0:00

We hold these truths to be self-evident. That

0:02

all men are created.

0:03

It is time to cover. As a member of Congress, I get

0:05

to have a lot of really interesting people in the office. Experts

0:08

on what they're talking about. This is the podcast

0:10

for insights into the issues. China, bioterrorism,

0:13

Medicare for all, in-depth discussions.

0:16

Breaking it down into simple terms. We

0:18

hold. We hold. We hold these truths.

0:20

We hold these truths. With Dan Crenshaw. The angle

0:22

has landed.

0:24

Welcome back everyone. With me today is

0:26

Dr. Marty Makari. He's a faculty

0:29

member at Johns Hopkins. And he's an expert on healthcare

0:31

pricing and public health. He's the author of

0:33

The Price We Pay, What Broke American Healthcare

0:36

and How to Fix It. It was published in 2019. So,

0:40

I hear about this from a lot of constituents and a lot of Americans.

0:43

And I

0:44

like to use

0:46

the following analogy. Imagine if we bought

0:48

food. You know, another thing we need. If

0:50

we describe healthcare as something we need. Imagine if

0:52

we bought food the same way we bought healthcare.

0:55

So you'd go into a supermarket

0:56

and nothing would have any prices.

0:58

You'd pick out sort of what you

1:00

wanted based on whatever limited

1:03

knowledge you have of what you need. You

1:05

take it to the cashier. They bill some

1:07

third party. Maybe you pay a copay

1:09

or a deductible or something that maybe

1:12

you knew ahead of time. But

1:14

literally- Who's your employer? Yeah, well, it

1:17

gets pretty complicated pretty fast. And on

1:20

top of that, you know, maybe you wanted to buy tomatoes

1:22

and then onions, but they're like, well, you have to buy the onions before

1:24

the tomatoes. And actually you can't even buy this

1:27

before that. That would be

1:28

kind of similar to how our healthcare system

1:31

is priced. So you wrote a whole book about

1:33

this. It's something you focus on a lot. At

1:37

the heart of everybody's, I think,

1:40

frustration with the healthcare system is

1:42

the pricing mechanisms we use.

1:45

There's plenty of good doctors in the United States.

1:47

There's plenty of good researchers. Plenty of good, interesting,

1:50

cutting edge technologies. In fact, you might argue that

1:52

we're still the best at everything across

1:54

the board. Holistically, especially

1:56

with the really tough stuff. But

2:00

it's the pricing, right? It's

2:02

the financing of it. So, geez,

2:04

where do we even begin? You

2:08

know, what were you seeing in

2:10

your practice? You practice as well. That's

2:13

right. You do the policy side, you practice. What kind

2:15

of doctor are you? I do pancreatic

2:17

surgery. Okay. And

2:19

what caused you to write this book? Like,

2:22

just sick of it all? How

2:25

did it start? Yeah, I mean, look, there's too many people

2:27

in healthcare just picking up their

2:29

paycheck every two weeks, frustrated,

2:32

but they don't do anything.

2:33

And I have been at the bedside

2:36

with people dying over a thousand times,

2:38

and it reminds you how short life is. You

2:40

got to speak up. You got to do something. So,

2:44

one of the great injustices, out

2:46

of all the injustices that make

2:48

headlines,

2:49

is the fact that the prices

2:51

are too high for healthcare, and you can't get

2:53

the price when you go in for the care, just

2:56

like you said, the grocery store. You can't know what it is.

2:58

It's insane. I mean, would you go to a

3:00

burger shop and ask

3:03

to see the menu, and they would say, who's your employer?

3:06

Well, you know, we can get, we'll work it out. We can't

3:08

give you the price after you eat the

3:10

burger.

3:11

Then we'll send you a bill. Well, so they say you get your burger first.

3:14

That's what's important. Well, I know, but I'm not sure

3:16

I want the burger. Right. This is especially

3:18

true for some things

3:20

that you just, you need or you'll die, right? But

3:22

there's a lot of healthcare in between,

3:25

you know, your kind of maintenance healthcare,

3:27

and you need this or you die healthcare.

3:30

Yeah, 60% of healthcare is shoppable.

3:33

These are non-emergent, non-urgent services,

3:35

where you can shop, but you really

3:38

can't because the system- Doesn't

3:40

let you. The fundamental problem in healthcare is we have non-competitive

3:43

markets. And when you see that as a

3:46

policymaker or a consumer, you want to create

3:48

rules around the bad behavior. But the real

3:50

solution is let them be competitive.

3:53

Let them be efficient. Just like when

3:55

you buy an

3:57

airline ticket on a travel site. And

4:00

the airlines don't say, we can't give you a price.

4:03

We don't know the price of fuel. They

4:05

have incredibly complicated algorithms that

4:07

give them a price. And that price changes on a minute by

4:09

minute basis. That's right. Somebody can obviously

4:12

figure this out. That's right. That's

4:14

right. They incorporate the variability

4:16

in their cost into a fixed pricing

4:18

model. And they give you one price.

4:20

And that's how you shop. And that's why airline

4:22

tickets have basically been stable for 35 years.

4:27

They actually have.

4:29

I've never even thought about that analogy. But

4:32

if I think about travel over the last 20 years,

4:34

it doesn't appear to me to have gotten really

4:36

more expensive. There's still very affordable ways

4:38

to travel. Yeah. It was about $2, $300 to

4:40

fly from here to Texas in the 70s. Yeah,

4:45

exactly.

4:47

There's no perfect analogies with health care.

4:50

I try to use food because I want

4:52

to focus on something we need. I

4:54

was stumped once when I will never forget

4:56

it. I also had no with myself. I

4:59

mean,

5:00

firefighters are like a public service.

5:02

Like, why can't it just be like that? And

5:04

I was like, I started

5:06

thinking about economic terms, like

5:09

common goods or whatever. But the real

5:11

answer in hindsight, I didn't come up with

5:13

it at the moment, but the real answer was,

5:15

I mean, you're comparing apples and

5:18

oranges right away. A firefighter

5:20

has one job to do. Put out a fire.

5:22

A doctor could potentially have millions of jobs

5:24

to do that last over different varying periods

5:26

of time. So you're comparing

5:28

an incredibly simple public service to an

5:30

incredibly complex one.

5:32

That's number one. Also, number

5:35

two is you don't need to innovate in the firefighter

5:37

world. Putting out a fire is

5:39

putting out a fire. There's some little innovations here and there. I don't

5:41

want to disparage the firefighting innovation

5:44

sector. But

5:45

it's pretty cut and dry, you

5:48

know? Pun intended. The

5:51

health care is not. You're

5:53

constantly trying to, you need

5:55

a profit incentive to invest in research and

5:58

development. So it's just good. It's complete.

5:59

apples and oranges. But is there a better analogy?

6:02

I don't know. I just, I look at things

6:04

we need. I need, we need shelter, food, and healthcare.

6:07

And in shelter and food, we use a voucher system

6:10

to give it to people who don't, who can't afford it.

6:12

Is that the, is that am I, am I lacking

6:14

in my analogies there? Well,

6:17

first of all, you got a cool life. You went on the Joe Rogan

6:19

show and you're next door

6:21

here to AOC's office. Yeah, we are. Yeah.

6:24

We're new neighbors. And

6:26

we're working on some healthcare stuff together. Oh good.

6:28

Good. Psychedelics therapy. What do

6:30

you think about that? Yeah, there's some interesting data

6:32

there. Interesting data. Yeah. There's

6:34

too many labels with, with

6:37

medications that are nonproductive.

6:40

I think this, this is a drug. What's

6:43

the difference between a drug and a medication? I mean,

6:46

so it really should, we should rely on the data

6:48

to tell us and same with, you know, public policy.

6:50

There's too many labels and all that, but in

6:53

healthcare, the,

6:55

the system was working pretty

6:57

good until we had generated a giant middleman

7:03

industry that is seething

7:06

money out of the system left and right. And

7:08

that industry is fed off of one

7:11

principle and that is you can't

7:13

get the price. You can't see the price.

7:16

So a giant re-pricing industry

7:18

moves in. When did this happen? Like

7:20

if you're looking at the history of healthcare pricing, because

7:22

that is true. I mean, my, my parents don't

7:25

recall a time when healthcare was so unaffordable.

7:27

It wasn't a thing. We were probably lower middle-class.

7:30

My mom had cancer. Like there was, there was a big

7:32

deal. I mean, this,

7:34

I don't recall it being a devastating

7:36

issue financially. Well, the first insurance

7:39

company really came out of Texas. It

7:41

was a group of doctors in a hospital that said,

7:43

Hey, we can just offer a sort

7:45

of plan so that you can make sure you

7:48

get cared for here by contributing

7:50

on a regular basis. And

7:53

the system worked fine. But then what happened

7:55

was in the 1980s, a

7:58

bunch of consultants out there.

8:00

went shopping when they went bouncing around

8:02

to the different hospitals and said, hey

8:04

you can charge a much higher

8:06

price point and then give people a

8:09

discount based on who they are. This

8:11

employer gets a big discount, this insurance

8:13

company gets a discount, and it started

8:15

this game of dialing up the

8:17

price and also dialing

8:20

up the discount but not quite as

8:22

much as you dial up the price. So

8:24

if you dial up your prices 10% and

8:26

then tell everyone we're going to give you an added 8% discount,

8:30

you just made $2 million for the hospital, congratulations

8:33

Joe, now you're the CFO, you know

8:35

we're going to give you all this promotion.

8:38

And so the hospital started hiring armies

8:40

of lawyers and staff to negotiate

8:42

these contracts and the doctors were in the background

8:44

saying, Who are they negotiating with? The insurance

8:46

companies? Insurance companies

8:49

and a

8:50

bit with employer groups. And

8:52

so the doctors in the background watching all

8:54

this saying, Hey what's going on over

8:56

there? We have a whole new building, what

8:58

are these people doing in there? They're not delivering patient

9:01

care. No, I'm not saying they're bad people,

9:03

they're doing exactly what the system is designed

9:05

to do and that is feed off of this

9:08

middleman industry. And then on top

9:10

of that you have no quality measures,

9:12

right? So then you're really flying blind.

9:14

So then became the mass crusade

9:17

to advertise on the NFL

9:20

stadiums and all over the world to say,

9:22

Hey we are the great fill

9:25

in the blank brand,

9:27

come to us, we use a robot,

9:29

we have a helicopter, and then

9:31

there was this perception that we have

9:33

to include this big brand in our insurance

9:36

network and then they would

9:38

then just dial up the prices and take people

9:40

for a ride. This is what's really

9:42

hard about this subject is multiple

9:45

things that happened over time

9:47

that are very difficult to dial back.

9:49

There's maybe the answer

9:52

is in the book, but

9:54

it's hard to distill that into

9:56

legislation, feasible and all the little

9:59

unfeasible legislation.

9:59

legislation that dials

10:02

back our system also in a responsible and

10:04

methodical way that doesn't break it right

10:06

away. I mean because

10:09

this stuff happened over time and you know because you know

10:11

well before that was the incentive for employers

10:13

to offer insurance right because of wage

10:16

controls during World War two so that's you know that

10:18

the history of that's right why why most insurance

10:20

is done through an employer in the first place

10:23

and

10:24

we find ourselves here

10:27

over time and It's

10:29

in talking so talk to us about Obamacare then like how did

10:31

that change the system even more?

10:33

What was what's the layman's view of that?

10:36

Well at one point healthcare was polling

10:38

as the number one issue in America and

10:41

The irony is healthcare

10:43

is more expensive now than it was then right

10:45

and now it's not even close doesn't it whole I

10:47

don't yeah, I don't get that either But

10:51

yeah back then it seemed that seemed to be the case.

10:53

I don't wonder why it's just I it's ironic Obviously,

10:57

maybe it should pull up there, but it's like

10:59

twice as expensive as when it was polling number

11:01

one So the frustration led

11:03

people to say let's address The

11:05

two giant issues that are burdening

11:08

every business and family in America number

11:10

one is We have a large group

11:13

of uninsured people there were 44 million

11:15

at the time and

11:16

People had a heart for those people

11:18

and they wanted to see them get coverage The

11:20

second problem was the rate

11:23

of increase of prices in health

11:25

care was unsustainable, right? So

11:27

the Affordable Care Act Try to

11:29

address both of these problems they

11:31

took the number of uninsured down from 44 million to

11:33

about 25 million and

11:37

On the price point

11:39

health care is about double the price is what so

11:41

it failed I mean any objective measure it

11:43

failed on lowering the prices now And

11:46

how did you even get 44 to 25? Let's talk.

