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Where we share our weekly news debriefs and discussions with industry experts. These are lo-fi recordings aimed at giving our readers more opportunities to engage with our analysis and a view into some of the conversations that shape it.
Martin: So, um, our n- first guest is Dr.
Ezekiel Emanuel.
He needs no introduction, but
it's a great resume so I'll share
a couple quick highlights here
before bringing him forward.
Vice Provost for Global Initiatives and
University Professor at UPenn, Special
Advisor to the Director General of the
WHO, Senior Fellow at the Center for
American Progress, and a member of the
Council on Foreign Relations, Founding
Chair of the Department of Bioethics at
NIH, helped write the Affordable Care Act,
Biden-Harris Transition COVID Advisory
Board, and he recently published a book
called Eat Your Ice Cream, which is
advice that I sincerely take to heart-
including this weekend, uh,
at Red Hen when I told my wife
that it was doctor's orders.
Um-
Zeke: Love that restaurant.
Martin: Yeah.
Uh, we were celebrating my one-year-old's
birthday, and he also- ⦠took
your advice and ate his ice cream.
Zeke: Great.
Martin: Uh, welcome to the show.
Thank you so much for, for being here.
How are you doing today?
Wonderful.
I'm doing great.
Soâ¦
So where we were hoping to start is
you wrote an article a couple weeks
ago, uh, maybe a month ago, in The
Bulwark called What Would You Give Up
to Make American Healthcare Better?
And it was a great piece.
It caused a lot of conversation
in our, our Slack community.
It feels like everyone's had their moment.
You know, pharma, and hospitals,
and insurance companies have all
had their moment in the hot seat
recently in front of Congress and,
and sort of getting admonished.
I'm curious to hear from you if you're
seeing any sort of areas of optimism
or green shoots where you're hearing
any willingness to accept some of
that collective coordinated sacrifice
that you, you outlined in the piece.
Zeke: Not sure I'm seeing that, but
you wouldn't see that until the end.
So what I am seeing is, I think,
uh ⦠Let me back up for a second, okay?
To get real change in a healthcare system,
um, the f- uh, late professor John Kingdon
from the University of Michigan said,
uh, you know, to get major legislation,
and therefore any change, you need
clear public recognition that there's
a problem, you need a vetted policy
alternative that addresses the problem,
and you need a political opportunity.
We have a clear, and I think this is
actually pretty important, we have a
clear recognition there's a problem.
Um, and I think the dimensions of the
problem almost everyone agrees to.
The public is pissed off.
You know, uh, uh, over 60% of the public
thinks we have a, either a crisis or
that the system needs major reform.
You get people, as I quoted in
that article, like Steve Helmsley
of United, uh, saying, "The
system needs to be disrupted."
No one's happy with it, so I think there's
a clear understanding of the problem.
You know, no universal access.
You have, uh, uh, a, a cost that are
just way too high, uneven, uh, and poor
quality in many areas, um, disparities.
Uh, so I think, I think we're,
we're clear on the problem.
I think what we're lacking at the moment
is a clear solution, and I, I go this
long route because I wanna make clear,
you know, you can't just ask the insurance
companies to give up something or the
hospitals to give up something or, um, you
⦠Th- all are gonna have to jump at once.
Everyone's gonna have to give up
something, and in return they're gonna
have to see that they gain something
somewhere else in the system, and that
can only happen if you've got m- multiple
reforms happening at the same time.
And what we lack at the moment,
to go back, i- is we lack a
clear plan that does that.
I, I'm literally, what did I just
stop doing before getting on with you?
I'm working on that plan, and I'm,
I'm trying to think of multiple
ways of getting people on the
same ⦠Or beginning to think
about what the outlines and, and
details of that plan would look like.
Um, but that people are ready for
disruption, uh, that an insurance
company's ready for disruption, um,
that, you know, drug companies are
talking MFN and really beginning to
realize there's gonna be some big change.
I think all of that is, is serious
progress in, you know, more
flexibility and more being open
in the initial reaction to any
ideas that, "No, can't do it."
So.
Martin: It feels like there's always
a lot of special pleading as soon
as you write an article like this.
We had people in our Slack group being
like, "Well, actually, if you wait longer
for surgeries, it'll, like, it increases
costs on here," and this is coming
from, you know, a, an orthopedic doctor.
And yeah, I, I- Attacking.
Yeah.
Kevin: Kevin, uh, I'll
pass it over to you.
Yeah.
Zeke, one of the things Martin and I
banter back and forth on a bit is it
feels like the easy button option is
to say, "Well, can we just increase
spending on healthcare and try to
make things better that way," right?
Like, it's 19, 20% of GDP today.
It, you know, it's always been going up.
Why, why is 19 too high, and what gets
better at 12 versus, you know, 22 or 25?
