1 00:00:04,519 --> 00:00:08,399 Speaker 1: On this episode of News World, thirty million Americans lack 2 00:00:08,560 --> 00:00:11,400 Speaker 1: formal health insurance. Many of the rest of us live 3 00:00:11,440 --> 00:00:14,600 Speaker 1: in constant danger of losing our coverage if we lose 4 00:00:14,640 --> 00:00:17,800 Speaker 1: our jobs, give birth, get older, get healthier, get richer, 5 00:00:17,960 --> 00:00:22,040 Speaker 1: or move. Even with insurance, most Americans live with the 6 00:00:22,120 --> 00:00:26,520 Speaker 1: risk of enormous medical bills for quote covered care. Few 7 00:00:26,560 --> 00:00:29,720 Speaker 1: of us need convincing that the American health insurance system 8 00:00:29,800 --> 00:00:33,800 Speaker 1: needs reform, but many of the existing proposals focus on 9 00:00:33,920 --> 00:00:38,240 Speaker 1: expanding one relatively successful piece of the system or making 10 00:00:38,320 --> 00:00:42,240 Speaker 1: piecemeal editions. In their new book, We've Got You Covered, 11 00:00:42,400 --> 00:00:46,560 Speaker 1: Rebooting American Healthcare Lauran I andav and Amy Finkelstein, but 12 00:00:46,640 --> 00:00:50,800 Speaker 1: two professors of economics at Stanford and MIT, argued, is 13 00:00:50,840 --> 00:00:53,640 Speaker 1: because no one is asking the right question, what is 14 00:00:53,680 --> 00:00:56,840 Speaker 1: it the US health insurance policy should accomplish? I was 15 00:00:56,920 --> 00:00:59,680 Speaker 1: so intrigued with that approach. I'm really pleased to welcome 16 00:00:59,680 --> 00:01:03,160 Speaker 1: my guest, Amy Finkelstein. She is the John and Jenny 17 00:01:03,280 --> 00:01:07,520 Speaker 1: McDonald Professor of Economics at the Massachusetts Institute of Technology. 18 00:01:07,959 --> 00:01:10,720 Speaker 1: She's an elected member of the Institute of Medicine, as 19 00:01:10,720 --> 00:01:13,920 Speaker 1: well as Director of the Healthcare Program at the National 20 00:01:13,959 --> 00:01:16,959 Speaker 1: Bureau of Economic Research. She co authored the book with 21 00:01:17,040 --> 00:01:34,119 Speaker 1: Lauren Inat, who's a professor of economics at Stanford. Amy, 22 00:01:34,240 --> 00:01:37,280 Speaker 1: welcome and thank you for joining me on news World. 23 00:01:38,120 --> 00:01:39,600 Speaker 2: Thank you so much for having me. 24 00:01:40,319 --> 00:01:42,200 Speaker 1: I want to start if I could, at the beginning, 25 00:01:42,240 --> 00:01:46,440 Speaker 1: which is, how did you get into economics, and in 26 00:01:46,440 --> 00:01:48,200 Speaker 1: particularly the economics of healthcare. 27 00:01:48,640 --> 00:01:53,280 Speaker 2: That's a great question. I've always been interested in social 28 00:01:53,360 --> 00:01:58,760 Speaker 2: problems and the potential role for government to make meaningful 29 00:01:58,800 --> 00:02:03,680 Speaker 2: difference in people's lives, but also cognizant of the potential 30 00:02:03,840 --> 00:02:09,840 Speaker 2: for government policy to backfire or be ineffective. That plus 31 00:02:09,880 --> 00:02:13,320 Speaker 2: an interest in rigorous scientific methods, is what drew me 32 00:02:13,360 --> 00:02:18,560 Speaker 2: to economics. Within economics, the appeal of studying the healthcare 33 00:02:18,600 --> 00:02:23,400 Speaker 2: sector is multifold. One. It's obviously incredibly important for health 34 00:02:23,400 --> 00:02:26,160 Speaker 2: and well being. It's also a huge part of the 35 00:02:26,280 --> 00:02:30,760 Speaker 2: nation's economy, about twenty percent at last count, and it's 36 00:02:30,800 --> 00:02:34,720 Speaker 2: a role where there's really active government policy and government 37 00:02:34,760 --> 00:02:39,880 Speaker 2: policy debate. I think most people agree that the cartoon 38 00:02:40,040 --> 00:02:44,720 Speaker 2: version of economics, in which Adam Smith's invisible hands magically 39 00:02:44,880 --> 00:02:48,119 Speaker 2: equates supply and demand and everything functions very well, does 40 00:02:48,200 --> 00:02:51,560 Speaker 2: not apply in the healthcare sector, and particularly in the 41 00:02:51,560 --> 00:02:54,920 Speaker 2: health insurance sector that we're studying in this book. But 42 00:02:55,000 --> 00:02:57,960 Speaker 2: that leaves open very much the question of whether and 43 00:02:58,000 --> 00:03:01,120 Speaker 2: what public policy can do to prove things, and so 44 00:03:01,240 --> 00:03:02,680 Speaker 2: that's what's always motivated me. 45 00:03:03,160 --> 00:03:05,280 Speaker 1: I was very struck when I stepped down as speaker. 46 00:03:06,160 --> 00:03:10,440 Speaker 1: I decided to work on two projects, national security and health. 47 00:03:11,120 --> 00:03:14,200 Speaker 1: Both involved life and death. Both are really big and complicated. 48 00:03:14,680 --> 00:03:16,679 Speaker 1: I was a little surprised after I'd had time to 49 00:03:16,680 --> 00:03:20,640 Speaker 1: early focus. Health is about ten times more complicated than 50 00:03:20,680 --> 00:03:23,400 Speaker 1: national security, and I think it's one of the reasons 51 00:03:23,440 --> 00:03:25,720 Speaker 1: people have a hard time coping with it. There's so 52 00:03:25,960 --> 00:03:29,440 Speaker 1: many different aspects and so many different directions. You've sort 53 00:03:29,480 --> 00:03:33,640 Speaker 1: of gone right at it and raised the question of 54 00:03:33,680 --> 00:03:37,080 Speaker 1: the whole scale. Now there's a kind of intriguing story 55 00:03:37,920 --> 00:03:41,480 Speaker 1: about how you got pushed into thinking about this, involving 56 00:03:41,840 --> 00:03:43,800 Speaker 1: your father in law, Mark, Can you tell us just 57 00:03:43,840 --> 00:03:44,920 Speaker 1: for a minute or two about that. 58 00:03:45,360 --> 00:03:48,200 Speaker 2: Sure, Well, having given you the high pollutant answer to 59 00:03:48,240 --> 00:03:51,040 Speaker 2: the question of why I got interested in working in 60 00:03:51,160 --> 00:03:55,240 Speaker 2: health economics, the real truth of the matter is that 61 00:03:55,480 --> 00:03:59,320 Speaker 2: is the motivation. But as is typical of academics, for 62 00:03:59,480 --> 00:04:03,680 Speaker 2: most of my twenty five year career. Thus far, often 63 00:04:03,760 --> 00:04:06,200 Speaker 2: along with my coauthit Luran and IV have been doing 64 00:04:06,840 --> 00:04:10,040 Speaker 2: is trying to make progress on these important, big picture 65 00:04:10,160 --> 00:04:15,800 Speaker 2: questions by tackling very specific, narrow, and occasionally fairly esoteric 66 00:04:16,240 --> 00:04:20,120 Speaker 2: problems where we felt we could get scientific traction. And 67 00:04:20,600 --> 00:04:25,160 Speaker 2: we've both deliberately steered clear of any involvement in public 68 00:04:25,240 --> 00:04:29,080 Speaker 2: policy or public debate, feeling that we wanted to stick 69 00:04:29,120 --> 00:04:33,280 Speaker 2: to the careful scientific rigor and leave it to others 70 00:04:33,360 --> 00:04:36,839 Speaker 2: to weave together our findings and those of others to 71 00:04:36,920 --> 00:04:40,560 Speaker 2: make policy pronouncements. And also because quite frankly, as you said, 72 00:04:40,640 --> 00:04:43,760 Speaker 2: it's a very complicated and difficult problem. If I knew 73 00:04:43,760 --> 00:04:46,200 Speaker 2: the solution, I wouldn't be trying to study it. I 74 00:04:46,200 --> 00:04:48,640 Speaker 2: would work on problems that I didn't know the answer to. 75 00:04:49,279 --> 00:04:52,359 Speaker 2: So that's always been our approach. But then, you know, 76 00:04:52,440 --> 00:04:54,440 Speaker 2: as you mentioned, and as we talk about in the 77 00:04:54,440 --> 00:04:58,200 Speaker 2: opening of the book, I was prodded or cajoled or 78 00:04:58,240 --> 00:05:01,640 Speaker 2: shamed out of that academ at comfort zone by my 79 00:05:01,880 --> 00:05:05,720 Speaker 2: father in law, Mark Olkin, who asked me during the 80 00:05:05,880 --> 00:05:10,760 Speaker 2: twenty nineteen Democratic primaries, where various candidates were coming up 81 