WEBVTT - Presenting a New Vision for US Health Care

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<v Speaker 1>This is Bloomberg Business Week with Carol Messer and Tim

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<v Speaker 1>Steneveek on Bloomberg Radio.

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<v Speaker 2>All right, we've got you covered Rebooting American health care.

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<v Speaker 2>It is a new book that's out and you know, Tim,

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<v Speaker 2>you talk about it, We all talk about it. A

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<v Speaker 2>few certainties in life, right, death taxes, and the American

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<v Speaker 2>healthcare system is, for lack of a better word, it's

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<v Speaker 2>a mess. Yeah, like disruption, innovation. Come on, come do something.

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<v Speaker 1>So remember we have the Affordable Care Act Obamacare, right right,

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<v Speaker 1>that's supposed to solve all of the problems for uninsured Americans. Well,

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<v Speaker 1>guess what. In twenty twenty one, nearly thirty million people,

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<v Speaker 1>more than eight percent of the US population, didn't have

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<v Speaker 1>health insurance. That's according to the US Census Bureau. Now,

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<v Speaker 1>don't get me wrong. This is a lot better than

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<v Speaker 1>things were in the decade leading up to the Affordable

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<v Speaker 1>Care Act, when more than fifteen percent of people did

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<v Speaker 1>not have health insurance. But this is still millions of

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<v Speaker 1>people who are at risk.

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<v Speaker 2>It's a lot of people in a very rich or

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<v Speaker 2>so we're told, wealthy country. So let's get to one

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<v Speaker 2>of the co authors, Amy Finkelstein. She is a Professor

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<v Speaker 2>of Economics at MIT, director of the Healthcare Program at

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<v Speaker 2>the National Bureau of Economic Research, and among other things,

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<v Speaker 2>a twenty eighteen MacArthur Fellow, and actually get a genius grant.

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<v Speaker 3>Correct, Yeah, that's correct.

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<v Speaker 1>I don't know if the geniuses are supposed to call

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<v Speaker 1>them genius grants. That's for just us, lay people.

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<v Speaker 2>Carol, we're going to call you a gen We've been

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<v Speaker 2>calling it, teasing you up. She is on Zoom in

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<v Speaker 2>Cambridge on the well.

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<v Speaker 1>I got to tell you it's going to take a

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<v Speaker 1>genius to figure out healthcare in this country. So we're

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<v Speaker 1>lucky to have you help us.

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<v Speaker 2>Help us because you know, Tim and I talk with

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<v Speaker 2>a lot of folks and we talk about disruption, innovation,

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<v Speaker 2>We've got the metaphorse coming, we've got generative AI, all

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<v Speaker 2>these wonderful things coming at us, and yet it still

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<v Speaker 2>feels like in some ways healthcare is way behind the times.

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<v Speaker 2>How do you see it? How do you think about it? Yeah?

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<v Speaker 3>Thanks a lot for having me on. I'd say, you know,

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<v Speaker 3>we didn't my co author Lauren and IV and I

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<v Speaker 3>didn't go into this thinking about disruption, but we concluded

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<v Speaker 3>that it was the only solution and part of the

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<v Speaker 3>reason is related to that fact that you started with

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<v Speaker 3>that thirty million Americans or one in ten Americans under

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<v Speaker 3>sixty five lack health insurance at any given moment. That

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<v Speaker 3>gets talked about endlessly. But a really, really important statistic

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<v Speaker 3>that gets very little coverage is the fact that more

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<v Speaker 3>than twice as many Americans, in fact, one in four

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<v Speaker 3>Americans under sixty five will have some period of time

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<v Speaker 3>without health insurance coverage over a two year period. In

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<v Speaker 3>other words, health insurance, whose very purpose is to be

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<v Speaker 3>secure and certain, is in fact highly uncertain. We all

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<v Speaker 3>live if we are lucky enough to have health insurance

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<v Speaker 3>with the risk of losing that coverage is.

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<v Speaker 1>That because it's tied to our jobs.

