk to doctors, I'm talking,
20:18
Speaker 4: you know, I'm trying to emphasize some things, and and
20:20
Speaker 4: and then with somebody who's in the industry it might
20:23
Speaker 4: be a slightly different conversation. So, you know, figuring out
20:26
Speaker 4: all of all of that is is kind of part
20:28
Speaker 4: of what we're what we're doing.
20:30
Speaker 2: But there's there are other programs and other things as well.
20:33
Speaker 4: There's last summer we had the first uh Summer Health
20:38
Speaker 4: Policy Fellows Program So we had a dozen students come
20:41
Speaker 4: up to Hanover, New Hampshire in person and for a week.
20:46
Speaker 4: And there's actually it actually actually was a program that lasted,
20:48
Speaker 4: you know, half the summer because there was like pre
20:50
Speaker 4: stuff and post stuff that was virtual. But for the
20:52
Speaker 4: week that we're here in person, you know, reading, sitting
20:56
Speaker 4: through and doing readings, close readings and discussions like roundtable
21:00
Speaker 4: uh you know, great book style uh kinds of discussions
21:03
Speaker 4: with uh with with with good articles that allow us
21:06
Speaker 4: to really dig in some pieces that you would know
21:09
Speaker 4: right uh you know medicine, the death of a profession Uh,
21:12
Speaker 4: you know that great piece. You know, things like that
21:15
Speaker 4: that that were part of the curriculum. We'll be doing
21:18
Speaker 4: that with with students again. I think that's really good.
21:22
Speaker 2: Medical students. Yeah, you know some of them.
21:24
Speaker 4: Are pre med. Yeah, absolutely, there's there's a couple. I
21:27
Speaker 4: think three of them are pre med. One of them
21:29
Speaker 4: is a current uh uh or was going into the
21:33
Speaker 4: Yale School of Public Health for his MPH program. And
21:36
Speaker 4: we had students from M I. T. And Brown and
21:38
Speaker 4: two from Yale, and I mean it was a great
21:40
Speaker 4: u a great set of students and we had a
21:45
Speaker 4: component to that program, the sort of capstone experience of
21:48
Speaker 4: that program was to was for them to pick a topic,
21:52
Speaker 4: a health policy topic, delve into it, meet with me
21:56
Speaker 4: a bunch of times, and send some draft an off
21:59
Speaker 4: ed basically, and and work through that and some of
22:02
Speaker 4: those we've published on on our website as well.
22:06
Speaker 2: That kind of thing. We would love to do that
22:08
Speaker 2: each year for the sort of you.
22:10
Speaker 4: Know that that college student or recent grad that that
22:13
Speaker 4: kind of uh, for that kind of opportunity. I could
22:17
Speaker 4: also see that very easily and and and profitably being
22:23
Speaker 4: duplicated for professionals like actual you know, working professionals in
22:27
Speaker 4: the medical field, and uh in aspect, you'll probably you
22:30
Speaker 4: probably shrink it down and you have maybe even have
22:33
Speaker 4: it more of like a tuition based kind of thing
22:34
Speaker 4: instead of a free thing that the that the students, uh,
22:38
Speaker 4: you know experience that's you know, fund foundation funded or something.
22:42
Speaker 4: You'd have one probably one model for that, but a
22:44
Speaker 4: different model for the for the ones with the professionals,
22:47
Speaker 4: but you know, getting them to to to kind of
22:49
Speaker 4: chew through some of these ideas and get exposure to
22:51
Speaker 4: some of these ideas and then also have a similar
22:53
Speaker 4: probably a similar kind of like writing component to that
22:56
Speaker 4: program as well. That is uh that that is something
23:00
Speaker 4: that could also be be really really effective. I think
23:04
Speaker 4: it to you know, to to raise point about needing
23:07
Speaker 4: more people. That's that's like two different, two slightly different
23:10
Speaker 4: ways of getting more uh more more people active in
23:14
Speaker 4: this not just building audiences of people who like to
23:17
Speaker 4: consume our you know, our articles and thoughts and and
23:20
Speaker 4: and podcasts, but also like getting more people kind of
23:23
Speaker 4: as part of this kind of community producing uh, these
23:27
Speaker 4: these thoughts. There's there's some as you know, there's so
23:30
Speaker 4: many issues and sub issues in policy. That's actually i
23:34
Speaker 4: think a part of a reason why like you do
23:37
Speaker 4: need a think tank for this and not just like
23:39
Speaker 4: like like an individual influencer, because you know, there are
23:42
Speaker 4: some there are some great uh you know, areas of opportunity,
23:47
Speaker 4: but it man, it's like a sub field of a
23:49
Speaker 4: sub field, and you know, it's great to have somebody
23:51
Speaker 4: doing some work in that because you can actually maybe
23:54
Speaker 4: get a state law changed, uh, you know, in a
23:56
Speaker 4: couple of weeks here on the on Wednesday, the twenty eighth,
23:59
Speaker 4: them I'm gonna be has to find the new New
24:01
Speaker 4: Hampshire State House on a on a bill that has
24:03
Speaker 4: to do with direct pay.
24:05
Speaker 2: You know, like like there are times when you have.
24:07
Speaker 4: To like dig in right at the ground level and
24:10
Speaker 4: do like the actual policy work. But then we're constantly
24:13
Speaker 4: trying to integrate this with the overall kind of higher
24:16
Speaker 4: level like philosophy that that that makes it all happen.
24:19
Speaker 4: But getting into the policy gives you the ideas, uh,
24:24
Speaker 4: and like the opportunity, it kind of helps you identify
24:28
Speaker 4: the some of the problems there and then you know
24:30
Speaker 4: the philosophy. Marrying the two is just a really effective
24:34
Speaker 4: way of you know, making some change.
24:37
Speaker 1: I think, So, what do you guys think is the
24:42
Speaker 1: some of the main issues that you know healthcare fasis
24:44
Speaker 1: today in the United States. Obviously, you know, Congress is
24:49
Speaker 1: dealing with the renewal of Obamacare and it looks like
24:53
Speaker 1: ultimately they'll probably knew it the subsidies for it, but
24:58
Speaker 1: they don't I mean, at least that the federal level,
25:00
Speaker 1: it doesn't see any any push for any dramatic reform.
25:04
Speaker 1: Are you guys seeing anything in terms of reform? And
25:07
Speaker 1: what do you think the main issues are that you
25:11
Speaker 1: know need to be reformed.
25:13
Speaker 3: Well before we get into like the specific policy issues,
25:17
Speaker 3: I just wanted to give it like a slightly wider perspective. So,
25:22
Speaker 3: I mean, there are people out there who are advocating
25:25
Speaker 3: for better ideas, right, And I feel like in this
25:28
Speaker 3: moment in American healthcare, people are open to new ideas
25:32
Speaker 3: just because of how miserable things are. And the way
25:37
Speaker 3: that I see it and the way that I think
25:40
Speaker 3: we all see it as a as a think tank,
25:42
Speaker 3: is that even the better people out there have kind
25:47
Speaker 3: of incomplete or an way that they're advocating for own
25:51
Speaker 3: ideas that are undermining.
25:53
Speaker 2: Right.
25:53
Speaker 3: So they'll be arguing for like, oh, we need hsas,
25:56
Speaker 3: we need this kind of reform, that kind of reform, Why, Well,
25:59
Speaker 3: because we want to take control away from corporations and
26:05
Speaker 3: give it to patients.
26:06
Speaker 2: Right.
26:07
Speaker 3: But at the end of the day, the problem with
26:10
Speaker 3: our relationship with corporations isn't that they have the power
26:14
Speaker 3: and we don't. The problem is that regulations warp our
26:18
Speaker 3: relationships with them. And what we need is a different
26:22
Speaker 3: kind of way of advocating for those kind of reforms
26:25
Speaker 3: that doesn't pit us against the people that were trying
26:27
Speaker 3: to trade with, right. And So that's just as like
26:31
Speaker 3: a kind of broader kind of perspective of how I
26:33
Speaker 3: see what we're trying to do and change them the conversation,
26:37
Speaker 3: and yeah, like within that, there are a lot of
26:40
Speaker 3: new opportunities for particular reforms. And of course right now
26:45
Speaker 3: the biggest thing in the headlines are the ACA subsidies,
26:53
Speaker 3: what are to extend them and what to replace them with?
26:55
Speaker 3: But that's just the tip of the iceberg. And there's
26:58
Speaker 3: all sorts of other structural issues that need to be fixed,
27:02
Speaker 3: but definitely the ACA and Trump's Great Healthcare Plan. So
27:06
Speaker 3: call this what's in the news now, Jared calling. Did
27:10
Speaker 3: you guys have any particular thoughts on that?
27:15
Speaker 5: Well, I mean, so Trump's Great Healthcare Plan, which is
27:17
Speaker 5: in the news now, is an outline on the White
27:20
Speaker 5: House dot gov website, but it's not there's no as
27:24
Speaker 5: far as I can find. And I actually, in preparation
27:27
Speaker 5: for this show, went on the House Legislation website and
27:33
Speaker 5: tried to look and see has anyone submitted any bill
27:36
Speaker 5: that could go along with this, because you can see
27:38
Speaker 5: the bills, you can see the text of the bills
27:39
Speaker 5: that are going into the next Congress, and there is
27:43
Speaker 5: one bill that's been submitted to try to change the
27:45
Speaker 5: nature of health savings accounts a little bit. But to me,
27:48
Speaker 5: that seems like it's called the Freedom Fund Bill or something.
27:52
Speaker 5: But to me, that seems separate from Trump's great healthcare plan.
27:56
Speaker 5: And there's nothing, no text of any actual legislation. All
28:00
Speaker 5: that exists so far is what Trump has put on
28:03
Speaker 5: his summary page or the you know, GOP has put
28:06
Speaker 5: on their summary page on the White House dot gov website.
28:09
Speaker 5: So it's a little bit hard to know what exactly
28:12
Speaker 5: he intends to do. However, he has said that instead
28:16
Speaker 5: of giving the subsidies directly to the health insurance companies
28:20
Speaker 5: that are in the marketplace, he will give the give
28:24
Speaker 5: people who would qualify for subsidies up to some certain
28:30
Speaker 5: certain level of what it's the sorry I'm blanking on
28:35
Speaker 5: the yeah, yeah, yeah, the federal poverty line, of the
28:41
Speaker 5: federal poverty line based on your household size. He has
28:45
Speaker 5: said he will give the money that would have gone
28:47
Speaker 5: to the insurance companies to the people. How he will
28:52
Speaker 5: give the money to the people, it's not clear how
28:54
Speaker 5: he will ensure that that money that's being given to
28:57
Speaker 5: the people goes to pay for health care. It's not clear. So,
29:04
Speaker 5: you know, it's it's a little bit hard to comment
29:06
Speaker 5: specifically on what he's going to do as far as
29:10
Speaker 5: that goes. You know, also, I do think that HSA
29:16
Speaker 5: should be rolled out, that we should make them bigger,
29:19
Speaker 5: there should be more of them. But there are some
29:20
Speaker 5: issues with HSA's as well. Uh, you know, I think
29:25
Speaker 5: I think HSA's really if you want to make hsas
29:29
Speaker 5: like really work, everyone should be able to open an HSA,
29:33
Speaker 5: regardless of what type of health insurance plan they have,
29:36
Speaker 5: because what we should really be doing is changing the
29:38
Speaker 5: culture to a culture where people think that it matters
29:41
Speaker 5: to say, for their health. So maybe you have to
29:47
Speaker 5: maybe you have to give them some sort of tax
29:50
Speaker 5: incentive to open an HSA to begin with, but everyone
29:53
Speaker 5: should be able to open an HSA. There should be
29:56
Speaker 5: no cap. People are going to not put all their
29:58
Speaker 5: money in an HSA, now I grant you that is
30:01
Speaker 5: going to That will probably result in some wealthier people
30:04
Speaker 5: using hsas as a place to put tax free money,
30:08
Speaker 5: because it's kind of this like triple whammy tax tax
30:11
Speaker 5: protecting thing where you get to put money in tax
30:14
Speaker 5: pre tax if you then can invest it, all the
30:18
Speaker 5: capital gains that you make on whatever you've invested is
30:21
Speaker 5: also tax free, and then after you're sixty five, or
30:24
Speaker 5: for any healthcare expense, you can take the money out
30:27
Speaker 5: without paying taxes on it. So that's like pretty awesome.
30:30
Speaker 5: But man, wouldn't it be nice if lower income families
30:33
Speaker 5: also were able to benefit from that sort of thing. Also,
30:37
Speaker 5: I think, I really think that if you let everyone
30:40
Speaker 5: have an HSA, they should be inheritable. And the reason
30:45
Speaker 5: is because again that will further encourage people to save
30:48
Speaker 5: and have accumulate generational wealth for their health care, and
30:54
Speaker 5: beyond that, it will encourage people to be more thoughtful
30:57
Speaker 5: about what they do with that money at the end
30:59
Speaker 5: of life, which is when you spend the most money
31:01
Speaker 5: on it. But you know, but I think, you know,
31:07
Speaker 5: even if you were to do all these things with
31:09
Speaker 5: HSA's the real issue with HSAS is you still have
31:17
Speaker 5: the producer side of healthcare is still not free to
31:22
Speaker 5: create new ways for you to spend that money.
31:27
Speaker 2: And to I don't say that.
31:29
Speaker 4: The thing about the HSAS, it's it's so it's kind
31:32
Speaker 4: of tangializing because it's it's like a great idea in
31:36
Speaker 4: so many ways, but it's also it's also constantly feel
31:41
Speaker 4: like I'm trying to manage expectations though too, because you know,
31:44
Speaker 4: changing the contribution limit let's say, for what is it
31:47
Speaker 4: of forty three hundred or forty four hundred right now,
31:49
Speaker 4: and you know, if you make that five thousand or
31:51
Speaker 4: six thousand, I think I've seen in one in one
31:54
Speaker 4: proposal to double it. You know, I'm not I'm not
31:58
Speaker 4: sure if you get a huge change. It's hard to
32:00
Speaker 4: it's kind of hard to know what the change will be.
32:03
Speaker 4: What we all hope would happen is that you like,
32:06
Speaker 4: you know, usher in this new like consumer age of
32:10
Speaker 4: people spending and then and then you get the effect
32:13
Speaker 4: of people posting their prices and like actually like advertising
32:18
Speaker 4: to to consumers and having you know, changing that relationship.
32:23
Speaker 4: But the thing but so this may be like a
32:26
Speaker 4: consumer side fixed in some sense, but you know, fiscally
32:29
Speaker 4: and in many senses. But but it doesn't it may
32:32
Speaker 4: or may not change that that produce. You know, what
32:35
Speaker 4: hospital is really going to kind of change the way
32:37
Speaker 4: they they they they price things right, A lot of
32:40
Speaker 4: I mean so many hospitals are are so used to
32:44
Speaker 4: you know, accepting the kind of like rate setting, which
32:48
Speaker 4: rates are different than prices actually because a rate that's
32:51
Speaker 4: set by medicare whether it's directly or like four steps
32:54
Speaker 4: down the line of some some chain. They just they
32:58
Speaker 4: sort of you know, inherit and go off that uh,
33:01
Speaker 4: that rate. That's not exactly an open market, you know,
33:05
Speaker 4: just determined a price. And so anyway, in this and
33:09
Speaker 4: then this this actually gets into some of the the
33:12
Speaker 4: the other components of the of the Great Healthcare Plan
33:16
Speaker 4: or Great Health Plan whatever it's called. You know, he
33:19
Speaker 4: talks about, uh, price transparency again a great idea in
33:25
Speaker 4: some sense, like the more we have prices, I mean,
33:29
Speaker 4: the better things would work. Except there's gonna be a
33:34
Speaker 4: difference between a price that a provider or or a
33:38
Speaker 4: hospital is forced to put on a website someplace. You know,
33:41
Speaker 4: you know, if if they don't really want to do that,
33:44
Speaker 4: it probably won't be that helpful. In fact, we've seen
33:46
Speaker 4: some of the price transparency laws not really had that
33:49
Speaker 4: much an effect for a while there.
33:50
Speaker 2: It's because they weren't even enforced.
33:52
Speaker 4: But you know, where we have had price transparency laws,
33:56
Speaker 4: the kind of compliance with that, if they're not really
33:59
Speaker 4: into it, it doesn't really change the behavior.
34:03
Speaker 1: This is just one price, right, I mean, because there's
34:08
Speaker 1: a price for mede can, there's a price for insurance
34:10
Speaker 1: and there's a price for you cash, and which price
34:14
Speaker 1: did they put up online? And did they put all three?
34:17
Speaker 1: You know, what exactly are they doing?
34:19
Speaker 4: It's very hard, it's very confusing, very hard. It's not
34:23
Speaker 4: going to be clear. The same way that like walking
34:25
Speaker 4: in and buying a gallon of milk is at your
34:28
Speaker 4: at your grocery store.
