Searching for Medicine's Soul Transcript

AARON ROTHSTEIN: I'm Aaron Rothstein of the Ethics and Public Policy Centers Bioethics and American Democracy Program. Welcome to Searching for Medicine Soul. Today's guest is Professor David Slusky. He is an applied micro economist whose research focuses on health economics, labor economics, and public policy. At the University of Kansas, he's affiliated with the Department of Economics, the Department of Population Health, and the Institute for Policy and Social Research, and serves as the interim Chair of the Department of Speech Language Hearing, Sciences and Disorders at the University of Kansas, and the Executive Director of the American Society of Health Economists.

He's also a research Associate at the National Bureau of Economic Research, and a research fellow at IZA, the Institute for Labor Economics in Bond Germany. David and I have known each other for, I don't know, about 16 years.

DAVID SLUSKY: That was what I calculated this morning also.

ROTHSTEIN: Yeah. So David it's great to see you, and thanks so much for coming on the podcast.

SLUSKY: It's my pleasure. It's nice to be here.

ROTHSTEIN: So at the University of Kansas, you've taught a class on the Affordable Care Act, also known as Obama Care. And you've written and spoken about it as well. We're now over a decade out from the passage of the bill. Republicans failed to overturn it during the Trump presidency. And I think it's safe to say that the ACA is almost certainly here to stay. What do you think the ACA did well? What do you think it didn't do well? Where do you see improvements or stop gaps that need to be passed or made?

SLUSKY: It's a great question. So Doug Elmendorf, who's now the Dan of the Kennedy School, but was the head of the Congressional Budget Office during the ACA ratification, said the ACA had three goals. Leave employer sponsored insurance as it is, as much as possible, cover everybody and don't raise the deficit. And within those three goals, this was about all you were going to get. In the sense that the ACA provides two primary mechanisms, expanding Medicaid eligibility, and subsidies on a competitive exchange to get the 5 - 10 million Americans who didn't have health insurance coverage before to have health insurance coverage.

That has happened. The uninsured rate is the lowest it's ever been. The benefits of insurance of reduced financial distress, of better access to health care have been reasonably achieved. The Medicaid expansion, as we'll discuss in a little bit, I think, is still not complete, though, you and I are too young to probably remember that Arizona didn't expand the original Medicaid until around 1990. So it is a long process, and we still have a long way to go, especially here in Kansas. The other piece on the subsidies, the federal government just this year addressed an issue where the subsidies arbitrarily stopped when you hit 400% of the federal poverty level. So there's still tweaking to go. The lack of a bipartisan mechanism to even do normal what used to be normal tweaking has made that slower and more difficult. But by and large, the goal of getting people health insurance is There are other pieces that I think are really helpful but less well discussed. Things like removing lifetime maximums, making it more difficult for your insurance to drop you when you get sick or because of a minor clerical error on a form, making sure your insurance covers essential benefits, letting the federal government and the executive branch experiment on ways to bundle payments and lower costs without hurting outcomes, and then if they're effective, actually implement them without going back to Congress.

This is even less well known provision that delegated a bunch of actual legislative authority over to the executive branch. These pieces are all there and are all making a difference. 

The big things left is this is by and large health insurance reform. That it's not doing enough to keep costs down. It's not doing enough to remove and change perverse incentives. It's not doing much to it's not doing as much as it could to improve the financial situations of households that are still exposed to substantial risk. And I think it took an absurdly complicated system and added another layer of complexity. The thing I also want to talk about is we spend more per capita on healthcare than almost any other country in the world, and that doesn't count the amount of time that patients spend, managing the finances of their own health care. If you added that in, the amount of, people who are at their jobs not working because they have to make phone calls during business hours, that's another drain on it, and this did really nothing to fix that or almost nothing to fix that, compared to many things it could have done.

ROTHSTEIN: You mentioned these perverse incentives. Yeah. What are some of those?