11:48

Let's explain that to massive subsidies

11:51

massive massive expansion

11:53

That was a part of it for sure Medicare

11:56

expansion and you know roughly half

11:58

the states in the country now the vast majority,

12:01

but it was creating insurance plans on

12:04

the on an open exchange network that people

12:06

could pick that were heavily subsidized.

12:09

So of course they would take people that are sicker

12:11

in

12:11

your general health insurance plan

12:14

that you have to climb on three flights

12:16

of stairs to sign up for because

12:18

you know it was sort of a screening test of who's

12:20

healthy. Sure. Or you have to use their app which

12:22

is going to select younger healthier people. Yeah.

12:25

So the sicker people tended to go

12:27

on these exchanges and they're just

12:29

massively subsidized. Now we

12:31

spend so much money on health care I would submit

12:33

to you we spend half of federal spending on health

12:36

care in its many hidden forms. It's

12:38

not just Medicare and Medicaid that's almost a

12:40

quarter of spending depending on the money

12:42

that comes back from the states

12:44

to the states from the FMAP.

12:46

Social security is like what a quarter of

12:49

all federal spending. Half of those social

12:51

security checks are going to health care

12:53

expenses. Co-pays deductibles non-covered

12:56

services and co-insurance. Because it's SSDI

12:58

the disability insurance is that is that what you

13:00

mean by that or is there a different

13:02

are you saying social security checks literally

13:05

are what seniors use to pay

13:07

their co-pays. That's right. That's what you mean. That's right.

13:09

Yeah. That was a Kaiser study and then

13:12

the Defense Department has its own health

13:14

care system. They got their own med schools and

13:16

hospitals and insurance program like

13:19

Medicare. It's called Tri-care. Yeah.

13:21

And then. That's what I'm on. Yeah. Okay. You're on Tri-care

13:23

and then the VA system is separate that's

13:25

almost like five percent of federal spending

13:28

and then interest on the debt is in part interest

13:30

on health care spending and then we pay for health insurance

13:32

for

13:34

nine million federal workers. No

13:36

you're easily right. It's probably 50%. 50% of federal spending. So what

13:40

do we do go to 80%, 90? Do

13:42

we cancel all other national priorities? Well

13:44

I told me I mean this debt ceiling debate last week I

13:46

was like guys. People

13:48

are like why we know if we just stop spending we wouldn't

13:51

have to have this debate. I was like all right

13:53

tell you what abolish the entire federal

13:55

government except for all the programs you won't

13:57

abolish right which you know what they are and all

13:59

the

13:59

entitlements to abolish the CIA, abolish

14:02

the, the FBI, abolish the,

14:04

the, the, the department of energy and the education

14:07

and the CDC to abolish all

14:09

of it. Still we'll

14:11

have to raise the debt ceiling probably next year

14:13

because it's, that's 11% non-defense discretionary

14:17

is 11% of the total budget.

14:18

That was like the big, that was a, that was a pretty eye opening

14:20

statistic. We were having that debate last week and, and,

14:23

uh, you know, 70% is entitlements and,

14:26

you know, it's easy to, I mean, you might

14:28

be even wrong. It might be more than 50%. During

14:31

COVID it was. For health. Um, but yeah, it's

14:33

massive and nobody wants to touch that.

14:35

Nobody. Not conservatives. Um,

14:38

well, there's, there's the real conservatives definitely

14:41

do. And, but it's like, we all got to do it together

14:43

and just walk into

14:45

the firing line that has to be addressed.

14:47

Well, thank you first of all for having that debate.

14:49

I mean, those are the real issues.

14:52

There's broad consensus in America on a lot of things.

14:54

A lot of the stuff is

14:56

they're not real issues, right? They're dangled in front

14:58

of us on the echo chamber. These are real issues

15:00

where there's broad consensus. I mean, what are we doing?

15:03

But yeah, the spent healthcare spending is completely.

15:06

Fear of dealing with it. And also I think broad

15:08

ignorance of how to deal with it. So I were doing this podcast

15:10

where to solve it all and within an hour. Um,

15:13

all right. But so I think we've outlined

15:15

some of the problem, but I mean, let's go, let's

15:18

go into more specifics on like, where, where does, where

15:20

does the problem even start? Is it, is it

15:22

price transparency? Is it the way these

15:24

hospitals have congregated because of Obamacare?

15:27

I mean, is it just, are they all equal

15:29

problems that we have to deal with separately? Well, first of all, you

15:32

bring up a good point on the mass

15:33

consolidation of hospitals is driving

15:35

monopoly pricing. And that was driven in part

15:38

by all the regulations that made

15:40

hospitals and independent physicians practices

15:43

say, Hey, the only way I can comply with all

15:46

this regulatory stuff is to just join

15:48

up, join up. Yeah. Join because they've got,

15:50

they've got a compliance team on the

15:52

15th floor and they'll deal with it. Right.

15:55

I mean, that makes sense. If you're just a doctor with a practice

15:57

and you have to sign up with an electronic health record.

15:59

and who's gonna launch a

16:02

massive IT implementation in your little

16:04

practice. No, people were retiring

16:06

early. They're just saying, and

16:08

I'm not gonna sign in. Here's my

16:10

retirement notice. So they folded

16:12

in. We got monopoly pricing in some

16:15

markets. But

16:17

we also, I was a part of this effort

16:19

to

16:22

get the price transparency executive

16:24

order signed in the last administration.

16:27

And only about 15% of hospitals

16:30

are complying. But there you have

16:33

what could actually ignite some competitive

16:35

marketplaces. And

16:37

as third party and app and tech guys

16:40

are starting to scrape this data to make it available

16:42

to you so you can use it to navigate where to go,

16:45

there's a lot of promise with price

16:47

transparency. AI, find me the

16:49

best price for X, I mean, that's not, that

16:52

can't be that far off, right? You can write us poems.

16:54

That's right. Yeah, it's coming, it's coming.

16:56

And then we're working on quality metrics too that

16:59

actually measure the appropriateness of care. It's

17:01

just difficult for policymakers. There's nowhere to start.

17:03

And I'm not sure. There's

17:05

not a great vision up here for where

17:08

that change can go. I mean, like the

17:10

far left has their Medicare for all.

17:12

Luckily, that's still not a

17:15

super serious conversation in the mainstream,

17:18

luckily. And

17:21

I'm constantly trying

17:24

to get Republicans to come up with our plan, right?

17:27

That we can name, that we can label, that we

17:29

can market. That's what politics is now, but

17:31

the devil's in the details. And my

17:35

personal take is we've

17:36

gotta enter the

17:41

healthcare policy debate, the same place

17:43

that a patient enters healthcare

17:45

system, just primary care.

17:47

I think it's, you gotta wrap

17:49

your arms around something solvable.

17:51

And, because what we tend to do is we get distracted,

17:53

we get this price transparency over here, this hospital consolidation

17:56

over here is PBMs. Nobody knows how to help

17:58

even explain what people do.

17:59

I

18:02

certainly don't. I get taught it and I immediately forget

18:04

it because it's so, it's so freaking complicated.

18:06

Um, for anyone listening, those pharmacy benefit

18:09

managers, there's the ones who, um, you know, buy

18:11

drugs from manufacturers that have a very

18:13

complicated pricing mechanism to get them eventually

18:15

to you. They're supposed to save you money, but they make billions

18:17

somehow. So tracking that money is very, uh, suspicious

18:21

and difficult. But you know, on the primary

18:23

care side, and one thing you know is there's because

18:25

med school has gotten so expensive, I

18:29

have a question as to why it's gotten so expensive. Maybe the

18:31

same reason all universities have gotten more expensive. I don't know.

18:33

Maybe you have an answer for that, but it's forced

18:35

people into specialties. You know, it's, it's probably

18:37

more, it's probably better to be you, right? You

18:41

do your pancreatic surgeon. I'm

18:42

assuming that's a much more lucrative job than being a primary

18:44

care physician.

18:47

But we have serious issues with shortages of primary care

18:49

physicians. Yeah.

18:51

And it's changing. Primary care is becoming

18:53

attractive again right now. And

18:57

the more people are going into it

18:58

in part because the market is

19:00

realizing that

19:03

if you have a primary care doctor doing all

19:05

the steering of patients to

19:06

specialists, that is that

19:08

job is a money job. And

19:11

so there are a lot of these direct

19:13

primary care clinics. Um,

19:15

a lot of employers are saying

19:17

now, Hey, we want to do our own steering. We're,

19:20

we don't want to

19:21

have people just randomly walk into an OBs practice

19:25

where the OB has a 90% C section rate. We want to, we

19:29

want somebody who can steer and use metrics

19:31

to steer. So a primary

19:34

care docs are coming out of med school now making $220,000, $230,000. We've

19:38

never seen that before. They were making half. Yeah.

19:41

They were making half when I came out of med

19:43

school. So it's becoming more attractive

19:46

and

19:46

that's good. That's good for the field. The problem

19:49

with primary care is the field has not

19:51

even figured out its own best practices yet.

19:54

You still have people saying

19:56

avoid fat, you know, go. You walk in and you're overweight.

20:00

you'll hear five different things from five different

20:02

doctors. How is that possible on nutrition? That drives me crazy.

20:04

Well, the food industry controlled a lot of the messaging

20:07

field of nutrition. I did a whole podcast on that

20:09

a month or two ago. Oh, it's nuts. But

20:14

it's nuts to me how anyone,

20:16

especially a doctor still buys it. I'm

20:19

not a doctor. And it's very easy for me to understand

20:22

what nutrition works and what doesn't. I

20:24

don't know. I mean, just coming

20:26

from the, maybe that's coming from

20:29

the military where we were constantly,

20:31

you know, it's like being on an elite sports team.

20:34

And so it was obvious to us, what's real and what isn't

20:36

as far as nutrition goes. But

20:38

I just don't understand. Well, you know, nutrition had

20:40

an Anthony Fauci in the 1960s. His

20:43

name was Dr. Ansel Keys, slick,

20:46

smooth, and with really

20:49

shoddy data. I mean, almost fraudulent

20:51

data, but very, very flip shoddy

20:53

data that he published on epidemiology and

20:56

low fat and high fat diets, leaving out a bunch

20:58

of countries and just drawing lines where they fit

21:01

his hypothesis. He convinced

21:03

the world slowly over time,

21:05

there was a lot of dissent

21:07

in the medical establishment letters in the New England

21:10

journal of medicine into the

21:12

late 1970s saying, Hey, what are

21:14

we doing recommending a low fat diet? This

21:16

is crazy. We don't have data. This

21:19

is an experiment with the government's recommending

21:21

low fat diet. This is a nutritional experiment

21:23

with no data. And there was a lot of dissent,

21:26

but what happened was this met

21:28

the medical establishment, the

21:30

American Heart Association

21:33

signed onto this idea of the low fat diet

21:35

and made millions of dollars licensing

21:37

out their little heart

21:39

to every mom and pop restaurant. Oh,

21:42

and that, and so that was, that became

21:44

the dogma. That was this sort of, you know,

21:47

let's all ignore natural immunity together

21:49

of the day back then. Yeah.

21:52

Well, it's, it's, it's ridiculous in it, but if it's still

21:54

going on, I mean, I guess I already did a whole podcast.

21:56

I don't want to dive too much into it, but it was, you

21:58

know, it stemmed from this like ridiculous.