34:29
Speaker 5: They probably have to put the price that the any
34:33
Speaker 5: they probably pick a price. This is generally what they do.
34:36
Speaker 5: Now that price that you see when you get your bill,
34:39
Speaker 5: you know, you have a surgery and you get your
34:41
Speaker 5: bill and the bill says one hundred thousand dollars this
34:44
Speaker 5: is and then it comes back and it says insurance
34:47
Speaker 5: insurance adjustment. Now the bill is is ten thousand dollars
34:52
Speaker 5: and the insurance paid eighty thousand dollars or you know,
34:55
Speaker 5: eight thousand dollars and you owe two thousand dollars. Right,
34:58
Speaker 5: that's usually what happens. Well, that one hundred thousand dollars
35:01
Speaker 5: comes from. They have to pick any price that's above
35:04
Speaker 5: what that's above the price that's above the rate that
35:09
Speaker 5: the highest rate that they'll get from any insurance company
35:12
Speaker 5: that they I think I said that clearly that they
35:15
Speaker 5: contract with. So if any insurance company will pay has
35:19
Speaker 5: agreed to pay them twelve thousand dollars and they charge
35:24
Speaker 5: someone else ten thousand dollars, that other insurance company can say,
35:28
Speaker 5: oh no, no, you charge somebody ten thousand dollars, so
35:32
Speaker 5: we're only going to pay you ten thousand dollars. So
35:34
Speaker 5: all these rate transparency things, you're going to have listed
35:37
Speaker 5: the highest some rate that's some random number that's higher
35:43
Speaker 5: than the highest rate that they've contracted with any insurance
35:46
Speaker 5: company to get to pay. And so it's it's also
35:49
Speaker 5: why when you wait and your cash pay and you
35:52
Speaker 5: call later and say, hey, man, I can't pay this
35:54
Speaker 5: hundred thousand dollars, They're like, oh, oh, it's it's five
35:56
Speaker 5: thousand dollars, right, Where does that come from? Just comes
36:00
Speaker 5: from they're giving you a discount, but they can't charge
36:04
Speaker 5: you that discounted rate to begin with, because if they do,
36:06
Speaker 5: some insurance company will say, wait, wait, wait, you didn't
36:10
Speaker 5: we agreed. You're charging less than what we agreed to
36:12
Speaker 5: pay you, so we're not going to pay you what
36:14
Speaker 5: we agreed anymore.
36:16
Speaker 1: Yeah. I had so thy years ago, and I think
36:19
Speaker 1: the first bill was in excess of half a million
36:22
Speaker 1: dollars and it was like, okay, well I had insurance,
36:26
Speaker 1: so said, okay, the insurance company is going to pay this,
36:29
Speaker 1: and it came back. It was onund one hundred thousand
36:31
Speaker 1: in the end that they actually paid, but the billing
36:33
Speaker 1: was for over half a million dollars. It was just
36:36
Speaker 1: it was unbelievable.
36:38
Speaker 4: And that moment there of being like, like, you know,
36:41
Speaker 4: people are petrified of getting a bill like that for something, right,
36:44
Speaker 4: and like that.
36:45
Speaker 2: Changes your behavior.
36:47
Speaker 4: That changes your relationship to the kind of insurance that
36:50
Speaker 4: you may seek to buy. It sort of changes your
36:53
Speaker 4: behavior toward making this decision should I self insured? What
36:58
Speaker 4: really is a euphemism for uninsured? You know, maybe maybe
37:01
Speaker 4: there are times in your life when you're young and
37:03
Speaker 4: you're you're trying to do other things with your money
37:05
Speaker 4: that there might be some you know, if you're really healthy,
37:07
Speaker 4: there might be some some moments where you say, oh
37:09
Speaker 4: I should I should self insured? But how many people
37:11
Speaker 4: are going to do that for you know, a couple
37:13
Speaker 4: of years or something like that. If if there's always
37:16
Speaker 4: this possibility of this like kind of meaninglessly high price,
37:20
Speaker 4: that's it's because it wouldn't be it wouldn't be so
37:22
Speaker 4: high if it was a true market price with competition happening,
37:25
Speaker 4: et cetera.
37:26
Speaker 2: It's but these are these like symbolically high.
37:29
Speaker 4: You know, kind of arbitrarily high prices.
37:32
Speaker 1: And these are the prices that are used to attack
37:34
Speaker 1: the system. I mean, I try, I do a lot
37:37
Speaker 1: of talks in Europe. And then number one thing I
37:39
Speaker 1: get is, but you Americans, you you know, you all
37:43
Speaker 1: going bankrupt as individuals because you get million dollar bills
37:47
Speaker 1: for your your you know, your your treatment. We get
37:49
Speaker 1: it all for free. And uh it. But I mean
37:53
Speaker 1: the mythology that exists about the American healthcare system is
37:58
Speaker 1: u is quite It's interesting. So, I mean I've been
38:02
Speaker 1: hearing about hsas for over thirty years, about thirty years,
38:07
Speaker 1: right since the mid nineties, when it was I think
38:10
Speaker 1: FoST introduced after.
38:12
Speaker 4: John Goodman good, yeah, yeah, good John. I love his
38:15
Speaker 4: book Priceless. I taught it to the to the health
38:18
Speaker 4: policy fells in the in the summer.
38:20
Speaker 1: And that's when Alcam kind of came into being. Is
38:22
Speaker 1: around the mid nineties, after clinton Care failed, Hillary's plan failed,
38:29
Speaker 1: and so and and I haven't h I had an HSA.
38:32
Speaker 1: I have an HSA. They've been around forever. Why have
38:36
Speaker 1: they had really no impact?
38:42
Speaker 3: Jared, I think it worked like an article on this right.
38:44
Speaker 4: Well, yeah, so I wrote it as sort of what's
38:48
Speaker 4: the right I wouldn't maybe not tongue in cheek is
38:50
Speaker 4: not the right word.
38:50
Speaker 2: But it was a little bit of a critique.
38:52
Speaker 4: Of like hsas and fessays, so flexible standing accounts. What
38:57
Speaker 4: I was trying to kind of the one sort of
38:59
Speaker 4: subtle point in there, and I tried to indicate many
39:01
Speaker 4: places that look I like HSA's I've I've advocated for
39:05
Speaker 4: them in the past, I will continue to do that.
39:08
Speaker 2: But it's a little bit of a.
39:10
Speaker 4: Kind of like a hidden tyranny of this like that
39:13
Speaker 4: it sort of reveals how dysfunction of a system that
39:16
Speaker 4: we have that it doesn't have more of a beneficial effect,
39:20
Speaker 4: and it you know, there's I think it's it's sort
39:23
Speaker 4: of not unreasonable to have a little bit of resentment
39:26
Speaker 4: that we need this like this, this I don't know this,
39:29
Speaker 4: this this special account as like a tax shelter for
39:32
Speaker 4: something that should be kind of like a regular you know,
39:36
Speaker 4: consumer thing that you buy, right, and like imagine having
39:40
Speaker 4: a special tax shelter for to like I don't buy
39:43
Speaker 4: a car or something or a cell phone, like you know,
39:46
Speaker 4: because because somebody along the way has made up made
39:49
Speaker 4: the argument that it's like really essential or something.
39:51
Speaker 1: Anyway, it's I think, yeah, didn't the Big Beautiful Bill
39:55
Speaker 1: include tax addictability of call, loans of interest, and.
39:59
Speaker 5: Call the medical portion?
40:04
Speaker 1: Yeah, so yeah maybe maybe the cause maybe we'll get
40:07
Speaker 1: a call essay or something. Who knows.
40:11
Speaker 4: Yeah, I mean I think at core it the reason
40:13
Speaker 4: it's been sort of I don't know, a kind of
40:15
Speaker 4: a lackluster. Although I mean like it's it's great for
40:18
Speaker 4: you if you can use it as a savings vehicle, right,
40:21
Speaker 4: I mean, like it actually is great for any reason there,
40:24
Speaker 4: but it's kind of had a little bit of a
40:25
Speaker 4: lackluster effect because it doesn't really change the provider a hospital,
40:32
Speaker 4: the person that's setting the prices. They're they're not really
40:36
Speaker 4: responding to that because you're not you're not really becoming
40:39
Speaker 4: a shopper with with kind of that that amount at
40:43
Speaker 4: your disposal, and things are still mostly paid for through
40:47
Speaker 4: through insurance.
40:48
Speaker 2: Yeah.
40:49
Speaker 3: And I also think that the lack of success of
40:54
Speaker 3: hs AS to transform American healthcare is reflective of kind
40:58
Speaker 3: of a filled approach to applying free market principles to
41:03
Speaker 3: healthcare in general, where you have a policy idea but
41:07
Speaker 3: without the kind of cultural like force behind it, like
41:10
Speaker 3: let us shop or like let us like be sellers. Right,
41:13
Speaker 3: it's just like this is a application of free market
41:19
Speaker 3: principles so that we can make the current system as
41:22
Speaker 3: it exists a little bit more efficient. Right, But we
41:25
Speaker 3: don't want efficiency, like we actually want to like control
41:27
Speaker 3: our own healthcare dollars and make our own decisions. And
41:29
Speaker 3: that requires so much more than HSAS and and even
41:34
Speaker 3: like legalizing catastrophic health insurance, you need to essentially legalize
41:40
Speaker 3: innovation in the financing of healthcare.
41:42
Speaker 1: So what would need So what structural change would be
41:45
Speaker 1: required to change that attitude to get us on a
41:50
Speaker 1: kind of a path towards ultimately long term of free
41:53
Speaker 1: market system. I mean, eahsays haven't really worked to move
41:56
Speaker 1: us in that direction. What kind of structural change would
42:00
Speaker 1: would help in that respect?
42:01
Speaker 3: Well, I think first you'd have to like diagnose the
42:05
Speaker 3: unique structural problem of American healthcare, which, unlike the way
42:10
Speaker 3: that healthcare is socialized in say Europe, for example, the
42:16
Speaker 3: distinction between public and private healthcare in America is less
42:22
Speaker 3: clear than in Europe, right, and so like, if you
42:24
Speaker 3: actually want to expand the free market from a purely
42:27
Speaker 3: structural perspective, you'd be better off doing that in Europe, right,
42:31
Speaker 3: because you actually have a private sector, even though it's
42:33
Speaker 3: small and so like, it might not be enough demand
42:38
Speaker 3: for it, and because a public sector is so big,
42:41
Speaker 3: but you could actually expand that. It's very hard to
42:43
Speaker 3: expand the private healthcare system in America because of all
42:47
Speaker 3: the ways in which the public system is intertwined with it.
42:50
Speaker 3: And there's all sorts of ways in which, for example,
42:55
Speaker 3: doctors in the UK are more free to operate across
43:00
Speaker 3: the public private divide than in America. Right, So American
43:06
Speaker 3: doctors are less free to operate in both the public
43:09
Speaker 3: and the private sector. So the unique kind of ill
43:14
Speaker 3: of the way that American healthcare social life is the
43:16
Speaker 3: ways in which the public and private sectors bleed into
43:19
Speaker 3: one another. And what you really need to do to
43:22
Speaker 3: have real change is start to separate the work cleanly.
43:26
Speaker 5: So a concrete example of that, I think your own you.
43:29
Speaker 5: I listened to your talk from a while ago on healthcare,
43:33
Speaker 5: and you've talked about how your dad was a doctor
43:35
Speaker 5: in Israel, and he worked for the public system during
43:38
Speaker 5: the day, and then in the evening to actually make money,
43:41
Speaker 5: he had a private practice and you would see more patients.
43:44
Speaker 5: Doctors in the US cannot do that. If I want
43:49
Speaker 5: to have a truly purely cash pay practice, I have
43:54
Speaker 5: to opt out of Medicare and Medicaid, which means I
43:57
Speaker 5: can't work in the hospital and see Medicare and Medicaid patients.
44:03
Speaker 5: If I do, then it so. And even if I,
44:09
Speaker 5: like say, I have this separate private practice and I
44:11
Speaker 5: have all my patients signed like I promise not to
44:14
Speaker 5: bill Medicare or Medicaid, like I'm just paying you cash.
44:18
Speaker 5: I know all this stuff. If there's ever a mistake,
44:21
Speaker 5: if say one of them just lies to me because
44:23
Speaker 5: they really want to see me and they know I
44:25
Speaker 5: won't be able to take care of them if they're
44:27
Speaker 5: on Medicare and Medicaid. As a doctor, I can be
44:31
Speaker 5: charged with Medicare and Medicaid fraud, be be forced to
44:36
Speaker 5: pay thousands, tens of thousands of dollars in fines, or
44:39
Speaker 5: face losing my license. So I wrote something about this
44:42
Speaker 5: on my sub stack. And I know this actually because
44:45
Speaker 5: I just had one day thought this is I wrote
44:48
Speaker 5: this on my subset too is the truth? Like I
44:50
Speaker 5: could I have gone to working part time because the
44:53
Speaker 5: emergency department is like a hard place to work. But
44:56
Speaker 5: I had this thought, Oh, I'll just I could just
44:59
Speaker 5: like for my building. Get I could take out insurance,
45:02
Speaker 5: like a medical insurance policy for myself and be like
45:05
Speaker 5: urgent care for my building. How nice would it be
45:08
Speaker 5: say you cut your hand on an avocado and you
45:11
Speaker 5: just have a doctor in your building and you can just
45:12
Speaker 5: come sow your black up and you know, I could
45:14
Speaker 5: charge fifty dollars for that plus the price of materials.
45:18
Speaker 5: It's easy for me, easy for them. I make relationships
45:21
Speaker 5: in my building. It could be kind of cool and
45:23
Speaker 5: like I wouldn't need to even charge that much. But
45:26
Speaker 5: it turns out I can't do that because of these
45:29
Speaker 5: weird regulations and also work shifts in the emergency department,
45:33
Speaker 5: and I'm just not willing to give that up. And
45:36
Speaker 5: so you have all these doctors who are now doing
45:38
Speaker 5: direct primary care, and which is different than concierge medicine,
45:42
Speaker 5: where they actually do usually still take Medicare and Medicaid,
45:45
Speaker 5: but the direct primary care doctors tend not to accept
45:48
Speaker 5: Medicare and Medicaid at all, and they have to go
45:50
Speaker 5: through this whole vetting process to make sure that none
45:53
Speaker 5: of their patients are Medicare and Medicaid patients and all
45:55
Speaker 5: of these things. Because they really are putting themselves at risk,
46:00
Speaker 5: they have to opt out of Medicare and Medicaid, which
46:02
Speaker 5: means none of them can work for like a week
46:04
Speaker 5: in the hospital seeing inpatient, you know, admitted patients, or
46:09
Speaker 5: or like do some urgent care shifts or whatever if
46:12
Speaker 5: they wanted to do a little more. So it really
46:15
Speaker 5: constrains doctors who might who might who might like have
46:20
Speaker 5: a little side business, see some private patients on the side,
46:24
Speaker 5: do something different or unique. You either have to be
46:27
Speaker 5: in or out.
46:28
Speaker 1: I don't think your condo is zoned for emergency care anyway.
46:33
Speaker 5: No, no, it's not. I mean, there would be a
46:35
Speaker 5: lot of other problems, but it's.
46:36
Speaker 1: Just no, it's a great idea. I mean, it's a
46:39
Speaker 1: beautiful idea. So does that mean that we can't really
46:44
Speaker 1: get anywhere without major reforms to Medicare and Medicaid.
46:51
Speaker 5: I don't even think they would need to be major.
46:53
Speaker 5: So this is another thing, like unfortunately, it's worse for
46:56
Speaker 5: Medicaid because Medicaid is state based, so of course all
47:01
Speaker 5: every state has a different Medicaid is largely paid for
47:04
Speaker 5: through state funds, although there's some federal matching, but every
47:08
Speaker 5: state has a different set of regulations pertaining to how
47:11
Speaker 5: they pay for Medicaid. Most states actually have written into
47:16
Speaker 5: their laws that Medicaid it like it's written in such
47:20
Speaker 5: a way that doctors, even if they have opted out
47:24
Speaker 5: of Medicare and Medicaid, will not see a Medicaid patient
47:27
Speaker 5: and accept money from them, because it's written in such
47:30
Speaker 5: a way that if they if a patient has a
47:32
Speaker 5: Medicaid card, they never have to pay cash for their
47:35
Speaker 5: medical care. And if you accept cash from them, even
47:38
Speaker 5: if Medicaid would not pay you because you're not part
47:40
Speaker 5: of Medicaid, you're now subject to being charged with fraud.
47:45
Speaker 5: There are a couple of states, though, that have one line,
47:48
Speaker 5: one sentence in their legislation that just says like these
47:53
Speaker 5: rules will It's something like these rules will like not
47:57
Speaker 5: be in effect in the instance that both parties have
48:00
Speaker 5: signed an agreement to the effect that they will be
48:02
Speaker 5: cash pay only. It's like one line. Yeah, And if
48:06
Speaker 5: every state wrote that one line in all the Medicaid
48:09
Speaker 5: patients would be free to either use their Medicaid dollars
48:12
Speaker 5: to see Medicaid doctors or pay cash. It would fix it.