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<v Speaker 3>For people with employer provided health insurance that you know

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<v Speaker 3>about half of the population that haves that, Yes, for

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<v Speaker 3>people with publicly provided health insurance, the risk is, you know,

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<v Speaker 3>like Medicaid or Medicare for certain diseases, the risk is

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<v Speaker 3>you can lose your coverage if your income changes, or

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<v Speaker 3>you get older, or you have a disease specific coverage

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<v Speaker 3>program and you get cured of that disease, or and

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<v Speaker 3>this is kind of the most heartbreaking part, or you

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<v Speaker 3>can simply lose your coverage because you fail to realize

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<v Speaker 3>that you need it to file forms to demonstrate that

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<v Speaker 3>you're still eligible under some income category. And that's why

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<v Speaker 3>we realized further patches and incremental reform won't work. We

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<v Speaker 3>have to tear this down and start over, because whenever

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<v Speaker 3>you have different pathways to eligibility and coverage through a

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<v Speaker 3>myriad of programs, you're going to have gaps at the themes.

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<v Speaker 3>And that's where people are falling through.

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<v Speaker 2>All right, So, Professor Finkelstein, if you could wave your

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<v Speaker 2>magic wand and change one thing that you think would

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<v Speaker 2>be a game changer in terms of improving healthcare in

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<v Speaker 2>the United States, what would it be. I'm just curious

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<v Speaker 2>who would you wave the magic wand over. Is it

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<v Speaker 2>the health insurers, is it politicians? Is it what?

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<v Speaker 3>To fix our coverage problem? We need automatic universal basic

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<v Speaker 3>coverage that's free for everyone, no patient payments, and then

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<v Speaker 3>the option to buy supplemental coverage if you want more

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<v Speaker 3>than the basic.

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<v Speaker 1>Is this this sounds forgive me, I'm not sixty five,

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<v Speaker 1>but my parents are over sixty five, and this sounds

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<v Speaker 1>like medicare.

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<v Speaker 3>It may sound like medicare. It's not. Here's one very

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<v Speaker 3>important difference, and that I think a lot of the

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<v Speaker 3>proponents of Medicare for all don't realize that Medicare for

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<v Speaker 3>some is actually very very incomplete insurance. So, for example,

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<v Speaker 3>for doctor visits, people have to pay twenty percent of

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<v Speaker 3>the doctor bill out of their own pocket, with no limit,

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<v Speaker 3>no cap. So you can if you're unfortunate enough to

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<v Speaker 3>be quite ill, you have cancer, say, and you rack

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<v Speaker 3>up lots of physician visits and bills, you can be

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<v Speaker 3>on the hook for tens of thousands of dollars that

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<v Speaker 3>you have to pay despite having coverage. A startling fact

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<v Speaker 3>is not only that there's enormous amounts of medical debt

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<v Speaker 3>in the United States, but that three fift of that

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<v Speaker 3>is incurred by people who have health insurance. So in

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<v Speaker 3>that sense, our plan would be much better than the

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<v Speaker 3>current Medicare plan, and there'd be no risk of having

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<v Speaker 3>to pay anything out of pocket. On the other hand,

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<v Speaker 3>because we are realists at least in the economic in

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<v Speaker 3>terms of the economics, we have that coverage be much

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<v Speaker 3>more basic than the current Medicare coverage. People are so

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<v Speaker 3>concerned about Medicare costs growing so fast and going through

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<v Speaker 3>the roof. One reason they do that is because there's

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<v Speaker 3>no budget constraint on the system. Patients want care, physicians

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<v Speaker 3>are willing to provide it. There's no gatekeeper on the

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<v Speaker 3>back end saying no, maybe we need to you know,

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<v Speaker 3>check to make sure you really need that CT scam

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<v Speaker 3>because you came in with a headache. So we would

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<v Speaker 3>have much more constraints on the nature of the care

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<v Speaker 3>that's provided, but anything that was provided would be completely free.

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<v Speaker 2>So how do we help you know, you know where

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<v Speaker 2>that gets to, like people making decisions about who gets what, like,

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<v Speaker 2>how do we make sure that is done in a

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<v Speaker 2>pure way?

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<v Speaker 3>That's a good question. So the first thing I want

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<v Speaker 3>to emphasize is that the whole point of a universal

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<v Speaker 3>basic health insurance system is to fulfill the social commitment

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<v Speaker 3>that we clearly have and it's revealed by all our

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<v Speaker 3>patchwork policies to provide essential medical care when people are ill,

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<v Speaker 3>regardless of their ability to pay for it. And so

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<v Speaker 3>the basic coverage has to cover what's medically essential, but

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<v Speaker 3>it doesn't have to cover things that we all might

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<v Speaker 3>like but that aren't actually essential medical care, such as

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<v Speaker 3>you know, so you can have longer wait times for

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<v Speaker 3>non urgent care, you can have fewer amenities the non

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<v Speaker 3>medical part, you know, like more people to a hospital

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<v Speaker 3>room or and this is what other countries do. Countries

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<v Speaker 3>like Singapore or Australia, they provide universal basic coverage, but

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<v Speaker 3>if you want a private hospital room or good hospital food,

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<v Speaker 3>that's what you pay extra for.