21:59

study that Tufts University

22:02

has involved in my alma mater. Oh

22:04

the food comments. Yeah, we're like Lucky Charms are

22:07

better for you than red meat and it's like yeah

22:09

how do you how do you think that. I

22:11

kind of want to I just want to go back to

22:13

we're gonna solve the we're gonna

22:15

solve the whole problem today. So Obamacare

22:18

comes yep there was the history of healthcare

22:20

pricing Obamacare comes you get more people covered

22:24

via a combination of this of

22:27

the ACA website the the marketplace

22:31

you know with the gold and platinum and silver plans

22:33

or whatever it is and but

22:36

I think most of it was Medicaid expansion am I wrong

22:38

about that a lot of it a lot of at least at least a good

22:40

part of it they did that by simply raising

22:42

the you know the the

22:44

poverty level by which made you eligible

22:47

for it how

22:49

did that

22:50

how exactly did that raise healthcare

22:53

costs and then I guess in the next question

22:55

obviously would be what should we have done

22:58

instead to

22:59

both give people what they need which is healthcare

23:01

I wouldn't call it a right I don't like when

23:03

people call it a right because a right assumes that

23:05

that

23:06

you're basically a conscripted

23:08

to my service as a doctor and I think that's a weird

23:10

thing but it is

23:13

something we need

23:14

just like food just like shelter so what

23:16

how did that raise prices and like

23:18

what are the mechanisms that caused that and then what

23:21

should we have done it failed

23:23

to address the

23:25

price inflation of healthcare so

23:27

it just completely failed to address it so

23:30

it was in motion before the Affordable Care

23:32

Act where prices were jumping

23:35

up and it it claimed

23:38

to do things that were going to finally tackle

23:40

price inflation and it completely failed in

23:42

that job and the reason is is

23:45

that the big issues driving up

23:47

prices were completely

23:49

unaddressed low-value care

23:51

that is us doing stuff as

23:54

doctors you don't need right

23:56

that's way to lower drug prices America's to stop

23:58

taking drugs you don't need. We

24:01

prescribed 2.4 billion prescriptions 10

24:03

years ago. Last year was about 5 billion. Did

24:05

disease really double in the last 10 years?

24:08

No. We want to pop a pill for everything.

24:10

Opioids was one little window

24:13

into our massive overprescribing problem.

24:16

And it's more than just that one drug, trust

24:18

me. And so we have all of these

24:20

problems growing and rampant and

24:23

this cozy relationship between pharma

24:26

and physicians and regulators. And

24:28

we have a lot of issues that can be

24:31

addressed that were not addressed. And one

24:33

of them is the PBMs that you mentioned, the pharmacy benefit

24:35

managers, group purchasing organizations.

24:39

Many of these solutions, ironically, can

24:41

be enacted today, not

24:43

on a government basis, but by

24:46

individual businesses in America buying

24:48

insurance in a smarter way.

24:51

And they generally don't do it. Most businesses

24:54

are getting ripped off on their health

24:56

insurance

24:56

in the order of 20

24:58

to 40%. Yeah. And can you

25:01

blame them? Because I have no idea how I would even shop.

25:04

And I'm on the healthcare subcommittee in

25:06

Congress. Like I kind of understand

25:08

the issue and I still don't know if I were running a small business.

25:10

I have no idea how I'm supposed to shop

25:12

for the right health insurance. Well, there's a smoke

25:15

screen.

25:15

And in that,

25:17

in that smoke cloud,

25:19

you are sort of dumbfounded.

25:22

So you basically say,

25:23

I need a broker to guide me

25:25

through the process. And who's that? And who pays

25:28

that broker? The broker is getting paid

25:30

on the back end. Sure. In the front

25:32

end.

25:33

Now, some of it's disclosed and some's not, but

25:35

there's so much money being made in that middleman

25:37

industry. So a group of doctors and I

25:39

are actually going to be starting a new health

25:42

insurance plan for self-funded insurers.

25:44

It's the pure doctor streamlined clean

25:46

plan that'll come in way below with

25:49

the prices of other plans. And I

25:51

actually think if the government does nothing on healthcare,

25:53

the

25:53

private sector can fix the problem. Yeah.

25:56

Well, there's a lot of interesting innovations at the

25:58

private sector level.

25:59

And

26:02

again, like from our level,

26:05

it's still not obvious how to fix it. As

26:07

you said, what it didn't address, you know, the

26:09

basic mechanisms which cause price inflation.

26:12

And I tell people all the time, the only things that

26:14

do bring prices down, the only forces are

26:18

some sort of competition. And

26:19

well,

26:22

that's pretty much it. You

26:24

have to have some sort of competition.

26:27

And without that mechanism, there's another element

26:29

that I think I'm missing when I usually make that comment. But

26:32

it didn't even come close to that, right? It

26:35

kind of dealt with it the way we deal with

26:37

increasing tuition

26:39

prices at universities. Just give

26:42

more people money to buy the thing that they

26:44

need to buy. That's right. Which is essentially

26:46

what Obamacare expansion is. But

26:49

there still has to be a thing to buy. Now,

26:51

in the university setting, at least

26:53

there's plenty of universities. There doesn't seem to be a shortage

26:56

of places to go.

26:58

That's not going to be true in the health

27:01

care system.

27:02

You know, eventually you get that piece of paper that says you have insurance.

27:05

But it doesn't work all the time. It

27:07

doesn't guarantee you access to a doctor.

27:10

That's kind of a big deal. So can you talk about

27:12

that and like that disconnect in the health care sector?

27:15

Well,

27:15

the Obamacare legislation changed

27:18

the way we finance health care.

27:21

But it did not fix health

27:23

care. We need to talk about not just how

27:25

to pay for health care, but how to fix health care. So

27:30

to actually get at these root problems,

27:33

we've got to think about,

27:36

are we going to throw good money after bad into

27:39

a system that's broken, littered

27:41

with middlemen,

27:42

re-pricing, markups on drugs

27:45

and devices? Things are coming to market

27:47

faster than we can study them. And people are

27:49

getting all sorts of medical intervention

27:52

with no data. Just look at the

27:54

COVID booster in young people. The

27:57

government just buys a hundred and seventy-one

27:59

dollars. 1 million doses of the bivalent

28:02

vaccine just last fall, no

28:04

randomized controlled trial. Pfizer

28:06

made a hundred million dollars. They can afford, I'm

28:09

sorry, a hundred billion. They can afford

28:11

to run a randomized controlled trial. And

28:14

so there's this, that is a symptom of

28:16

a larger problem in medicine. Low value

28:18

care that we finance good money after bad into

28:20

a broken system. So you can say, look, we need more money.

28:22

We got to throw more money into the system. Sure,

28:24

you're financing healthcare, but you're not fixing

28:27

it.

28:27

Well, and one of the problems is,

28:30

a lot of doctors won't take Medicaid

28:33

because it underpays. They don't even

28:35

like taking Medicare because it in theory

28:38

underpays by what

28:40

people say, maybe 60% on the dollar

28:44

of what their actual costs are. So

28:46

it's kind of funny when hospitals say that, because I'm like,

28:48

so you do know your costs. You

28:51

know, they fight the price

28:53

transparency legislation

28:55

that

28:55

actually just passed out of ENC in a bipartisan

28:57

way. So, you know, that Trump administration

29:00

stuff you guys worked on, we're trying to codify

29:02

that into law. Hospitals are not

29:04

happy about it, but

29:06

look, I mean, it's got to get done. But

29:11

talk about that dynamic from the doctor's

29:14

point of view and how you have to weigh all

29:16

of these different financing mechanisms. You

29:19

know, the Medicare, the Medicaid,

29:21

which underpays, and how

29:24

that affects a normal,

29:26

a regular person who has regular insurance versus

29:30

somebody who's just paying out of pocket. So

29:33

the hospitals claim that

29:35

they lose money on Medicare and Medicaid

29:38

patients. So they have to overcharge the private

29:40

commercially insured patients.

29:43

There's a fair amount of debate as to

29:45

whether or not that's actually correct

29:47

because

29:48

there are hospitals that take by and large

29:51

Medicare patients, vast majority are

29:53

government patients,

29:54

and they are profitable.

29:56

So either those hospitals have really lean

29:58

management, good administration.

29:59

and are doing good care,

30:02

or the other hospitals are bloated

30:04

and are using money for

30:06

five deans of diversity and everything else. So

30:09

in my book, The Price We Pay, I highlight a

30:11

hospital in Nebraska that's making a lot

30:14

of money doing really well, taking mostly Medicare.

30:16

So that begs the question, is Medicare really

30:18

a money loser? Well, I do

30:20

think if it's not already

30:22

a money loser, it's becoming a money loser, because

30:25

Medicare cannot keep up with inflation. And

30:27

this is true with every government in the world. Any

30:30

government that has government-sponsored

30:32

healthcare cannot

30:35

keep up. It sounds great early on.

30:38

You're gonna cut the middleman out, government's just gonna pay

30:40

directly. Sounds super simple. Sounds great, 10, 20 years, 50 years.

30:45

100% of the time, government's underfunded and

30:47

squeeze the belt. I

30:48

mean, Medicare's doing it right now. NHS

30:51

does it, Canada. Everyone does it

30:53

down the road. So that's

30:55

the problem with that. It's a price control mechanism. And

30:58

in any market, doesn't matter what the market

31:01

is, that constricts supply. That's

31:03

kind of a big deal. And when you're talking about healthcare, because

31:05

supply, when we say supply in healthcare, we mean

31:08

number of doctors, number of facilities, amount

31:11

of money going to research and development. That's

31:14

a big deal. And you just get less of everything.

31:17

If you have less of a selection

31:20

in a certain market, it's not

31:23

life-threatening. But in this market,

31:25

it kinda is. So

31:27

it's dangerous. What would

31:29

we say if we

31:30

were designing a new society right

31:33

now from the ground up,

31:38

how would you design a healthcare system? What would be the

31:41

proper way to do it? With

31:43

a couple of assumptions in mind, which is one, healthcare's

31:45

something you need. We're gonna stand by

31:47

this idea

31:49

that everybody should have access to a doctor

31:53

in some way, shape, or form. That it's

31:55

a human right. I think we already stand by that idea

31:58

because by law, if I go to your emergency room,

31:59

you have to treat me. So assuming

32:02

that's true, what's

32:05

the best way to design a healthcare system that is, another

32:07

assumption is that it's innovative, that

32:09

it's constantly

32:10

improving quality of care, and

32:15

that it's profitable for

32:17

everyone involved. So

32:19

if I, first of

32:22

all, I love being a doctor, and most

32:24

doctors do the right thing, or always try to, but

32:27

if I could create a perfect

32:29

healthcare system, I would remove the perverse

32:32

extreme financial incentives, just

32:35

to do more stuff without doing

32:38

quality stuff. We don't have

32:40

good quality measures. When you shop

32:42

for care, you should be able to know the,

32:45

roughly the quality of that doctor,

32:48

and the price of that doctor, and

32:50

not the price of the steering wheel, and the brake

32:52

pad, and the, you

32:54

know,

32:56

the tire, and

32:58

nobody shops like that. You want a bundle, you

33:00

want a price for the whole product. And

33:02

so we got to get away from a code for

33:05

every little thing we do, and say,

33:07

you're pregnant, we will take care of

33:09

you for $10,000. Just

33:11

like an airline's gonna fly you if

33:14

the plane has an emergency landing,

33:16

or has to divert, or the fuel costs

33:18

are three times the size, you build it into

33:20

the model, and you make patient,

33:23

simple, understandable bundles,

33:26

and we have competition

33:28

around valuing. And some people check multiple

33:30

bags, some people's bag, some people's has

33:32

a 10 pound bag, versus a 50 pound

33:35

bag, it's the same price. Yeah, that's right. And,

33:37

you know, it's, yeah, they were right, they

33:40

just put it in the algorithm. It's not a terrible

33:42

analogy. I mean, if you have massive

33:44

extreme comorbidities, there could be an adjustment,

33:47

but right now it's crazy, the coding

33:49

game is burning out the doctors,

33:51

the hospital will spend all this money playing the coding

33:53

game. But I mean,

33:55

go even more basic than that. Would you have insurance

33:58

companies

33:58

in your perfect utopia? I

34:01

think there's a role for

34:04

money being put aside for a rainy

34:07

day when you get sick. Kind of like a catastrophic

34:09

care sort of fund. Yeah. So

34:11

is that, so again, we're talking about

34:14

utopia now. Because I think the only way we

34:16

get to a better healthcare system and message

34:18

that to people is if we tell, if we explain

34:21

it to our constituents in terms of a utopia.