48:17
Speaker 5: But most states, I think it's like two or three
48:19
Speaker 5: states have that, and the rest it's either it's either
48:22
Speaker 5: expressly written that it's illegal or it's so vague that
48:26
Speaker 5: no doctor would risk it. But that's a tiny fix.
48:31
Speaker 5: It's really a tiny fix if you could just get
48:33
Speaker 5: every state to put that in, or if you could
48:36
Speaker 5: get the federal government to do something like that in
48:38
Speaker 5: one of these bills, like the way that they recently
48:41
Speaker 5: defined direct primary care as not a health insurance, which
48:45
Speaker 5: now makes it so that some states. Sorry, this is
48:49
Speaker 5: like a little getting in the weeds, but in some
48:52
Speaker 5: states direct primary care was considered health insurance and so
48:55
Speaker 5: you couldn't pay for it using your health savings account funds.
48:59
Speaker 5: Oh okay, And in other states it wasn't, and so
49:02
Speaker 5: the federal government just fixed that in the big beautiful bill.
49:05
Speaker 5: It's one of the good things that bill did by
49:07
Speaker 5: just specifically saying direct primary care is not health insurance.
49:11
Speaker 5: Boom done. It's fixed. So there are a lot of
49:14
Speaker 5: little tweaks that could be done that could fix some
49:17
Speaker 5: of these big things. But ultimately we need to Jared
49:20
Speaker 5: said this the other day, we really need to do
49:22
Speaker 5: something that cleaves the public system from the private system
49:26
Speaker 5: to allow them to operate separately.
49:28
Speaker 6: Is that even possible, Jared, Well, you know, I think
49:33
Speaker 6: it is if you if you free the private system
49:36
Speaker 6: to be this this thing that people want to go to.
49:40
Speaker 4: Right, So, like I agree, it's it's a hard sell
49:43
Speaker 4: for you know, to have a lot of conversations with
49:46
Speaker 4: people about you know, shrinking medicaid. I mean that you get,
49:49
Speaker 4: you get that's where you get a lot of resistance. Okay,
49:51
Speaker 4: I get that, But what if you what if you
49:54
Speaker 4: think of it more as the you're making the private
49:56
Speaker 4: system so much you know, so much better, are thriving
50:00
Speaker 4: over there, things are flourishing over there, Prices are falling,
50:04
Speaker 4: and now that that marginal person who who's just just
50:07
Speaker 4: kind of like barely on medicaid, meaning like they they
50:11
Speaker 4: they they have just barely become eligible, that they could,
50:16
Speaker 4: you know, if things were a little bit better in
50:18
Speaker 4: the in the private sector, they could go over there
50:20
Speaker 4: get something much better and they can afford it because
50:23
Speaker 4: because we've got a much better functioning system, you'd have
50:26
Speaker 4: people actually leaving those those public systems and and and
50:31
Speaker 4: flooding into the private system. It shrinks the public systems
50:36
Speaker 4: down to something that maybe isn't even that big of
50:39
Speaker 4: a budget item anymore. And you know, and and so
50:42
Speaker 4: then you have less you kind of lower lowers the
50:45
Speaker 4: temperature on those kinds of debates, and you can still
50:47
Speaker 4: push for the long term ideal of you know, eventual
50:52
Speaker 4: phasing out of things that that's not out of the question,
50:55
Speaker 4: but in fact that I think it actually becomes more
50:58
Speaker 4: more more feasible when you when you have you know,
51:01
Speaker 4: imagine we you know, we we we made a bunch
51:03
Speaker 4: of changes and and you know, you open up the
51:07
Speaker 4: newspaper one day and you see that, you know, five
51:10
Speaker 4: million people have left Medicaid because they can now ford
51:13
Speaker 4: the what what's what's on offer in the private sector
51:16
Speaker 4: because there's a I don't know, a new health insurance
51:18
Speaker 4: company or just all the health insurance companies have redesigned
51:21
Speaker 4: their their their their plans, and they have you know,
51:25
Speaker 4: they've innovated in various ways and they've they've found way
51:27
Speaker 4: to make things more affordable.
51:29
Speaker 1: But that means, for example, if you're in Medicare that
51:32
Speaker 1: you could only go to hospitals. You will public somehow
51:36
Speaker 1: they were hospitals that treated medicaan and there were private
51:40
Speaker 1: hospitals and those would be separate.
51:43
Speaker 2: Well, I mean that could be part of it. I
51:44
Speaker 2: don't know.
51:45
Speaker 5: Uh, yeah, that's how it is now. If you're on Medicare,
51:49
Speaker 5: you can't go to a private hospital. You can only
51:51
Speaker 5: go to hospitals if you're on I'm sorry Medicaid.
51:54
Speaker 1: Sorry talking about Medicare Medicare One because I'm going on
51:57
Speaker 1: Medicare next year and so I'm interested and be I'm
52:01
Speaker 1: getting to that age. And b because you know, that's
52:05
Speaker 1: where the dollars are, right, Medicare is where you know,
52:08
Speaker 1: end of life, it's the last thirty years of your
52:11
Speaker 1: life or whatever. It's where all the spending happens. It
52:14
Speaker 1: seems that's that's the really eight hundred pound gorilla in
52:17
Speaker 1: the room is more than anything.
52:19
Speaker 2: Yeah, yeah, yeah, and we'll we're eager to take that on. Yeah.
52:23
Speaker 4: That's again, that's that's where we've got to you know,
52:26
Speaker 4: be be thinking through these things, integrating the philosophy plus
52:30
Speaker 4: the on the ground you know, policy evidence and everything
52:34
Speaker 4: out there, and figuring out ways to.
52:38
Speaker 2: To make that better.
52:40
Speaker 1: Yeah, I mean at some point when Republicans had balls,
52:43
Speaker 1: I mean they suggested something like a voucher system for Medicare,
52:48
Speaker 1: that's right, which would at least get the government out
52:51
Speaker 1: of paying hospitals. Right. So, so if you have a
52:54
Speaker 1: voucher system, it's all it's all private insurance companies at least,
52:58
Speaker 1: and then you can start tinkering with them on the
53:00
Speaker 1: velchure and you can and you can do things like that.
53:02
Speaker 1: But as always strikes me, as long as the goblin
53:05
Speaker 1: is literally buying healthcare products you've got to miss in
53:10
Speaker 1: your hands.
53:12
Speaker 2: It is messy.
53:13
Speaker 4: Yeah, I mean there there there could be some kind
53:15
Speaker 4: of genuine opt out though that that that is proposed,
53:19
Speaker 4: and and you know, you'd need you'd need seniors to
53:23
Speaker 4: think of the of the private system as well functioning
53:27
Speaker 4: and and something that they'd rather want to be part of, right,
53:30
Speaker 4: I mean, right now, it sort of feels, probably to
53:32
Speaker 4: most seniors like oh, I've paid into this thing for
53:35
Speaker 4: a while, even even though that's not quite true, but
53:38
Speaker 4: you know, they feel like, oh, I finally gotten to
53:41
Speaker 4: that that age. Now I can now I can qualify,
53:44
Speaker 4: and now I'm now I'm there and and now I'm
53:45
Speaker 4: going to benefit from this thing. But you could, you know,
53:49
Speaker 4: you could have a really long term private health insurance
53:53
Speaker 4: actually calling we were talking about this the other day.
53:55
Speaker 4: You know, you could you could have a you know,
53:57
Speaker 4: why why are we doing this one year at a time.
53:59
Speaker 4: You know, say you're renewing your health insurance, you know
54:01
Speaker 4: each year at a time. Why can't you have a
54:03
Speaker 4: fifty year health policy, right.
54:05
Speaker 5: Your lifetime health policy. I mean people don't want to
54:09
Speaker 5: do that now because it's tied to your job. But
54:11
Speaker 5: I mean that's another real you could have.
54:15
Speaker 1: You could have health insurance policies and then have I
54:18
Speaker 1: mean John Cochran has suggested having a you could buy
54:23
Speaker 1: insurance when you're very young against pre existing conditions, so
54:28
Speaker 1: you would have a policy that covered you if you
54:31
Speaker 1: got if you couldn't renew a policy because you have preexist.
54:34
Speaker 2: I mean, that's the beauty of the market.
54:36
Speaker 1: Who knows how it would develop and what would evolve
54:38
Speaker 1: as a consequence of it.
54:39
Speaker 4: Yeah, I think they call that health status insurance, and
54:43
Speaker 4: so it's it's not like you're that's the thing that's
54:45
Speaker 4: like pays, but that's the thing that ensures how you would.
54:48
Speaker 2: Get that exactly exactly.
54:50
Speaker 4: Yeah, it's a it's a great and somebody would work
54:53
Speaker 4: that out to like an actual, like functioning kind of
54:56
Speaker 4: product if if they were you know, if we had
54:59
Speaker 4: a bit of a different system. I think we have
55:00
Speaker 4: a lot of small steps to get there, which maybe
55:06
Speaker 4: it would be better done as as a sort of
55:08
Speaker 4: like omnibus uh you know, you know, change, right, because
55:11
Speaker 4: some of these things and this is where the this
55:14
Speaker 4: is where the health services researchers and the health policy
55:16
Speaker 4: researchers can sometimes not be helpful, which is that they'll
55:19
Speaker 4: study something very much in isolation. This is what happened
55:23
Speaker 4: in in the with like the shopper incentives and the
55:26
Speaker 4: shopper initiatives. You know, employers and even some state kind
55:33
Speaker 4: of like state governments experimented with these with these ideas
55:37
Speaker 4: of like letting their their employees shop around for like
55:40
Speaker 4: a you know, a cheaper MRI, right, and like, well,
55:43
Speaker 4: if you do that, if you find a cheaper MRI,
55:45
Speaker 4: that's just as good. We'll let you share some of
55:47
Speaker 4: the savings, right and keep some of the savings for yourself,
55:49
Speaker 4: because after all, you were the one who who made
55:52
Speaker 4: that just made the effort there and you and you
55:54
Speaker 4: made the judicious decision to do that. Well there there
55:58
Speaker 4: are people that will study that very academically and they'll
56:02
Speaker 4: they'll just look at that one program and you know,
56:05
Speaker 4: maybe the effects of it are relatively modest and and
56:08
Speaker 4: and then it looks like some sort of failure or something,
56:10
Speaker 4: but it's really just it's a sort of a lack
56:12
Speaker 4: of appreciation that if you were to really adopt that,
56:15
Speaker 4: other things would also change and these kind of like
56:19
Speaker 4: second order effects, you know, So the modest performance of
56:23
Speaker 4: that in its test, you know, status doesn't really give
56:26
Speaker 4: you a good sense of how it would or might
56:29
Speaker 4: perform if it was adopted. More broadly, I've called that
56:33
Speaker 4: the Ceteris Parabos fallacy, because because you're like you know,
56:37
Speaker 4: and you usually c's power of this is a good thing.
56:39
Speaker 4: You know, you isolate one thing, keep everything else the same,
56:42
Speaker 4: and then and then you can see what the effect
56:44
Speaker 4: is on that thing. But it actually, in this case
56:46
Speaker 4: it sort of hurts you because you're not allowing other
56:48
Speaker 4: things to react the way they would and there are
56:52
Speaker 4: other benefits that would would would redown to.
56:54
Speaker 3: That medicare I mean, to the extent that older people
57:05
Speaker 3: expect as entitlements as it is being sold to them,
57:12
Speaker 3: and if what is required as a kind of cultural
57:15
Speaker 3: change where you think, like, hey, I have a good
57:19
Speaker 3: relationship with my health ensure, right, Like I don't want
57:22
Speaker 3: to lose that when I turn sixty five. Right, Well,
57:27
Speaker 3: maybe older people just don't have that now, or like
57:29
Speaker 3: not enough of them. And so the pessimistic version of
57:33
Speaker 3: this is that we might just have to wait until
57:37
Speaker 3: we're further down a generation where you do have people
57:41
Speaker 3: who are getting older who think that I don't want
57:44
Speaker 3: to get medicair, right. I don't want to get stuck
57:47
Speaker 3: in that. That's a pessimistic version, but I'm open to
57:52
Speaker 3: being convinced that we can convince old people to not
57:55
Speaker 3: want their medicare well.
57:56
Speaker 1: I mean, I think the potential about your system, you know,
58:01
Speaker 1: is I think that's the way to go, because that
58:05
Speaker 1: gives you the sense, Okay, supposedly we paid into the
58:08
Speaker 1: system of getting some of it back, but now I
58:13
Speaker 1: have choices in terms of health insurance and what I
58:15
Speaker 1: can what I can buy, and what's available to me.
58:18
Speaker 1: You also have to give to buy the pig existing conditions.
58:21
Speaker 1: So the policies would have to adapt and people have
58:24
Speaker 1: to get comfortable with catastrophic I mean, there's a lot
58:26
Speaker 1: of things that have to happen for people to get
58:30
Speaker 1: comfortable with that. I mean when Paul Ryan proposed that
58:34
Speaker 1: years ago, when again when the Republican Party was actually
58:37
Speaker 1: proposing stuff, he was lamb blasted. I mean he was
58:41
Speaker 1: throwing grandmothers off the cliff, right. I mean, this is
58:44
Speaker 1: where we are. Everybody over sixty five was going to
58:46
Speaker 1: die the next day as a consequence of this, So
58:49
Speaker 1: a lot of education still has to be done.
58:52
Speaker 5: That's why I think if we really could roll out
58:54
Speaker 5: hsas to everyone and give time for people to begin
58:56
Speaker 5: to accumulate that type of money. I mean, if you could, really,
58:59
Speaker 5: if you could really say for your entire life, and
59:02
Speaker 5: then you look at and say it like, Okay, I
59:05
Speaker 5: could I could have this voucher system. I could stay
59:07
Speaker 5: on my health care plan. Plus I have this nest
59:10
Speaker 5: egg of savings that I can use for myself or
59:14
Speaker 5: or use a portion of it, and then and then
59:16
Speaker 5: when I die, give it to my children. I mean,
59:19
Speaker 5: to me, that just seems like it would be such
59:21
Speaker 5: a better situation, even if eventually hsas were rolled out,
59:24
Speaker 5: because people should save should just say for their health care.
59:30
Speaker 5: You know, I think there needs to be some intermediate
59:33
Speaker 5: steps to really convincing people that to really like making
59:37
Speaker 5: that cultural change.
59:40
Speaker 1: And what's right now? How bad is medicaid is compared
59:44
Speaker 1: to private insurance from a from a consumer perspective, I mean,
59:48
Speaker 1: I know, the costs ridiculous, but from a consumer perspective, I.
59:53
Speaker 5: Actually, right now, if if you can find a doctor,
59:57
Speaker 5: it's not that bad. So in in big cities, for example,
1:00:00
Speaker 5: it's not that bad because you know, in New York
1:00:03
Speaker 5: City has a like tons of hospitals, there's a pretty
1:00:07
Speaker 5: good wait for a lot of things. But but really
1:00:12
Speaker 5: my senses from my patients here that it's not that
1:00:15
Speaker 5: bad where it is bad. And I have, you know,
1:00:19
Speaker 5: so I have you know, friends and colleagues that work
1:00:22
Speaker 5: in more rural areas and in more rural areas, especially
1:00:28
Speaker 5: with some of the changes that have gone through with
1:00:30
Speaker 5: this big beautiful bill. But it's kind of been happening
1:00:32
Speaker 5: for years now. It's not just the big beautiful bills.
1:00:36
Speaker 5: Health centers that have traditionally accepted Medicaid have been closing
1:00:40
Speaker 5: down because they're just if they're not affiliated with the hospital,
1:00:43
Speaker 5: they don't make a lot of the extra fees that
1:00:46
Speaker 5: hospitals are able to pull in from Medicaid. They don't
1:00:49
Speaker 5: get the payments for education because hospitals get paid by
1:00:53
Speaker 5: Medicaid in part for their residents that they train things
1:00:56
Speaker 5: like that, so they just it's it's basically impossible if
1:00:59
Speaker 5: you're if all of your patients are Medicare and Medicaid
1:01:02
Speaker 5: and you're not affiliated with the hospital system to remain solvent.