00:05:10,760 --> 00:05:13,919 Speaker 2: with their own healthcare proposals, what I thought should be 82 00:05:13,960 --> 00:05:19,200 Speaker 2: done to improve US health insurance. And I answered truthfully 83 00:05:19,800 --> 00:05:21,919 Speaker 2: that I thought that was a very hard problem and 84 00:05:21,920 --> 00:05:24,320 Speaker 2: that I didn't know the answer, and that's why I 85 00:05:24,400 --> 00:05:27,960 Speaker 2: was devoting my professional career to studying it. And my 86 00:05:28,080 --> 00:05:31,880 Speaker 2: father in law is both a insightful and also persistent 87 00:05:31,960 --> 00:05:34,719 Speaker 2: man who doesn't really take no for an answer, And 88 00:05:34,760 --> 00:05:38,320 Speaker 2: he got back to me a couple days later and said, look, Amy, 89 00:05:38,480 --> 00:05:41,400 Speaker 2: I know you like to stick in your narrow academic 90 00:05:41,440 --> 00:05:43,960 Speaker 2: comfort zone and not get out ahead of your skis 91 00:05:44,000 --> 00:05:47,160 Speaker 2: and make pronouncements on things that there's not rigorous evidence for. 92 00:05:47,320 --> 00:05:51,560 Speaker 2: But come on, you've been studying the US healthcare sector 93 00:05:51,640 --> 00:05:55,960 Speaker 2: for the last twenty years. You're probably one of the 94 00:05:56,000 --> 00:05:59,039 Speaker 2: world experts on the US health insurance system. You know, 95 00:05:59,080 --> 00:06:00,960 Speaker 2: he's my father in law. He should be forgiven for 96 00:06:01,000 --> 00:06:03,640 Speaker 2: a little bit of generous hyperbole there. But then he said, 97 00:06:03,760 --> 00:06:06,800 Speaker 2: are you really telling me you don't have anything you 98 00:06:06,839 --> 00:06:09,600 Speaker 2: can say to me or other people on what we 99 00:06:09,640 --> 00:06:13,159 Speaker 2: can do to improve the US healthcare system? And that 100 00:06:13,320 --> 00:06:16,000 Speaker 2: hit home. I thought, ouch, And when I talked to 101 00:06:16,040 --> 00:06:19,919 Speaker 2: my co author, who's probably even more dedicated to sticking 102 00:06:19,920 --> 00:06:22,480 Speaker 2: to the straight and narrow science than I am, I 103 00:06:22,560 --> 00:06:25,080 Speaker 2: was surprised to find that he agreed, and he said, 104 00:06:25,080 --> 00:06:28,960 Speaker 2: you know, Mark's right, we should think about this problem 105 00:06:29,000 --> 00:06:32,040 Speaker 2: to have some clarity in our minds at least and 106 00:06:32,080 --> 00:06:35,000 Speaker 2: for your father in law on how to tackle the 107 00:06:35,040 --> 00:06:39,560 Speaker 2: big problem. And so we started talking and reading and 108 00:06:39,600 --> 00:06:42,800 Speaker 2: researching and arguing. There's a lot of arguing. It helps 109 00:06:42,960 --> 00:06:46,880 Speaker 2: clarify ideas, I think, And when we finally thought we 110 00:06:46,960 --> 00:06:50,360 Speaker 2: had figured something out, it became so in some sense 111 00:06:50,360 --> 00:06:52,800 Speaker 2: that kind of light bulb moment, so in some sense 112 00:06:52,880 --> 00:06:56,440 Speaker 2: startlingly simple and obvious, at least to us, that we thought. 113 00:06:56,880 --> 00:06:58,719 Speaker 2: We didn't want to just share it with my father 114 00:06:58,800 --> 00:07:01,040 Speaker 2: in law. We wanted to get it out there into 115 00:07:01,080 --> 00:07:04,960 Speaker 2: the broader discussion and debate and hopefully actually into the 116 00:07:05,000 --> 00:07:05,840 Speaker 2: policy world. 117 00:07:06,120 --> 00:07:08,039 Speaker 1: You have a quote from both you and Lauren that 118 00:07:08,080 --> 00:07:10,840 Speaker 1: I think is interesting and probably the opposite of how 119 00:07:10,840 --> 00:07:14,400 Speaker 1: I've always approached things, which is you say, quote, there 120 00:07:14,440 --> 00:07:18,720 Speaker 1: will be something in our proposal to upset everyone. 121 00:07:18,840 --> 00:07:20,080 Speaker 2: That's the academic in me. 122 00:07:20,760 --> 00:07:22,880 Speaker 1: I mean, shouldn't you, if you want to get it 123 00:07:22,920 --> 00:07:26,400 Speaker 1: actually done, shouldn't the quote be there will be something 124 00:07:26,440 --> 00:07:28,760 Speaker 1: in our proposal to attract everyone. 125 00:07:28,880 --> 00:07:31,480 Speaker 2: For sure? And that's why we leave the politics to 126 00:07:31,680 --> 00:07:34,160 Speaker 2: people with far more experience than us. I think we 127 00:07:34,240 --> 00:07:36,920 Speaker 2: said that a little bit to lay the groundwork and 128 00:07:37,000 --> 00:07:39,960 Speaker 2: warn people that if you've come into this with your 129 00:07:40,160 --> 00:07:44,080 Speaker 2: favorite plan already in mind and your preconceived solutions, this 130 00:07:44,200 --> 00:07:47,040 Speaker 2: wasn't going to be a yes man piece in which 131 00:07:47,080 --> 00:07:49,560 Speaker 2: we just preached to the choir. I do think, and 132 00:07:49,600 --> 00:07:52,160 Speaker 2: as we say by the end, we think actually what 133 00:07:52,200 --> 00:07:57,400 Speaker 2: we're proposing can and should have broad support across the 134 00:07:57,400 --> 00:08:01,720 Speaker 2: political spectrum, and we give examples of both intellectuals and 135 00:08:02,000 --> 00:08:06,000 Speaker 2: politicians from the liberal to the conservative spectrum, who at 136 00:08:06,000 --> 00:08:09,080 Speaker 2: some fundamental level we believe agree with what we're proposing. 137 00:08:09,400 --> 00:08:12,160 Speaker 2: So yes, I think there is something to attract everyone, 138 00:08:12,640 --> 00:08:17,320 Speaker 2: but it's neither the slogan of single payer medicare for 139 00:08:17,360 --> 00:08:21,400 Speaker 2: all government does everything of the left, or leave it 140 00:08:21,440 --> 00:08:24,560 Speaker 2: to the markets and the wonders of magic of competition 141 00:08:24,640 --> 00:08:27,440 Speaker 2: of the right. There's something in it both to attract 142 00:08:27,600 --> 00:08:31,040 Speaker 2: I take that important correction, but also to upset everyone 143 00:08:31,480 --> 00:08:32,319 Speaker 2: at one level. 144 00:08:33,080 --> 00:08:34,839 Speaker 1: In your analysis, I think you and I are in 145 00:08:34,920 --> 00:08:38,200 Speaker 1: complete agreement that the current system needs to be really 146 00:08:38,320 --> 00:08:41,440 Speaker 1: rethought from the ground up. It is such a total 147 00:08:41,520 --> 00:08:45,480 Speaker 1: mess and has sort of grown chaotically for the last 148 00:08:45,520 --> 00:08:49,240 Speaker 1: seventy or eighty years, that it really requires a much 149 00:08:49,280 --> 00:08:54,200 Speaker 1: more fundamental thinking than just tinkering at the margins. And 150 00:08:54,280 --> 00:08:56,520 Speaker 1: you have some grade lines when you say at one point, 151 00:08:56,920 --> 00:09:00,160 Speaker 1: the coverage we do have is a universal mess. It 152 00:09:00,200 --> 00:09:04,520 Speaker 1: is nonsensical by design or more accurately, by lack of design. 153 00:09:05,120 --> 00:09:07,440 Speaker 1: One of the things that has struck me. Took me 154 00:09:07,480 --> 00:09:09,600 Speaker 1: a while to get this into my own head, although 155 00:09:09,679 --> 00:09:12,600 Speaker 1: as a conservative it's sort of obvious, and that is 156 00:09:13,240 --> 00:09:16,720 Speaker 1: virtually everybody in the health system has a legitimate self 157 00:09:16,720 --> 00:09:21,040 Speaker 1: interest and then explains a reform that would help them, 158 00:09:21,520 --> 00:09:24,720 Speaker 1: and is opposed to any reform which would challenge them. 159 00:09:25,559 --> 00:09:27,960 Speaker 1: And so what you have is sort of a collection 160 00:09:28,080 --> 00:09:31,680 Speaker 1: of centers of self interest, which makes it really hard 161 00:09:31,720 --> 00:09:34,840 Speaker 1: to then start the conversation because each of them promptly 162 00:09:34,840 --> 00:09:37,280 Speaker 1: wants to know what does it mean immediately for me, 163 00:09:38,120 --> 00:09:40,840 Speaker 1: as opposed to is this the right thing for the country? 