34:23

Right? This is, I know it'll take 50 years for

34:25

us to get there, but at least I tell you what our vision is. This is

34:27

what Republicans lack, very, very badly lack.

34:30

Democrats have it. They're utopia is Medicare for

34:32

all. And it's really easy to understand. We

34:34

don't have an easy to understand utopia. So

34:38

in this utopia, how

34:40

do you pay for catastrophic care? Is it through

34:42

a reinsurance program? Is

34:45

it like a kind

34:47

of whatever, that rainy day fund? I'm

34:50

blanking on the term for what

34:53

we call a fund. High

34:55

risk pools. High risk pools. Yeah. What

34:57

is it? Again, you can design anything

35:00

you want. Like how would you start? You got 100

35:02

people in your new society. How

35:04

would we do it? Yeah. I mean, I like

35:06

the idea of a minimum coverage

35:08

requirement. So insurance

35:11

company can't

35:12

pull a fast one and say, well, we cover everything,

35:14

but not type B lymphoma.

35:18

Too bad for you. You didn't read the fine print. Those

35:20

gotcha games have been outlawed already.

35:22

And that's probably a good thing. And then

35:24

you have basic insurance plans. But you have

35:27

competition at the level of price

35:29

and quality. We have competition in health care

35:32

today. But it's at the level of valet parking

35:34

and billboards and signs at the

35:37

NFL game. We need competition

35:39

at the level of price and quality

35:42

of the

35:42

service. If you are going to deliver

35:44

a baby in New

35:47

York City, the price of delivering

35:49

that baby ranges from $5,000 to $71,000

35:51

for

35:55

the exact same service. And

35:58

like even in the same hospital? No,

36:00

in different hospitals in the New York City region. There's

36:03

no difference. There's no difference in quality. I

36:05

mean, in Boston, the range is 6,000 to 31,000. And

36:09

those two extremes are both at Harvard

36:11

affiliate hospitals. There's no difference

36:13

in quality. So do you, if you're an employer,

36:16

if you're a patient, do you want to go to the $70,000 place or

36:18

this $4,000 place? You

36:21

want to go to a place with best quality. And

36:24

if it's more expensive, you'll pay for it. But

36:26

right now you're flying blind. And it turns

36:28

out in all the research that's been done,

36:31

and I go through it in the price we pay, the more

36:33

expensive hospitals tend to be

36:35

the lower value hospitals and

36:38

the most of the best surgeons in the world are sometimes

36:41

operating at the most median or

36:43

average or below average price points. Okay.

36:46

But

36:46

again, how do we fix that? Like, how do we, so

36:48

as part of, so how do you fix, is that price transparency

36:51

issues that's still forcing them to

36:53

post price is the first thing, but then measure,

36:55

measuring quality. That's still complicated.

36:58

I mean, only way to measure quality is, is outcomes.

37:01

I mean, hospitals have reputations, doctors

37:03

have reputations. And so as patients,

37:05

we, we kind of get a sense for that, but

37:08

is there a better way, is there a more obvious

37:10

way to, to measure that? The field of quality

37:13

measurement in medicine has been

37:16

stagnant for like 30 years. It's

37:18

been frustrating. All the healthcare

37:21

experts make it sound like we're right around

37:23

the corner from being able to measure quality. Well, they're

37:25

not. Okay. They have painted

37:27

themselves into a corner with such elite

37:29

criteria for quality measures and

37:31

the associations, which are trade associations

37:34

of doctors have to approve it. Well,

37:36

nobody wants to approve measures on how you're

37:38

going

37:38

to be paid and evaluated. So

37:41

what we've done at Johns Hopkins has

37:43

created a new generation of quality measures

37:45

that looks at the appropriateness of care. How

37:48

often during spine surgery are

37:50

you as a spine surgeon putting

37:52

in hardware, screws and plates in

37:54

the back? It should never be at a rate greater

37:56

than 50% of your non-deformity,

37:59

non-trauma.

37:59

by non-cancer patients.

38:01

We can measure now the appropriateness

38:04

of care. We can measure C-section rates.

38:06

We can measure how many

38:08

times during a colonoscopy a

38:10

doctor does a biopsy. Biopsies

38:13

are important, it can save lives, but not in 100%

38:15

of your colonoscopies. We

38:18

can measure these patterns. We can measure

38:20

them in the Medicare data set, and we're doing

38:22

it. So that is our work called

38:24

global appropriateness measures that

38:26

we're doing nationwide. And the attempt is to

38:29

come up with meaningful measures of quality,

38:31

because that is what we have to do in health

38:33

care, is measure quality and price. So

38:37

go back to the perfect world. Price transparency

38:41

is perfectly transparent. It's easy to find.

38:43

That seems feasible.

38:46

There's some kind of quality measure. I think

38:48

it'll always be imperfect when you're talking about health care.

38:50

It's got to be. That's right. Because at the

38:52

same time, even what you're talking about, the first thing that

38:55

I'm sure you hear from doctors

38:58

is I'm the doctor. I

39:00

know what I'm doing. You don't need to be looking over my

39:02

shoulder and looking at my data. 50%, 45%.

39:07

51% makes me a bad doctor. 49% makes me a good doctor.

39:11

I'm sure that's what you hear back, because it's

39:13

hard to measure quality. But

39:16

again, so there'd be an insurance company, but they'd

39:18

have to cover everything. No

39:21

hidden gimmicks. Like you said, that's

39:24

widely agreed upon, I think.

39:28

But

39:31

what about the deductible system? And

39:33

how should you shop for insurance?

39:36

How should you pool people into insurance? So

39:38

Democrats, when they were pushing Obamacare, their

39:41

logic is if everybody,

39:44

this is why they wanted to tax people

39:46

who didn't have a health insurance

39:49

plan, because the logic went that if everybody

39:51

was paying into it, it would lower everyone's

39:54

price. That's right.

39:56

That's not

39:58

incorrect logic. Yeah. That is

40:01

technically how insurance works, right? You have

40:03

to have car insurance. That's, that's why it

40:05

works. Now, of course you run into a problem with just basic

40:07

personal liberties and,

40:10

uh, which is where it all fell apart and why

40:12

that tax went away. Um,

40:15

but what is the solution then?

40:17

Yeah.

40:19

Yeah. And that promise was by and large a broken

40:21

promise, you know, the idea that

40:23

if you remember, and I'm not, not

40:25

speaking as a partisan anyway, but if you remember

40:27

when Obama ran for office

40:30

for president the first time, his

40:32

campaign speech and

40:35

his, one of his, you know, stump points

40:37

everywhere he went was that I'm

40:39

going to lower the price of your health insurance

40:42

by 20 plus percent. And

40:45

audiences loved it. It was a great message.

40:47

And I love the, I love it. And I love the

40:49

idea. It just, it never happened.

40:52

It went the other direction. Yeah. Right.

40:54

And the problem was they just didn't

40:56

recognize the other drivers of healthcare

40:59

inflation. Yeah. I mean, also like there's

41:02

this myth out there that if we do more mammograms,

41:05

if we do more colonoscopies, we're going

41:08

to lower the price of healthcare. Well, those services

41:10

cost money. And while I

41:12

support those interventions, how about

41:14

school lunch programs? Yeah. Instead of

41:16

just all the money we're spending on bariatric

41:18

surgery and ozepic, how about communities

41:21

for kids? So they're not on

41:23

five anxiety medications and depression

41:26

medications. How about treating more

41:28

back pain with ice and physical

41:30

therapy instead of just surgery and opioids?

41:32

How about treating people with high blood pressure by talking about

41:35

their sleep? The sleep medicine is

41:37

very mature now. Instead we're just throwing

41:39

antihypertensives at people. So when somebody

41:41

comes in to see us who's a, has diabetes,

41:44

we should be putting them in cooking

41:46

classes, not just throwing insulin at

41:48

them. I agree with all that, but that little

41:51

gets it. Like I can't change any of that policy. You

41:53

know, that, that, that's like in the medical, that's a medical profession.

41:55

As a legislator. Yeah. I mean, that's the medical

41:58

profession that has to, you know, get to a point.

41:59

where you're giving people the right treatment and not telling

42:02

them that lucky charms are more healthy than steak.

42:05

Right? It's like, that's basically what you're telling me. And I agree with

42:07

all that, but I can't like, you know, I mean, we could outlaw,

42:10

like we could outlaw sugary snacks out

42:12

of the snap program. There's serious discussions

42:14

about that. That's right. I'd probably be okay with it. I

42:16

mean, you know, it's bring back fat shaming.

42:18

I mean, bring it back. It was, it's, cause

42:21

it's honestly, if you care about somebody, you

42:23

got to tell them the truth. But,

42:25

but as far as, but I want to focus on the pricing

42:27

and the financing and utopia, because

42:30

I can't get us, I can't get this

42:32

Congress to a, of a solution

42:35

until we understand what we're trying to go. That's right.

42:37

Like you got to know what the end looks like. And so what

42:39

is insurance for? Like, is

42:41

it,

42:42

is it, should it only be like car insurance,

42:44

right? Is that, is that we, do we have to get to that point?

42:47

And then what about the people who can't pay for the tire

42:49

chain? So, so my insurance, my car insurance

42:51

doesn't pay for me to get new tires. Um,

42:54

it's, it's not what it's designed for. It's only for, for Rex

42:56

and car insurance works as a market.

42:59

And is that what we have to do with,

43:02

with healthcare and what is, what is the

43:04

tire change? Is that your primary care doctor?

43:06

You know, is this where direct primary care

43:08

comes in? And then do we, do we subsidize

43:11

that? Do we have like a debit card? Does everybody have

43:13

a health savings account that

43:15

funds, whether it's their insurance or their direct

43:18

primary care doctor, all the money flows

43:20

through one account, you

43:21

know, and, and, and, and if you're built in, if you're, if

43:23

you're in need, you get it subsidized, but

43:26

then you go on the open market and do it,

43:28

is that, is that a better system?

43:30

I'll tell you the most exciting thing

43:32

I've seen is you

43:35

get to see the price

43:37

and the very immature quality scores

43:40

on every doctor or medical center. And

43:43

if you, and you get an allotted amount

43:46

for whatever it is for a medication

43:48

or for a visit,

43:49

for a consultation or

43:51

for a procedure, there's an allotted amount

43:54

that is what you're entitled to.

43:56

If you select a provider below

43:59

that allotted amount,

43:59

you get a check for the difference. If

44:02

you go to place above the allotted amount,

44:04

you are

44:05

on the hook.

44:07

And so some groups, including this one group

44:09

that I advise called Sidecar Health, is

44:12

basically gives you a, they're doing amazing

44:14

stuff, they give you a Visa card. And

44:16

they're like, this is your allowed amount

44:18

at the different places, it's on the app, you can look, go

44:20

wherever you want, you can go wherever you want. But

44:23

if you go below the allotted amount somewhere, you're gonna

44:25

get a check for the difference. If you go above, you're

44:28

on the hook, it's gonna be billed to your Visa card. It's

44:30

like rollover minutes. It's great, it's like rollover

44:32

minutes and things were going great until

44:35

CMS

44:37

basically blocked them from going on

44:39

the exchange, CMS, Center for Medicare and Medicaid

44:41

Services, and said,

44:43

you don't have a network

44:45

and that could be confusing to patients.

44:48

Well,

44:48

that's the whole point. The point

44:50

is to get rid of networks. Why do you need a network?

44:53

The network is by definition confusing

44:55

to patients. The network is the arsonist

44:57

and the firefighter. It's the problem

44:59

and it's the solution there to create the problem.

45:02

It creates. Right. Why do

45:04

we need networks if you had an open market

45:06

of prices and quality? Yeah,

45:09

and it's like, I don't, the

45:11

one thing I'm okay with on the Obamacare thing is

45:13

a website where

45:14

you see all the insurance plans. So that's

45:16

like step one. And that already exists for direct primary

45:18

care. You can type in your zip code, find

45:21

your primary care doctor, you

45:24

know, but that should be normalized. You know, you

45:26

should be able to go to an app just like you just

45:28

like you shop for for, you know, your

45:31

airline tickets and compare

45:33

and contrast. And

45:35

so,

45:36

you know, obviously I keep trying to push us towards

45:38

the utopia that I push. I

45:41

want. But I just want to want to test it

45:43

again, see if you disagree. I mean, that's kind of the

45:45

point of this. So

45:47

I categorize it in three in three

45:49

ways. Healthcare generally, right. You've got primary

45:52

care. You've got

45:54

broken bones. You know, you got like

45:56

care that's not exactly primary, but it is

45:58

exactly cancer.