1:01:07
Speaker 5: So in a lot of rural areas and even kind
1:01:10
Speaker 5: of suburban areas that are just kind of far away
1:01:12
Speaker 5: from major hospitals, these clinics that have seen Medicare and
1:01:17
Speaker 5: Medicaid patients have been shutting down. And so what that
1:01:20
Speaker 5: means is the Medicaid patients have to drive two or
1:01:23
Speaker 5: three hours to the city where the hospital is to
1:01:25
Speaker 5: see a doctor. And in some sense it's great because
1:01:28
Speaker 5: they're going to a hospital that's a tertiary care center
1:01:31
Speaker 5: where they can get all the care that you can imagine, transplants, echmo,
1:01:36
Speaker 5: great cancer care, cutting edge studies are available. On the
1:01:40
Speaker 5: other hand, if all you need is to see your
1:01:43
Speaker 5: doctor because you like, I don't know, think you might
1:01:47
Speaker 5: have broken your thumb or twisted your ankle, or you
1:01:50
Speaker 5: have a bad cold, or you're a little bit more
1:01:52
Speaker 5: short of breath today than you were yesterday. You know,
1:01:58
Speaker 5: taking an entire day worked to drive three hours to
1:02:02
Speaker 5: go see your doctor is pretty prohibitive. And and you're
1:02:05
Speaker 5: considering that Medicaid patients are the our patients who are poor,
1:02:10
Speaker 5: and so a lot of them can't take a day
1:02:12
Speaker 5: off work without losing their job. And so you've we've
1:02:16
Speaker 5: created this kind of situation where it's just almost impossible
1:02:21
Speaker 5: for them to get medical care unless they're very, very sick.
1:02:25
Speaker 5: And they and and the doctors in that area that
1:02:28
Speaker 5: don't accept Medicaid are essentially legally barred from taking money
1:02:32
Speaker 5: from them.
1:02:32
Speaker 1: Yeah, that's crazy, and so that's.
1:02:35
Speaker 5: The real problem.
1:02:37
Speaker 1: Right, So let's see, let's take a few questions and
1:02:43
Speaker 1: you guys out there, I ask anything you want. The
1:02:47
Speaker 1: flow is yours, So feel free. Let's see Wes, thank yous.
1:02:54
Speaker 1: It says thanks for this. I woke with health care
1:02:57
Speaker 1: health care systems across the country and it's frustrating how
1:03:01
Speaker 1: difficult it is for them to operate and make money. Yeah,
1:03:07
Speaker 1: it's yeah, you're very constrained and how you can make money, and.
1:03:14
Speaker 3: That leads to all sorts of misalignment of incentives where
1:03:19
Speaker 3: sometimes the alignment is beneficial for patients and doctors and
1:03:25
Speaker 3: sometimes it isn't. And that's a kind of like I
1:03:28
Speaker 3: feel like that's kind of gamble that you take in
1:03:31
Speaker 3: the American health care system. Sometimes you don't know what
1:03:33
Speaker 3: you're going to get to.
1:03:34
Speaker 1: What extent is is the structure of the health care
1:03:38
Speaker 1: system put us oude the FDA, But at what extent
1:03:40
Speaker 1: the structure of the health care system today hampering innovation
1:03:44
Speaker 1: and and you know, new procedures and and you know.
1:03:54
Speaker 3: So CMS is probably the place to look at their
1:03:58
Speaker 3: centers for care Medicaid services, so they have like an
1:04:03
Speaker 3: innovation like arm right where where like they want to
1:04:06
Speaker 3: encourage innovation. But the main problem is that they set
1:04:10
Speaker 3: the trend not just for the government programs but also
1:04:12
Speaker 3: for private insurers. Like private insurers will very often point
1:04:16
Speaker 3: to CMS policy of we made these changes to our
1:04:19
Speaker 3: private policy because that's what CMS is doing, and so
1:04:22
Speaker 3: we're just mimicking them. So I would say that there's
1:04:27
Speaker 3: definitely hampering of innovation because the way that things are
1:04:31
Speaker 3: paid are either directly or indirectly being geared towards a
1:04:36
Speaker 3: certain direction by CMS.
1:04:40
Speaker 4: And it sounded like your question might have been steered
1:04:43
Speaker 4: towards like technology and like medical innovation, and I think
1:04:47
Speaker 4: there is an effect there. But I was also going
1:04:49
Speaker 4: to say that the I think there's a real effect
1:04:51
Speaker 4: on like the business plan side and the how do
1:04:55
Speaker 4: you how do you come up with new business offerings
1:04:57
Speaker 4: when everything is so uh, it's just kind of structured
1:05:02
Speaker 4: and regulated the way it is, it becomes very difficult.
1:05:04
Speaker 4: You see a lot less you know, innovation around clinics
1:05:09
Speaker 4: in the way that they operate. That's why something like
1:05:12
Speaker 4: direct primary care feels like so fresh.
1:05:15
Speaker 2: I mean, even though it's it's it's.
1:05:16
Speaker 4: Actually kind of like like an old almost like an
1:05:18
Speaker 4: old fashioned way, but it's but it's been given you know,
1:05:21
Speaker 4: kind of like a new uh, a new veneer and everything.
1:05:24
Speaker 4: And that's a great thing. You know that that that's
1:05:26
Speaker 4: something that should have been you know, it should probably
1:05:29
Speaker 4: be a little bit more widespread. I don't think a
1:05:32
Speaker 4: lot of these things have sort of natural caps on
1:05:35
Speaker 4: how much.
1:05:35
Speaker 2: Good they can do.
1:05:37
Speaker 4: You know, direct primary care is I should say what
1:05:40
Speaker 4: it is for any of the listeners who don't know.
1:05:43
Speaker 2: It's basically a subscription model.
1:05:46
Speaker 4: You can think of it if you know what concierge
1:05:48
Speaker 4: care is for, like you know, like really wealthy people
1:05:50
Speaker 4: and superstars and UH and and Hollywood actors and that
1:05:53
Speaker 4: sort of thing where you have like a doctor almost
1:05:55
Speaker 4: like on call for you. Well, this is like the
1:05:58
Speaker 4: consumer version of that where you can you you can
1:06:00
Speaker 4: get it for seventy five or eight dollars a month
1:06:02
Speaker 4: in many places and you have a close relationship with
1:06:06
Speaker 4: your physician. A lot of times it is actually they're
1:06:11
Speaker 4: not allowed to say now that it's unlimited visits. They
1:06:14
Speaker 4: used to be able to say that, but that that
1:06:16
Speaker 4: runs a file of of of the UH insurance regulations
1:06:19
Speaker 4: to call yours to allow unlimited UH fit visits like
1:06:23
Speaker 4: that because it's like, well in theory they can't be
1:06:26
Speaker 4: seen unlimited.
1:06:27
Speaker 2: Well anyway, that's that's.
1:06:29
Speaker 4: The kind of thing where you know that there's a
1:06:31
Speaker 4: there's a little bit of an innovation there, but we
1:06:33
Speaker 4: would see more of that on on like the business
1:06:35
Speaker 4: model side, and I think that's almost as big a
1:06:38
Speaker 4: story and then than like what you know, are we
1:06:41
Speaker 4: missing out on like a biotech because the I mean
1:06:43
Speaker 4: the biotech folks and you know they're to the scent
1:06:46
Speaker 4: that they're like venture capital funded and stuff like they're
1:06:48
Speaker 4: they're doing. Okay, I mean, I'm sure there are effects there,
1:06:51
Speaker 4: but the I think I think that there's almost a
1:06:54
Speaker 4: bigger effect on the business models and the business uh
1:06:58
Speaker 4: uh plans that we see out there.
1:07:00
Speaker 5: It's there will ultimately be an effect on those things.
1:07:04
Speaker 5: And we were talking about this a little bit before,
1:07:07
Speaker 5: and I recently I attended a Progress conference in Berkeley,
1:07:11
Speaker 5: and there were people there doing all of this amazing
1:07:14
Speaker 5: cutting edge research on sort of individualized healthcare and longevity
1:07:21
Speaker 5: and drug how to test drug molecules and ways that
1:07:26
Speaker 5: are really innovative and new, and they are going to,
1:07:30
Speaker 5: I think, eventually run up against regulations that make it
1:07:34
Speaker 5: hard for them to really push the limits of some
1:07:39
Speaker 5: of this technology that is so innovative innovative, I don't
1:07:43
Speaker 5: know how you say that word, but and so I
1:07:47
Speaker 5: do think there's some degree to which the way that
1:07:51
Speaker 5: the regulations are structured now and some of the things
1:07:54
Speaker 5: that Trump is doing where like this most favored Drug Nation,
1:07:59
Speaker 5: same pharmaceutical company sort of thing that he's doing, these
1:08:04
Speaker 5: things are going you know, these things are going to
1:08:07
Speaker 5: have long term outcomes and impact on our ability to
1:08:11
Speaker 5: innovate in the scientific realm as well, and so I
1:08:17
Speaker 5: think we that's kind of one of the things that
1:08:19
Speaker 5: we are focusing on is that, and part of why
1:08:24
Speaker 5: we're called Center for Modern Health is we're trying to
1:08:26
Speaker 5: really think about what is modern health and how can
1:08:29
Speaker 5: we have a healthcare system that supports all of these
1:08:33
Speaker 5: amazing innovations and both in terms of drugs and devices,
1:08:41
Speaker 5: but also ai that we're looking at right coming right
1:08:44
Speaker 5: down the pipeline, things we can't even imagine, and we're
1:08:47
Speaker 5: still stuck in this system that like treading water in
1:08:51
Speaker 5: this system from the nineteen eighties that isn't serving us.
1:08:55
Speaker 1: Seems one area in which this has to have an
1:08:59
Speaker 1: effect is like on preventive health. Right. So you know
1:09:05
Speaker 1: there's all these companies out there that do these screenings.
1:09:08
Speaker 1: You know, I'm subscribe to one and if promoted one
1:09:13
Speaker 1: of them where you go in for a day and
1:09:16
Speaker 1: they do they screen you for everything. And I know
1:09:19
Speaker 1: some doctors somehow find this offensive, but I love it, and.
1:09:27
Speaker 5: It's a little offensive.
1:09:31
Speaker 2: If they you.
1:09:32
Speaker 1: Know, I had a listener to the show, right, I
1:09:34
Speaker 1: mean this true story had a listener to the show.
1:09:36
Speaker 1: Is subscribe to this right, and he went in and
1:09:40
Speaker 1: got got the the MRI, the full buddy MRI, and
1:09:43
Speaker 1: they found something in his lungs. Not a smoker and
1:09:46
Speaker 1: no symptoms nothing. They it looked suspicious enough that they
1:09:50
Speaker 1: investigated it was cancer and they got it out and
1:09:54
Speaker 1: he's fine. And that wouldn't have happened if he'd waited
1:09:57
Speaker 1: until he got symptoms. I mean, it's it's it be
1:10:00
Speaker 1: life of death catching these things early. So I'm a
1:10:04
Speaker 1: I'm a I'm a fan anyway, but but it doesn't
1:10:08
Speaker 1: work in the existing healthcare model, right, and you know,
1:10:13
Speaker 1: you have to make some money to foot it. It's
1:10:14
Speaker 1: it's expensive, you know.
1:10:17
Speaker 4: And yeah, there's on the preventive health side, there's there's
1:10:21
Speaker 4: this sort of lack of incentive for people to invest
1:10:25
Speaker 4: in that. It meaning that the business businesses, like in
1:10:29
Speaker 4: your insurance company or your employer, let's say you get
1:10:31
Speaker 4: your your care, your your insurance or your employer. In fact,
1:10:35
Speaker 4: there's a there's a famous article a while ago. I
1:10:37
Speaker 4: think the title of it was something like, uh, you'll
1:10:40
Speaker 4: be gone and will be gone or something like that,
1:10:42
Speaker 4: you know, meaning by the time this pays off, you know,
1:10:45
Speaker 4: this business might not be around and you know you're
1:10:48
Speaker 4: going to be working for someone else and say, you know,
1:10:50
Speaker 4: people don't stay for stay at their employer for decades
1:10:54
Speaker 4: and decades anymore, right, And so so there there is
1:10:57
Speaker 4: a bit of a misalign to send that something that
1:10:59
Speaker 4: I think could be corrected to some extent with what
1:11:01
Speaker 4: we were talking about earlier, having a more long term
1:11:06
Speaker 4: outlook on on on on, on your the kind of
1:11:11
Speaker 4: coverage that you buy. I also have to I feel
1:11:15
Speaker 4: obligated to jump in. So I learned epidemiology and biostatistics
1:11:20
Speaker 4: from Gil Welch. I don't know if that maybe that
1:11:23
Speaker 4: name will ring some bells in with the audience. He's
1:11:27
Speaker 4: the author of over Diagnosis, and so I've seen I
1:11:30
Speaker 4: kind of see both sides, and I think it's a
1:11:32
Speaker 4: very it's a very interesting debate. Yeah, you don't want
1:11:35
Speaker 4: to be just like catching incidental omas that that that
1:11:38
Speaker 4: don't you know, lead to anything, and then like overtreating.
1:11:42
Speaker 4: But at the same time, these are really you know, promising,
1:11:46
Speaker 4: uh screen techniques. I mean, maybe the best thing to do,
1:11:50
Speaker 4: I've I've thought about doing this for myself, although I
1:11:52
Speaker 4: can't afford it, you know, is to like get that
1:11:54
Speaker 4: skian but not look at it, or at least make
1:11:56
Speaker 4: a promise to yourself not to not to take like
1:12:00
Speaker 4: heroic action.
1:12:02
Speaker 2: Until you do, like experience a symptom, because it would.
1:12:05
Speaker 4: Be handy to know, like, let's say, three years later,
1:12:08
Speaker 4: you do get some symptoms, you get the target it's
1:12:12
Speaker 4: imaging of that, it would be nice to know, well,
1:12:15
Speaker 4: has this thing changed in size, this tumor or whatever
1:12:18
Speaker 4: you're looking at, has it changed.
1:12:20
Speaker 2: Since three years ago?
1:12:21
Speaker 4: And if you can look back in time, it kind
1:12:24
Speaker 4: of gives you know, the original scan gives you a
1:12:26
Speaker 4: way of looking back in time so that you can
1:12:28
Speaker 4: know whether it's progressed or not.
1:12:29
Speaker 1: So you see, you have to be good with you
1:12:32
Speaker 1: have to accept the false positives, right, so you have
1:12:35
Speaker 1: to be good at that. So I did it. I
1:12:37
Speaker 1: don't know. Twenty years ago, I did a full body
1:12:39
Speaker 1: scan and they found this on my kidney and this
1:12:43
Speaker 1: and my live in, some nodules and my lungs and
1:12:45
Speaker 1: everything is okay. You know, we'll do another scan of
1:12:48
Speaker 1: six months and we'll see if anything changed, and do
1:12:50
Speaker 1: it against six months and everything's about the same, and okay,
1:12:53
Speaker 1: I'm fine. Now. I know people who would freak out
1:12:57
Speaker 1: from the first one and would lose it and do
1:12:59
Speaker 1: bio season all of them, and that is a disaster.
1:13:02
Speaker 1: So you have to the right attitude going in knowing
1:13:06
Speaker 1: exactly what's what, you know what's going to be found.
1:13:09
Speaker 1: And I actually enjoy the process. I like data. So
1:13:13
Speaker 1: if there's data on my body, give it to me.
1:13:15
Speaker 1: I mean, I knowing is better than not knowing, is
1:13:19
Speaker 1: my view.
1:13:20
Speaker 4: Well, yeah, it sounds like you were able to keep
1:13:22
Speaker 4: that all on context and make a you know, an informed,
1:13:26
Speaker 4: rational decision about it, not freak out right away.
1:13:28
Speaker 1: And now twenty years late, I still have those same things, right,
1:13:31
Speaker 1: We still want, you know, and I do it once again.
1:13:33
Speaker 1: We still monitor it. And as long as none of
1:13:36
Speaker 1: them changing size, or if they change the size a
1:13:38
Speaker 1: little bit, you know, we'll get But we have a benchmark,
1:13:41
Speaker 1: you know, we have a we know exactly what we're monitoring.
1:13:43
Speaker 2: So yeah, yeah, yeah.
1:13:45
Speaker 4: Gil Welch would say that you have a bunch of tortoises,
1:13:47
Speaker 4: so they're very slow moving, they don't progress that there's
1:13:50
Speaker 4: may maybe nothing they're never going to probably never harm you.
1:13:53
Speaker 4: But what you do want to kind of catch if possible,
1:13:56
Speaker 4: is the rabbits. Yeah, they're kind of quick quick moving
1:13:59
Speaker 4: because is maybe fence those in. They're quick moving, hard
1:14:02
Speaker 4: to corral. You can't do anything about the birds. That's
1:14:05
Speaker 4: that's his Uh, that's the full metaphor.
1:14:08
Speaker 1: There.
1:14:09
Speaker 2: I'll stop. I'll stop with that, though, I think.