SLUSKY: So much of medicine is still what we call fee for service, which is where, I guys you're aware as a provider, the provider gets paid per thing they do. And the problem is that incentivizes the provider to do more. Even the best meaning, most honest, most altruistic provider still has that incentive there, and still probably has a medical director who is pushing that because that's how you grow the revenue of the practice. There are lots of rules about conflicts of interest that I have to go with that lawyers have to deal with that physicians have to deal with. But when your provider is recommending different treatment options, they don't have to disclose which one makes them more revenue, which one makes them more profit. Even though even if they believe they're not affected by that, I don't think that's true in aggregate, because they're human just like the rest of us.

ROTHSTEIN: Right. And I would say Some of these things, like, I don't even know. Like, I don't know if I order one test one lab versus another lab, whether that's creating more.

SLUSKY: But your medical director knows, and the people who look at your targets and your billables at the end of the year know, when the people who design the policies in the practice or the hospital about what you're supposed to do and not do, they all know. And so you are sadly probably less insulated from this than you hope, you wish?

ROTHSTEIN: I think it's 100% true. I feel like a lot of us who are seeing patients are ignorant of these prices. But the people above us, as you said, know what's going on and can push us to do certain things.

SLUSKY: I would say further, not just should they are employed to do that. That is their job description. They are doing the job no, they're not malicious. They are doing the job that they were recruited and selected and hired to do. 

ROTHSTEIN: Right. And the fee for service, is that something that's recent, or has this been true of our healthcare system for decades?

SLUSKY: It's been true for decades. I mean, I think the move toward provider organizations and managed care are attempts at chipping away at it, right? The DRG movement for Medicare for hospitals in the 80s, was a way to move away from it. So we've been chipping away from it. The thing is, as  health care prices have risen, and has the menu of treatment options grown enormously. The incentives have become more and more distorted because there's so much more money to make per thing.

We didn't used to have proton beam therapy for prostate cancer. We didn't used to have biologics and protein drugs and infusions. I can go on and on. You can go on and on. But we have these amazing technologies that we didn't have a generation or two ago, and that just exacerbates the fever service.

ROTHSTEIN: Hm. David, you mentioned this employer based kind of healthcare insurance, which I think a lot of people really love because it's basically tax free in a way, and it's a way for employers to get employees and offer them these incredible benefits. I think some people point to this as one of the reasons that health care costs have exploded. Do you think that's true? And is there an alternative to doing this?

SLUSKY: Yeah, kind of classic undergraduate microeconomics, right? You buy things until the price ratio equals the marginal benefit ratio. And if I give you a discount on one good versus another, you're going to keep consuming that good more until the benefit of the next unit gets smaller. And so the fact that many things you buy, most things you buy, you buy with after tax income, but you buy health insurance, and therefore, healthcare with pretax income is going to twist you toward more health care and less other things because of the tax structure.

The ACA actually had a provision to deal with this called the Cadillac tax, which was going to, at some point, start taxing health insurance benefits. This was hated by the right because of the tax. It was hated by the left because often unionized employees are the ones who have the fanciest most expensive health insurance plans. I, until more recent events, I have not seen a consensus in my profession about anything as much as there was about keeping the Cadillac tax, but no one likes this except for economists, and it no longer is in effect.

ROTHSTEIN: Let's talk a bit about Medicaid. You've done some really interesting work on Medicaid expansion and divorce rates. How did you come to look into the effects of Medicaid expansion on divorce and tell us about what you found?

SLUSKY: Yeah. I think there was a Nicholas Christoph column around the time of the ACA that talked about, like, a couple getting divorced to get one of them on Medicare because the challenges, I think, especially left of center, we want to take these limited program dollars, right? We never get enough public funding for the programs we want, and therefore, we want to get it to exactly the right people work and have the most good. That both creates an enormous administrative burden because figuring out who the right people are takes a lot of time and a lot of effort on all sides, but also it can create these perverse incentives because if you have too much assets, you can't qualify.

And because so much of what we do in the US is based on the household unit, these retirement assets, for example, are for both people. And if you got a situation where you've got a 60 some year old and a healthy 60 some year old, if you drain their joint assets to get one of them on Medicaid, the other one could wind up, first of all, without a partner, and then without the assets they needed for the rest of their life, which, you know, easily could be another 20 years.