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<v Speaker 2>There was one point my husband got ill over in

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<v Speaker 2>the UK and we were initially in I guess their

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<v Speaker 2>public system and.

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<v Speaker 1>Yeah, and it.

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<v Speaker 2>Was a ton of people in a room and you

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<v Speaker 2>had to get up to get your own food. It

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<v Speaker 2>wasn't great, I'm going to be quite honest. And he

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<v Speaker 2>was with an employer who pulled him out and put

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<v Speaker 2>him over to a hospital that is was like a

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<v Speaker 2>nice hotel and you know, got a bunch of tests

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<v Speaker 2>that they could do as soon as he walked in.

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<v Speaker 2>Although we had to see the finance person. That was

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<v Speaker 2>the first person we saw to make sure that it

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<v Speaker 2>was going to be paid for. Like, it was just

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<v Speaker 2>such a contrast, and I guess so I'm trying to understand,

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<v Speaker 2>you know, how we move forward and get to something

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<v Speaker 2>where more people are getting better care. And I'm wondering,

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<v Speaker 2>how do we pay for all of this?

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<v Speaker 3>So I think those are related questions. The example we

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<v Speaker 3>give in the book is, you know, how do we

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<v Speaker 3>fulfill our obligation obligations but without you know, all the

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<v Speaker 3>extra stuff. So your your husband's example is a perfect one.

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<v Speaker 3>It's I can totally understand why you liked going outside

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<v Speaker 3>of the system more you had a private room, more convenience,

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<v Speaker 3>et cetera. But I think our commitment as a society

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<v Speaker 3>is not to provide everyone with luxury, high end medical care,

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<v Speaker 3>such as your husband was fortunate to receive, but to

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<v Speaker 3>provide essential medical care. And that's also how we keep

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<v Speaker 3>the price down. So if you are fortunate enough to

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<v Speaker 3>be able to afford it, and you want to buy

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<v Speaker 3>those extra amenities, that's great, but that's not what we're

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<v Speaker 3>committed to as a society. We're not committed to providing

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<v Speaker 3>a luxury experience. We're committed to providing essential medical care.

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<v Speaker 3>And as we discuss in the book, that's also how

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<v Speaker 3>we keep the price tag deck great.

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<v Speaker 2>And I certainly wasn't arguing in favor of the other

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<v Speaker 2>because he wasn't fixed. He was basically just fixed enough

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<v Speaker 2>to get on a plane and come back home to

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<v Speaker 2>the United States. But it was just such a contrast,

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<v Speaker 2>and I was trying to get my head around, like,

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<v Speaker 2>how do we figure this out? Professor Finkelstein, don't go anywhere.

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<v Speaker 2>We want to continue this conversation. We are talking with

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<v Speaker 2>Amy fink Stein. She is a co author of a

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<v Speaker 2>new book. It's called We've Got You Covered, Rebooting American Healthcare,

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<v Speaker 2>professor of economics at MIT and director of Healthcare Program

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<v Speaker 2>at the National Bureau of Economic Research. I mean, really

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<v Speaker 2>is coming at this from just checking all the boxes

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<v Speaker 2>of someone I think who needs to understand how to

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<v Speaker 2>fix this.

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<v Speaker 1>She's at the NBER. I wonder if she can tell

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<v Speaker 1>us if there's a recession.

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<v Speaker 2>That's our next question. Carol Masser along with Tim Stenovik

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<v Speaker 2>here on Bloomberg Business Week, and we want to get

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<v Speaker 2>back to Amy Finkelstein. She's co author We've Got You Covered,

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<v Speaker 2>Rebooting American Healthcare, Professor of economics at MIT, director of

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<v Speaker 2>the Healthcare Program at the National Bureau of Economic Research,

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<v Speaker 2>And as we mentioned earlier at twenty eighteen, MacArthur Fellow

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<v Speaker 2>on Zoom in Cambridge, So do you know is it

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<v Speaker 2>a recession? Is a recession coming?