1:14:17
Speaker 3: I mean we're talking about preventive health. I think we
1:14:20
Speaker 3: should also contend with the fact that within the current situation,
1:14:26
Speaker 3: we're being told by people like RFK that well, we
1:14:30
Speaker 3: have a sick care system that only rewards treating you
1:14:35
Speaker 3: once you're sick, and clearly the free market has filled
1:14:39
Speaker 3: that investing in prevented health, so like we need the
1:14:42
Speaker 3: governments to have play a bigger role. But what people
1:14:45
Speaker 3: just don't realize is that the reason why there isn't
1:14:48
Speaker 3: more investment in preventive health is because we've gotten rid
1:14:51
Speaker 3: of the incentives. Right when when before insurance started playing
1:14:56
Speaker 3: this huge role in funding most health care services, there
1:15:02
Speaker 3: were other models which did incentivize preventative health, where what
1:15:06
Speaker 3: was being monetized was the patient's health on its own,
1:15:10
Speaker 3: where the doctor in a sense had an incentive to
1:15:15
Speaker 3: make sure that they prevented their patient from getting sick
1:15:18
Speaker 3: because if they got sick, well, that meant more expensive
1:15:21
Speaker 3: care and you come up with an agreement with your
1:15:23
Speaker 3: patient that we're gonna take care of your health and
1:15:28
Speaker 3: and for a certain amount, and if you get sicker, well,
1:15:32
Speaker 3: then like that it's on both of us to actually
1:15:35
Speaker 3: keep you healthy. But the AMA said no, like we
1:15:38
Speaker 3: want to maintain the fee for service model where you're
1:15:40
Speaker 3: being paid for particular procedure, right, and we're going to
1:15:44
Speaker 3: have insurance pay for that. But what does that do
1:15:47
Speaker 3: That fragments care then, like you're focused on procedures and
1:15:49
Speaker 3: it's not this idea that well, the healthcare system focuses
1:15:53
Speaker 3: on sickness because that's where the money is. Is that
1:15:55
Speaker 3: no healthcare focuses on sickness because that's how we've constructed
1:15:59
Speaker 3: the system, and we need freedom in order to monetize
1:16:03
Speaker 3: our health long term. But that's those are not the
1:16:06
Speaker 3: decisions that were made, and so it's just a complete
1:16:09
Speaker 3: myth that there's no money to be made and preventive.
1:16:12
Speaker 1: Of course, of course, it's it's lack of business models
1:16:16
Speaker 1: and innovation and the business models that have to do
1:16:18
Speaker 1: with it. But I find it interesting this service that
1:16:21
Speaker 1: I do once a year, where I do scanning, they
1:16:24
Speaker 1: are now offering like something like a million dollars if
1:16:29
Speaker 1: over the next five years for certain cancers you're diagnosed
1:16:35
Speaker 1: with stage four, right, So they're saying, if we miss
1:16:39
Speaker 1: it and you get stage four because we missed it,
1:16:41
Speaker 1: we'll give you a million dollars, you know. So that's
1:16:44
Speaker 1: that's you know, things like that are gonna I think
1:16:47
Speaker 1: you're going to see more of that evolve and provide
1:16:51
Speaker 1: kind of incentives.
1:16:52
Speaker 2: That's pretty cool.
1:16:53
Speaker 4: The only other thing that I've seen that's like that,
1:16:55
Speaker 4: I think it might have been guising your health who
1:16:58
Speaker 4: like guaranteed their own heart starts a while back or
1:17:01
Speaker 4: something along those lines.
1:17:03
Speaker 2: That's yeah, No, that's really cool. I think I do
1:17:04
Speaker 2: think you would see more of.
1:17:05
Speaker 1: That, right, Wes says, continues, what is the trend of
1:17:11
Speaker 1: concierge medicine in the United States? Has it flatlined or
1:17:14
Speaker 1: is it increasing? Any know? I think, I mean, you
1:17:17
Speaker 1: you Captchus concierge medicine. JOUD is the superstar one. I
1:17:22
Speaker 1: mean I had a concierge doctoring in Orange County in California.
1:17:25
Speaker 1: I paid two thousand dollars a year I think, and
1:17:28
Speaker 1: it was just it just increased access and no weight
1:17:31
Speaker 1: and you know, no weight and things like that. So
1:17:34
Speaker 1: I think in parts of the country it's quite available
1:17:37
Speaker 1: and accessible, but I don't know what the status is today, Colleen.
1:17:41
Speaker 5: Uh, Well, so the concierge medicine and direct primary care
1:17:46
Speaker 5: slightly different. Concierge doctors tend to accept a variety of insurances.
1:17:51
Speaker 5: Usually they all accept Medicare as well as a couple
1:17:55
Speaker 5: of the bigger private quote unquote private insurances, and then
1:18:01
Speaker 5: they charge a separate fee to the patient for the
1:18:05
Speaker 5: access and sometimes they'll include like weird things like nutrition counseling,
1:18:09
Speaker 5: and they'll have a fancy office and you can you know, text.
1:18:12
Speaker 1: Them, and yeah, email and text was a big deal.
1:18:15
Speaker 5: I think, you know, things like that. So and the
1:18:19
Speaker 5: So that's kind of one version. And then direct primary
1:18:22
Speaker 5: care is they've opted out of Medicare and Medicaid and
1:18:26
Speaker 5: you they only take cash and usually you pay a
1:18:31
Speaker 5: subscription fee that's somewhere between seventy and one hundred and
1:18:35
Speaker 5: fifty dollars a month. Sometimes it's a little more, although
1:18:39
Speaker 5: the Big Beautiful Bill capped it, so there's a maximum
1:18:43
Speaker 5: amount that you can pay, unfortunately, which just is frustrating
1:18:46
Speaker 5: because that would be a way that you could drive
1:18:49
Speaker 5: innovation if you had, like, some of those practices would
1:18:52
Speaker 5: be able to innovate more and do more interesting things
1:18:54
Speaker 5: if they could charge a little bit more money. But
1:18:56
Speaker 5: that's not an option in any case. So I don't
1:19:03
Speaker 5: have exact numbers. But I wrote about this maybe six
1:19:07
Speaker 5: months ago, and at the time when I was writing
1:19:09
Speaker 5: about it and researching it, both of them are growing slowly.
1:19:13
Speaker 5: Both direct primary care and concierge practices are growing, and frustratingly,
1:19:18
Speaker 5: there's a little bit of a cultural backlash against them
1:19:21
Speaker 5: from them from other doctors who are accusing them of
1:19:26
Speaker 5: doing things like abandoning their patients, abandoning their colleagues, to
1:19:31
Speaker 5: who now have to struggle in the traditional healthcare system
1:19:36
Speaker 5: where they can only see one patient, you know, where
1:19:38
Speaker 5: they're like seven to ten minutes per patient visits. Now
1:19:42
Speaker 5: the primary care doctors have to have to take over
1:19:45
Speaker 5: all that work, and there's this real sense that direct
1:19:51
Speaker 5: primary care and concierge doctors who have left traditional medical
1:19:55
Speaker 5: practices for direct primary care and concierge medicine are kind
1:19:59
Speaker 5: of selling out. And it's pretty unfortunate because I think,
1:20:06
Speaker 5: you know, what they're actually doing is saying, here's how
1:20:09
Speaker 5: I want to produce. I want to be a producer
1:20:12
Speaker 5: in this way, in a way that allows me to
1:20:15
Speaker 5: have a relationship with my patients, to make money doing
1:20:19
Speaker 5: something that matters to me. And so but yeah, they
1:20:23
Speaker 5: are growing, so that's that's a good sign. It's just
1:20:28
Speaker 5: hard for them to grow, like I said, because you
1:20:31
Speaker 5: either have to be in one world or the other
1:20:33
Speaker 5: in many ways.
1:20:35
Speaker 3: One thing about Derek Premier Care or ratter that Derek
1:20:39
Speaker 3: Premacare movement that I think is interesting to point out
1:20:42
Speaker 3: to your audience is that while it's true that what
1:20:47
Speaker 3: motivates them is well, I want to get out of
1:20:49
Speaker 3: this system, I want to become my own business person
1:20:51
Speaker 3: and whatnot. I think there's psychologically a lot of healthy
1:20:56
Speaker 3: reactions there. But unfortunately, if you talk to some people
1:21:00
Speaker 3: in that space, they will criticize direct paramary care doctors
1:21:06
Speaker 3: who want to scale that model right, Like they want
1:21:08
Speaker 3: to like partner with like a big corporation so they
1:21:11
Speaker 3: can duplicate it like a franchise model, and they're like,
1:21:15
Speaker 3: what are you doing. You're like re introducing like right
1:21:20
Speaker 3: and and and so just imagine that as a doctor
1:21:24
Speaker 3: trying to escape the system of uh where you're being
1:21:28
Speaker 3: paid by insurance and like give all these regulations on
1:21:32
Speaker 3: you that you're escaping that, and then you're being told
1:21:36
Speaker 3: from the other side that, well, you just be your
1:21:39
Speaker 3: own boss, but don't grow, you know. It's like that's
1:21:42
Speaker 3: just absolutely tragic. And and and so, like me speaking
1:21:45
Speaker 3: to some people in the space who are more sympathetic
1:21:48
Speaker 3: to working with corporations to skill healthcare, they told me
1:21:52
Speaker 3: that when it comes to a more kind of cultural
1:21:55
Speaker 3: embrace of free markets and like a capitalist ethos, you
1:22:02
Speaker 3: might have more luck looking at people coming from certain
1:22:09
Speaker 3: specialties better than the double because they also like realized
1:22:16
Speaker 3: that like high tech work requires a lot of capital
1:22:20
Speaker 3: and it can't just be like a mom and pop
1:22:22
Speaker 3: story and like a big building and things like that.
1:22:24
Speaker 3: And so maybe culturally that's like the spearhead of the
1:22:27
Speaker 3: embrace of like a more kind of capitalist mindset. In medicine,
1:22:31
Speaker 3: like some.
1:22:31
Speaker 5: Of these surgery centers like Surgery Center of Utah, I
1:22:35
Speaker 5: forget what exactly what it's called, but it's like a
1:22:37
Speaker 5: direct primary care surgery direct care, I should.
1:22:42
Speaker 1: Say, all right, moulten splendid asks since consumers are variable
1:22:47
Speaker 1: in their ability to pay or even plan to ensure
1:22:51
Speaker 1: themselves and if the government is removed, what pays system
1:22:56
Speaker 1: insurance cash hu SA would be attractive to both doctors
1:23:00
Speaker 1: and hospitals.
1:23:05
Speaker 5: I mean, I think any of the above as long
1:23:07
Speaker 5: as you got paid, right, you know, I think I
1:23:10
Speaker 5: think if the government were removed, and please, this is
1:23:13
Speaker 5: sort of a hypothetical exercise and kind of being creative,
1:23:17
Speaker 5: so please jump in and help me, guys. But you know,
1:23:22
Speaker 5: first of all, we would I think, over over a
1:23:25
Speaker 5: pretty short time, begin to see that that actual prices
1:23:29
Speaker 5: would come down because they would have to meet levels
1:23:34
Speaker 5: that most people could pay for most medical care. I
1:23:39
Speaker 5: think there are some things that are kind of weird
1:23:41
Speaker 5: and really like like organ transplants and you know, major
1:23:47
Speaker 5: cardiac surgery, some that that might be slightly different. But
1:23:50
Speaker 5: I think for most things, overall prices would come down
1:23:53
Speaker 5: so people would be able to afford more. But ultimately,
1:23:59
Speaker 5: you know, I think, just like if you think about
1:24:02
Speaker 5: cell phones, your cell phone plan company has a million
1:24:06
Speaker 5: ways you can pay for your cell phone. You can
1:24:08
Speaker 5: sign up for another five year plan and then you
1:24:10
Speaker 5: get a discount on your cell phone. You can just
1:24:12
Speaker 5: buy a cell phone outright and then buy your cell phone,
1:24:15
Speaker 5: cover your cell phone, your cell service plan. You can
1:24:19
Speaker 5: buy you cell phone. You can buy a cheap cell
1:24:21
Speaker 5: phone from China. You can buy a really fancy, brand
1:24:24
Speaker 5: new expensive iPhone. I think you would have some kind
1:24:27
Speaker 5: of variety in what you could buy, some kind of
1:24:29
Speaker 5: variety in kind of like the bells and whistles that
1:24:33
Speaker 5: so you know, maybe if you're in the hospital, you
1:24:35
Speaker 5: could buy the like private bed with the personal chef
1:24:39
Speaker 5: and you know whatever, or you could just be in
1:24:42
Speaker 5: the big ward with ten other beds and like you know,
1:24:46
Speaker 5: makeshift walls that go between you. So you would begin
1:24:50
Speaker 5: to see all this variety, and so it would be
1:24:52
Speaker 5: more possible for people who can't afford to pay as
1:24:55
Speaker 5: much to pay. You'd have real health insurance. That would
1:24:59
Speaker 5: be you paid for what you contracted to have them pay.
1:25:02
Speaker 5: And so as a consumer you could know what to
1:25:04
Speaker 5: expect and and ultimately hospitals and doctors wouldn't care how
1:25:09
Speaker 5: you paid them. It would just be a matter of
1:25:11
Speaker 5: whether you paid or not. And they probably would also
1:25:14
Speaker 5: as they do now have systems in place for you
1:25:17
Speaker 5: to for you to set up payment plans.
1:25:21
Speaker 1: Yep, there's one add anything.
1:25:25
Speaker 4: Well, if I was attempted to what was it Morton
1:25:29
Speaker 4: is that the name.
1:25:31
Speaker 1: It's a great name.
1:25:33
Speaker 4: I was tempted to say, well, say more because I'm curious,
1:25:35
Speaker 4: like what what premises on there? But but no, I
1:25:38
Speaker 4: mean I agree, I think there would be a lot
1:25:40
Speaker 4: of new variety that would seek to try to address
1:25:44
Speaker 4: each of these markets. I mean, we have you know,
1:25:48
Speaker 4: look at look at when you buy. I don't know,
1:25:50
Speaker 4: you go shopping for a car, you can you know,
1:25:51
Speaker 4: if you want to spend half a million dollars on
1:25:54
Speaker 4: a car.
1:25:54
Speaker 2: You can do it.
1:25:54
Speaker 4: Somebody will will sell you a luxury sports car that
1:25:58
Speaker 4: has all sorts of amazing things.
1:25:59
Speaker 2: And if you yet, at the same.
1:26:01
Speaker 4: Time, we managed to find you know, there are car
1:26:04
Speaker 4: makers that make the cars for the new you know,
1:26:08
Speaker 4: college graduate who doesn't have much to spend on a car.
1:26:12
Speaker 2: There's uh. The one other thing that I would add.
1:26:15
Speaker 4: That, uh is that I think there's there would be
1:26:18
Speaker 4: a definitely a new relationship with with insurance and you
1:26:20
Speaker 4: can really if you're allowed to really go with like
1:26:23
Speaker 4: a catastrophic plan and and weed out some of the
1:26:26
Speaker 4: things that you probably don't need coverage for. I mean,
1:26:28
Speaker 4: I know it's probably a uh, you know, it raises
1:26:31
Speaker 4: a lot of eyebrows to say that we're over insured,
1:26:34
Speaker 4: but but we kind of are in many ways, you know,
1:26:37
Speaker 4: and and think and the key thing to kind of
1:26:40
Speaker 4: appreciate there is that if you are if you can
1:26:44
Speaker 4: whittle down what you're insured for, that's money back in
1:26:47
Speaker 4: your pocket, because that the premium goes way way down
1:26:50
Speaker 4: once you're not once you're not paying for absolutely everything
1:26:53
Speaker 4: and all sorts of things that you don't need.
1:26:55
Speaker 5: Yeah, I mean, what we have now, we pay for
1:27:00
Speaker 5: absolutely everything except what we really need because when there's
1:27:03
Speaker 5: a catastrophe, then then the insurance comes back with their
1:27:07
Speaker 5: prior authorizations and doesn't cover any of it. So you know,
1:27:11
Speaker 5: we have this weird kind of bait and switch thing
1:27:13
Speaker 5: going on that is worse than any insurance that we
1:27:17
Speaker 5: would buy if we had a real free market.
1:27:19
Speaker 1: Yeah, and all of that is a consequence of regulations, right,
1:27:22
Speaker 1: I mean, I you know, my insurance policy in California
1:27:25
Speaker 1: covered acupuncture and pregnancy even though we were too old
1:27:32
Speaker 1: to have kids, and you know a million other things
1:27:35
Speaker 1: that we don't want, we didn't want, we had no
1:27:37
Speaker 1: interest in, and would easily you know, get rid of
1:27:40
Speaker 1: and minimize the policy to just the things we actually needed.
1:27:44
Speaker 4: I've often wanted to sort of on the back burner here.
1:27:48
Speaker 4: One one kind of empirical research study that would would
1:27:51
Speaker 4: be really interesting is to really take a close look
1:27:54
Speaker 4: at everything that is covered in let's say your average
1:27:58
Speaker 4: insurance policy and and and either whether you subtract out
1:28:03
Speaker 4: the things that you that you don't think you would
1:28:07
Speaker 4: need or or or you start from scratch and just
1:28:09
Speaker 4: add the things that you do need.
1:28:11
Speaker 2: The the idea would be, I.