And so couples are actually starting to get divorced to get onto Medicaid. Hard to get numbers on how prevalent this was because nobody wants to talk about it. Certainly, if you Google a state planning attorney help me with medical divorce, you'll find lots of people who will sell you their services to help So we heard about this. We started looking into it. We tried to use college graduates as a proxy for for individuals who might have enough wealth for this to matter. We looked at various wealth distributions, and actually found that Medicaid expansion reduced divorce prevalence among the 55 to 64 age college educated population. And then, kind of in the lifecycle of a paper, right, it starts with anecdotes.

You look in the broad dataset representative, you put your study out, and then people come up to you and say, that's my story. Say, that's my story or say, when my dad was sick, they told my parents to get divorced, but they didn't do it. Now, that story is not in the data because they didn't actually do it. They just considered it. And certainly nobody's measuring, like nobody's serving social workers and hospitals and saying, how often do you recommend this? But we started hearing more and more that this was people's story. And again, it comes back to this, I think, good intention to target our federal dollars and our state dollars where they can do the most good, but that creates perverse incentives.

So the idea here is that people don't want to give up all their assets to pay for expensive medical care for someone who gets a horrible stroke or? It's not pay for it. They have to give it up to be eligible for public assistance for that individual. Either because they're below the Medicare eligibility age or because there are gaps in Medicare that this is not covering. And they want to get this sick person who's probably never going to work again, they want to get them the healthcare they need and find a way to pay for that without putting the healthy spouse in situation.

They don't have enough assets to cover their retiree. I mean, this is certainly an upper middle class problem, but it's not a 1% problem. 

ROTHSTEIN: Right. Because those medical bills will drain someone's entire life savings, you know, probably for a very short time. 

SLUSKY: It's not just the bills will drain it. It's the public assistance will often not come in until you have drained your assets.

ROTHSTEIN: And do we have any sense of the rates now versus what they were before Medicaid expansion?

SLUSKY: I mean, our paper suggest that it went down. We're really measuring it two or three degrees of indirect. 

ROTHSTEIN: So let's talk a little bit more about Medicaid. And I think the right likes to cite this 2013 New England Journal of Medicine paper, looking at random assignment Oregon in 2008 to Medicaid or no Medicaid, and followed these patients out to see what their health outcomes were like. And they reported basically no improvement in physical health outcomes in the first two years between those with and those without Medicaid. And again, I think Medicaid's critics like to cite this paper. I've seen it cited kind of in popular articles about Medicaid.

And you've written elsewhere in Econofact, in particular, that you think Medicaid expansion works. We talked a little bit about it maybe decreasing the medical divorce rates. But in what other ways do you think Medicaid expansion works?

SLUSKY: So first of all, I recommend these individuals read the rest of the papers that wrote and the rest of even that paper. This is Amy Finkelstein out of MIT, and a large set of co authors, Kate Baker, Joe Newhouse. So first of all, they find that people's self reported health actually goes up substantially. Which matters. People think they are healthier, in part because they are exposed to less financial risks. And they don't just speculate about that. They actually look at people's credit files and find that being eligible for Medicaid actually makes people's household financial situations better. So I think this idea that health insurance is all about health or all about medical use is really quite too narrow, right?

Because the other thing we want it to be about is we want families to not be exposed to these huge financial tail risks to pay for health care. Sometimes it's consumption insurance, not health insurance. And so I think that the Medicaid expansion, right? This is not the Oregon one in the late oughuts, but the ACA one is probably the most studied thing I've ever seen health economics.

The Kaiser Family Foundation has a couple of really amazing literature reviews. We're talking about hundreds and hundreds of studies. And if you look at those studies, right, majority does find better health outcomes then finds worse or no health outcome change, and a majority do find self support health increasing. But most of actually what they're finding is on the financial side. That access to health insurance makes households in a better financial situation than they otherwise would be. So I think that looking only at health and measured health is really far too narrow a measure then, you know, did you skip medication because you couldn't afford it, or did this make your household able to weather other shocks, or did you less likely to go into delinquency or default on your mortgage?

I think those broader measures, which we society should care about are also really important. 

ROTHSTEIN: It makes sense. One of the things that people also have pointed out is that the Medicaid reimbursement rates are really low. And so what happens  is physicians end up or hospital systems end up turning away patients who are, you know, solely on Medicaid. How do you see us addressing that issue? Because I imagine if it's true that physicians would lose money from taking patients who are on Medicaid, then it's a totally reasonable decision economically to turn those patients away.