164 00:09:40,840 --> 00:09:42,360 Speaker 1: I mean, does that make any sense? 165 00:09:43,120 --> 00:09:48,280 Speaker 2: Yes, I completely agree with your obviously much more knowledgeable 166 00:09:48,320 --> 00:09:51,880 Speaker 2: analysis of the politics than we provide, and certainly with 167 00:09:51,920 --> 00:09:54,160 Speaker 2: that in mind, we do at the end of the book, 168 00:09:54,720 --> 00:09:58,720 Speaker 2: at least for various types of American citizens, those who 169 00:09:58,800 --> 00:10:01,600 Speaker 2: currently don't have insurance, those who have Medicaid, those who 170 00:10:01,600 --> 00:10:05,319 Speaker 2: have private insurance. We do address what does the proposal 171 00:10:05,400 --> 00:10:08,280 Speaker 2: mean for you? In what ways would you be better off? 172 00:10:08,640 --> 00:10:11,800 Speaker 2: In what possible ways might you not like it? But 173 00:10:12,520 --> 00:10:16,520 Speaker 2: while that's certainly how things play out in the political sphere, 174 00:10:16,920 --> 00:10:20,040 Speaker 2: we thought it was very important related to that quote 175 00:10:20,040 --> 00:10:23,240 Speaker 2: you read about the system never having been deliberately designed 176 00:10:23,640 --> 00:10:26,280 Speaker 2: to take a step back, and before we get into 177 00:10:26,679 --> 00:10:28,680 Speaker 2: how do you sell it and how do you package it, 178 00:10:28,760 --> 00:10:33,320 Speaker 2: what's in it for different influential stakeholders to say, what 179 00:10:33,559 --> 00:10:37,600 Speaker 2: is it that American health care policy has been trying 180 00:10:37,720 --> 00:10:41,760 Speaker 2: to do for the last seventy years, seven decades, and 181 00:10:41,840 --> 00:10:46,120 Speaker 2: once we identify the goal, what is the actual solution 182 00:10:47,040 --> 00:10:51,640 Speaker 2: freed from political constraints but not of course economic constraints. 183 00:10:51,679 --> 00:10:53,959 Speaker 2: We think it's very important that if we can clarify 184 00:10:54,360 --> 00:10:57,360 Speaker 2: and get to some broad agreement or even consensus on 185 00:10:57,400 --> 00:11:00,520 Speaker 2: the goal and the solution, only then as it makes 186 00:11:00,520 --> 00:11:03,000 Speaker 2: sense to start talking about how do we feasibly get 187 00:11:03,000 --> 00:11:08,360 Speaker 2: this enacted. Even in academia, I'm surprised at casual conversations 188 00:11:08,400 --> 00:11:12,080 Speaker 2: that start with, oh, that's not politically feasible or that 189 00:11:12,120 --> 00:11:14,800 Speaker 2: will never happen. And I at least I guess I 190 00:11:14,960 --> 00:11:17,960 Speaker 2: miss that day in economics graduate school when they handed 191 00:11:18,000 --> 00:11:21,680 Speaker 2: out the crystal balls. I don't think it's easy for me, 192 00:11:22,000 --> 00:11:23,880 Speaker 2: and I'm not even an expert, but even for the 193 00:11:23,960 --> 00:11:28,160 Speaker 2: experts to forecast what policy windows will open when. And 194 00:11:28,200 --> 00:11:30,720 Speaker 2: I think there's a really important role to play for 195 00:11:30,840 --> 00:11:34,800 Speaker 2: articulating what policy should be so that we can have 196 00:11:34,880 --> 00:11:38,000 Speaker 2: that north star in mind, either for when we're making 197 00:11:38,040 --> 00:11:41,000 Speaker 2: the hard compromises, we at least know what we're compromising on, 198 00:11:41,559 --> 00:11:45,440 Speaker 2: or so that when that policy window inevitably does open, 199 00:11:45,840 --> 00:11:48,880 Speaker 2: people are clear minded on where we're trying to get to. 200 00:11:49,240 --> 00:11:52,520 Speaker 1: I want to encourage you in that attitude, because very 201 00:11:52,520 --> 00:11:55,480 Speaker 1: often what we need is for someone to tell us 202 00:11:55,520 --> 00:11:59,280 Speaker 1: what they really honestly believe will work, not what they 203 00:11:59,320 --> 00:12:03,560 Speaker 1: have fudged, in order for us to decide we'll accept it. 204 00:12:03,600 --> 00:12:07,400 Speaker 1: Because if you start compromising before we even talk, I 205 00:12:07,520 --> 00:12:11,000 Speaker 1: have no idea what the original idea was, Whereas if 206 00:12:11,000 --> 00:12:13,040 Speaker 1: I can at least know what your idea is, then 207 00:12:13,080 --> 00:12:15,040 Speaker 1: we can talk about whether or not we compromise. So 208 00:12:15,360 --> 00:12:17,480 Speaker 1: I want to commend you for that. And you say 209 00:12:17,520 --> 00:12:20,120 Speaker 1: something which I agree with although I'm not totally sold 210 00:12:20,160 --> 00:12:22,680 Speaker 1: in some of your solution, but I'm very sold in 211 00:12:22,720 --> 00:12:27,280 Speaker 1: the intellectual way via approcess. When you said incremental reform 212 00:12:27,400 --> 00:12:29,880 Speaker 1: isn't the answer, and that the only option is to 213 00:12:29,920 --> 00:12:31,760 Speaker 1: tear down the current system and build it from the 214 00:12:31,760 --> 00:12:35,280 Speaker 1: ground up, I think as an intellectual effort, that's exactly right. 215 00:12:36,120 --> 00:12:38,680 Speaker 1: That is, rather than go in and say, how do 216 00:12:38,720 --> 00:12:41,880 Speaker 1: I take the current hospital system, the current insurance system, etc. 217 00:12:42,679 --> 00:12:45,280 Speaker 1: And marginally shove it around. It's a point that Peter 218 00:12:45,360 --> 00:12:48,160 Speaker 1: Drucker used to say that if you weren't already doing it, 219 00:12:48,200 --> 00:12:51,800 Speaker 1: would you start? And if you wouldn't, wire you still 220 00:12:51,840 --> 00:12:54,080 Speaker 1: doing it. And I think when you go through a 221 00:12:54,080 --> 00:12:56,200 Speaker 1: lot of that, you begin to realize how much this 222 00:12:56,360 --> 00:13:00,000 Speaker 1: is a jury ridge system of self interest. Aggregate it 223 00:13:00,080 --> 00:13:03,599 Speaker 1: together with everybody kind of elbowing each other to maximize 224 00:13:04,040 --> 00:13:07,520 Speaker 1: their sub marginal advantage. And I think in that sense, 225 00:13:07,520 --> 00:13:09,760 Speaker 1: what you're attempting to do here is look at the 226 00:13:09,800 --> 00:13:13,160 Speaker 1: whole country and ask whether or not there's a solution. So, 227 00:13:13,520 --> 00:13:16,280 Speaker 1: in that sense seem to mean you had some core 228 00:13:17,200 --> 00:13:20,480 Speaker 1: values at the heart of how you thought about this. 229 00:13:20,679 --> 00:13:23,160 Speaker 1: Can you share a little bit about what you all 230 00:13:23,200 --> 00:13:25,600 Speaker 1: sat down and began talking about the book and talking 231 00:13:25,600 --> 00:13:28,400 Speaker 1: about the ideas in the book. What were the sort 232 00:13:28,400 --> 00:13:34,120 Speaker 1: of absolutely central premises or central values on which you 233 00:13:34,240 --> 00:13:35,720 Speaker 1: then built the rest of the framework. 