1:28:13
Speaker 4: Wonder what you know insurance would really cost if you're
1:28:17
Speaker 4: if you're if you just limited to the things that
1:28:19
Speaker 4: are truly like insurable events, right even just that things
1:28:22
Speaker 4: that are like out of your control, unusual things that
1:28:26
Speaker 4: you you can't contribute to in any way.
1:28:28
Speaker 2: You know, you didn't cause it.
1:28:29
Speaker 4: It's it's nothing that you're nothing that you that's like
1:28:32
Speaker 4: a consumer item that you want, right, Like there's a
1:28:34
Speaker 4: reason we don't put like plastic surgery on most insurance plans, right,
1:28:39
Speaker 4: you know, things that you would actually like desire to
1:28:42
Speaker 4: have that those those aren't insurance insurable events.
1:28:45
Speaker 2: And and and they think.
1:28:47
Speaker 1: I think somebody once calculated it would be cheaper than
1:28:50
Speaker 1: your cell phone bill, significantly cheaper than your cell phone bill. Yeah,
1:28:54
Speaker 1: and therefore everybody could afford it.
1:28:56
Speaker 2: Yeah, I think it really would be very form.
1:28:58
Speaker 3: I think that the role of hospitals would also be different, right,
1:29:02
Speaker 3: because I mean in graduate school, I need I needed
1:29:06
Speaker 3: a psychotherapist, and I couldn't afford it, so I went
1:29:09
Speaker 3: to the psychology department and got seen by a very
1:29:13
Speaker 3: good PhD student in psychology. And that's what teaching hospitals
1:29:18
Speaker 3: used to be, is that like you would get high quality,
1:29:22
Speaker 3: affordable care where you just pay like a small amount,
1:29:26
Speaker 3: because the trade was that, like, well, you're not going
1:29:29
Speaker 3: to get like the top surgery guide, but a lot
1:29:33
Speaker 3: of these medical residents like they there's a like a
1:29:37
Speaker 3: selection effect. They're they're very good, and they provided a
1:29:42
Speaker 3: lot of uh free or essentially subsidized care that they
1:29:47
Speaker 3: subsidized themselves.
1:29:48
Speaker 5: I mean, we have that for dental care now. I
1:29:50
Speaker 5: got my teeth, my wisdom teeth removed in college when
1:29:53
Speaker 5: I couldn't afford to pay for a real oral facial
1:29:57
Speaker 5: surgeon at at like u I University of Illinois at
1:30:01
Speaker 5: Chicago Dental School, and I paid eighty dollars. And the
1:30:05
Speaker 5: only reason I paid the eighty dollars was because I
1:30:08
Speaker 5: wanted them to actually give me some like medication to
1:30:12
Speaker 5: make me forget instead of just numbing my numbing me
1:30:18
Speaker 5: up with light. And so I was like, I can
1:30:20
Speaker 5: think I can find eighty dollars, but I couldn't have
1:30:22
Speaker 5: paid the several thousand. You know, so.
1:30:28
Speaker 1: Neo asks, which way do you see healthcare going for
1:30:32
Speaker 1: replacing limbs and organs? Are we more likely to use
1:30:36
Speaker 1: robotics to replace them or more likely to use lab
1:30:40
Speaker 1: grown human organs?
1:30:43
Speaker 3: Feel like that's more of like a biomedical question that
1:30:48
Speaker 3: I'm not qualified to speak on, but certainly like if
1:30:52
Speaker 3: you allow the profit motive to reign in this area,
1:30:55
Speaker 3: you will definitely have a lot more people trying to
1:30:58
Speaker 3: find alternatives for expense of organ transplants which fail, right,
1:31:02
Speaker 3: like they only last for for so long. But I'm
1:31:06
Speaker 3: not a scientist. I'm not going to speculate on which direction.
1:31:10
Speaker 5: Although I do know there's a bill before Congress though
1:31:13
Speaker 5: that is offering to pay people something like fifteen thousand
1:31:18
Speaker 5: or fifty thousand, I can't remember which it is per
1:31:21
Speaker 5: for a kidney. Oh, really, donate a kidney. You can
1:31:24
Speaker 5: make some money.
1:31:25
Speaker 1: Yeah, I don't think it'll pass paid.
1:31:27
Speaker 5: For by the government.
1:31:28
Speaker 1: I suspect it won't pass this trivia existence, the idea
1:31:33
Speaker 1: of paying people for the organs.
1:31:36
Speaker 4: Yeah, Iran is the only country where you can. Oh god,
1:31:39
Speaker 4: it's a little piece of trivia there. Yeah, let's not
1:31:43
Speaker 4: go down. That's a whole different story. Yeah, although he
1:31:47
Speaker 4: was was he asking about organ transplants or like.
1:31:49
Speaker 1: Ash Cam about whether we think organs replacement organs are
1:31:54
Speaker 1: going to be robotic or grown from human.
1:31:58
Speaker 5: Cells will most likely ultimately be grown from human self.
1:32:04
Speaker 5: And the reason is because we already have some robotic
1:32:07
Speaker 5: replacement organs. One of them is called ELVAD, a left
1:32:11
Speaker 5: ventricular assist device. It's a pump that goes in your
1:32:15
Speaker 5: heart and pumps your blood and you have to have
1:32:18
Speaker 5: a wire that connects that comes from your heart out
1:32:21
Speaker 5: through your stomach and then connects to a battery. You
1:32:23
Speaker 5: have to be connected to a battery twenty four to
1:32:25
Speaker 5: seven or plugged into the wall. It's actually amazing. It
1:32:31
Speaker 5: is a bridge to heart transplant for many people, or
1:32:33
Speaker 5: for older people who can't get a heart transplant because
1:32:36
Speaker 5: they're too old. It can add like five ish years
1:32:38
Speaker 5: to your life, which is a lot. You know, you
1:32:41
Speaker 5: could see a kid graduate from college or get married
1:32:43
Speaker 5: or meet a grandchild. So it's pretty awesome. But it's
1:32:46
Speaker 5: also it's also really cool because you don't have a
1:32:49
Speaker 5: pulse anymore when you have it, because your heart is
1:32:52
Speaker 5: just constantly the blood is constantly going like through your body.
1:32:56
Speaker 5: So it's really fun to take trainees like med students
1:33:00
Speaker 5: and ask them to find the pulse on that person
1:33:01
Speaker 5: and then they like flip out as a person that's
1:33:05
Speaker 5: like a But in any case, there are a lot
1:33:07
Speaker 5: of problems with it. They're really prone to infection if
1:33:10
Speaker 5: the power goes out, they have to dependents have to
1:33:13
Speaker 5: go to the hospital to get plugged in. I mean,
1:33:15
Speaker 5: it's just like it's really really difficult. They're prone to
1:33:19
Speaker 5: blood to forming blood cloths. But then at the same
1:33:22
Speaker 5: time they'll eat your blood up and cause you to
1:33:24
Speaker 5: be anemic because they cut up the blood cells. So
1:33:26
Speaker 5: it's just these mechanical organs like in an ideal you know,
1:33:31
Speaker 5: they seem amazing, and they are amazing in many ways,
1:33:34
Speaker 5: but they also have so many problems that we really
1:33:37
Speaker 5: do need to find a better bio kind of prosthetic
1:33:41
Speaker 5: solution makes sense.
1:33:44
Speaker 1: Mary Alene says, thank you, Jared Ray and Coleen for
1:33:49
Speaker 1: your work in promoting freedom and healthcare. Many people think
1:33:52
Speaker 1: healthcare should be free because they need it, but it
1:33:57
Speaker 1: makes doctors slaves and someone has to pay Gumany volment
1:34:00
Speaker 1: in healthcare is horrific. There's no question there. But thank you,
1:34:05
Speaker 1: Mary Ellen.
1:34:07
Speaker 4: Uh I will say I'll jump in with one quick
1:34:11
Speaker 4: comment and this kind of gets back to like the
1:34:14
Speaker 4: the vision of health being like the start of it,
1:34:18
Speaker 4: which is that like when you're having the conversation with
1:34:23
Speaker 4: people and you and you put it in the terms
1:34:25
Speaker 4: right like of of would this be something that you want?
1:34:28
Speaker 2: Do you do?
1:34:28
Speaker 4: You want control over how you pursue health and and
1:34:32
Speaker 4: and the freedom to do so and everything. You know,
1:34:34
Speaker 4: like when you when you do come across somebody who
1:34:37
Speaker 4: is is just like really fixated on the on the
1:34:40
Speaker 4: need aspector or the you know what, what about the
1:34:43
Speaker 4: person who can't uh get that if you at least
1:34:48
Speaker 4: get them to kind of agree to the core idea
1:34:52
Speaker 4: that that the freedom is the is something that they
1:34:55
Speaker 4: would want for themselves.
1:34:56
Speaker 2: There at least they're usually less.
1:35:00
Speaker 4: They're less willing to stand in the way of of
1:35:02
Speaker 4: other people that are that are they are trying to
1:35:06
Speaker 4: pursue health as they see fit, and so it just
1:35:08
Speaker 4: kind of changes. That's not some sort of like knocked
1:35:11
Speaker 4: out argument or something, but that it's kind of changes
1:35:13
Speaker 4: the whole perspective of that conversation. And then and then
1:35:17
Speaker 4: you can it leads to a different conversation about like
1:35:19
Speaker 4: needs and so.
1:35:20
Speaker 1: Forthright, RFL says, I see doctors practice medicine with clinical
1:35:26
Speaker 1: guidelines and if then then that approach. Do you think
1:35:30
Speaker 1: this undermines progress as it discourages understanding of underlying biological mechanisms.
1:35:38
Speaker 2: Oh, yeah, that's you. I think, not clinical.
1:35:42
Speaker 5: So I think there's I think it's the answer to
1:35:47
Speaker 5: that is a little bit more nuanced than Yes. No, Unfortunately,
1:35:53
Speaker 5: I think it can. I think test checklist medicine can
1:35:59
Speaker 5: result in doctors looking at a checklist and making decisions
1:36:05
Speaker 5: based on the checklist. And I think, you know, there
1:36:07
Speaker 5: are cases where that's a good thing because it provides
1:36:10
Speaker 5: you kind of a mental model, so you know, you
1:36:12
Speaker 5: can hold only so many things in your head at
1:36:14
Speaker 5: one time, and if you you know, it's like three
1:36:17
Speaker 5: plus or minus two or five plus or minus two,
1:36:20
Speaker 5: and so to fall back on checklists and mnemonics and
1:36:25
Speaker 5: things like that, in order to try to, you know,
1:36:27
Speaker 5: especially in emergencies or in situations that maybe you're not
1:36:30
Speaker 5: super familiar with, Like those things are good to have,
1:36:34
Speaker 5: and I think kind of clinical guidelines are meant to
1:36:37
Speaker 5: sort of fit in that place. But it is very
1:36:40
Speaker 5: much the case that clinical guidelines are often based on
1:36:45
Speaker 5: evidence that isn't so strong, and usually those guidelines will say,
1:36:49
Speaker 5: you know, this is you know, if like say the
1:36:52
Speaker 5: American Heart Association comes out with guidelines on how to
1:36:54
Speaker 5: treat cholesterol, they'll give a lot of recommendations and it'll
1:36:59
Speaker 5: say this is based on level A evidence, meaning like
1:37:02
Speaker 5: we've got really great studies and years and years of research,
1:37:06
Speaker 5: or this is based on level D evidence, and a
1:37:09
Speaker 5: lot of people will read those guidelines and maybe not
1:37:12
Speaker 5: recognize how good the evidence is for some of the
1:37:14
Speaker 5: things that are there. And so yes, I think guidelines
1:37:17
Speaker 5: can be kind of a crutch for doctors, kind of
1:37:21
Speaker 5: can move them away from making individualized decisions for their patients.
1:37:27
Speaker 5: That being said, I also think that it's important to
1:37:30
Speaker 5: have those summaries because you only can do so much,
1:37:33
Speaker 5: and you only can learn so much, and you can
1:37:35
Speaker 5: only read so much. Most doctors who I know, most
1:37:40
Speaker 5: of my colleagues. We spend a lot of time when
1:37:43
Speaker 5: new guidelines come out talking about and we do this
1:37:46
Speaker 5: for ourselves so that we don't fall back on that
1:37:49
Speaker 5: crutch talking about things like, Okay, here's this new guideline.
1:37:53
Speaker 5: For one that I deal with a lot is for CPR,
1:37:59
Speaker 5: because I do cp A on patients all the time
1:38:01
Speaker 5: in the emergency department, and there are a lot of
1:38:03
Speaker 5: guidelines on what medications to give during CPR and how
1:38:06
Speaker 5: fast should you give chest compressions and all these different things.
1:38:09
Speaker 5: And so every time a new set of guidelines comes out,
1:38:12
Speaker 5: I look at it with my colleagues and we discuss, well,
1:38:14
Speaker 5: why do they make this change, where did this come from?
1:38:17
Speaker 5: And and so what that ultimately results in is that
1:38:20
Speaker 5: and I think that this is in my responsibility as
1:38:22
Speaker 5: a doctor to do. And this is why, like how
1:38:26
Speaker 5: I am a good doctor is that I don't rely
1:38:28
Speaker 5: one hundred percent on the guideline. But for things that
1:38:32
Speaker 5: are not in my wheelhouse that I don't do all
1:38:34
Speaker 5: the time, like treating cholesterol, I might just read the
1:38:38
Speaker 5: guideline because I'm not treating people's cholesterol. And so that
1:38:41
Speaker 5: way I have some sense of it. If I have
1:38:43
Speaker 5: a patient that comes to the ED and I think, like, ah,
1:38:45
Speaker 5: that guy probably should be on a statin. I can
1:38:48
Speaker 5: say to him, you might like, based on my understanding
1:38:52
Speaker 5: of the guidelines, you should maybe talk to your primary
1:38:54
Speaker 5: care doctor about starting a statin or a drug for
1:38:56
Speaker 5: your high blood pressure. But I'm not going to start it.
1:38:59
Speaker 5: But I know the guideline enough that I can kind
1:39:02
Speaker 5: of have a set so I so, you know, like
1:39:04
Speaker 5: the guidelines have a real role. They're important, but also
1:39:07
Speaker 5: it's a come upon doctors to go deeper than the
1:39:10
Speaker 5: guidelines for the things that are part of what they
1:39:12
Speaker 5: do all the time.
1:39:15
Speaker 1: Good Linda really likes you have. It's quote real markets
1:39:18
Speaker 1: and real prices would fix healthcare.
1:39:21
Speaker 2: That's from my Twitter profile. I think, right there you go.
1:39:25
Speaker 1: She's impressed. Marius says, it's the enormous cost of healthcare
1:39:30
Speaker 1: in the United States a problem of supply or demand
1:39:34
Speaker 1: or both.
1:39:36
Speaker 4: Oh boy, so this is the this is the ove
1:39:39
Speaker 4: Reinhart paper famously from U from a couple of decades ago.
1:39:44
Speaker 4: We've been we've been talking about it for that long. Well,
1:39:48
Speaker 4: so it's yeah, supplier demand, it's it's the prices in
1:39:53
Speaker 4: many in many ways in the lack of lack thereof
1:39:57
Speaker 4: you know, there have been there have been a lot
1:39:58
Speaker 4: of debates over like weather or you know, do we
1:40:00
Speaker 4: do we really order more stuff than other countries and
1:40:04
Speaker 4: and and when you look at that, it's it's not
1:40:06
Speaker 4: really clear that that's the case. And if so, if
1:40:10
Speaker 4: we're spending more, if you know, I mean, if if
1:40:13
Speaker 4: what you're spend, you know, expenditure is going to be
1:40:16
Speaker 4: volume times price, right, and so that that tells you
1:40:20
Speaker 4: what your national expenditure is.
1:40:21
Speaker 2: So if if if you.
1:40:23
Speaker 4: Look at our utilization, how many tests we're ordering, and
1:40:26
Speaker 4: how many surgeries we're doing that sort of thing, and
1:40:28
Speaker 4: how many patient visits there are, if they're not that
1:40:31
Speaker 4: out of line with other countries, then then it must
1:40:33
Speaker 4: be the prices. And that is that you know that
1:40:36
Speaker 4: that that seems to be the more of the culprit here, which.
1:40:40
Speaker 1: Means we're not allow supplying demand to work. We're not allowing.
1:40:43
Speaker 2: Yeah yeah, yeah, yeah, oh yeah.
1:40:45
Speaker 4: So it absolutely does come back to supply and demand
1:40:47
Speaker 4: in that sense, because we don't have like a functioning
1:40:49
Speaker 4: of a functioning price system.
1:40:51
Speaker 1: Really yeah right, multen splendor again, what is your opinion
1:40:58
Speaker 1: on the Joint Mission accreditation. I don't know what that is,
1:41:04
Speaker 1: so maybe you guys know what that is.
1:41:05
Speaker 2: The Joint Commission. Now it's not yeah, yeah, here we go.
1:41:08
Speaker 5: Okay, So the Joint Commission is an accrediting body for hospitals.