SLUSKY: So a couple of things. So first is the question is, what's the valid counterfactual? Meaning, if you were providing uncompensated care to a patient in a hospital, Medicaid looks great. It's a lot more than zero. One. Two, the ACA actually had a provision that addressed this that for a couple of years had primary care, pay Medicare rates, not Medicaid rates. It's called the FBA.

And there are a couple of studies at the University of Pennsylvania that Michael Richards and Dan Polsky and others did when they did these secret shoppers, where you call and you say you have a certain kind of insurance before and after, you see if you can get an appointment, and it did substantially help people get appointments. Now, the most amazing study on this looked at IRS data and matched it up to the federal licensing that Medicare does for physicians. You probably have an MPI number, maybe several, a national provider identifier. So they matched up those two things.

So now we can actually look at physician tax returns. And what they found, first of all, was that about a third of physicians income is coming from retained profits as the business owners of their practices as opposed to a wage income. But the second thing they found is that physicians in these private settings actually their profits went up during the fee bump. Was physicians who are in salary situations or in non for profit situations or one they don't have retained earnings, their profits didn't go up.

So that's to say that raising the reimbursement rates, a good bit of that is actually going into physician income. Much more so than we would have thought.

ROTHSTEIN: Right. One of the other points I think some folks have made is that the hospital systems themselves, even the non for profit systems, and we had Danielle O'free on the podcast, and she made this point, and Ovic Roy on the podcast made this point. It feels like it's a agreement between left and right, that these institutions are monopolies in some way. They're able to raise prices without consequences and they retain their not for profit status. I wonder if this ties to the Medicaid issue as well.

SLUSKY: I think there's a couple of things. One of them is Steve Parente, who is Minnesota, who was in the Trump CEA, did a lot of amazing work on price transparency, and actually got, you're probably aware of this, got laws passed that hospitals have to disclose their prices. Now, hospitals amazingly, there this Wall street journal article that those websites had code in them, so Google couldn't find them.

And so, but I think we're now only starting to figure out how to work with that data. Now the Federal Trade Commission doesn't have to use discovery to get those prices and try to target it. They actually have it all now and can look much more closely at this. So like, like Leo Daphne from Harvard, who is the deputy director of the FTC for Antitrust, Healthcare antitrust, has worked on this as well. I think if you talk to pretty much anybody in the kind of industrial organizations healthcare space, they will tell you the FTC is woefully underfunded under resource. And that we should have much more robust health care antitrust work than what we have now.

We're doing the, the Biden administration has focused a lot more on tech antitrust. There's a lot to do on healthcare antitrust, both on the provider side and on the insurer side. 

ROTHSTEIN: When we think of cost cutting and cost saving in the medical field, we don't always jump to ambulances as an issue. And it seems like emergency medical transportation is absolutely necessary. A naive question might be, what waste or fraud could possibly be found in an ambulance rise to the hospital. But over the last decade, a significant amount of reporting has been done. Not only on surprise billing from ambulances and emergency transportation, but the incredibly exorbitant cost for patients. And as early as 2013, the New York Times reported charges to patients who called an ambulance of almost $1,800. Though 40 years ago, according to the times report, they were often free of charge.

And then back in 2013, ambulance rides cost our system $6,000,000,000 a year up from 2 billion in 2002. During the COVID pandemic, Sarah Cliff wrote a piece for the times about the urgent transfer of us a COVID patient from actually one Philadelphia Hospital, 20 miles away from another, and it cost over $50,000. I know there's been recent legislation prohibiting, as you mentioned, surprise medical billing from out of network providers. But my understanding is that ambulances were a notable exception to this, and in a lot of states, there is no cap on what ambulance companies can charge.

I know you've described a personal experience with opting for Uber transportation rather than ambulance, and that seemed to inspire you to study the question of how ambulance use shifted because of Uber. Can you tell us the story and about your research?