46:00

OK, so it's a broken bone. It's

46:03

a sickness that can be resolved within

46:05

whatever, at a given period of time with

46:08

treatment. I don't know. Semi-elective, we should.

46:10

Yeah. I'm sure there's a smart person term

46:12

for this, but I call it

46:14

phase two. OK, then there's

46:17

the catastrophic care. Like, this is really

46:20

the big stuff. This is the stuff that costs $100,000. You're

46:23

hospitalized for weeks at a time. That's a really big

46:25

bill.

46:28

My theory has always been insurance

46:31

should have nothing to do with phase one or phase

46:33

two.

46:34

It should only be number two.

46:35

One should be paid for by you. And

46:38

if you can't pay for that,

46:39

well, because we're talking primary care. Do

46:42

you know, as well as I do, $75 a month will

46:44

get you direct primary care subscription these days. That's

46:47

pretty good.

46:48

That's less

46:50

than a gym membership. It's

46:52

less than your cell phone bill. And if you really

46:55

can't afford it, maybe that's where a Medicaid

46:57

program or some kind of pilot program, that's what I'm actually

46:59

trying to figure out, comes into play. And that goes

47:01

on your debit card that you pay. And

47:03

then if you want to find the primary care doctor you like,

47:07

you get $75, but maybe you want to pay $85 because

47:09

that guy went to Harvard. OK, well, then you pay the extra $10. This

47:12

isn't that complicated. This is easily doable.

47:16

Insurance should do that second

47:18

part. And the third part, that's what we have to

47:20

figure out. Because if you make insurance through the third

47:22

part, which is what we do now, what do

47:24

they do?

47:25

They raise everybody's premiums astronomically

47:28

in order to cover those patients. That 10%

47:31

of the patient population that accounts for like 80% of the

47:34

cost.

47:36

And so you look at these

47:39

numbers and you're like, there's just got to be a better

47:41

way. Again, if you were crafting a solution right

47:43

from the beginning, got to be a better way

47:45

to do this.

47:46

I like the way you think. And I agree with you

47:48

that it needs, this

47:51

whole concept that we're talking

47:53

about, needs a good

47:55

name, right? Because it needs a name. I don't know

47:57

what the name is yet. I've been trying to figure it out for two years. Yeah,

48:01

an open market of shopping for price and quality,

48:03

it doesn't resonate with people, right? It doesn't.

48:06

It sounds like you're just gonna take, you're gonna

48:08

rip the rug out from under. That's right. Anytime you use things

48:10

like open market,

48:11

whatever, it feels like you're gonna rip the rug

48:13

out. You know, repeal and replace, that was both the worst

48:16

term. Yeah, so

48:18

we don't have a replacement. Yeah, exactly.

48:20

Yeah,

48:21

so, look, I get it. It's

48:24

like, I don't know, patient-centered care. I know it's

48:27

called a premium. We're talking about premium support

48:29

models is what we're talking about, but that doesn't make sense

48:31

to people either. It's not

48:33

obvious what the name

48:35

of it is, but we haven't even decided that

48:37

that's our utopia. That's right. This

48:40

is why I sort of, I test this amongst

48:42

experts like yourself to make sure that,

48:44

is this even with the direction we want to go? Can

48:47

we agree on that? I tend to focus on

48:49

what's feasible politically because

48:52

there's a saying in Washington that you can't

48:54

do anything unless all four healthcare

48:57

stakeholders are on board. Pharma,

49:00

AHIP, which is the insurance lobby, American

49:02

Medical Association, and the American

49:04

Hospital Association. Those are the four

49:07

big boys. And sure enough,

49:09

when we got the Affordable Care Act, all four

49:11

signed off. And so, I tend

49:14

to think about what can we change. For example,

49:16

the employer-sponsored healthcare. If not that your employer

49:19

covers your healthcare

49:21

or part of it, and then you're afraid to leave

49:23

jobs because you might lose energy. That system

49:25

makes no sense at all, but it's what we

49:27

inherited. It's what we inherited from

49:30

World War II time like you alluded to. So,

49:32

I tend to think, what can we do

49:35

that's feasible? And I tend to think

49:37

that employers can be proxy

49:40

shoppers of healthcare. So,

49:42

even though you don't care which doctor is going

49:44

to charge $71,000 to deliver

49:47

your baby or $6,000 for the same procedure,

49:50

your employer may care. And they can

49:53

give you a stake in the game.

49:55

They can reward you if you go

49:57

to the docs that does

49:59

it.

49:59

it for $6,000. You're not gonna

50:02

pay anything. Either way, you can go anywhere, you got freedom.

50:04

But if you go to the doc that's gonna charge $6,000, we

50:06

will give you

50:08

diapers and wipes for a year. That's

50:11

what one employer did in Boston. You

50:13

create a way to partner with them to

50:16

convert a non-competitive market to a competitive

50:18

market. Then the hospital that's charging $71,000 says,

50:20

hey, where's the business going?

50:22

We're not seeing the patients. Well, you

50:24

guys are charging $71,000. And so

50:28

that those are the creative solutions

50:29

I think we can do. But we don't

50:32

need networks. Yeah. Well,

50:34

what do you do? Do you outlaw networks? How do we

50:37

deal with that in Congress? Well, you

50:40

know, the idea of here's a pre-selected

50:42

curated group of doctors or hospitals is

50:45

essentially like a preferred

50:48

network, if you will. But the

50:50

idea of the network

50:53

was the reason why

50:54

this idea of the Visa card being your

50:56

insurance card was blocked by Medicare.

50:59

So what can Congress do? I think a lot about this question.

51:02

What can Congress do?

51:03

I honestly think a lot of the big health care

51:06

reform is going to happen with the private

51:08

sector employers choosing

51:10

to buy their health care differently. Choose a

51:12

health plan that is going to create

51:14

these creative incentives for

51:17

your patients to go to the $6,000 doctors.

51:20

And guess what? You're paying less

51:22

money as an employer because you're covering 80 to 90%

51:24

of all health care costs.

51:26

So we're starting to see movement in that sector.

51:30

Yeah. I

51:30

agree. I mean, I don't disagree with your logic

51:33

either. I mean, the reason I harp

51:35

on the utopia is one because I'm

51:37

a politician. I have to explain this to people. That's right.

51:40

And their eyes glaze over when you

51:42

start going into the details about price transparency. You

51:45

know, I mean, it's just it's but I totally

51:47

agree that when I when I say, look, we have

51:49

to at least establish utopia like an end game that

51:51

we'd love to get to. But then also the next

51:53

sentence should be, look, it'll take 30 years to get

51:56

there if I were a dictator. And

51:57

that's if I were a dictator because that's

51:59

that's how slow that process would be. You

52:03

know, that's the other reason I said, look, you

52:05

do have to have these entry points, which is, I mean, my

52:07

entry point is just making

52:09

it slightly easier for direct

52:11

primary care to be a thing.

52:14

And you know, for

52:16

instance, allowing health savings accounts to even

52:18

pay for a direct primary care doctor.

52:21

Like that's step one. You know, so

52:23

it's very, very discreet, definable

52:26

steps that should be easier. And even those are difficult.

52:29

What do you think about this? And this is an honest

52:31

question in terms of

52:33

a solution that can be messaged.

52:36

To fix health care, we need to

52:39

all agree to get rid of secret

52:41

prices and to get rid of kickbacks.

52:44

There's pretty good agreement on that. That

52:47

was just what we've been working on in ENC.

52:51

Pretty wide agreement on price transparency

52:53

at this point. Pretty wide

52:56

agreement from hospitals that don't like it. And

52:59

our answer is, this is, you

53:01

know, we could be a lot meaner to you guys,

53:03

I think, than price transparency. This

53:05

is just something you have to deal with.

53:08

And everybody's mad at PBMs

53:10

and the kickbacks. So a lot of kickbacks.

53:12

A lot of that. So there is some good agreement on

53:14

that. Yeah. I mean, half of the price

53:17

of some of these drugs goes

53:19

to the kickback. Can you explain PBMs

53:22

in a way that a normal person can understand and

53:24

how that pricing mechanism works? So

53:26

think of it as you've got a business

53:29

and someone comes and says,

53:32

we're going to set up a Girl Scout cookie

53:34

stand. Right now, your employers

53:36

are getting it on their own. And we're just

53:38

going to take care of it for you

53:40

because you've told your employees

53:43

you're going to

53:44

pay for the Girl Scout cookies. So

53:47

rather than have them go out there and buy

53:49

them and bring in the receipts and you administer

53:52

the claims and process, we're going to

53:54

take care of it for you. We're going to set up a nice Girl

53:56

Scout cookie stand. OK.

53:59

So what happens is that the company

53:59

is the person who says that says, I

54:02

want $1,000 to manage

54:05

that Girl Scout cookie benefit for you. Right,

54:07

it makes sense, a fee of some sorts to make it easier

54:10

on you. Yep, sounds good. And they say, hey,

54:12

we're gonna be independent and we buy

54:14

Girl Scout cookies in bulk. Okay,

54:16

sounds very attractive. Then

54:18

you find out they're paying the Girl Scouts a

54:21

dollar 50 an hour.

54:23

And you find out they're paying the Girl Scout

54:26

cookie, the Girl Scouts for the box,

54:28

instead of the standard $6, they're

54:31

paying them $2. And you're

54:33

like, whoa, whoa, whoa, where's all this money going?

54:36

Oh, well, we're giving you a discount, we buy

54:38

in bulk and look at how we're managing

54:40

the operations for you. And we're gonna give you a full

54:42

transparency print out of all of our finances.

54:46

But

54:46

with drugs, you can't understand

54:48

it as an employer because you get a thousand

54:51

names of different drugs with different

54:53

biosimilars and frequencies and doses.

54:56

And you see these names and prices.

54:59

You don't know what the base price is. Girl

55:01

Scout cookies, you know, you're getting ripped off. Drugs,

55:03

you have no idea. Do you know 90% of

55:05

drugs cost less than 20 bucks a month?

55:07

And yet people are getting gouged.

55:10

And what they do by say, charging

55:12

the employer far

55:15

more than

55:17

what they pay for the drug is called spread

55:20

pricing. And so they're

55:22

paid to manage the benefit and then they

55:24

gouge them on the spread. And hospitals

55:27

are in on it too with the drugs and chemo

55:29

that they infuse in the hospital. And the

55:31

devices, they charge a markup.

55:34

The differences with PBMs is the

55:37

pharma companies will

55:39

say, hey, we want in your list of

55:41

drugs that you offer something called

55:43

a formulary. In other words, we want you

55:46

to sell our cookies alongside the Girl

55:48

Scout cookies. And our

55:50

drug costs $50,

55:52

but I'll tell you what, we'll make it $150 and

55:54

we're gonna give you a hundred of it. That's

55:59

a... rebate

56:01

and the middleman

56:03

might give 10% of that rebate

56:05

onto the employer and say, Oh look, we're getting you

56:07

free money. Yeah. Because we bulk, well

56:10

you've kept 90% of that rebate and it's

56:12

a giant scam and it's, this is the

56:14

stuff that employers. And it keeps going because

56:18

somehow everybody is a little better off. Like

56:21

the employers a little bit bright, but not the patient.

56:24

That's, that's, and then, and then although are

56:26

the manufacturers better off here?

56:29

They're kind of, they're kind of, they don't really, it doesn't

56:31

seem like they benefit or get hurt. They're

56:33

kind of agnostic. They're neutral. Cause they're just building

56:36

in the price of these kickbacks into the

56:38

products. Yeah.

56:39

Right. You want a hundred and sometimes they'll tell

56:41

you, they don't like it. The pharma lobby will tell you, we're

56:43

kind of sick of all these, you know, the putting

56:46

the gun to our head. The PMs

56:48

are putting the gun to our head saying we want a $500 markup

56:50

on each drug and

56:53

we want that money coming to us.