234 00:13:36,240 --> 00:13:39,160 Speaker 2: Great question, and it was our starting point. Maybe as 235 00:13:39,200 --> 00:13:42,079 Speaker 2: economists we would have phrased it slightly differently and said, 236 00:13:42,240 --> 00:13:45,520 Speaker 2: not as a normative matter, what are our values, but 237 00:13:45,640 --> 00:13:49,600 Speaker 2: as an empirical matter, what does it look like health 238 00:13:49,679 --> 00:13:53,520 Speaker 2: policy is trying to accomplish. We don't feel it's our 239 00:13:53,600 --> 00:13:57,240 Speaker 2: role as academics to define our goals as a nation, 240 00:13:57,480 --> 00:13:59,880 Speaker 2: but we think we can look historically at what we 241 00:14:00,160 --> 00:14:03,120 Speaker 2: been doing and trying to do to try to determine 242 00:14:03,679 --> 00:14:06,800 Speaker 2: what those goals are. And our read of this was 243 00:14:06,840 --> 00:14:09,320 Speaker 2: actually something of a surprise to us. When I lecture 244 00:14:09,400 --> 00:14:12,120 Speaker 2: to my students on US health policy, I give a 245 00:14:12,200 --> 00:14:17,440 Speaker 2: laundry list of possible rationales, including an interest in improving 246 00:14:17,480 --> 00:14:20,800 Speaker 2: population health, or the one that my co author and 247 00:14:20,800 --> 00:14:22,720 Speaker 2: I had actually been working on for most of the 248 00:14:22,760 --> 00:14:26,280 Speaker 2: last twenty years, trying to intervene in areas where the 249 00:14:26,320 --> 00:14:30,400 Speaker 2: medical marketplace isn't functioning as well as our textbook models 250 00:14:30,440 --> 00:14:34,040 Speaker 2: suggest that most markets should function, but neither of those 251 00:14:34,120 --> 00:14:36,680 Speaker 2: it turned out our read at least of the history 252 00:14:36,960 --> 00:14:39,320 Speaker 2: actually going back to the dawn of the Republic, but 253 00:14:39,680 --> 00:14:42,720 Speaker 2: particularly in the last seven decades. Our read of the 254 00:14:42,800 --> 00:14:45,840 Speaker 2: history of the problem that we've been trying but failing 255 00:14:45,880 --> 00:14:51,760 Speaker 2: to solve, stems from a social contract, if you would, 256 00:14:52,120 --> 00:14:57,080 Speaker 2: that people should have access to essential medical care, regardless 257 00:14:57,200 --> 00:14:59,760 Speaker 2: of their resources, or to put it a little more 258 00:15:00,440 --> 00:15:03,680 Speaker 2: crudely and colorfully, that we're not comfortable as a society 259 00:15:03,760 --> 00:15:07,440 Speaker 2: with letting people die in the street. Now we talk 260 00:15:07,520 --> 00:15:11,520 Speaker 2: about the psychological and philosophical origins of that impulse, but 261 00:15:11,600 --> 00:15:14,200 Speaker 2: as we try to make clear in the book, whether 262 00:15:14,320 --> 00:15:17,080 Speaker 2: or not you agree that that's what we should be 263 00:15:17,120 --> 00:15:20,280 Speaker 2: doing as a society, it's very hard when you see 264 00:15:20,280 --> 00:15:22,320 Speaker 2: the evidence we present in the book, we believe at 265 00:15:22,400 --> 00:15:25,800 Speaker 2: least to argue that that's against the idea that that's 266 00:15:25,800 --> 00:15:27,840 Speaker 2: what we've been trying to do. That if you look 267 00:15:27,880 --> 00:15:31,600 Speaker 2: at many of these patchworks of policies that come in 268 00:15:31,680 --> 00:15:35,760 Speaker 2: and provide coverage to a particular group of people under 269 00:15:35,800 --> 00:15:41,480 Speaker 2: particular circumstances or with particular diseases, those often arise because 270 00:15:41,680 --> 00:15:47,360 Speaker 2: some issue becomes politically salient, and the outcry that emerges 271 00:15:47,440 --> 00:15:50,400 Speaker 2: that people are dying of end stage renal disease because 272 00:15:50,440 --> 00:15:54,280 Speaker 2: they can't afford life saving dialysis, or low income women 273 00:15:54,360 --> 00:15:58,400 Speaker 2: are dying of breast and cervical cancer that we've funded 274 00:15:58,440 --> 00:16:01,760 Speaker 2: the diagnosis of but now aren't providing payment for the 275 00:16:01,760 --> 00:16:07,440 Speaker 2: treatment of These prompt a political outcry and some limited 276 00:16:07,480 --> 00:16:11,320 Speaker 2: policy action, and yet that action is always punching below 277 00:16:11,360 --> 00:16:14,600 Speaker 2: its weight because each of these programs, by trying to 278 00:16:14,640 --> 00:16:19,120 Speaker 2: tackle a narrow part of the problem, leaves enormous gaps 279 00:16:19,120 --> 00:16:21,760 Speaker 2: at the seams that people fall through. So that I 280 00:16:21,760 --> 00:16:23,680 Speaker 2: think we would argue, is what the core value is 281 00:16:23,720 --> 00:16:36,600 Speaker 2: that policy has been trying to accomplish. 282 00:16:36,720 --> 00:16:39,400 Speaker 1: Hi This is newt In my new book, March the Majority, 283 00:16:39,440 --> 00:16:42,960 Speaker 1: The Real Story of the Republican Revolution, I offer strategies 284 00:16:42,960 --> 00:16:46,680 Speaker 1: and insights for everyday citizens and for season politicians. It's 285 00:16:46,680 --> 00:16:49,760 Speaker 1: both a guide for political success and for winning back 286 00:16:49,800 --> 00:16:53,480 Speaker 1: the Majority. In twenty twenty four, March the Majority outlines 287 00:16:53,520 --> 00:16:57,280 Speaker 1: the sixteen year campaign to Write the Contract with America, 288 00:16:57,520 --> 00:17:00,960 Speaker 1: explains how we elected the first Republican House majority in 289 00:17:01,120 --> 00:17:04,560 Speaker 1: forty years, in how we worked with President Bill Clinton 290 00:17:04,800 --> 00:17:10,040 Speaker 1: to pass major reforms, including four consecutive balance budgets. March 291 00:17:10,080 --> 00:17:13,159 Speaker 1: to the Majority tells the behind the scenes story of 292 00:17:13,200 --> 00:17:16,080 Speaker 1: how we got it done. Go to gingrishtree sixty dot 293 00:17:16,080 --> 00:17:19,280 Speaker 1: com slash book and order your copy now. Order it 294 00:17:19,320 --> 00:17:33,439 Speaker 1: today at gingishtree sixty dot com slash book. Maybe I 295 00:17:33,440 --> 00:17:36,280 Speaker 1: misunderstand your position here, but it seemed to me that 296 00:17:36,320 --> 00:17:39,080 Speaker 1: in the section where you talk about the future study 297 00:17:39,480 --> 00:17:41,400 Speaker 1: of a tale of two states, and then you talk 298 00:17:41,440 --> 00:17:46,040 Speaker 1: about the more recent updating of that study, basically higher 299 00:17:46,080 --> 00:17:50,240 Speaker 1: life expectancy doesn't seem to be a function of the 300 00:17:50,320 --> 00:17:53,080 Speaker 1: quality of medical care or the higher rates of health insurance. 301 00:17:53,560 --> 00:17:56,760 Speaker 1: That there's actually a function of the cultural values of 302 00:17:56,800 --> 00:17:59,800 Speaker 1: the community. If you're in a community that smokes less, 303 00:18:00,000 --> 00:18:04,480 Speaker 1: exercises more, is less likely to be abuse, and I suspect, 304 00:18:04,480 --> 00:18:07,200 Speaker 1: coming out of all that has a somewhat different diet, 305 00:18:08,080 --> 00:18:10,679 Speaker 1: you're likely to be dramatically healthier without regard to your 306 00:18:10,720 --> 00:18:12,560 Speaker 1: insurance state. Am I misunderstanding that? 307 00:18:13,080 --> 00:18:15,280 Speaker 2: No, you're not. And it's a subtle point and it's 308 00:18:15,280 --> 00:18:19,560 Speaker 2: worth clarifying. So first, there's an enormous amount of evidence 309 00:18:19,760 --> 00:18:22,600 Speaker 2: you mentioned the original Fuch study, and there's more recent 310 00:18:22,640 --> 00:18:25,919 Speaker 2: evidence as well that makes what I think is a 311 00:18:25,960 --> 00:18:31,000 Speaker 2: somewhat surprising point that the fundamental impediments to better population 312 00:18:31,200 --> 00:18:36,560 Speaker 2: health and reduced health disparities is not access to medical 313 00:18:36,600 --> 00:18:40,479 Speaker 2: care or health insurance, which is about providing greater access 314 00:18:40,480 --> 00:18:46,320 Speaker 2: to medical care. It's actually about exposure to pollutants, the 315 00:18:46,359 --> 00:18:49,359 Speaker 2: air we breathe, the food we eat, the cigarettes we 316 00:18:49,440 --> 00:18:52,480 Speaker 2: do or don't smoke. And one of the most stunning 317 00:18:52,600 --> 00:18:56,320 Speaker 2: examples of that comes from looking at Scandinavian countries like 318 00:18:56,359 --> 00:19:00,960 Speaker 2: Norway and Sweden, that not only have universal health insurance coverage, 319 00:19:00,960 --> 00:19:04,560 Speaker 2: but a much more extensive cradle to the grave social 320 00:19:04,600 --> 00:19:08,080 Speaker 2: safety net. And yet even there, the differences in life 321 00:19:08,119 --> 00:19:11,000 Speaker 2: expectancy between the high and the low income individuals in 322 00:19:11,040 --> 00:19:13,680 Speaker 2: these countries is as large as it is in the 323 00:19:13,800 --> 00:19:16,679 Speaker 2: United States. And so we go into this in the 324 00:19:16,720 --> 00:19:20,520 Speaker 2: book to make a cautionary tale that health insurance reform 325 00:19:20,600 --> 