SLUSKY: Yes, and then I want to say more broadly about the question of ambulances. So the story was that when my wife went into labor, we lived in Center City, Philadelphia, like 5:00 in the morning. You can't walk out and catch a cab. Its not like New York City. Our friends were all asleep, right zip car like you had to bring it back to that spot or the bill would keep running. And so we called an Uber. We get in the Uber. My wife's like play cool. He won't know in labor. And so we're on Walnut Street which goes the wrong way from Pennsylvania Hospital. So he takes a left, and then we're expecting another left to go the right way to a Pennsylvania Hospital, and he blows past it. 

And I'm thinking like worse night to be kidnapped by a Uber driver. Goes by the next street, which goes the wrong way and then turns left. And he says, Look, I have three kids at home. I understand your situation. This is a much smoother street than the other one. Wow. And so, what's my dream of what emergency transportations should be?

An ambulance is like the most resource intensive thing we have. It's like a mobile ER. Sometimes that is an amazing lifesaving piece of technology. Often, that is extremely inefficient use of limited resources. So there's a Black Mirror episode where like somebody calls the equival 911, and this is why where everybody's got these contact lenses where they're recording everything, and they asked you consent to us getting the feed from your contact lens? We can see what's going on. So my dream is like you call 911. They say, you consent to us getting the feed from your Apple watch and please turn on the camera on your phone.

And then they use all of that data to look at a menu of options. Maybe you do need an ambulance. Maybe you only need a cop car with lights and sirens, driven by an EMT with a defibrillator and a first aid kit. Maybe you'll need an Uber car that drives, normally, but it is driven by an EMT. Maybe you need an Uber car driven by a regular guy with no first aid training, and maybe you can see somebody in the morning.

But I'd love to move toward a continuous system where we can push triage a little farther upstream to the actual that moment when you call 911, and they can help you get the right thing so that we can reduce ambulance, not just reduce ambulance usage, but actually reduce ambulance waiting time, people who really need it. Okay.

The issue with surprise medical billing and ambulances is actually two different issues. So I had thought that this is really kind of a classic monopolist overcharging where you have these single provider ambulance services, and they are intentionally staying out of network because they can because they can charge you more that way and they can get away with it. And you know you don't this is like the best example I can think of where you do not have time to shop around. You don't have time to price compare. This is not a competitive market, at all, not a full information, efficient market. You need an ambulance right now. And you are incredibly vulnerable at that point to being price gouged. 

I said this on a podcast. And I got a very angry e mail from somebody in Colorado whose job it is working for the county for the public ambulance company there to maintain the relations with insurers. Person said, for the public ambulance. So in here in Lawrence Kansas, in Douglas County Kansas, we have a public ambulance company, and they are not a network for any private insurance. They're only a network for Medicaid and Medicare. Now, as a public employee here on private insurance or pseudo private insurance, I think this is ridiculous. I wish our benefit people would fix it. I list with this podcast, please fix it.

But one of the reasons they haven't fixed it is the county doesn't have enough funding to employ someone to manage all the insurance contracts. And basically take a full time employee the whole year every year to manage all of those negotiated contracts with all the different private insurance options. So one of the reasons that the ambulance companies are out of network is because we, as local taxpayers, are not willing to pay slightly higher local taxes to fund them employing someone to keep our ambulance prices down.

We are some combination of risk loving and kind of dystopian small government addicts, that we just won't do this. And that to me is like a deeply sad like civilization failure We can't get this one to work.

ROTHSTEIN: Can you tell us about the research you did about Ubers and ambulances? Is there any possibility that ride sharing will put downward pressure on ambulance costs for patients?

SLUSKY: It's a great question. So what we did was, we looked at 100 different cities in the US that rolled out Uber X at different times over a couple of years. And we worked with a company called Nepsis, that aggregates up ambulance volumes across the country and we maxed the two of these up and we looked within locations over time and found that when Uber became available, ambulance volume went down about 7% because, again, as I mentioned before, with kind of anecdotes coming out the end of research, as soon as we did this, my ER Doc friends called me and said, of course, we know this, right?

And you know, the amazing news agencies that cover it could find Uber drivers who did this and find people who took Uber to the emergency room. Because sometimes you're fine except your driving leg is swollen and you can't drive. And, you know, you want to get at ultrasound to make sure you you're a physician to whatever you need to get, make sure you have a blood clot or whatever it is, but you can't drive yourself. And you know, your spouse had to be home with your kid who's asleep or there's nobody else in the house or whatever the issue is, you don't need to get there.