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<v Speaker 1>We had a great Bloomberg story a few months ago,

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<v Speaker 1>Amy and the group of folks at the NBER were

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<v Speaker 1>described as eggheads, who are the ones who decide whether

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<v Speaker 1>or not we're in a recession. Yes, we'll have to

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<v Speaker 1>go to you for how we fix American healthcare.

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<v Speaker 3>What just the egghead on health Hey.

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<v Speaker 1>That's good enough for us. We appreciate that. What is

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<v Speaker 1>the one country that is doing this the best?

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<v Speaker 3>Every high income country but the US is doing it

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<v Speaker 3>much better than we are. None of them do or

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<v Speaker 3>doing it exactly as we propose.

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<v Speaker 1>Which one is closest.

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<v Speaker 3>It's not a fair question. We're like some of them

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<v Speaker 3>in some dimensions and like others on others. What I

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<v Speaker 3>can say that every other high income country is doing,

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<v Speaker 3>which is what we propose, is automatic universal basic coverage

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<v Speaker 3>and the option to supplement or top it up if

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<v Speaker 3>you want more. And the third element, which is really key,

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<v Speaker 3>a budget that is enforced in terms of how much

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<v Speaker 3>can be spent by the taxpayer on healthcare. One thing

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<v Speaker 3>that's shocking about the US system is there is no

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<v Speaker 3>healthcare budget in the sense of what a budget really means,

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<v Speaker 3>a budget constraint, an amount that you can't suspend beyond.

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<v Speaker 3>When people talk about the Medicare budget. They mean how

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<v Speaker 3>much Medicare has spent or will spend, not the cap

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<v Speaker 3>on how much it can spend. So we need to

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<v Speaker 3>enforce a budget and use that taxpayer money that we've

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<v Speaker 3>allocated to provide universal basic coverage. Now you ask which

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<v Speaker 3>country we're like, Well, in one dimension, we're very much

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<v Speaker 3>like the UK and Canada in having absolutely no patient

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<v Speaker 3>copays in the basic coverage. No patients don't have to

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<v Speaker 3>pay anything out of pocket. On the other hand, in

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<v Speaker 3>terms of the design of the supplemental coverage, we very

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<v Speaker 3>much don't want to do it the way the UK

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<v Speaker 3>does it, but we want to do it the way

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<v Speaker 3>say Singapore or Australia do it, where you can just

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<v Speaker 3>pay the extra cost to top up, like upgrading to

0:11:42.360 --> 0:11:45.640
<v Speaker 3>business class, you don't have to repurchase the entire ticket

0:11:45.679 --> 0:11:47.600
<v Speaker 3>to get a little extra library and just pay for

0:11:47.640 --> 0:11:48.640
<v Speaker 3>the additional cost.

0:11:49.160 --> 0:11:54.000
<v Speaker 2>But doesn't that create again inequities because obviously not everybody

0:11:54.040 --> 0:11:56.439
<v Speaker 2>can can upspend if you.

0:11:56.400 --> 0:12:02.120
<v Speaker 3>Will absolutely we know we see the key mission of

0:12:02.720 --> 0:12:05.760
<v Speaker 3>health care policy to make sure that everyone has access

0:12:05.760 --> 0:12:10.200
<v Speaker 3>to essential medical care, regardless of resources. And beyond that

0:12:10.640 --> 0:12:14.720
<v Speaker 3>we tolerate inequality in you know, the supplemental and the

0:12:14.720 --> 0:12:18.240
<v Speaker 3>same way we tolerate inequality in other aspects of our society,

0:12:18.480 --> 0:12:21.600
<v Speaker 3>you know, housing, food, et cetera. Our proposals about a

0:12:21.600 --> 0:12:25.600
<v Speaker 3>floor not a ceiling. And one thing that's really important

0:12:25.600 --> 0:12:27.400
<v Speaker 3>to understand because I know that makes a lot of

0:12:27.400 --> 0:12:32.120
<v Speaker 3>people uncomfortable, because however we feel about inequality in say clothing,

0:12:32.480 --> 0:12:35.640
<v Speaker 3>you know, many people feel rightly that that health is different,

0:12:35.720 --> 0:12:38.280
<v Speaker 3>that it occupies, you know, a sort of special place

0:12:38.320 --> 0:12:41.400
<v Speaker 3>in our moral firmament. One of the things we make