00:19:22,960 Speaker 2: is not the policy lever to be pushing on if 326 00:19:22,960 --> 00:19:26,960 Speaker 2: one wants dramatic improvements in population health. Now to your point, 327 00:19:27,000 --> 00:19:30,119 Speaker 2: you're saying, well, if health insurance isn't essential for health, 328 00:19:30,600 --> 00:19:33,520 Speaker 2: why is it so important as a social or moral 329 00:19:33,520 --> 00:19:37,560 Speaker 2: commitment that we provide access to health insurance. And the 330 00:19:37,720 --> 00:19:41,719 Speaker 2: answer there is that one of the reasons in fact, 331 00:19:42,320 --> 00:19:46,680 Speaker 2: that we don't think that the key lever for health 332 00:19:46,680 --> 00:19:50,360 Speaker 2: improvements is health insurance reform is the fact that, as 333 00:19:50,359 --> 00:19:53,000 Speaker 2: we dwell out in some detail in the book, the 334 00:19:53,400 --> 00:19:56,880 Speaker 2: people who currently lack health insurance, those thirty million Americans 335 00:19:56,880 --> 00:20:01,240 Speaker 2: without health insurance, are not actually on a insured If 336 00:20:01,240 --> 00:20:04,240 Speaker 2: you have a car that's not insured and it breaks down, 337 00:20:04,480 --> 00:20:07,200 Speaker 2: nobody's going to come give you a tow for free 338 00:20:07,800 --> 00:20:10,600 Speaker 2: or lend you a beat up secondhand car so that 339 00:20:10,680 --> 00:20:13,040 Speaker 2: you can get to work. Whereas what we see with 340 00:20:13,200 --> 00:20:16,639 Speaker 2: the quote unquote uninsured in the United States is that 341 00:20:16,680 --> 00:20:22,600 Speaker 2: they actually get an enormous amount of medical care, most 342 00:20:22,640 --> 00:20:25,119 Speaker 2: of which they don't pay for. In fact, the Oregon 343 00:20:25,160 --> 00:20:29,679 Speaker 2: Health Insurance Experiment which I led, indicated that low income 344 00:20:29,760 --> 00:20:34,320 Speaker 2: uninsured adults get about four fifths as much medical care 345 00:20:34,480 --> 00:20:37,639 Speaker 2: as they would have if they had Medicaid coverage, and 346 00:20:37,680 --> 00:20:40,359 Speaker 2: they pay for only about twenty cents on the dollar 347 00:20:40,440 --> 00:20:43,000 Speaker 2: of that care. So, in other words, one of the 348 00:20:43,040 --> 00:20:45,520 Speaker 2: reasons that health insurance reform is not going to make 349 00:20:45,520 --> 00:20:50,399 Speaker 2: a dramatic difference in population health is precisely because of 350 00:20:50,440 --> 00:20:53,560 Speaker 2: the social contract that we have to provide essential medical 351 00:20:53,560 --> 00:20:57,320 Speaker 2: care regardless of resources, and the patchwork of policies we 352 00:20:57,400 --> 00:21:00,119 Speaker 2: have in place to make sure that even the un 353 00:21:00,200 --> 00:21:04,200 Speaker 2: ensured get a lot of medical care that they don't 354 00:21:04,240 --> 00:21:06,399 Speaker 2: pay for when they need it. And our point is 355 00:21:06,800 --> 00:21:10,160 Speaker 2: given that we are clearly committed to doing this, revealed 356 00:21:10,160 --> 00:21:13,159 Speaker 2: by our current public policies as well as the history 357 00:21:13,200 --> 00:21:15,879 Speaker 2: of them, no one would argue that we're doing it 358 00:21:15,960 --> 00:21:20,399 Speaker 2: well or efficiently or effectively. So let's formalize and fund 359 00:21:20,440 --> 00:21:26,000 Speaker 2: that commitment upfront with universal, automatic but very basic coverage 360 00:21:26,040 --> 00:21:29,920 Speaker 2: for essential medical care, and then allow individuals who want 361 00:21:29,960 --> 00:21:33,480 Speaker 2: to and can afford it, to buy supplemental coverage out 362 00:21:33,480 --> 00:21:36,680 Speaker 2: of their own money. In a well functioning marketplace. 363 00:21:36,720 --> 00:21:41,479 Speaker 1: If say Sweden, Norway and Finland, to take the three 364 00:21:42,080 --> 00:21:47,040 Speaker 1: Nordic countries, if they actually have similar patterns of health 365 00:21:47,040 --> 00:21:51,720 Speaker 1: outcomes for the top and bottom income levels, even though 366 00:21:51,760 --> 00:21:55,199 Speaker 1: they have basically pretty universal coverage, is that then a 367 00:21:55,240 --> 00:21:58,080 Speaker 1: function of culture? What is it a function of. 368 00:21:58,840 --> 00:22:02,479 Speaker 2: So the evident that we've seen and that we discuss 369 00:22:02,560 --> 00:22:07,920 Speaker 2: in the book suggests that a lot of the differences 370 00:22:07,960 --> 00:22:15,040 Speaker 2: in health outcomes across the income distribution reflect differences in 371 00:22:15,680 --> 00:22:21,520 Speaker 2: exposure to pollution and to violence, but also something that's 372 00:22:21,560 --> 00:22:29,320 Speaker 2: called goes often by the name of health behaviors, diet, exercise, smoking, drinking. 373 00:22:29,440 --> 00:22:33,000 Speaker 2: The original Fuchs study made that very clear, and subsequent 374 00:22:33,040 --> 00:22:36,199 Speaker 2: work as well. Now, whether you want to call that 375 00:22:36,640 --> 00:22:40,440 Speaker 2: values gets beyond my remit as an academic economist. One 376 00:22:40,480 --> 00:22:42,920 Speaker 2: thing we do know from the evidence is whether or 377 00:22:43,000 --> 00:22:46,200 Speaker 2: not these stem from some values. They are very amenable 378 00:22:46,240 --> 00:22:51,320 Speaker 2: to public policy that higher cigarette taxes reduce smoking, regulation 379 00:22:51,600 --> 00:22:55,360 Speaker 2: of pollution, reduces exposure to pollution, and improves health. We're 380 00:22:55,359 --> 00:22:59,680 Speaker 2: not advocating for those policies in particular. That's outside the 381 00:22:59,720 --> 00:23:02,720 Speaker 2: scope of our book. We're just saying, if people want 382 00:23:02,760 --> 00:23:06,840 Speaker 2: to dramatically improve population health, the policy levers to think 383 00:23:06,880 --> 00:23:11,159 Speaker 2: of are not expanding health insurance and access to medical care, 384 00:23:11,520 --> 00:23:16,480 Speaker 2: but really policy levers. It might change diet, exercise, smoking, 385 00:23:16,760 --> 00:23:19,200 Speaker 2: exposure to pollution, et cetera. 386 00:23:19,920 --> 00:23:22,320 Speaker 1: Part of this, I think started with your father in 387 00:23:22,440 --> 00:23:26,720 Speaker 1: law asking you about Medicare for all. Why, in your judgment, 388 00:23:26,840 --> 00:23:29,080 Speaker 1: is Medicare for all not a solution. 389 00:23:29,600 --> 00:23:32,040 Speaker 2: Well, let's start with the fact that Medicare for all 390 00:23:32,119 --> 00:23:35,520 Speaker 2: is a slogan and it means different things to different people. 391 00:23:36,040 --> 00:23:39,480 Speaker 2: At a literal reading of it. Taking the current Medicare 392 00:23:40,080 --> 00:23:43,919 Speaker 2: program for Medicare for some, as it were, and expanding 393 00:23:43,960 --> 00:23:46,680 Speaker 2: it to everyone not just people who are sixty five 394 00:23:46,680 --> 00:23:49,480 Speaker 2: and older or disabled or have then stay drenal disease. 395 00:23:49,960 --> 00:23:54,320 Speaker 2: We think that that has at least two major problems. 