I mean, yesterday, my car was being fixed, and it was done, but the shuttle that the Toyota dealer uses that was done for the day, and I called Uber to go and pick up my car and drive back. This is an amazing service that didn't used to exist, right?

I think when Erin and I were in college, we were in college about, you know, a 20 minute walk away from the train station. And so you would call a cab to get to your train, and you would leave enough time, you could call a second cab when the first cab didn't show up, and then you would just give up and walk and drag your luggage across town to the train station. 

ROTHSTEIN: Yeah. 

And now with Uber, the ability to watch the car move toward you and confirm that somebody really has your reservation and do call and communicate with the driver enormous value. 

ROTHSTEIN: Do you see maybe Uber being incorporated into...

SLUSKY: Yeah. So I did talk to Johnson County actually, which is the next county over on the Kansas City suburbs. We did talk about integrating their ride sharing with actually some primary care data. There have been some experiments with coupons for lifting for Uber primary care providers and looking at missed appointments. So there is some talk about this. I think Uber actually has their own Uber health product. I've talked to them a little bit.

So there is some movement in that direction of trying to incorporate these kind of relative low cost transportation into the healthcare system.

ROTHSTEIN: So, David, let's do a little hypothetical here. Let's say the American people have elected you president, and in their infinite wisdom. They've also elected 70 senators and 300 members of the House of Representatives who will do whatever you tell them to do. So you have absolute power. What's your approach as an economist to make the US healthcare system more efficient, more reasonable, more affordable, manageable, reformable.

SLUSKY: Can I have the state legislatures also?

ROTHSTEIN: Yes, you can have every.

SLUSKY: Okay. So let me start small and I'll move big. So research that we haven't talked about is reproductive healthcare and the ways that limiting access to reproductive health care can not just affect birth rates, but also affect household financial situations and actually also affect preventive care that is offered delivered through these clinics. So enshrining protections for reproductive health care nationally, for those who want to make use of it is super important.

Okay. Now, let me go back to the bigger question. And I want to step back and talk about kind of what is the problem we're trying to solve?

The problem we're trying to solve is that you and I, or let's say I because you actually are a physician, but I not a physician, wants to live a long, healthy life and doesn't actually know what healthcare I need when to do that because I didn't go to medical school. I got a different kind of doctor. So I need to work with a specialist or a general physician or someone who knows this that I don't.

So at first order, we could pay that person two ways. We could say, I'll pay you for everything you do. They're going to say, Okay, lots of stuff I can do. Let's do it all.

Or we could say, I'll give you a fixed amount of money and to be my doc, and then you have to pay for things out of your end. We're going to say, Okay, we're not going to do it. We're going to do very very little. Only the most egregious things we have to do, and the rest I'm going to keep it.

So both of these don't work for opposite reasons. We need some way to incentivize my provider to take care of me as if my body were theirs as if they live inside my body. And the way I want to do that, and nobody does this, but the way I would want to do it is basically say, if you're my doc for a year, you get a little bit of money for being my doc, and you have to find a way to pay for all my healthcare.

And then for every year of the rest of my life, whether you're still my doc or not, that I get healthier or stay as healthy as I am, you get money.

So the idea being that I want to make you incentive compatible with me to keep me healthy. Now, we have to make it very little money up front and almost all the money later or else you're just going to take the money and run. And we have to make sure to risk adjust it to where I am now so that you don't just get patients who are healthy and going to stay healthy, right? It has to be such that, it was relative to my health new.

But the thing is, then I go see you, and then you say, okay, what I'm going to have to pay for everything I do to keep David healthy. But if I've succeeded keep David healthy, I get paid money. So how do I figure out as the provider, with all my provider knowledge, the most efficient ways to keep David healthy. That's the system I'd want to create. What do you think?

ROTHSTEIN: That sounds pretty cool. What kind of I guess how would you do that? Policy wise

SLUSKY: I think I and many other health economists are totally done with consumer directed health care and high and high deductible plans. Because it turns out when you do that, and this has been well documented, people just get less health care across the board, that non physicians are actually terrible at knowing what is a good use of their money and what is not.