0:12:41.520 --> 0:12:43.680
<v Speaker 3>very clear in the book is that there's an enormous

0:12:43.720 --> 0:12:47.280
<v Speaker 3>body of research that makes it clear that, as counterintuitive

0:12:47.280 --> 0:12:50.400
<v Speaker 3>as it may seem, if you're concerned, and you should be,

0:12:50.520 --> 0:12:53.600
<v Speaker 3>about the shocking health disparities it exists in the United

0:12:53.640 --> 0:12:56.640
<v Speaker 3>States between high end low income, between black and white,

0:12:57.320 --> 0:13:00.400
<v Speaker 3>health insurance policy is simply not the lever to lean

0:13:00.440 --> 0:13:03.960
<v Speaker 3>on health insurance would make reform would have little effect

0:13:04.240 --> 0:13:08.000
<v Speaker 3>on those health disparities. And probably the clearest way to

0:13:08.040 --> 0:13:10.720
<v Speaker 3>see that is from work that some economists have done

0:13:11.280 --> 0:13:15.240
<v Speaker 3>ichen Chen Maria Poliakova and Petra Parson, who shows it

0:13:15.240 --> 0:13:17.520
<v Speaker 3>in a country like Sweden, and there's other work showing

0:13:17.520 --> 0:13:21.640
<v Speaker 3>this in Norway. Despite universal health insurance and cradle to

0:13:21.679 --> 0:13:26.600
<v Speaker 3>the grave social safety net. The health inequality across the

0:13:26.640 --> 0:13:30.800
<v Speaker 3>income distribution is as large in say, Sweden, as.

0:13:30.640 --> 0:13:32.880
<v Speaker 1>It is in the United Wow, that's surprising to hear.

0:13:33.320 --> 0:13:36.000
<v Speaker 1>So yeah, if you look, I have two questions for you,

0:13:36.040 --> 0:13:38.480
<v Speaker 1>one yes or no. But you can also tell me

0:13:38.520 --> 0:13:40.760
<v Speaker 1>it's not a fair question. Do doctors in the US

0:13:40.800 --> 0:13:42.400
<v Speaker 1>make too much money?

0:13:43.440 --> 0:13:45.280
<v Speaker 3>It's not relevant to our proposal.

0:13:45.600 --> 0:13:47.520
<v Speaker 1>So that's my next question. When you look at the

0:13:47.840 --> 0:13:50.960
<v Speaker 1>when you look at the value chain across patient access,

0:13:51.000 --> 0:13:53.679
<v Speaker 1>and you know you hear the stat thrown around all

0:13:53.720 --> 0:13:55.680
<v Speaker 1>the time that you know a fifth of our GDP

0:13:55.880 --> 0:13:58.959
<v Speaker 1>goes to health care costs. Where is that money going?

0:13:59.400 --> 0:14:01.360
<v Speaker 1>Who is getting that money? Who doesn't deserve it?

0:14:03.800 --> 0:14:07.280
<v Speaker 3>One of the key things about our proposal is to

0:14:07.360 --> 0:14:10.640
<v Speaker 3>realize that you can separate the question of how do

0:14:10.720 --> 0:14:13.240
<v Speaker 3>we make sure that everyone has access to es central

0:14:13.280 --> 0:14:17.199
<v Speaker 3>medical care regardless of resources, from the very hard questions

0:14:17.200 --> 0:14:22.200
<v Speaker 3>that you're raising about how to fix healthcare spending, how

0:14:22.200 --> 0:14:24.800
<v Speaker 3>to make sure that we can spend less and still

0:14:24.840 --> 0:14:27.960
<v Speaker 3>achieve good outcomes. The coverage problem turns out to be

0:14:27.960 --> 0:14:30.240
<v Speaker 3>a really easy one. As I said, basically every other

0:14:30.320 --> 0:14:33.480
<v Speaker 3>high income country has done it. The question you're asking,

0:14:33.520 --> 0:14:35.920
<v Speaker 3>which is a good question, is one that no one

0:14:36.000 --> 0:14:38.880
<v Speaker 3>knows the answer to, and I don't care what they're claiming.