1:41:12
Speaker 5: They may accredit other things too, But I work at
1:41:14
Speaker 5: a hospital, so that's my that's how I know about them.
1:41:17
Speaker 5: They come by every now and then. Sometimes it's because
1:41:20
Speaker 5: there's a complaint, but other times it's just a regular
1:41:22
Speaker 5: scheduled visit and they go through the whole hospital and
1:41:25
Speaker 5: they check records and they they like make sure that
1:41:28
Speaker 5: you don't have expired things, and they make sure doctors
1:41:31
Speaker 5: aren't drinking water in the patient care space, which, by
1:41:34
Speaker 5: the way, I drink water in the patient care space
1:41:36
Speaker 5: all the time, and when Joint Commission comes, I put
1:41:38
Speaker 5: my bottle of water in the drawer. You can tell
1:41:44
Speaker 5: on me if you want to. But I have to
1:41:46
Speaker 5: drink water in a twelve hour shift, sure, and I
1:41:50
Speaker 5: only work in the patient care space, So I don't
1:41:52
Speaker 5: know what you want from me, Joint Commission. In any case,
1:41:55
Speaker 5: I think that there is a role for having group
1:42:00
Speaker 5: that go to hospitals and say, like, this hospital is
1:42:04
Speaker 5: clean and this hospital is doing things that result in
1:42:08
Speaker 5: good patient outcomes, and this hospital is like gross and
1:42:13
Speaker 5: their pharmacy has like mold growing in it, and you
1:42:16
Speaker 5: don't want to go there.
1:42:18
Speaker 1: Yep.
1:42:19
Speaker 5: But I think that those should be private groups, like
1:42:22
Speaker 5: the way that we have Consumer Reports magazine, and you can,
1:42:26
Speaker 5: as a consumer can read those reports and say, I
1:42:29
Speaker 5: don't want to go to this hospital. I want to
1:42:32
Speaker 5: go to that hospital because like the consumer report for
1:42:36
Speaker 5: hospitals said that there's mold growing in their pharmacy. Instead,
1:42:40
Speaker 5: what we have is one accrediting body. Maybe we have two,
1:42:44
Speaker 5: but really we have in like because we have OSHA,
1:42:47
Speaker 5: there are sort of like other groups that kind of
1:42:49
Speaker 5: look at other things, but really we have just this
1:42:52
Speaker 5: like one accrediting body, and like we kind of most
1:42:59
Speaker 5: hospitals to some degree fudge what's going on there. They
1:43:03
Speaker 5: just do the same way that I put my water
1:43:06
Speaker 5: bottle in the drawer, Like I actually don't think my
1:43:08
Speaker 5: water bottle is putting patients at risk. Actually most of
1:43:12
Speaker 5: the things that get fudged aren't putting patients at risk.
1:43:15
Speaker 5: But but it's just like, you know, just to give
1:43:21
Speaker 5: an example though of something that kind of does one
1:43:24
Speaker 5: of the things that Joint Commissions looks at is central
1:43:27
Speaker 5: line infections. So if you have some number of central
1:43:30
Speaker 5: line infections, so central line is a big IV that
1:43:33
Speaker 5: gets put in the veins of your neck or you're
1:43:37
Speaker 5: growin like in your inguinal area in order to deliver
1:43:41
Speaker 5: like really strong medicine. That either would be that either
1:43:45
Speaker 5: would hurt your arm if we put it through the arm,
1:43:48
Speaker 5: or is like is active at your heart and so
1:43:51
Speaker 5: you need to deliver it right to your heart. So
1:43:55
Speaker 5: we put those lines in people all the time, and
1:43:58
Speaker 5: there's a slight risk of getting infected, and those infections
1:44:01
Speaker 5: are worse than like a regular ivy infection because the
1:44:03
Speaker 5: ivy goes down to your heart. So when we put
1:44:06
Speaker 5: those lines in, we do like a whole sterile thing
1:44:09
Speaker 5: like in the operating room. But sometimes they still get infected.
1:44:12
Speaker 5: So if they get infected, you get dinged by Joint commission.
1:44:16
Speaker 5: And if you have some number of infections, then you
1:44:18
Speaker 5: your hospital like goes down in ranking. So instead what
1:44:22
Speaker 5: we start doing is putting in this thing called a midline. Well,
1:44:26
Speaker 5: a midline is this like tunneled IV that starts like
1:44:29
Speaker 5: here and you tunnel it through the arm into your heart. Well,
1:44:33
Speaker 5: if so so like if and they don't. They don't
1:44:37
Speaker 5: track midline infections, but it's still an IV that goes
1:44:40
Speaker 5: right into your heart. It's just Joint Commission doesn't track
1:44:42
Speaker 5: the infection and you don't have to do the whole
1:44:45
Speaker 5: sterile feel for it because Joint Commission doesn't track the infection.
1:44:49
Speaker 5: So now you're doing this like you're clean. You're like
1:44:51
Speaker 5: doing sterile gloves and sterile stuff, but it's not as sterile,
1:44:55
Speaker 5: so your actual risk of infection is like a little
1:44:58
Speaker 5: bit higher with the midline. So personally, I have I
1:45:01
Speaker 5: don't do midlines because I actually think that they result
1:45:04
Speaker 5: in us being So the hospitals get annoyed at me
1:45:07
Speaker 5: because I will refuse to do the midline because I
1:45:09
Speaker 5: know I'm doing a sterile line with the central line,
1:45:11
Speaker 5: and I think my outcomes are tracked and I can
1:45:14
Speaker 5: look and see, am I having steril line infection? Like
1:45:17
Speaker 5: infections with my lines? But other But but the hospitals
1:45:20
Speaker 5: are pushing us to start doing this other kind of
1:45:22
Speaker 5: line because JACO doesn't track it, not because it's better
1:45:25
Speaker 5: for patients, not because not because it saves money, not
1:45:29
Speaker 5: because anything.
1:45:29
Speaker 1: And that would go away if there was real competition
1:45:32
Speaker 1: in in uh, you know, doing the service right in
1:45:37
Speaker 1: reading hospitals.
1:45:38
Speaker 4: Yeah, more good housekeeping, more more underwriters, laboratories that those
1:45:43
Speaker 4: kinds of things.
1:45:44
Speaker 2: Yeah.
1:45:44
Speaker 1: Yeah, competition would drive out the stupid stuff and and
1:45:48
Speaker 1: keep the good stuff.
1:45:49
Speaker 5: And insurance companies would also look to look at hospitals
1:45:53
Speaker 5: and evaluate hospitals and track these things and and warn
1:45:58
Speaker 5: they're not They probably wouldn't like, they wouldn't say, oh,
1:46:01
Speaker 5: we're not going to work with the hospital. They would
1:46:02
Speaker 5: go to their patients, their clients and say, you know, hospital,
1:46:07
Speaker 5: warn them not to go to hospital acts.
1:46:11
Speaker 1: So say Linda says, I'll be sixty two next month
1:46:14
Speaker 1: and I'm considering taking SO Security that I've paid into
1:46:18
Speaker 1: since I was fifteen. Is this likely to affect my
1:46:21
Speaker 1: health care insurance? No, no, no relation between the two.
1:46:27
Speaker 2: Yeah, not really.
1:46:29
Speaker 1: Yeah, although you get a big better bang for your
1:46:32
Speaker 1: buck if you wait until you're seventy to take out
1:46:34
Speaker 1: SO security. Yeah, just financial advice.
1:46:39
Speaker 2: Now.
1:46:39
Speaker 4: I don't know, maybe there's some sort of creative thing
1:46:41
Speaker 4: where you like, take out more, or you wait and
1:46:43
Speaker 4: then you put it in an HSA somehow, or I
1:46:47
Speaker 4: don't know, maybe there's something there.
1:46:48
Speaker 1: Oh, they might do something there.
1:46:49
Speaker 5: Yeah, yeah, that's interesting. I hadn't thought of that.
1:46:52
Speaker 4: I maybe ponder a little bit more on that, but yeah,
1:46:55
Speaker 4: off the top of my head. Now, I don't think
1:46:56
Speaker 4: there's a real connection.
1:46:58
Speaker 1: Michael says. Is Trump doing anything to deregulate healthcare? Perhaps?
1:47:09
Speaker 4: Ye? Little things, right, I mean, like even let's let's
1:47:13
Speaker 4: just to talk about the great Healthcare plan there again?
1:47:16
Speaker 1: Right?
1:47:16
Speaker 4: That Again, there was a as you'd expect, you know,
1:47:19
Speaker 4: a bit of a mix. There's there's things in there
1:47:22
Speaker 4: where he talks about let's let's make more medications available
1:47:26
Speaker 4: over the counter.
1:47:28
Speaker 2: Then there might be something to that. Actually, I'm actually not.
1:47:31
Speaker 4: Sure why he would need Congress to act on this.
1:47:34
Speaker 4: He's you know, the whole thing is is positive as
1:47:37
Speaker 4: I'm going to call on Congress to do this, because
1:47:39
Speaker 4: that's actually an FDA kind of thing, unless unless what
1:47:42
Speaker 4: he's doing is changing the legal like the statute standard,
1:47:47
Speaker 4: because the standard on that is, uh, it's supposed to
1:47:52
Speaker 4: be that if if there's more cost, if there's more
1:47:55
Speaker 4: benefit than cost of letting people self administer than you
1:47:59
Speaker 4: can do over the counter, and if it's too risky
1:48:02
Speaker 4: in some way more costant benefit, then then it.
1:48:05
Speaker 2: Needs to be prescribed only.
1:48:06
Speaker 4: So anyway, he's he's like proposed to talk about that
1:48:09
Speaker 4: and maybe revisit that. So there's some good there, and
1:48:13
Speaker 4: you know, we talked about HSA's being some.
1:48:15
Speaker 5: Good and maybe that that goes to pharmacists though that
1:48:18
Speaker 5: like maybe pharmacists will be able to prescribe some amount
1:48:20
Speaker 5: of medication, which would be fine I think also anyway, sorry,
1:48:24
Speaker 5: but as.
1:48:24
Speaker 1: You said that nothing is actually moving on that, right.
1:48:26
Speaker 1: There's no actually legislation anyway, not that.
1:48:28
Speaker 5: I can find. No, it's just.
1:48:31
Speaker 4: A fact sheet that that came out, which, by the way,
1:48:34
Speaker 4: like totally by surprise, Like I don't think anybody was
1:48:38
Speaker 4: expecting last Thursday.
1:48:40
Speaker 2: Yeah, you know, midday Thursday.
1:48:43
Speaker 4: Like all of a sudden, there's this announcement that there's
1:48:45
Speaker 4: a great plan. But it's really it's like a one pager,
1:48:48
Speaker 4: just a fact sheet.
1:48:49
Speaker 2: We haven't seen.
1:48:50
Speaker 1: Anything, and we haven't seen anything from ran Paul. Ran
1:48:52
Speaker 1: Paul's me talking about promoting some kind of free market
1:48:55
Speaker 1: healthcare bill, but nothing should come I don't think.
1:49:00
Speaker 2: So I know he was involved.
1:49:01
Speaker 4: He expressed he actually came to campus over here a
1:49:05
Speaker 4: couple of weeks ago and he and he talked about
1:49:08
Speaker 4: he pulled the audience on whether, uh what was it,
1:49:13
Speaker 4: whether snap benefits should be like, uh should be whether
1:49:18
Speaker 4: you should be able to like buy sugary beverages right
1:49:21
Speaker 4: with with your with your kind of food stamp at
1:49:24
Speaker 4: benefit right and and you know there's a mix of
1:49:27
Speaker 4: opinions in the audience.
1:49:28
Speaker 2: I mean that that's one that kind of goes everywhere here.
1:49:29
Speaker 4: You could you could have a endless debate about that.
1:49:32
Speaker 4: But yeah, like that's the only like health relay thing
1:49:35
Speaker 4: that I know that he's currently working on. I mean,
1:49:37
Speaker 4: he's been good in the past on some things. Yeah,
1:49:41
Speaker 4: but yeah, I don't know if he's working on anything
1:49:42
Speaker 4: right now.
1:49:44
Speaker 5: As far as I know, he's working on a health
1:49:45
Speaker 5: savings account.
1:49:47
Speaker 1: Yeah, he was doing something first time that Trump came
1:49:50
Speaker 1: out with, well, we'll give this money to individuals instead
1:49:53
Speaker 1: of the insurance companies. He was trying to put something
1:49:58
Speaker 1: together around that. I don't know if anything came of it.
1:50:02
Speaker 4: Some of that language has appeared in maybe even the
1:50:06
Speaker 4: Great Health Plant health Care Plan. But again, like Ray
1:50:10
Speaker 4: was talking about, like it's you got to be careful
1:50:12
Speaker 4: with that because it's like, why are we demonizing the
1:50:15
Speaker 4: health insurance companies?
1:50:17
Speaker 2: Exactly. And and the.
1:50:18
Speaker 4: Other thing is like, what how are you going to
1:50:20
Speaker 4: design that intervention or or if it's a repeal, if
1:50:23
Speaker 4: it's a if it's a you know, really is a deregulation,
1:50:25
Speaker 4: then how are you going to design the deregulation so
1:50:27
Speaker 4: that so the money really like somehow stays with the
1:50:31
Speaker 4: with the person, because if you're giving it to the
1:50:33
Speaker 4: person so they didn't go by an insurance plan, you know,
1:50:36
Speaker 4: that's that that may or may not have any desired effect.
1:50:40
Speaker 3: Although I think it should be pointed out that even
1:50:43
Speaker 3: though this is just like a fact sheet, he had
1:50:45
Speaker 3: a similar fact sheet when he announced that, oh, I'm
1:50:48
Speaker 3: gonna lower drug prices by telling drug companies to charge
1:50:53
Speaker 3: only what they charge in other countries. And at that
1:50:55
Speaker 3: time it was not at all clear how he was
1:50:57
Speaker 3: going to do that. But in the meantime, like he's
1:51:01
Speaker 3: like come up with his own like I thing and
1:51:06
Speaker 3: uh like deals with I believe it's Pfizer or something
1:51:10
Speaker 3: on like.
1:51:10
Speaker 5: Some couple of drug companies.
1:51:12
Speaker 3: Think yeah, exactly, So like if that's any indication, like
1:51:15
Speaker 3: we're going to have like a deal maker in a
1:51:20
Speaker 3: chief go help a shop for insurance by bullying insurance companies.
1:51:26
Speaker 4: Yeah, we have one deal at a time. I mean,
1:51:28
Speaker 4: how what kind of Yeah, so ye wouldn't.
1:51:32
Speaker 3: Call that deregulation.
1:51:33
Speaker 1: No, right, Richard says, I had a great experience this
1:51:37
Speaker 1: month with hot ablation, and wonder about the sustainability of
1:51:43
Speaker 1: that level of care. My Medicaid plus supplement premium is
1:51:48
Speaker 1: seventy five dollars of my pre medicare seventy of my
1:51:52
Speaker 1: pre medicaire premium. Will seniors end up paying retail?
1:51:58
Speaker 5: I mean maybe, but actually, something like a heart ablation
1:52:03
Speaker 5: like what you had, that's the kind of thing that
1:52:05
Speaker 5: prevents people from ending up having heart failure long term.
1:52:09
Speaker 5: So that's exactly the sort of thing that a health
1:52:12
Speaker 5: insurance policy would want to cover if you really had
1:52:15
Speaker 5: a long term health insurance policy, because often it's for
1:52:19
Speaker 5: an abnormal heart rhythm or an arrhythmia, usually atrial fibrillation,
1:52:23
Speaker 5: and people can live in atrial fibrillation, but many of
1:52:27
Speaker 5: them will have heart failure as a result of being
1:52:29
Speaker 5: in atrial fibrillation, and so this ablation prevents them from
1:52:34
Speaker 5: developing heart failure, keeps them off of medication that can
1:52:37
Speaker 5: be risky, does all sorts of great things, and it's
1:52:40
Speaker 5: like a one shot procedure that often fixes all of
1:52:43
Speaker 5: those things. So like, this is a sort of thing
1:52:46
Speaker 5: that I think, you know, in a kind of rational
1:52:51
Speaker 5: world with good health insurance that was long term, a
1:52:54
Speaker 5: health insurance policy would cover that because of the impact
1:52:58
Speaker 5: that would have on your life long term.
1:53:01
Speaker 1: And they're expensive, right, Neil, Why does the American public
1:53:08
Speaker 1: view the current health care model as capitalist free market
1:53:11
Speaker 1: and one more of a Scandinavian style system.
1:53:15
Speaker 3: I mean, because that's what we've been sold, right and
1:53:21
Speaker 3: and and you can really trace that history back when
1:53:25
Speaker 3: when when the AMA was fighting against the passage of Medicare,
1:53:31
Speaker 3: and even before that they were fighting Truman's National Health
1:53:36
Speaker 3: Insurance Bill. They were saying, we're fighting for the free market,
1:53:39
Speaker 3: But what were they actually fighting for. They were fighting
1:53:41
Speaker 3: for a very particular arrangement between doctors and insurance companies.