56:55

Well, if you're the pharma company, okay, I'll do

56:57

it, but they make the same amount of money,

57:00

but they, and then they get blamed

57:02

by the public because yeah, because, oh,

57:04

your, your drug is too high. Well, it's like, it's not actually,

57:07

you

57:07

might be blaming the wrong person. You might as well, you should be playing

57:09

the PBMs for that. Not necessarily the

57:12

pharma companies. That's interesting. And everyone's

57:14

got a piece of the pie in healthcare right now. Everyone's

57:16

got a look, including us physicians and

57:19

see where we can be more efficient and just disarm

57:21

from this tug of war, the blame game

57:23

goes around, but you know what? We're all

57:26

getting rich. Everyone is getting rich

57:28

in healthcare right now except for one stakeholder

57:30

that has no lobbyists and that is

57:32

the American worker. And they are financing

57:35

this giant mess through 50%

57:38

of federal spending going to healthcare. And then they buy

57:40

private insurance for $22,000 per household

57:42

under the illusion

57:45

that my employer paid for 80 or 90% of

57:47

that in my paycheck. Well, guess what? That

57:50

money comes from the pool of wages and benefits.

57:52

That's your, that's your earnings. Yeah. And

57:54

so they're, they're, they are financing

57:56

this broken system where everyone is getting

57:58

rich right now, arguably.

57:59

with the exception of rural hospitals. So

58:02

I mean, if you're advising a mid-sized

58:05

company on how to do their health care,

58:09

what's their best option? You got to get a really

58:11

good consultant, health care benefits

58:13

consultant, one that's going to tell

58:15

you what they're getting paid on the back end, if they're

58:17

getting paid on the back end. Put it out

58:20

to bid. Talk to a couple consultants.

58:22

The consultants can be very territorial,

58:25

almost like drug territory.

58:28

This is my group. I've been with them. The relationships

58:31

get very cozy. And you're not getting

58:33

good options as an employee when that relationship's

58:35

cozy. For example, a consultant, also

58:39

known as a broker, can come to you

58:41

and say, your

58:43

Blue Cross Blue Shield plan's going up 15% this

58:45

year. I'm sorry.

58:48

This is terrible. They'll blame everyone. They'll

58:50

blame Obama. They'll blame drugs. You

58:52

had a sick employee last year. They'll

58:55

blame the world. The reality is

58:57

the insurer could be telling them,

59:00

hey, see if they'll fall for a 15% increase.

59:03

Yeah, of course. It's kind of like it feels a little bit

59:05

like real estate.

59:07

It's like, are you

59:09

sure you're negotiating on my behalf? Because you do

59:11

benefit if it's higher. Right.

59:14

Actually, like real estate, they're getting paid as

59:16

flat commission based on your total

59:18

health insurance premium spend.

59:21

Now, why would a consultant,

59:24

why should they make more if you're spending

59:26

more on health insurance premiums? It's probably the

59:29

same amount of work. So they

59:31

could get,

59:32

and these are good people, by the way, a lot of them, but the

59:34

system is broken.

59:36

In New York, it's regulated at 4%. So

59:39

every year, 4% of your health insurance

59:41

premium dollars go to that consultant,

59:44

in addition to what that consultant's getting paid on

59:46

the back end with a kickback from the insurance

59:48

company that says, pass them on the back, good job

59:50

selling our product. But unlike

59:53

a real estate

59:54

agent where you're paying 3% or

59:56

some percent once, you're paying

59:58

your broker every single year. year.

1:00:00

Right. So there's multiple

1:00:03

pieces of legislation on PBMs.

1:00:05

I don't think there's any on the broker side. But

1:00:07

on PBMs there certainly is. Some of them are anti-kickback.

1:00:12

Remove spread pricing. You

1:00:14

like all of those? Yes. Yeah, they just crush them.

1:00:17

And there are symptoms of a larger problem. So when

1:00:19

you fix one whack-a-mole,

1:00:22

they've come up with five creative

1:00:24

ways to say, well, when it comes

1:00:26

to the biologic agents, which are the

1:00:28

real expensive drugs, the $60,000, $80,000 infusions like Humira,

1:00:32

you've got to use our preferred

1:00:35

select vendor that we own.

1:00:37

Yeah. And they're gouging you on that

1:00:39

one. So you're, you're getting a better deal

1:00:41

by being more fair on the day-to-day

1:00:44

drugs, but they've got games.

1:00:47

And the bottom line is they're not fiduciaries.

1:00:49

I mean, the big PBMs are also pharmacies

1:00:51

like CVS Care Mart is a PBM.

1:00:54

Yeah. Now they're all vertically integrated. So they're a pharmacy,

1:00:57

they're a PBM, and they're an

1:01:00

insurance company. Yep.

1:01:02

They're all co-owned. So when you

1:01:04

tell your consultant

1:01:06

or broker, hey,

1:01:07

I'm getting ripped off on this PBM.

1:01:10

I want to look at other PBMs. The

1:01:12

insurance company who owns that PBM

1:01:14

will say, hey,

1:01:15

you're getting a preferred rate on our

1:01:17

health insurance because you're using our preferred

1:01:19

PBM that we own. If you

1:01:22

unbundle this, your insurance

1:01:24

premium is going to go way up.

1:01:26

It's blackmail. Yeah. It goes on all

1:01:28

the time. So you need more employers to just,

1:01:30

just kind of band together and be like, call your bluff.

1:01:32

Call your bluff. You're not going to, you're not going to buy. I'll just go to somebody

1:01:35

else. Yeah. Unbundle your services,

1:01:37

talk to more consultants. Yeah. There's

1:01:39

a lot of ways that employers could save 20, 30% on their

1:01:42

healthcare spend. Yeah. And I've said this a bunch of

1:01:44

times on this podcast, but you know, in, in, in Houston

1:01:46

and,

1:01:47

uh, there's a fairly

1:01:49

healthy DPC, direct primary care market

1:01:51

and they they're there. It's

1:01:53

not so much individuals that they get as their patients.

1:01:56

And we're trying to get to that point where it's just, I want

1:01:58

to normalize in

1:01:59

that you're

1:02:00

in your 20s, maybe you don't wanna buy

1:02:03

health insurance, I get it,

1:02:04

but you should at least have a doctor. So

1:02:07

do the 75 a month, have a direct primary

1:02:10

care doctor, at least, and they can walk

1:02:12

you through how you should maybe look at insurance. That's, and

1:02:14

my ideal utopia, that's how insurance

1:02:17

should work. But what

1:02:19

they, so what they are doing though, is they

1:02:21

partner with companies, you know, with hundreds of

1:02:24

employees, and it works better for everyone. Every

1:02:26

employee knows who their doctor is. It's

1:02:28

not like,

1:02:29

most people don't use

1:02:31

healthcare that often, so when they do, they're like, wait,

1:02:33

who's my doctor? How do I even, do I go to an

1:02:35

emergency room? What do I do? No, you should

1:02:37

have somebody call. All

1:02:39

right, so it solves that problem, and it solves the relationship

1:02:42

problem, which I think is lacking, and should be our

1:02:44

first priority.

1:02:45

But from what I understand, it also

1:02:48

allows employers to renegotiate their

1:02:50

premiums, because an insurance

1:02:52

company is looking at this contract

1:02:54

and saying, well,

1:02:56

yeah, that saves us money, so fine,

1:02:59

we'll renegotiate your premium, and we'll, your insurance will now be

1:03:01

cheaper, because you already

1:03:03

have primary care figured out on

1:03:05

your own, and it just works better for everyone.

1:03:08

Yeah, I mean, those are things that are good.

1:03:10

There are

1:03:11

things around the periphery, as I describe

1:03:14

it.

1:03:15

A lot of times, those prices of health insurance

1:03:17

premiums are

1:03:18

artificial. I mean, if the broker says to the

1:03:21

insurance company, hey, I ran the 15%

1:03:23

increase by the employer, they're freaking

1:03:25

out, they're talking about taking it out to bid, the

1:03:28

insurance company could say, well, okay, tell them

1:03:30

you got it down to a 10%. You

1:03:33

know, well, I mean, I talked to them, and I told

1:03:35

that insurance guy, I got it down for you, I'm your

1:03:37

guy, and those are the games

1:03:40

right now. Yep.

1:03:42

So. So it requires employers

1:03:44

to just, to be more

1:03:47

judicious with their spending and more jealous of their own

1:03:49

profits, I guess. All

1:03:52

right, what do we miss? We've been going on for a

1:03:54

while here. No COVID, that's impressive. You wanna do COVID,

1:03:56

yeah. You see Lori Lightfoot

1:03:59

is just.

1:03:59

got named on the faculty of the Harvard School

1:04:02

of Public Health. No. Yeah. She's

1:04:04

going to join a build de Blasio who's

1:04:06

already there. Really? Yeah. No

1:04:08

joke. Does she even have a healthcare background? Doesn't

1:04:11

matter.

1:04:12

She doesn't, right? I mean, she definitely doesn't

1:04:15

know. No healthcare background except she and

1:04:17

build a Blasio made others mask

1:04:19

for two and a half years. I don't

1:04:21

know what Harvard's thinking there. We were, they,

1:04:24

the fellows, I wouldn't say faculty, their fellows

1:04:26

and teaching. Yeah. Well, they did this. Um,

1:04:28

I was really pissed off and they, they, they backed

1:04:31

down on it, but they, um,

1:04:33

they added Chelsea Manning as a,

1:04:35

as a fellow Bradley, Chelsea Manning

1:04:38

as a fellow. Um, and it's some

1:04:40

kind of like national security fellow and they're

1:04:42

like, what the hell does this person

1:04:44

know about national security except how, how

1:04:46

to put it at risk? That's the only thing

1:04:49

this person knows. And it's not

1:04:51

as if this, you know, you could maybe make the case

1:04:53

if it was some top general who

1:04:56

did it and there's some kind of

1:04:58

re you know, there was some deeper reason

1:05:00

for it and it was interesting,

1:05:02

but this was just some idiot who

1:05:05

was like a, you know, an E two or

1:05:07

whatever he was at the time. I mean, a nobody,

1:05:09

uh,

1:05:10

just giving up secrets because they were

1:05:12

crazy. Is that a military rank you two

1:05:14

or is that

1:05:16

a military rank? And it's, it's one of

1:05:18

the, as low as you can get. You want is the lowest.

1:05:21

So if you just even listed it's because he one, two, three,

1:05:23

four, depending on what branch you're in, it's called something.

1:05:25

I mean, you know, the Navy, it's like it's semen

1:05:27

and then petty officer third class, but

1:05:30

in their case, they go sergeant or something. Um,

1:05:33

but it's low. It was a low ranking

1:05:35

person. Doesn't matter. It has no business being

1:05:37

a fellow at Harvard. Um,

1:05:40

it's done nothing but, but betray America

1:05:42

and, and, and then go to jail and then

1:05:44

become a woman. So

1:05:46

that's it. Uh,

1:05:48

but they, but they did, they did rescind that. So that's

1:05:50

disappointing. But yeah. So you, you recently wrote about,

1:05:52

um, uh, all the, all of the, um,

1:05:55

kind of the myths of COVID and, and

1:05:57

how the data has just, has just destroyed

1:06:00

all of these popular

1:06:02

talking points that were

1:06:05

just considered made

1:06:07

stream, considered the consensus,

1:06:10

the scientific consensus, et cetera, et

1:06:12

cetera. We'll focus on

1:06:14

a couple of these maybe. Some of these are more important.

1:06:17

I think the mask one is interesting

1:06:20

because that one still keeps going back and forth, but you say

1:06:22

it's, as far as the Cochrane reviews

1:06:24

go, you consider that most authoritative independent

1:06:26

assessment of evidence in medicine, and

1:06:30

we just don't have evidence that masks prevent

1:06:32

COVID transmission. So

1:06:35

what do you think is the reasoning behind

1:06:38

that? Because I mean,

1:06:40

obviously masks are good for something. Doctors

1:06:42

wear them. That's right. Right.

1:06:45

And like doctors who are treating COVID patients would tell me constantly, they're

1:06:47

like, obviously we're going to wear a mask treating COVID patients.