396 00:23:54,840 --> 00:23:59,320 Speaker 2: The first is the current Medicare program is not well 397 00:23:59,359 --> 00:24:02,440 Speaker 2: designed as an insurance product. Remember, the point of any 398 00:24:02,440 --> 00:24:05,919 Speaker 2: insurance product, and health insurance is no exception, is to 399 00:24:06,000 --> 00:24:10,159 Speaker 2: protect you economically or financially in the event of the 400 00:24:10,200 --> 00:24:13,320 Speaker 2: event occurring, in this case poor health. And yet the 401 00:24:13,600 --> 00:24:19,880 Speaker 2: Medicare program has an unlimited twenty percent physician co insurance, 402 00:24:19,920 --> 00:24:22,840 Speaker 2: which means whatever your physician bills are, you as a 403 00:24:22,920 --> 00:24:25,960 Speaker 2: patient have to pay one in five dollars out of 404 00:24:26,000 --> 00:24:28,920 Speaker 2: pocket with no cap insight, so that if you have 405 00:24:29,000 --> 00:24:33,600 Speaker 2: a very expensive disease, you can end up with unlimited 406 00:24:33,640 --> 00:24:36,960 Speaker 2: and catastrophic medical bills that you have to pay. That's 407 00:24:37,040 --> 00:24:40,679 Speaker 2: not a well designed insurance system. On the other hand, 408 00:24:41,280 --> 00:24:46,080 Speaker 2: Medicare as it's currently designed is in some sense too generous, 409 00:24:46,280 --> 00:24:48,960 Speaker 2: not basic enough for what we would have the universal 410 00:24:49,000 --> 00:24:53,720 Speaker 2: basic system be in the sense that there's no gatekeeping 411 00:24:54,040 --> 00:24:58,760 Speaker 2: or limits on essentially any care the patient wants that 412 00:24:58,760 --> 00:25:02,240 Speaker 2: the doctor's willing to order, and so you have a 413 00:25:02,280 --> 00:25:07,320 Speaker 2: lot of excessive and perhaps unnecessary care you know, people 414 00:25:07,880 --> 00:25:11,840 Speaker 2: often extol the Medicare system for having very low administrative costs, 415 00:25:11,840 --> 00:25:14,760 Speaker 2: but the reason it has low administrative costs is because 416 00:25:14,800 --> 00:25:19,840 Speaker 2: it doesn't administer. There's no oversight or review of what 417 00:25:19,960 --> 00:25:23,280 Speaker 2: kind of care an individual can get. Now, certainly we 418 00:25:23,320 --> 00:25:25,800 Speaker 2: want individuals to be able to make their own medical 419 00:25:25,840 --> 00:25:29,080 Speaker 2: decisions with their doctor, but when it comes to taxpayer 420 00:25:29,119 --> 00:25:32,439 Speaker 2: finance medical care, we think it should be limited to 421 00:25:32,840 --> 00:25:35,360 Speaker 2: the basic and the essential, and so we would have, 422 00:25:35,440 --> 00:25:39,960 Speaker 2: compared to the current Medicare system, longer wait times for 423 00:25:40,240 --> 00:25:44,960 Speaker 2: non urgent care, less flexibility and choice of doctor, much 424 00:25:45,040 --> 00:25:48,399 Speaker 2: less in the way of non essential amenities like having 425 00:25:48,400 --> 00:25:51,520 Speaker 2: a private or a semi private hospital room. We give 426 00:25:51,560 --> 00:25:56,399 Speaker 2: the example of countries like Singapore or Australia, where the 427 00:25:56,760 --> 00:26:00,800 Speaker 2: universal basic coverage gets you something quite basic. In Singapore, 428 00:26:00,960 --> 00:26:04,840 Speaker 2: a notoriously hot and humid climate, the basic coverage gets 429 00:26:04,880 --> 00:26:07,520 Speaker 2: you hospital care in a room with ten beds to 430 00:26:07,600 --> 00:26:10,879 Speaker 2: a room, and then you can buy supplemental coverage. They 431 00:26:10,960 --> 00:26:14,479 Speaker 2: euphemistically refer to that as natural ventilation. But you can 432 00:26:14,480 --> 00:26:16,960 Speaker 2: buy supplemental coverage if you want a private room with 433 00:26:17,000 --> 00:26:20,760 Speaker 2: air conditioning. And similarly, that's our view of the role 434 00:26:20,800 --> 00:26:24,320 Speaker 2: of supplemental coverage in the US to get shorter lines 435 00:26:24,359 --> 00:26:28,520 Speaker 2: for non urgent care, greater flexibility about choice of doctor 436 00:26:28,560 --> 00:26:32,880 Speaker 2: and procedure, and better amenities. So our basic coverage would 437 00:26:32,920 --> 00:26:55,359 Speaker 2: be both better and worse than the current traditional Medicare program. 438 00:26:55,640 --> 00:26:58,159 Speaker 1: When you look at the British system or the Veterans 439 00:26:58,200 --> 00:27:02,160 Speaker 1: Administration system, which you cite as an example of a problem, 440 00:27:02,600 --> 00:27:04,680 Speaker 1: they end up with long wait times, and in Britain 441 00:27:04,680 --> 00:27:08,000 Speaker 1: at least they end up just denying benefits. At one 442 00:27:08,000 --> 00:27:10,639 Speaker 1: point they had an extraordinarily bad record, for example, with 443 00:27:10,720 --> 00:27:11,359 Speaker 1: breast cancer. 444 00:27:11,840 --> 00:27:15,679 Speaker 2: Whenever you try to keep things basic, as the experience 445 00:27:15,720 --> 00:27:19,400 Speaker 2: of other countries and also the US Veterans Administration as 446 00:27:19,400 --> 00:27:23,080 Speaker 2: you mentioned, show, one of the big concerns is excessively 447 00:27:23,160 --> 00:27:27,879 Speaker 2: long wait times. We imagine in our basic universal system 448 00:27:27,960 --> 00:27:31,600 Speaker 2: wait times would be about the length experience in the 449 00:27:31,640 --> 00:27:35,640 Speaker 2: current US Medicaid program for low income individuals, which are 450 00:27:35,760 --> 00:27:39,680 Speaker 2: longer than what people with private insurance have. Again, those 451 00:27:39,720 --> 00:27:43,160 Speaker 2: who want to and can afford it can purchase supplemental 452 00:27:43,200 --> 00:27:48,280 Speaker 2: coverage to speed that up. What systems like Britain or 453 00:27:48,520 --> 00:27:51,520 Speaker 2: the US Veterans Administration or systems around the world have 454 00:27:51,680 --> 00:27:55,080 Speaker 2: done when weight times get too long. They've done one 455 00:27:55,119 --> 00:27:58,399 Speaker 2: of two things. They've either tried to increase funding and 456 00:27:58,640 --> 00:28:02,560 Speaker 2: otherwise pressure in the basic system to speed things up. 457 00:28:02,600 --> 00:28:05,960 Speaker 2: That's often known as targets and terror. The UK tried that, 458 00:28:06,119 --> 00:28:08,879 Speaker 2: I think Finland also did. Or the other thing that 459 00:28:09,040 --> 00:28:11,560 Speaker 2: some countries like Norway have done, and also the US 460 00:28:11,640 --> 00:28:15,199 Speaker 2: Veterans Administration is they say we're going to decide what 461 00:28:15,320 --> 00:28:18,359 Speaker 2: is a reasonable wait time, and if the system can't deliver, 462 00:28:18,840 --> 00:28:22,600 Speaker 2: the public system will then pay for patients to go 463 00:28:22,920 --> 00:28:26,800 Speaker 2: get their care at the public prices no cost to them, 464 00:28:26,840 --> 00:28:30,439 Speaker 2: but in the private market. So the Veterans Administration passed 465 00:28:30,440 --> 00:28:33,880 Speaker 2: the Choice Act that did exactly this. It said, we're 466 00:28:33,880 --> 00:28:36,439 Speaker 2: going to say what we think are reasonable drive times 467 00:28:36,440 --> 00:28:39,560 Speaker 2: and wait times, and if a veteran can't get care 468 00:28:39,600 --> 00:28:43,600 Speaker 2: at the VA within those what we've decided are reasonable limits, 469 00:28:43,960 --> 00:28:47,400 Speaker 2: then the US Veterans Administration will pay the cost for 470 00:28:47,480 --> 00:28:50,479 Speaker 2: that individual to go seek care in a private clinic. 471 00:28:51,400 --> 00:28:55,320 Speaker 2: So there are ways of handling excessive weight times. 472 00:28:55,800 --> 00:28:59,280 Speaker 1: So you inherently are proposing in the sense of two 473 00:28:59,320 --> 00:29:04,000 Speaker 1: tier system and that everybody would be in the basic system, 474 00:29:04,160 --> 00:29:07,960 Speaker 1: but they would have access to alternatives if they're willing. 475 00:29:07,760 --> 00:29:11,680 Speaker 2: To pay for them correct and depending where you come from, 476 00:29:11,720 --> 00:29:15,200 Speaker 2: sometimes the word two tier system is seen as a 477 00:29:15,240 --> 00:29:18,560 Speaker 2: dirty word or dirty words. Our view is this is 478 00:29:18,600 --> 00:29:21,760 Speaker 2: inherent in how everything is done in the United States. 