1:53:46
Speaker 3: Right after they went after group practices, right so right,
1:53:53
Speaker 3: like whereas if they should let the group practices flourish,
1:53:55
Speaker 3: that would have been the free market, they said, no,
1:53:58
Speaker 3: we want a particular but we're going to tell the
1:54:01
Speaker 3: American people that this is the voluntary system. And like that,
1:54:05
Speaker 3: that kind of trick has been repeated over and over again.
1:54:08
Speaker 3: You see it now also with like Medicare advantage, right,
1:54:11
Speaker 3: like like some kind of idea that by private companies
1:54:18
Speaker 3: taking your Medicare dollars, that this is somehow private, but
1:54:23
Speaker 3: it's not. There's all sorts of rules and strings attached
1:54:26
Speaker 3: to what they can do, and then also perverse incentives, right,
1:54:30
Speaker 3: So like, in order for the government to get insurance
1:54:34
Speaker 3: to do Medicare advantage, they told them, We're going to
1:54:36
Speaker 3: pay you more to diagnose all sorts of illnesses so
1:54:43
Speaker 3: that you can take on sicker people because we don't
1:54:47
Speaker 3: want you to be disincentivized to do that. Well low
1:54:49
Speaker 3: and bull, hold what happened? Like they started coming up
1:54:51
Speaker 3: with all sorts of fake diagnoses, right and then yeah,
1:54:55
Speaker 3: and then they and and then people will say like, well,
1:54:57
Speaker 3: this is what happens when you let private insurance accept
1:55:02
Speaker 3: public dollars. Like no, it's it wasn't free to begin with.
1:55:05
Speaker 1: Yep.
1:55:06
Speaker 5: Yeah, And just to be the group practices that Ray
1:55:10
Speaker 5: is talking about, those were these groups of primary care
1:55:15
Speaker 5: doctors and specialists that were forming back before the Truman
1:55:18
Speaker 5: Plan a long time ago, and they were subscription based.
1:55:21
Speaker 5: So just like kind of like what direct primary care
1:55:24
Speaker 5: is now, except they included specialists, They sometimes included some
1:55:27
Speaker 5: hospital stays, and you would pay a subscription fee to
1:55:31
Speaker 5: basically have all of your healthcare taken care of. Specialists
1:55:33
Speaker 5: were involved, if you needed to see the cardiologists, if
1:55:35
Speaker 5: you needed your appendix out, whatever it was. But those
1:55:39
Speaker 5: doctors were literally run out of business.
1:55:42
Speaker 3: Yeah, So I think very often the concept of free
1:55:46
Speaker 3: market is used either to refer to the status quo
1:55:50
Speaker 3: or to some other preferred private arrangements which lets doctors
1:55:56
Speaker 3: or some other private interest group have a little bit
1:56:00
Speaker 3: more say about how the regulated system is run, as
1:56:04
Speaker 3: opposed to handing more over of it to the governments.
1:56:08
Speaker 3: But that's not really a free market.
1:56:12
Speaker 4: There's so many people just on the on the idea
1:56:15
Speaker 4: that if it's free and universal, that's government care, and.
1:56:19
Speaker 2: If it's not, it must be capitalism.
1:56:22
Speaker 4: Right now, there's all sorts of lots of radiations in between.
1:56:27
Speaker 1: Absolutely right, Nwick Cash. I've moved to concierge medicine. The
1:56:32
Speaker 1: combination of primary and cardiologists is about thirty thousand a year.
1:56:37
Speaker 1: Are the methods to find out which doctor is a
1:56:40
Speaker 1: best fit for concierge Where I can pay cash.
1:56:47
Speaker 5: I think it's different for everybody, but most When I
1:56:52
Speaker 5: was looking for a concierge doctor, I reached out to
1:56:54
Speaker 5: offices and most of them were happy to let me
1:56:56
Speaker 5: come and meet them and like interview them. Yep, you know,
1:57:01
Speaker 5: it's a lot of money to pay two thousand and
1:57:03
Speaker 5: five thousand dollars a year. Ultimately, I didn't go with
1:57:07
Speaker 5: anyone because I felt like I could deal with all
1:57:10
Speaker 5: the little many things myself, Like if I twist my ankle,
1:57:14
Speaker 5: I like I know whether I need an X ray
1:57:15
Speaker 5: or not, a lot of stuff. I can even just
1:57:18
Speaker 5: go to like the X ray text in my hospital
1:57:19
Speaker 5: and be like, hey, will you shoot this film and
1:57:21
Speaker 5: just let me look at it and if something's bad,
1:57:23
Speaker 5: I'll register.
1:57:24
Speaker 1: Ye.
1:57:24
Speaker 5: So so I didn't go with a concierge doctor, but
1:57:28
Speaker 5: but I did interview several and they were happy to
1:57:32
Speaker 5: set up times to meet with me for free.
1:57:36
Speaker 1: Good let's see multen splendid. Are they any legislative efforts
1:57:41
Speaker 1: commonly in the wooks to eliminate certificate of need requirements.
1:57:47
Speaker 2: Any But that's a state by state issue.
1:57:50
Speaker 4: So that's therein lies the challenge, the yeah, certificate of need,
1:57:55
Speaker 4: because I don't think it's come up today, I'll I'll
1:57:57
Speaker 4: just define it real quickly. So, certificate of need is
1:57:59
Speaker 4: basically like a permission slip that a let's say a
1:58:03
Speaker 4: hospital or a facility of any type would would would
1:58:08
Speaker 4: need to be would be required to get from their state,
1:58:11
Speaker 4: usually like a state and state commissioner of some sort.
1:58:15
Speaker 4: They have to basically they have to ask the state
1:58:17
Speaker 4: for permission to expand a service or open up a
1:58:20
Speaker 4: new wing, or add some beds to a hospital, or
1:58:24
Speaker 4: you know, become a new provider of something. Sometimes you
1:58:27
Speaker 4: have to get it for like to be to add
1:58:29
Speaker 4: a specific piece of equipment like an MRI machine. And
1:58:34
Speaker 4: anyway that it's a it's something that came into vogue
1:58:37
Speaker 4: a long time ago, as this is this idea of
1:58:39
Speaker 4: well if we restrict supply, then then aren't we restricting
1:58:43
Speaker 4: like overall expenditure. Of course, you know we talked earlier
1:58:47
Speaker 4: about like what that does to price if you restrict supply.
1:58:49
Speaker 4: But long story short is at a lot of a
1:58:53
Speaker 4: lot of plates, a lot of states had certificate of
1:58:56
Speaker 4: need laws, and then starting around like late seventies early eighties,
1:59:01
Speaker 4: they some states started getting rid of them, seeing that
1:59:04
Speaker 4: it wasn't really that effective and and so now but
1:59:07
Speaker 4: we still have a lot of states that do have them.
1:59:08
Speaker 4: I want to say, it's like thirty six states that
1:59:10
Speaker 4: still remember yeah right, yeah, because and and and there
1:59:15
Speaker 4: are some moments where some states would like repeal them,
1:59:19
Speaker 4: you know, and and so anyway that that that has
1:59:21
Speaker 4: there's so there's there's some activity there and you know,
1:59:25
Speaker 4: it's it's something that we uh deal with and and
1:59:28
Speaker 4: and we'll be writing about and you know, if if
1:59:31
Speaker 4: any like the state that I happened to be in
1:59:34
Speaker 4: New Hampshire, we actually technically got rid of our Certificate
1:59:36
Speaker 4: of need law, but we kind of replaced it with
1:59:40
Speaker 4: something else that's that's not great either. And so there's
1:59:42
Speaker 4: still work to be done there. And uh, anyway, there's
1:59:46
Speaker 4: there's just other other states that will that that where
1:59:50
Speaker 4: these bills will come up from time to time.
1:59:51
Speaker 2: So and the takeaway there is that you unfortunately you.
1:59:54
Speaker 4: Have to you have to follow each state individually and
1:59:56
Speaker 4: so you know see what each debate is happening.
2:00:00
Speaker 5: Yeah, but this is something that hopefully at a national level,
2:00:03
Speaker 5: if it got enough attention, it wouldn't take that much
2:00:07
Speaker 5: to change, you know, in some sort of omnibus bill
2:00:10
Speaker 5: to add something in and just make a small change
2:00:14
Speaker 5: and they would be gone.
2:00:15
Speaker 4: Kind of wondered from time to time, like wonder is
2:00:17
Speaker 4: there some sort of test case that could, like I
2:00:20
Speaker 4: don't know, declare them like unconstitutional or something. I mean,
2:00:24
Speaker 4: I see that that's where my I may be a
2:00:26
Speaker 4: policy guy, but I'm not a constitutional lawyer. I don't
2:00:29
Speaker 4: like no law like that, So so I don't know.
2:00:33
Speaker 2: Probably not.
2:00:33
Speaker 1: But at some point if a hospital has denied expansion
2:00:38
Speaker 1: because of it, they could sue under the constitution. I
2:00:42
Speaker 1: don't know how far they would get, you know, it's
2:00:45
Speaker 1: how to tell how how it would be antipidate, You
2:00:47
Speaker 1: have to ask somebody from IGOR.
2:00:49
Speaker 5: Well. Part of the problem also, though, is that the
2:00:54
Speaker 5: certificate of need, the like decision on Certificate of need
2:00:59
Speaker 5: applications and part art is a little bit of like
2:01:04
Speaker 5: a community thing, and so large hospitals have representatives on
2:01:08
Speaker 5: that Certificate of Need board who will vote down, vote
2:01:11
Speaker 5: no on certificate of need applications to decrease the competition
2:01:17
Speaker 5: that they face. So it's become it, you know, it's
2:01:21
Speaker 5: it really is a major issue, and I think it
2:01:23
Speaker 5: is one of the things that would free up the
2:01:27
Speaker 5: producer side of things if we could get rid of them.
2:01:31
Speaker 1: So we have any of you know anything about this
2:01:34
Speaker 1: but healthcare and the POC. I assume that's China, which
2:01:40
Speaker 1: is better us. Do you know anything about health care
2:01:42
Speaker 1: and China?
2:01:45
Speaker 2: Not a lot?
2:01:46
Speaker 4: But I'll say this and maybe I should I'll be
2:01:50
Speaker 4: a little koy here not use a name. But we
2:01:53
Speaker 4: have on our board a well known, very thoughtful and
2:02:00
Speaker 4: good speaking objectivists who who has spent many years in
2:02:05
Speaker 4: China living there and uh, and he's he's got some
2:02:09
Speaker 4: stories and so I feel like I can't say too
2:02:12
Speaker 4: much more. Ray you lived in China, for which I
2:02:15
Speaker 4: just recently I just recently learned you. But you you
2:02:18
Speaker 4: lived in China for a little while, did you have
2:02:20
Speaker 4: any experience with it?
2:02:21
Speaker 3: I mean I was a young, healthy man, so fortunately
2:02:23
Speaker 3: I didn't have to engage much in that. But from
2:02:26
Speaker 3: what I do understand, UH, there is more UH in
2:02:32
Speaker 3: certain cases, like if you go outside of the public hospitals,
2:02:35
Speaker 3: more direct pay right and and maybe that might also
2:02:39
Speaker 3: have to do a different attitudes around Chinese medicine. Historically
2:02:44
Speaker 3: that it was seemed more as like compatible or similar
2:02:48
Speaker 3: to other forms of merchants and business that that's just
2:02:52
Speaker 3: like less of a taboo there. But but what country
2:02:55
Speaker 3: where we contrasting this with period United States?
2:03:00
Speaker 1: Yeah, I mean they generally the China has less welfare
2:03:03
Speaker 1: programs than we do. Right, the communist program in China
2:03:07
Speaker 1: is very low on welfare and redistribution of wealth and
2:03:11
Speaker 1: socialized medicine. You have to pay for stuff in China.
2:03:13
Speaker 1: There's a lot more if you don't. If you don't pay,
2:03:16
Speaker 1: you don't get treated. There's all more of that in
2:03:18
Speaker 1: China than there's in the US.
2:03:21
Speaker 5: More.
2:03:22
Speaker 1: Yeah.
2:03:23
Speaker 3: Well, I will say, if there's any country that I
2:03:27
Speaker 3: would want to be and if I'm very sick and
2:03:29
Speaker 3: you know, have have good insurance, it is here.
2:03:31
Speaker 2: In the US.
2:03:32
Speaker 1: Yes, all right, I think this is the last question.
2:03:37
Speaker 1: Mary Alan says, my conscierge doctor advised me not to
2:03:40
Speaker 1: sign up for Medicare advantage because she thought she because
2:03:46
Speaker 1: she couldn't refer me to the doctor she preferred. Any thoughts, I.
2:03:53
Speaker 5: Mean, I think this is this is sort of a
2:03:58
Speaker 5: problem across the board that you know, in the in
2:04:03
Speaker 5: the so called private sector, doctors who take so called
2:04:06
Speaker 5: health insurance only take certain insurances and not others. And
2:04:12
Speaker 5: so if you want to be able to to see
2:04:17
Speaker 5: a particular doctor, you have to either make sure that
2:04:20
Speaker 5: your insurance will pay for them by calling them, don't
2:04:24
Speaker 5: look online because the list online is usually wrong or outdated,
2:04:29
Speaker 5: and and you never know. They might take not take
2:04:34
Speaker 5: your insurance today and they'll take it in a year,
2:04:36
Speaker 5: or they might take it today and then they won't
2:04:38
Speaker 5: take it in a year. There's no way to know.
2:04:43
Speaker 4: This is this is a little bit different than like
2:04:44
Speaker 4: a narrow network kind of question, but sort of the same.
2:04:47
Speaker 4: And the one kind of add on I would say
2:04:50
Speaker 4: is that the development of narrow networks is a little
2:04:55
Speaker 4: bit yeah.
2:04:57
Speaker 2: I mean some ways you.
2:04:58
Speaker 4: Could think of it as like an a vation, but
2:05:00
Speaker 4: it's really sort of like an attempt on the part
2:05:05
Speaker 4: of insurers to reigning costs in some way because they
2:05:09
Speaker 4: don't really have a lot of other options. We've sort
2:05:11
Speaker 4: of taken away other options for them to you know,
2:05:14
Speaker 4: just design their plan in a way that they that
2:05:16
Speaker 4: they can that they would like, and to to address costs,
2:05:22
Speaker 4: you know, using other means.
2:05:25
Speaker 2: It's hard.
2:05:27
Speaker 1: Great. Well, thanks guys, really appreciate you joining me today. Thanks.
2:05:32
Speaker 1: Oh Chad, maybe you want to say something about what
2:05:35
Speaker 1: people can find out more information about.
2:05:38
Speaker 4: Yeah, yeah, well just in closing, yeah, thanks thanks for
2:05:41
Speaker 4: having us on.
2:05:42
Speaker 2: This has been really fun.
2:05:43
Speaker 4: We uh we're you know, we've got a lot of
2:05:45
Speaker 4: things going on this this uh, this year, it's going
2:05:48
Speaker 4: to be it's always a big year in healthcare. Right,
2:05:51
Speaker 4: everybody is unhappy, and we're going to be looking through
2:05:55
Speaker 4: uh to you know, to to to to say, shed
2:06:00
Speaker 4: some light on these issues. You know, and and no
2:06:03
Speaker 4: matter where you are in the sort of in your
2:06:06
Speaker 4: understanding of like health policy. I mean, it is a
2:06:08
Speaker 4: really complicated issue. But you know, wherever you are, and
2:06:13
Speaker 4: if you if you find the the the sort of
2:06:15
Speaker 4: high level analysis of topics helpful, that's great. Well we'll
2:06:20
Speaker 4: be producing that kind of stuff. If you're a policy
2:06:22
Speaker 4: wonk and you want to like follow us along while
2:06:25
Speaker 4: we you know, testify on some bill someplace, or you know,
2:06:29
Speaker 4: get get way down in the d down in the weeds.
2:06:32
Speaker 2: You know, we do that too. So it's the whole range.
2:06:34
Speaker 4: So you know, whatever you're if you're genuinely interested in health,
2:06:37
Speaker 4: you know, follow us. We're on center fromodernhealth dot org.
2:06:41
Speaker 4: We've also got a Twitter or x account, and we
2:06:47
Speaker 4: we look forward to you know, connecting with everybody out there.
2:06:50
Speaker 4: Thank you, you're on again and thanks to your your
2:06:52
Speaker 4: awesome audience, great questions and good yeah, thank you everything.
2:06:56
Speaker 1: Thanks guys, the rest of you. I will see you
2:06:58
Speaker 1: later tonight for a regular news show. And thank you Colleen,
2:07:04
Speaker 1: Thank you, Jed, thank you A. I'm sure I'll see
2:07:07
Speaker 1: you on the show sometimes in the future.
2:07:10
Speaker 5: Bye, guys, great, thanks so much for having us