1:06:50

Like they do work for us. So but

1:06:53

why don't they work as just a general public health

1:06:55

guidance? So you put two

1:06:57

high quality masks on two people when

1:06:59

they interact, say in the hospital when

1:07:02

a tuberculosis patient comes to see us

1:07:04

and it reduces transmission. Those studies have been done

1:07:06

and it's clear. The question is on a population

1:07:09

level, if you

1:07:10

tell all the kids in a school to wear a

1:07:12

mask and you don't specify

1:07:14

what kind of mask, are you changing

1:07:16

the trajectory of COVID transmission?

1:07:19

Those studies have been done. They're

1:07:21

very clear. They're out of Europe

1:07:23

and all over the

1:07:24

different parts of the country, a world not

1:07:27

in the US because we don't allow that kind of research.

1:07:30

And they definitively showed it does not

1:07:32

change the trajectory of transmission. Kids

1:07:34

probably don't wear them. Most of them are wearing cloth masks. And

1:07:38

by the way, they've got harm associated

1:07:40

with it. A lot for kids. Yeah. Yeah.

1:07:43

I mean, I feel like there was harm for me too, but for

1:07:45

kids, definitely.

1:07:47

Yeah. And then, you know, the amount

1:07:49

of energy and time and money and

1:07:51

political capital we spent arguing

1:07:53

masks.

1:07:55

And in the end, the study shows

1:07:57

the mask mandates had no impact.

1:07:59

I mean, honestly, we

1:08:02

never talked about obesity,

1:08:04

the number one common modifiable risk factor,

1:08:07

reducing your COVID

1:08:08

risk. Never, we never talked about getting

1:08:10

outside, right? Be outside. In

1:08:13

fact, in the beginning, they arrest people for

1:08:15

being outside in a park. Arrested surfers and put

1:08:17

sand on skate parks and

1:08:20

Michigan closed parks. I mean, you

1:08:22

know, people like to

1:08:23

politicize COVID.

1:08:25

New York did better than California

1:08:28

or Florida or what.

1:08:29

You cannot do these

1:08:32

comparisons because of the chronicity. The

1:08:34

waves occurred at different points and

1:08:36

the treatments improved over time. However,

1:08:39

Michigan and Sweden are the identical

1:08:42

population. They got hit with the concurrent

1:08:45

waves at the exact same times. They

1:08:47

have the same percent of elderly, over 65,

1:08:50

exact same percent. And

1:08:53

in the final analysis, twice

1:08:55

as many people died in Michigan from

1:08:58

COVID. And they also had a lot of excess

1:09:00

mortality

1:09:02

in Sweden. Half the number of people died

1:09:04

and they had no excess mortality and the economy has

1:09:06

been thriving. And the number one

1:09:08

predictor of health has always

1:09:11

been in every study that's

1:09:13

ever been done in the last 50 years,

1:09:15

socioeconomic status. When

1:09:17

people have more resources,

1:09:20

they're healthier. So these

1:09:22

were giant blind spots and you couldn't

1:09:24

talk about them because all the studies

1:09:27

on masks

1:09:28

were all rigged by the CDC. They

1:09:31

used their own shoddy data. They'd

1:09:33

be out there criticizing hydroxychloroquine

1:09:35

for having

1:09:37

an odds ratio that included one.

1:09:40

That's a statistical test that tells you it's not

1:09:42

significant.

1:09:43

But their own mask studies would have the exact

1:09:45

same odds ratio. And I'm

1:09:47

not an advocate of hydroxychloroquine.

1:09:50

But- But it doesn't hurt either. I think that was

1:09:52

what pissed people off. It's like, look, if

1:09:54

it doesn't hurt me, then why can't I at least try it?

1:09:57

I think that was a thought process. I

1:09:59

didn't advocate.

1:09:59

for it one way or the other but

1:10:02

because I don't know. The amount

1:10:05

of energy we spent debating those things

1:10:08

when people should have been outdoors,

1:10:10

the school should have been open, people should have been

1:10:12

losing weight. Go back to the Michigan-Sweden

1:10:14

comparison. So what was the underlying,

1:10:17

I think I missed it when you were when you were comparing

1:10:19

these two things, what do you think was the underlying difference

1:10:21

and why the mortality rate was twice? Part

1:10:24

of it is obesity rates. But that won't

1:10:27

account for double the deaths in Michigan

1:10:30

over Sweden. And so

1:10:32

part of it is they just had you know

1:10:35

more open society living their lives strong,

1:10:37

healthy, and active. People gained on average

1:10:39

seven pounds during COVID.

1:10:42

So that was part

1:10:44

of it. But it's why are we not

1:10:46

doing this autopsy of actually

1:10:48

evaluating the largest public health intervention

1:10:51

in history? No one is saying let's scientifically

1:10:53

evaluate whether or not it was. Well a lot of people

1:10:55

are. I mean you reference studies that actually prove,

1:10:58

so I mean at least some people are because we're

1:11:00

referencing them. But you didn't mention lockdowns

1:11:02

in any of these myths. So what do you

1:11:04

what do you generally think about

1:11:06

that? I mean I've seen a lot of studies that show that there's

1:11:08

really insignificant changes

1:11:10

to COVID

1:11:13

transmission or mortality rates because of

1:11:15

lockdowns. But

1:11:17

do you disagree with that? No I

1:11:19

mentioned in that article on the 10

1:11:22

myths now debunked about COVID that

1:11:24

school closures for example was one of those things

1:11:27

right. We cannot let kids in school because

1:11:29

they can get COVID.

1:11:31

And so when

1:11:33

you look at the data was out there

1:11:36

in Europe in July 2020 that they had

1:11:38

schools open free and clear in Europe

1:11:40

and they had no differences in transmission from

1:11:42

the ones that were closed. Same with masking.

1:11:45

I wish the New York Times would have sent one single

1:11:47

reporter over there to cover it or CNN

1:11:50

just to

1:11:51

look hey look the kids has

1:11:54

first let me ask you this question this is you know

1:11:56

I like to push the field has any healthy child

1:11:58

ever died of COVID CDC

1:11:59

he won't tell us.

1:12:01

All the deaths could be in kids with comorbidity,

1:12:03

probably most the majority, not all.

1:12:06

It's massively small. They're

1:12:08

more at risk for basically everything else in

1:12:11

life, you know, like just

1:12:14

everything. Suicide is like five times. Everything.

1:12:16

So yeah,

1:12:18

it's almost nothing. And yet that was,

1:12:20

yeah, the school stuff, I think, is rather

1:12:23

obvious. The data is very, very clear, especially

1:12:25

for that age group. But I mean,

1:12:27

I still

1:12:28

wonder about some of the

1:12:30

sanity, then the thinking behind lockdowns

1:12:33

in general.

1:12:35

You

1:12:39

want to get it right for the next one, because

1:12:42

there's always a next one.

1:12:43

And it's

1:12:46

a complicated question, because it depends on what you mean

1:12:48

by lockdowns. Were we locked

1:12:50

down in Houston? Kind of. I mean,

1:12:52

the gyms and bars were closed. Restaurants

1:12:55

and neighbor closed for not very long. I

1:12:58

remember. Was that a lockdown? I mean, kind

1:13:00

of.

1:13:02

Sweden basically said, nursing

1:13:04

homes, we want to try to protect

1:13:07

the nursing homes. They did it about

1:13:09

two months too late. And they've apologized

1:13:11

as a government. They feel bad. They feel that they

1:13:14

made a mistake.

1:13:15

So they were late in protecting nursing homes. But

1:13:17

then again, every country was late.

1:13:20

And they had restaurants

1:13:22

open with some distancing for

1:13:25

a few months. And otherwise, they're pretty

1:13:27

much living their lives, sending out the information

1:13:29

that if you are older, you have

1:13:31

comorbidities or both, you're at

1:13:34

high risk.

1:13:35

Be careful. That's what I always said to people. I'm like, you

1:13:37

know, if you don't want COVID, you don't

1:13:39

have to get COVID. You

1:13:41

are capable as a human being. You

1:13:44

can lock yourself down. This is not a crazy

1:13:46

thought. I

1:13:48

never understood the sanctimonious, the

1:13:51

cool pearl clutching of like, you got to

1:13:53

get me COVID. I'm like, you just not

1:13:55

be near people. Like it's

1:13:57

possible. And if also if you're that type

1:13:59

of person.

1:13:59

who's so afraid of others, what would you, if

1:14:02

you were smart, what you would want the most

1:14:04

is everyone giving each other COVID out

1:14:07

in the world,

1:14:08

getting it being done with it while

1:14:10

you sat at home for a few weeks. Like that would,

1:14:13

that would be what you want. Instead, instead of what lockdowns

1:14:15

do is sort of extends this transmission. Now

1:14:17

there's an argument to be made about hospital capacity.

1:14:20

I get that. You don't want everyone getting

1:14:22

it at once. And so, you know, I

1:14:24

admit this is a very complicated discussion on that,

1:14:26

on how you should go about it, but the people who do

1:14:28

go out or kind of fearless tend to be younger, tend

1:14:31

to not have serious,

1:14:33

you know, reactions to COVID

1:14:35

unless, you know, here and there. But I

1:14:38

don't know. It is as

1:14:40

far as morbidity rates go though, it doesn't,

1:14:42

I know, I know the data show, they've done the studies, it doesn't,

1:14:45

there's

1:14:45

not big differences between

1:14:47

states that were harsher on lockdowns, longer

1:14:50

on lockdowns versus states that weren't.

1:14:52

And again, again, you always go back to the

1:14:55

Sweden example, but that is a very

1:14:57

healthy society just in general. That's

1:14:59

right. So it's, it does make it more difficult. California,

1:15:02

they were arresting surfers.

1:15:04

They, you know,

1:15:06

it was completely out of control in California.

1:15:09

And

1:15:10

people talk about it like, you know, oh, we had to

1:15:12

do that for three years and no one's talking

1:15:15

about it. NIH, no one's talking about

1:15:17

it.

1:15:17

My own school, public health, like

1:15:19

we made tragic mistakes. We

1:15:22

spread misinformation to the

1:15:24

public on COVID as a public health

1:15:26

community. And no one's apologizing.

1:15:29

The data were clear two years

1:15:31

ago, right? That vaccines didn't stop transmission.

1:15:34

Well, I was, I was kind of furious. I'm not, I'm not an

1:15:36

anti-vaxxer by any stretch. Like I think

1:15:38

in, holistically, the vaccine

1:15:40

is a good thing. Probably saved a lot of old

1:15:42

people's lives, but it didn't save my life. And I never thought

1:15:45

it would save my life. It's already had COVID

1:15:48

had COVID. I still can't smell. I'm one

1:15:49

of those really tiny people who still have

1:15:52

like super long-term issues,

1:15:55

but, but it, you know, it wasn't that bad at the time.

1:15:57

I remember California, I was going to say

1:15:59

a.

1:15:59

studies showed Stanford students bicycling

1:16:02

in Palo Alto,

1:16:03

43% were wearing a mask while

1:16:06

bicycling outside and only 17% were

1:16:08

wearing a helmet. That's

1:16:11

funny. There's still people masking.

1:16:14

That ain't stopped. All right. It's still happening.

1:16:16

But, uh, yeah, I mean, since some talk about the vaccine

1:16:18

and kind of what's come out about that, I mean, somebody in

1:16:21

their twenties or thirties or, or

1:16:24

certainly below, like, I don't know what age you tell

1:16:26

me, like as a doctor now, what,

1:16:29

what age group would you recommend? Get a

1:16:31

vaccine? What would you recommend? Do not get a vaccine

1:16:34

on COVID. Yeah. If you had

1:16:36

COVID, there's no data to say,

1:16:39

you didn't have COVID, right? Cause you're,

1:16:41

yeah, because, okay. Yeah. Let's assume you've never had

1:16:43

COVID. So you have no natural immunity, which we know

1:16:45

based on the data that you pointed out here is easily,

1:16:47

if not more successful

1:16:51

in protecting you from future COVID infections

1:16:53

or from the,

1:16:55

the harm of COVID infections. That's

1:16:57

right. And the harm of the vaccine is after

1:16:59

the second dose, one in 6,000 will

1:17:01

have myocarditis and a Swedish study

1:17:04

found that 2% of people after a COVID

1:17:06

vaccine have some heart

1:17:08

injury that's subclinical manifested with something

1:17:12

called an elevated troponin level, which

1:17:15

is a blood test that suggests your heart

1:17:17

muscle has had some damage subclinical.