479 00:29:21,800 --> 00:29:27,080 Speaker 2: We have a publicly funded police force to provide security, 480 00:29:27,280 --> 00:29:30,640 Speaker 2: and yet many people will then opt to install a 481 00:29:31,080 --> 00:29:34,200 Speaker 2: private alarm system in their house, or security cameras in 482 00:29:34,240 --> 00:29:37,600 Speaker 2: their business, or even live in a gated community. We 483 00:29:37,680 --> 00:29:41,680 Speaker 2: think it is important that the public system provide access 484 00:29:41,680 --> 00:29:44,560 Speaker 2: to essential medical care, but that's a floor, not a ceiling, 485 00:29:44,960 --> 00:29:46,920 Speaker 2: and people who want and can afford it should be 486 00:29:47,000 --> 00:29:49,960 Speaker 2: able to supplement. Of course, it's extremely important, and we 487 00:29:50,040 --> 00:29:52,160 Speaker 2: deal with this at length in the book that you 488 00:29:52,160 --> 00:29:54,880 Speaker 2: don't end up with the tail wagging the dog, that 489 00:29:55,120 --> 00:29:58,400 Speaker 2: so many people opt into the supplemental system that it 490 00:29:58,440 --> 00:30:02,080 Speaker 2: erodes political support for funding for the basic system. I 491 00:30:02,080 --> 00:30:04,840 Speaker 2: think you've seen that happen in some Latin American countries. 492 00:30:05,280 --> 00:30:07,640 Speaker 2: This is a real risk, and we talk about how 493 00:30:07,680 --> 00:30:10,479 Speaker 2: countries such as Israel that encountered this have dealt with 494 00:30:10,520 --> 00:30:14,440 Speaker 2: it by making sure they adequately fund the basic system. 495 00:30:14,760 --> 00:30:18,600 Speaker 2: We estimate that probably about two thirds of the American 496 00:30:18,640 --> 00:30:23,080 Speaker 2: public would be purchasing supplemental coverage. Those who are currently 497 00:30:23,160 --> 00:30:27,320 Speaker 2: uninsured would be strictly better off with our basic coverage. 498 00:30:27,720 --> 00:30:31,120 Speaker 2: Those who currently have Medicaid, the health insurance for low 499 00:30:31,160 --> 00:30:35,600 Speaker 2: income individuals, Our basic coverage would look pretty much like Medicaid, 500 00:30:35,760 --> 00:30:38,840 Speaker 2: except they wouldn't have the risk of losing that coverage 501 00:30:38,840 --> 00:30:41,560 Speaker 2: if they got older, or their income went up, or 502 00:30:41,600 --> 00:30:44,440 Speaker 2: they moved states, or they forgot to re certify, and 503 00:30:44,560 --> 00:30:47,240 Speaker 2: they'd have the option to supplement, although we suspect many 504 00:30:47,280 --> 00:30:49,920 Speaker 2: would not. And then for half of the country that 505 00:30:50,000 --> 00:30:54,800 Speaker 2: currently has employer provided private health insurance, our basic coverage 506 00:30:54,840 --> 00:30:58,920 Speaker 2: would actually be much better in two important ways. First, 507 00:30:58,960 --> 00:31:01,719 Speaker 2: there'd be no risk of ever losing that coverage if 508 00:31:01,760 --> 00:31:05,320 Speaker 2: you change jobs or lose your job. And second, for 509 00:31:05,400 --> 00:31:08,400 Speaker 2: the essential medical care, there'd be no risk of out 510 00:31:08,400 --> 00:31:11,720 Speaker 2: of pocket coverage, so no risk of these catastrophic medical debt. 511 00:31:11,840 --> 00:31:14,520 Speaker 2: Insurance would be doing what it's supposed to, and yet 512 00:31:14,520 --> 00:31:17,160 Speaker 2: it would be a lot worse on these dimensions of 513 00:31:17,600 --> 00:31:20,840 Speaker 2: wait times and being able to have nice hospital rooms, 514 00:31:20,880 --> 00:31:24,120 Speaker 2: And so we suspect most of those people would supplement, 515 00:31:24,520 --> 00:31:27,200 Speaker 2: not out of taxpayer money as they currently do with 516 00:31:27,280 --> 00:31:30,280 Speaker 2: purchasing private employer provided health insurance. But out of their 517 00:31:30,280 --> 00:31:32,560 Speaker 2: own pocket, and that we think is a good way 518 00:31:32,600 --> 00:31:33,240 Speaker 2: to end up. 519 00:31:33,320 --> 00:31:36,120 Speaker 1: In the system. You would design what would happen to 520 00:31:36,160 --> 00:31:41,000 Speaker 1: the employer based system and the employer providing health insurance. 521 00:31:41,640 --> 00:31:45,480 Speaker 2: Well, it wouldn't have to go away. Some countries, for example, 522 00:31:45,560 --> 00:31:49,320 Speaker 2: Germany have their universal basic coverage with the top up 523 00:31:49,800 --> 00:31:55,280 Speaker 2: run in part through large industry base or occupation based systems. 524 00:31:55,720 --> 00:31:58,920 Speaker 2: You quoted the line from Peter Drucker. If you weren't 525 00:31:58,960 --> 00:32:02,200 Speaker 2: already doing it, you start there. I for one, would not, 526 00:32:02,400 --> 00:32:05,440 Speaker 2: and I think most people who've analyzed the system would 527 00:32:05,440 --> 00:32:09,400 Speaker 2: not shed any great crocodile tiers if health insurance were 528 00:32:09,440 --> 00:32:12,760 Speaker 2: not provided through the employer. That's a historical accident that 529 00:32:12,800 --> 00:32:15,880 Speaker 2: came out of wage and price controls during World War Two. 530 00:32:15,960 --> 00:32:19,480 Speaker 2: And I don't think there's any first principle sensible reason 531 00:32:19,600 --> 00:32:22,960 Speaker 2: to have health insurance link to employment. That being said, 532 00:32:23,120 --> 00:32:28,479 Speaker 2: if for ease of transition or political expediency we wanted 533 00:32:28,520 --> 00:32:32,120 Speaker 2: to keep the supplemental coverage link to employment, there's no 534 00:32:32,200 --> 00:32:35,200 Speaker 2: impediment to doing so in our proposal. 535 00:32:35,440 --> 00:32:38,240 Speaker 1: Well, I mean, as long as you kept the tax status, 536 00:32:38,960 --> 00:32:40,960 Speaker 1: you wouldn't have to have it specifically link. But you 537 00:32:40,960 --> 00:32:44,920 Speaker 1: could say that those employers who wanted to could provide 538 00:32:44,960 --> 00:32:48,760 Speaker 1: the supplemental insurance, but wouldn't that then transfer to the 539 00:32:48,760 --> 00:32:52,560 Speaker 1: public treasury a substantial amount of the cost currently being 540 00:32:52,600 --> 00:32:53,840 Speaker 1: borne by the corporations. 541 00:32:54,200 --> 00:32:59,800 Speaker 2: So we estimate that for the basic coverage, one would 542 00:32:59,840 --> 00:33:04,000 Speaker 2: not have to raise taxes. One could if we decide 543 00:33:04,000 --> 00:33:07,600 Speaker 2: as a society that we want very high end basic coverage. 544 00:33:07,840 --> 00:33:10,800 Speaker 2: But if you simply take what the taxpayers are currently 545 00:33:10,840 --> 00:33:16,760 Speaker 2: paying for Medicare, for Medicaid, and for that tax subsidy 546 00:33:16,800 --> 00:33:19,280 Speaker 2: for employer provided health insurance that you mentioned, which is 547 00:33:19,280 --> 00:33:22,760 Speaker 2: about three hundred billion dollars a year, so it's non trivial, 548 00:33:23,240 --> 00:33:26,600 Speaker 2: and you combine all that together, that is sufficient to 549 00:33:26,720 --> 00:33:32,200 Speaker 2: finance the universal automatic basic system that we're proposing. And 550 00:33:32,240 --> 00:33:36,240 Speaker 2: then for the rest, individuals can supplement it out of 551 00:33:36,280 --> 00:33:39,480 Speaker 2: their own income in the same way that people supplement 552 00:33:40,040 --> 00:33:44,000 Speaker 2: their home security systems or the food they purchase, et cetera. 553 00:33:44,200 --> 00:33:47,840 Speaker 2: So our concern is about the cost to the taxpayer, 554 00:33:48,160 --> 00:33:50,600 Speaker 2: and then individuals who want more and are able to 555 00:33:50,640 --> 00:33:54,040 Speaker 2: afford it, you know, that's what their income and choices are. 556 00:33:54,040 --> 00:33:57,600 Speaker 1: For a couple quick questions, One, what is your take 557 00:33:57,680 --> 00:34:00,120 Speaker 1: of why large parts of the British National Health of 558 00:34:00,160 --> 00:34:00,920 Speaker 1: US don't work. 559 00:34:02,200 --> 00:34:05,200 Speaker 2: That's a good question, one that I'm not going to 560 00:34:05,240 --> 00:34:09,080 Speaker 2: have a very deep answer for. I think it's important 561 00:34:09,120 --> 00:34:12,880 Speaker 2: to distinguish that when we talk about universal automatic basic coverage, 562 00:34:13,320 --> 00:34:17,319 Speaker 2: that doesn't necessarily mean the British National Health Service. There 563 00:34:17,360 --> 00:34:21,440 Speaker 2: are many different ways that countries around the world have 564 00:34:22,040 --> 00:34:26,040 Speaker 2: enacted universal automatic basic coverage. Some have done it like 565 00:34:26,080 --> 00:34:28,040 Speaker 2: the British do it, and like we do it with 566 00:34:28,080 --> 00:34:31,359 Speaker 2: the Veterans Administration in the United States, where there's a 567 00:34:31,400 --> 00:34:36,560 Speaker 2: single payer, publicly provided insurance and actually all the physicians 568 00:34:36,640 --> 00:34:42,239 Speaker 2: and healthcare providers are public employees. That's one extreme. At 569 00:34:42,280 --> 00:34:46,480 Speaker 2: another extreme, you have systems like in the Netherlands and 570 00:34:46,640 --> 00:34:51,640 Speaker 2: Switzerland where all of the insurance is privately provided through 571 00:34:51,680 --> 00:34:57,320 Speaker 2: competing private insurers, but still everyone has universal automatic basic coverage. 