0:14:39.040 --> 0:14:41.880
<v Speaker 3>It's a very very hard problem. But the way we

0:14:41.960 --> 0:14:45.040
<v Speaker 3>can afford it is to realize that, yes, that statistic

0:14:45.120 --> 0:14:47.080
<v Speaker 3>you said is right. We spend twice as much as

0:14:47.120 --> 0:14:50.080
<v Speaker 3>any other country on healthcare fifth of our economy as

0:14:50.080 --> 0:14:52.640
<v Speaker 3>a share of the economy, but only half of that

0:14:52.800 --> 0:14:56.800
<v Speaker 3>is publicly funded. So taxpare dollars in the US are

0:14:56.800 --> 0:15:00.120
<v Speaker 3>not more than in other countries. We're already paying for

0:15:00.240 --> 0:15:03.200
<v Speaker 3>universal coverage through the tax system. We're just not getting

0:15:03.200 --> 0:15:03.600
<v Speaker 3>it all.

0:15:03.560 --> 0:15:05.440
<v Speaker 2>Right, So, just got about a minute left here, so

0:15:06.040 --> 0:15:09.520
<v Speaker 2>forgive me, and I'm just maybe a little brain day,

0:15:10.440 --> 0:15:15.400
<v Speaker 2>But I mean, so, what's the step one towards what

0:15:15.480 --> 0:15:18.680
<v Speaker 2>you are talking about? What do what would we have

0:15:18.800 --> 0:15:19.560
<v Speaker 2>to change?

0:15:20.560 --> 0:15:24.080
<v Speaker 3>What is it? We'd have to completely tear down the

0:15:24.120 --> 0:15:28.120
<v Speaker 3>current system and build system in quotations, the current patchwork

0:15:28.160 --> 0:15:30.960
<v Speaker 3>of policies we have in place, and actually design and

0:15:31.000 --> 0:15:34.160
<v Speaker 3>build a coherent, automatic universal.

0:15:33.760 --> 0:15:37.720
<v Speaker 2>Basically, how does that start? Is it politics? Is it politicians?

0:15:37.880 --> 0:15:40.040
<v Speaker 2>Is it the private sector? How do we start?

0:15:40.360 --> 0:15:42.960
<v Speaker 3>It's it's public policy? So yes, we need it. We

0:15:43.000 --> 0:15:45.120
<v Speaker 3>need to wait. We're waiting for the first you know,

0:15:45.160 --> 0:15:48.000
<v Speaker 3>would be presidential candidate to sign on board for our plan.

0:15:48.280 --> 0:15:50.080
<v Speaker 3>The book just came out today, so you know, I'm

0:15:50.080 --> 0:15:51.240
<v Speaker 3>willing to give it a week or two.

0:15:52.000 --> 0:15:53.800
<v Speaker 2>I guess what you know and listen. I wish we

0:15:53.840 --> 0:15:56.320
<v Speaker 2>had more time because this is a really, I think

0:15:56.320 --> 0:15:59.040
<v Speaker 2>difficult I always feel like healthcare and education these are

0:15:59.080 --> 0:16:01.960
<v Speaker 2>the two things that really need some disruption to happen

0:16:02.000 --> 0:16:04.040
<v Speaker 2>in But healthcare, I feel like there's so much money

0:16:04.040 --> 0:16:08.800
<v Speaker 2>in it. You know that it complicates it?

0:16:08.840 --> 0:16:09.320
<v Speaker 3>Is that fair?

0:16:09.360 --> 0:16:12.080
<v Speaker 2>I just got about fifteen seconds. It complicates it, right.

0:16:12.840 --> 0:16:15.200
<v Speaker 3>It does. But once we agree on the solution, then

0:16:15.240 --> 0:16:17.680
<v Speaker 3>we can start trying to figure out how to achieve it.

0:16:17.720 --> 0:16:19.080
<v Speaker 2>I gotta say, I love a book that says more

0:16:19.120 --> 0:16:21.280
<v Speaker 2>than fifty shades of gray. But it has to do

0:16:21.520 --> 0:16:25.160
<v Speaker 2>with what's going to be considered. You know, kind of

0:16:26.000 --> 0:16:29.440
<v Speaker 2>basic coverage, right, what things go? Fertility treatments?

0:16:30.120 --> 0:16:30.720
<v Speaker 1>Is it basic?

0:16:31.000 --> 0:16:35.640
<v Speaker 2>I don't know physical therapy anyway. Amy Finkelstein, incredible. Check

0:16:35.640 --> 0:16:36.080
<v Speaker 2>out the book.

0:16:36.120 --> 0:16:36.640
<v Speaker 3>Everybody