1:17:19

You don't feel anything. 2% of

1:17:22

people after in the days, in the

1:17:24

immediate a few

1:17:25

days after the vaccine had an

1:17:27

elevated troponin. So we

1:17:29

are, we get, we have

1:17:31

not had good research on this, but myocarditis

1:17:34

means that for a young, healthy

1:17:38

individual, young, healthy person

1:17:40

under age 25, healthy,

1:17:43

the second dose results in

1:17:45

a net public health harm and the

1:17:48

booster results in a net public

1:17:50

health harm. And there are many deaths

1:17:53

from the vaccine. When I say many, there's a

1:17:55

series of a couple at a Germany, there's

1:17:57

eight out of Korea that were just reported.

1:18:00

I know of three in the United States.

1:18:03

That's just me, like through somebody who reached

1:18:05

out to me. And how do they

1:18:07

clinically attribute it to the vaccine?

1:18:10

How does that work? So in these cases

1:18:12

that I'm describing, like out of Germany

1:18:14

and Korea, they've done autopsies

1:18:16

where they demonstrate there was myocarditis-elected

1:18:20

cardiomyopathy. Gotcha.

1:18:22

Okay, so

1:18:25

that's been made clear, and like you said, no apologies.

1:18:28

But again, who would you recommend actually takes the

1:18:30

vaccine? I mean, the vaccine downgrades

1:18:32

the severity of illness in

1:18:35

somebody who is high risk and

1:18:37

would benefit from that downgrading. And

1:18:40

so I've always recommended it for people that

1:18:42

are high risk. And if you're very high risk, even

1:18:45

if you've had a strain a long time ago, it

1:18:47

may make sense. But the

1:18:49

idea that you've got circulating antibodies

1:18:52

from

1:18:53

prior infection and you're pretty

1:18:55

healthy,

1:18:56

and you have to get the vaccine because you

1:18:58

have circulating antibodies that neutralize the virus,

1:19:01

but they are antibodies the government does not recognize.

1:19:04

That is a joke. And that's where the public health officials

1:19:06

lost a lot of trust. When we ignored natural

1:19:09

immunity, first of all,

1:19:11

a lot of people died. Thousands of Americans

1:19:13

died from the doctrine that we

1:19:15

cannot recognize natural immunity. They say,

1:19:17

well, how did people die from it?

1:19:19

When we had a limited vaccine supply,

1:19:22

we were giving two life preservers to

1:19:24

some people, two doses to some, when

1:19:27

we should have

1:19:27

given people drowning at least one

1:19:30

life. One was fine.

1:19:31

One would have saved their life at that time.

1:19:34

It was so effective against the strain that was circulating

1:19:37

in December through 2020 to

1:19:40

April 2021. We could have saved

1:19:42

thousands of more lives, but they ignored natural

1:19:44

immunity. And then- I didn't think

1:19:46

about it that way. That's right. We could have saved thousands

1:19:48

more lives. And we wrote article after article.

1:19:50

I was saying it until I was blue in the face

1:19:53

and the media on TV and the Wall Street

1:19:55

Journal.

1:19:56

Why are we giving two life preservers to someone?

1:19:58

So it should have gone to people who've come up.

1:19:59

and old people, how do you define

1:20:02

old? Like at what age, even if they have no comorbidities,

1:20:05

at what point does your age become a comorbidity?

1:20:07

Well 80% of the deaths were in people over 65. We knew

1:20:09

that when the vaccine was being distributed. So just go down

1:20:12

by age. Instead of your category

1:20:15

2C and you get in line here and you get it, just

1:20:17

go down by age. That's what the UK did

1:20:19

and they saved more lives and they spread it

1:20:22

out by three months. No vaccines given

1:20:24

three or four weeks apart. That's why half

1:20:26

of America was in bed for a day. No

1:20:28

vaccine is given three or four weeks apart. And

1:20:30

where did they even come up with this four week booster? So

1:20:33

it was with good intentions. They wanted

1:20:35

to end the clinical trial early when

1:20:37

they were experimenting with the vaccine. It was with good intention,

1:20:40

but very quickly, people realized,

1:20:42

hey, the protection of the first dose was pretty

1:20:45

darn good with the variant that was

1:20:47

circulating at the time, 90%. So

1:20:49

space it out and that's what the UK

1:20:51

did. Matter of fact, the UK did a formal

1:20:53

study comparing a three

1:20:56

week interval to a three month

1:20:58

interval

1:20:59

and guess what? At three months, they're the

1:21:01

same. And you actually had better immunity.

1:21:04

Interesting. And that's true of all vaccines. And your point

1:21:06

is that if we had known that, or

1:21:09

well, we didn't know it, but if we had not ignored

1:21:11

it,

1:21:11

you would have been able to use those extra

1:21:14

doses for people. To save lives. Yeah,

1:21:17

say young people with comorbidities that weren't prioritized.

1:21:19

What's that even, I don't even remember how we actually handed

1:21:21

them out,

1:21:22

to be honest. I think it was whoever wanted them.

1:21:25

There wasn't like a system. I think I could

1:21:27

have gotten it pretty early if

1:21:29

I'd wanted to, I didn't. The

1:21:33

only reason I ever got a vaccine was because I had to travel

1:21:35

to the UK, like at

1:21:37

November of 2021.

1:21:39

And I'd already had COVID, I didn't see a need

1:21:41

to go get a vaccine.

1:21:44

The problem was

1:21:47

we would talk to public health officials. Many

1:21:49

of us have believed in these,

1:21:52

the research and the data. We'd be like, hey,

1:21:54

there's this amazing data. Let's

1:21:56

space out the dosing frequencies. You

1:21:58

can reduce the number of myo. carditis cases

1:22:01

and complications and maybe even deaths

1:22:04

and you ration better you'd

1:22:06

have lower complications better immunity

1:22:09

and they would

1:22:10

listen to our argument and just Fauci

1:22:12

decided this and that's it.

1:22:14

Yeah

1:22:15

yeah it's just frustrating.

1:22:18

I mean the public health is

1:22:20

the public health officials you know lost a lot

1:22:22

of trust but

1:22:24

you know you can't always you can't blame

1:22:26

them entirely. I blame politicians

1:22:28

a lot more because

1:22:31

it's a public health officials

1:22:33

it's a public health officials job to say these

1:22:36

are the risks I would

1:22:38

this is the only thing I look at so yeah

1:22:40

of course I'm gonna tell you how to bring COVID

1:22:43

infections down to zero you lock everyone

1:22:45

up.

1:22:46

Of course I'm gonna tell you that because that's the only thing

1:22:48

that that person looks at but

1:22:50

a politician is supposed to look at other

1:22:52

things an elected official so they're

1:22:54

supposed to look at I don't know how does it affect the

1:22:57

economy how does it affect other health

1:22:59

aspects of health well I know it would also be public health

1:23:01

officials problem they didn't do that but

1:23:03

there's trade-offs everything in policies about trade-offs

1:23:06

and there's just

1:23:07

some elected officials understood those trade-offs

1:23:09

and cared about them others

1:23:12

didn't care and completely

1:23:15

destroyed segments of society as a result you

1:23:17

know and your kids obviously took it the worst

1:23:20

by far kids and small businesses so

1:23:23

yeah minority

1:23:25

and poor populations experienced

1:23:27

the absolute worst outcomes of the COVID

1:23:29

restrictions. Wealthy

1:23:32

Americans did very well they're in the country

1:23:34

clubs in the suburbs and live in life and

1:23:37

and so for the public health officials like the

1:23:39

CDC director Rochelle Walensky whose kids

1:23:41

were in a school that was doing

1:23:44

great and open and you know

1:23:46

one of these schools that everyone wants to get into

1:23:48

or go to life was good

1:23:50

people living in their second homes life was good

1:23:53

but for kids in inner city Baltimore

1:23:56

where I work who were told hey go

1:23:58

log on to this IP

1:23:59

pad, they never logged on and

1:24:02

they never showed up in school again. And

1:24:04

so with all the talk of, you

1:24:06

know, the importance of health equity,

1:24:08

these policies were the most destructive policies

1:24:11

you could design to exacerbate

1:24:14

inequities in the system. I

1:24:16

was just at a medical conference and half of the presentations

1:24:20

were on health equity or transgender

1:24:22

medicine. And I'm like, this is fine,

1:24:25

but you know, at some point we have to, we just banned that in Texas.

1:24:27

Pretty excited about that. Yeah. I heard about that. Yeah.

1:24:30

I mean, I just sent a scathing letter to the Texas children's

1:24:33

hospital, arguably one of the

1:24:34

greatest children's hospitals in the world. And I'm like, you're

1:24:36

losing credibility by, by

1:24:39

doing this. I mean, there's

1:24:41

no science behind this. This is, this is pseudoscience

1:24:44

insanity and they're not doing trend. They're

1:24:46

not doing surgeries. They're like, we're not doing surgeries. You're

1:24:49

permanently disfiguring the physiology of

1:24:51

a child with hormone therapy. Tell

1:24:53

me I'm wrong.

1:24:54

Is that what hormone therapy does? Is it permanently

1:24:56

changed the physiology? Yes, it does. I

1:24:59

don't need to be a doctor to understand the basics

1:25:01

here. Uh, very frustrating.

1:25:04

It's in, you know, and of course it's on the parents for

1:25:06

pushing it, but like,

1:25:08

at least the buck has to stop

1:25:10

somewhere. And you know, a medical professional has to say

1:25:12

no at a certain point that they'll do no harm.

1:25:14

And so I, geez, what is

1:25:17

it? The

1:25:19

AMA, AMA is condone this stuff.

1:25:22

Um, you know, they lost just complete credibility, but

1:25:24

what's their, am I, am I correct? Is it the AMA or is

1:25:26

it? Pediatrics. I mean, it's them. Yeah, it's definitely them.

1:25:29

Um, if it's the, all of them

1:25:31

are everybody's behind the transgender

1:25:33

stuff. That one, that one's bad.

1:25:35

It'll be our next podcast. I think I've done enough

1:25:38

podcasts on that. I'm sure.

1:25:40

I mean, I've had guests on who have transitioned

1:25:42

and now are like, Hey, this, other advocates against

1:25:44

it. This is, this ruins their people's lives. I'd love

1:25:46

to see the research on regret

1:25:49

because that's data. That's important. If you're going to do an

1:25:51

informed consent, but it's very

1:25:53

difficult to do research in this topic, either people

1:25:55

have a full conclusion.

1:25:57

Or you're dismissed from the discussion.

1:25:59

So we're going to keep speaking up, those of us

1:26:02

that feel that it's important to challenge deeply

1:26:04

held assumptions in medicine. Well, it's just frustrating

1:26:06

that you go to a conference and like these are the topics,

1:26:09

you know, this kind of woke stuff, like because there's, there's

1:26:11

real problems that need to be solved in healthcare. We

1:26:13

got to cure cancer at some point, you know what I mean? Yeah, that's the

1:26:15

thing. There's, you know, there's Alzheimer's,

1:26:17

there's, these are very costly, uh, uh,

1:26:20

devastating diseases. Um, yeah,

1:26:23

it just seems like that would be something, something good

1:26:25

to talk about. There's a fertility crisis,

1:26:27

uh, in our country. Yes. I'm going

1:26:29

to talk about that.

1:26:30

Um, you know, I'll, I'll make that,

1:26:32

I'm going to make that topic the, the

1:26:34

main part of my healthcare summit actually, um,

1:26:37

coming up in November. Um,

1:26:39

because I've met some amazing doctors that are, that are, that

1:26:42

are pioneering that. So there's just, there's important things

1:26:44

to actually talk about and interesting

1:26:46

and uplifting things too, uh, about,

1:26:49

about innovation and then things that people are doing that

1:26:51

just nobody's want

1:26:53

to talk about transgender surgeries. It's like,

1:26:55

why? And you know, it's

1:26:58

like health equity will Vanderbilt

1:27:00

will spend a million dollars trying