So, you know, kind of the UK model of the patient never sees a bill, I am very much leaning toward that direction, in part because I watch my sick friends who already have less leisure time because they're sick, spend a lot of it managing the finance of their own healthcare, and it's a travesty. Right? We got to stop doing that. And so I mean, what I'm describing, it's going to take single payer. It's going to take completely operable nationalized health care records, right? Because how do I know you move across the country? How does the doc you had in New York? How do they even know that you're still healthy? It's got to be all documented and measured and integrated? Right? If you show up in the ER for something that I came to have you treated by, that should ding your future payments.

Because you didn't do enough potentially to prevent that from happening. It also would take a whole financing system on the background, because you as the provider would have to find the money to pay for my healthcare now that you're getting the dividends for later.

We need a reinsurance system because, if you take a bunch of patients and, you know, they all have bad draws and such that bad things happen, no matter even though you did everything right, you don't want your practice to go out of business. So there needs to be some kind of reinsurance on the back end. We need to do a lot of those things. But I think make a single system like that, even though the system itself would be quite complex on how all the payments work. We would remove a lot of the patchwork on insurance and on patient involvement that we currently have.

ROTHSTEIN: Got it. So UCA kind of like Medicare for all. I know that 

SLUSKY: I think it's actually it's actually it's closer to Medicare advantage for all than Medicare for all. Because Medicare for all is all kinds of things, right? There's fee for service, you know, the Part B, right? Physician administered cancer drugs, right? On regular Medicare, you got to pay 20% of that until infinity. Right? So so Medicare advantage where you're actually bundling and having a single risk adjusted payment that goes to the insurer, right, that more in that direction, plus this piece that nobody does on kind of the lifetime payments for keeping your patients healthy.

ROTHSTEIN: Hmm. The Medicare advantage model does incorporate some like, private insured, right? A combo kind of thing. And so you see the advantage there being that the government says, we're just going to give you this fixed amount of money, and you have to basically do the right thing with it.

SLUSKY: Again, in the extreme, that mean that puts you that has a huge inaction bias. That's like you send your kid to buy groceries and they even keep the money you don't spend. They don't buy groceries. There was a home improvement episode where the kids bought all dented discounted cans and kept the money. But that's not actually what you were trying to do. 

ROTHSTEIN: Right. Right. Interesting. Very cool. Well, David, thanks so much for taking the time today to come on the podcast. Look forward to more of your research and writing.

SLUSKY: I want to plug one more thing.

ROTHSTEIN: Please.

SLUSKY: Because you might say everything you just said is totally implausible. Tell me it actually something that would really work. And what I would direct you toward is a website called 1% Steps, which is a website that Zach Cooper at Yale and others did. That lists a dozen, two dozen different things that reduce healthcare spending by about 1% each. The idea is that without all the state legislatures and, you know, veto proof majorities in the House and the Senate, you're going to need to do smaller things that are plausible. And actually, the first one on that list that we already discussed was the out of Network billing legislation in 2020. But there's many more things on there, and I encourage you to read that and to pick your favorite one.

I want to say one other thing on Medicaid expansion that I forgot to mention, which is, even though those studies did not show as much in the early years, if you look a little farther, some amazing researchers wanted to look at mortality. So how do you look at mortality? Because Medicaid affects a very specific population, generally by definition, a low income population, but broadly also a population with less educational attainment. But the mortality data we have at the federal level, you can't just use surveys for mortality. You have to use broad data. That data doesn't have the demographics to look at the right population. And so they got the census to merge mortality data from Social Security with survey data that had education and income. And then they could look at mortality. And they found that mortality from kind of internal causes kind of medically treatable and preventable went down among the 55 to 64 age population that was either low educational attainment or low income. And they actually even did this by by state, and at least the estimate for Kansas, for example, was 72 fewer deaths per year that would have happened from Medicaid expansion.

ROTHSTEIN: Really cool stuff. David. Thank you. Thanks so much. Really appreciate it, hope to talk to you again soon.

SLUSKY: My pleasure.

ANNOUNCER: This podcast has been produced by the Ethics and Public Policy Center in Washington, DC. Visit eppc.org to learn more about our programs events and podcasts.