572 00:34:57,360 --> 00:34:59,759 Speaker 2: So I just want to be clear that we don't 573 00:34:59,800 --> 00:35:02,480 Speaker 2: have to go the way of the US Veterans Administration 574 00:35:02,719 --> 00:35:05,560 Speaker 2: or the National Health Service to get to our proposal. 575 00:35:06,120 --> 00:35:09,440 Speaker 2: And then my understanding is, as with everything in healthcare, 576 00:35:09,480 --> 00:35:12,600 Speaker 2: the National Health Service is complicated. There are aspects of 577 00:35:12,640 --> 00:35:16,120 Speaker 2: it that work very well in terms of essential medical 578 00:35:16,120 --> 00:35:21,160 Speaker 2: care delivered without the kinds of complications and torturous patches 579 00:35:21,200 --> 00:35:23,319 Speaker 2: that we have in the United States, but there are 580 00:35:23,960 --> 00:35:28,200 Speaker 2: real concerns about, in particular wait times and access to 581 00:35:28,920 --> 00:35:31,279 Speaker 2: non urgent care that can still feel urgent if you 582 00:35:31,320 --> 00:35:34,400 Speaker 2: need a hip replacement and you have to wait eighteen months. 583 00:35:34,800 --> 00:35:39,720 Speaker 2: The solutions inevitably involve more funding for the basic system, 584 00:35:39,840 --> 00:35:43,400 Speaker 2: and that's something that's debated often in the national elections 585 00:35:43,680 --> 00:35:47,759 Speaker 2: among competing politicians. One reason I think we don't have 586 00:35:47,840 --> 00:35:49,719 Speaker 2: these kinds of debates in the United States is that 587 00:35:49,719 --> 00:35:52,400 Speaker 2: we don't even have a healthcare budget. There is no 588 00:35:52,520 --> 00:35:55,560 Speaker 2: budget for Medicare in the sense of a budget constraint. 589 00:35:55,840 --> 00:35:57,960 Speaker 2: Here's how much Medicare can spend, and now we have 590 00:35:58,040 --> 00:36:00,640 Speaker 2: to make tough choices about what we're going to spend 591 00:36:00,680 --> 00:36:05,880 Speaker 2: it on. Instead, it's a completely unlimited entitlement that whatever 592 00:36:06,280 --> 00:36:09,320 Speaker 2: patients and their doctor want, the government will pay the bills. 593 00:36:09,480 --> 00:36:12,560 Speaker 2: And so yes, when you put in constraints, it doesn't 594 00:36:12,640 --> 00:36:15,759 Speaker 2: always work out exactly how each person might want it. 595 00:36:15,800 --> 00:36:18,400 Speaker 2: But we can't even begin to talk about optimal design 596 00:36:18,440 --> 00:36:21,120 Speaker 2: if we don't have a budget constraint to make hard 597 00:36:21,239 --> 00:36:21,919 Speaker 2: choices within. 598 00:36:22,239 --> 00:36:25,640 Speaker 1: That's a fascinating and legitimate weight approach it. The only 599 00:36:25,680 --> 00:36:30,440 Speaker 1: observation I'd make is you are in fact converting, as 600 00:36:30,480 --> 00:36:34,280 Speaker 1: you put a three hundred billion dollars an employer provided 601 00:36:35,360 --> 00:36:41,680 Speaker 1: tax free coverage into a government program. Your critics would 602 00:36:41,680 --> 00:36:43,640 Speaker 1: in fact describe that as a tax increase. 603 00:36:44,160 --> 00:36:48,000 Speaker 2: As I said, we're focused on the substance of what 604 00:36:48,080 --> 00:36:49,920 Speaker 2: we think we should do, and if we can get 605 00:36:50,040 --> 00:36:54,080 Speaker 2: some agreement on that, particularly across the political parties, then 606 00:36:54,120 --> 00:36:56,880 Speaker 2: I am more than happy to defer to the many 607 00:36:56,920 --> 00:37:00,359 Speaker 2: people more expert than I the language one you to 608 00:37:00,400 --> 00:37:03,279 Speaker 2: package that to deal with the complaint that getting rid 609 00:37:03,320 --> 00:37:05,680 Speaker 2: of a tax subsidy is a tax increase. 610 00:37:06,239 --> 00:37:09,399 Speaker 1: As you can imagine, we probably have some significant philosophical 611 00:37:09,400 --> 00:37:12,799 Speaker 1: differences about this. But having spent a large part of 612 00:37:12,840 --> 00:37:15,200 Speaker 1: my time in the last twenty five years on this, 613 00:37:15,320 --> 00:37:18,680 Speaker 1: and I should notice that it was I believe seventy 614 00:37:18,719 --> 00:37:22,359 Speaker 1: four years ago that Harry Truman first proposed national health 615 00:37:22,400 --> 00:37:24,680 Speaker 1: care in the State of the Union. So this is 616 00:37:25,040 --> 00:37:28,120 Speaker 1: a long conversation we've been having as a country. I 617 00:37:28,120 --> 00:37:32,960 Speaker 1: think you have in fact offered a very important part 618 00:37:33,000 --> 00:37:36,080 Speaker 1: of that conversation, and I think you're going to generate 619 00:37:36,600 --> 00:37:41,400 Speaker 1: some very interesting and very useful conversations about what is 620 00:37:41,480 --> 00:37:44,520 Speaker 1: the core mission we ought to be about, what's the 621 00:37:44,560 --> 00:37:47,280 Speaker 1: best way to achieve that mission and are there ways 622 00:37:47,280 --> 00:37:50,240 Speaker 1: to structure it based on lessons not just from the US, 623 00:37:50,280 --> 00:37:52,279 Speaker 1: but from around the world. And I think you two 624 00:37:52,320 --> 00:37:56,759 Speaker 1: have really made a significant contribution. Your new book, We've 625 00:37:56,760 --> 00:38:00,040 Speaker 1: Got You Covered Rebooting American health Care is available and 626 00:38:00,360 --> 00:38:02,839 Speaker 1: and bookstows everywhere. We are going to have a link 627 00:38:02,880 --> 00:38:05,279 Speaker 1: to it on our show page. And I want to 628 00:38:05,280 --> 00:38:07,280 Speaker 1: thank you for joining me. I think this has been fascinating. 629 00:38:07,320 --> 00:38:10,160 Speaker 1: I hope you've enjoyed it. It's been very, very interesting. 630 00:38:10,680 --> 00:38:12,399 Speaker 2: Thank you so much for having me on. 631 00:38:16,040 --> 00:38:18,640 Speaker 1: Thank you to my guest Amy Finkelstein. You can get 632 00:38:18,640 --> 00:38:21,520 Speaker 1: a link to buy her new book, We've Got You Covered, 633 00:38:21,880 --> 00:38:26,560 Speaker 1: Rebooting American Healthcare on our show page at newsworld dot com. 634 00:38:26,680 --> 00:38:29,880 Speaker 1: News World is produced by gingridh three sixty and iHeartMedia. 635 00:38:30,360 --> 00:38:33,880 Speaker 1: Our executive producer is Guarnsey Sloan and our researcher as 636 00:38:33,960 --> 00:38:37,319 Speaker 1: Rachel Peterson. The artwork for the show was created by 637 00:38:37,320 --> 00:38:40,800 Speaker 1: Steve Penley. Special thanks to the team at Gingrid three sixty. 638 00:38:41,320 --> 00:38:43,600 Speaker 1: If you've been enjoying Newtsworld, I hope you'll go to 639 00:38:43,600 --> 00:38:47,200 Speaker 1: Apple Podcast and both rate us with five stars and 640 00:38:47,320 --> 00:38:50,000 Speaker 1: give us a review so others can learn what it's 641 00:38:50,040 --> 00:38:53,480 Speaker 1: all about. Right now, listeners of Newtsworld consign up for 642 00:38:53,600 --> 00:38:57,520 Speaker 1: my three free weekly columns at gingrishtree sixty dot com 643 00:38:57,560 --> 00:39:01,160 Speaker 1: slash newsletter. I'm Newt Gingrich. This is neutral.