Like, how do you, how do you think
about that general topic of what is
the right amount of GDP to be spending
on healthcare, and how do we know
when we've gotten to the right answer?
Zeke: Okay.
Uh, lots of answers, or lots
of things that need to be,
uh, put into that calculation.
The first thing I should say
is we all need to be clear, the
more we spend on healthcare, the
less we spend on other things.
It's an opportunity cost.
It's, so getting to 22 or 25% of GDP
on healthcare is an opportunity cost
that we can't spend on education,
we can't spend on environment,
we can't spend on long-term care,
which is separate from healthcare.
Um, we can't spend on,
uh, military defense.
So there's this big opportunity
cost, and we shouldn't hide that.
The second thing is, how would
you think about what's the right,
quote unquote, right number?
Well, you guys are well aware
because you're health nerds that
there is this graph where the X
axis is how much you spend per
capita on healthcare, and the Yâ¦
I mean, that's the Y axis.
Mm-hmm.
The X axis is GDP per person, and it's
a pretty s- it's a pretty straight line,
slight upward curve as the richer you
get, the more you spend on healthcare.
And almost all the countries
fit pretty closely to that line.
The R squared is, uh, over .8.
Um, so my argument to everyone who
says, "What's the right number?"
I said, "You know, you have to give
me a good reason we're not on the line
or pretty damn close to that line."
We are, you know, over a trillion
dollars, I think, uh, over 1.5
trillion, 1.25
trillion, uh, last I
looked, over that line.
To give you round numbers, it's about
$5,000 per person between, depending
on how you calculate it, between 3,500
and $5,000 per person off the line.
Um, higher than Germany, which
is the next highest country,
uh, higher than Switzerland.
Um, so that's what I would say.
We don't need more money, okay?
We simply don't need more money, and I
think that's a pretty definitive, uh,
comment, and I'm willing to defend it.
Um, you know, Germany, Switzerland,
Netherlands, Norway all have universal
coverage, all have, uh, pretty high
quality care, certainly comparable
to the United States, um, and spends
considerably less than we do, okay?
So we don't even get universal coverage,
and we have quality that's no better.
I mean, in some areas it'll be better.
Many areas, like infant mortality
or hypertension control, it's worse.
Um, so you would have to tell me why
we can't cut $3,500, forget adding
money, to where we're spending now.
That would be my main argument.
And I think our target should be
we're staying exactly at 18% of
GDP, and it should go down, be able
to go down to something like 15%.
Is the problem money?
No.
The problem is how we organize the system,
and that's where the reform has to be.
Martin: Can you give us a bit of a
preview on what your, like, top, you know-
as, as you're, you're
penciling in this plan.
Like, it, it seems to me like, you
know, you're author of the ACA.
Uh, uh, you helped, you're
instrumental in writing it.
We, we, we did this exercise back
then, and we had every- we asked
everyone to sort of give, give up
some stuff, and it made everyone
really angry, and the president lost
a bunch of seats in- Oh, wait, wait,
Zeke: wait, wait, wait, wait, Martin.
Let me- Let me, let me take issue.
It made a segment of the population
angry, the Tea Party, and it wasn't
what we were asking them to give up so
much as what we were making them do,
which was you gotta have insurance,
and you have to have insurance that
meets a certain minimum requirement.
And why do you wanna
have that requirement?
Because otherwise you're a free rider.
Let's just be serious.
Everyone, unless you die as
a hermit in Alaska, everyone
will use the healthcare system.
It's virtually impossible, frankly, to
die in America, even acutely, without
using the healthcare system and spending
a whole lot of money doing that.
Um, and so, you know, if you say, "I don't
want insurance," or a young man says,
"Look, I, I, I'm not gonna have a baby,
why should I pay for maternity care?"
No, this is, like, nonsense.
You will use the system.
You may not plan to, it comes out
of the blue, or you plan to and
you have a chronic di- whatever
it is, or you father a child.
Whatever it is, you use
the healthcare system.
And the Tea Party objected to the
government saying you have to have
insurance be- but we guarantee
that you can get emergency care.
Why should we not say you have to
contribute to a system that's ready
to take you for emergency care?
That, I think, was the s-
the sum total of the problem.
What we've seen Since then is, um, that,
uh, everyone, including Republicans,
think that healthcare is a right.
How can I firmly say that?
First of all, support for the ACA
after 2018 went up and has stayed up.
It's now over 60% of the population.
That's the first point.
The second point is every time expansion
of Medicaid has been on a state ballot
in a red state, every time it has passed.
Um, Florida, y- you wanna say, "Oh,
it didn't pass because it didn't
get the two-thirds necessary to
actually implement it," but it got
a majority of people in Florida.
But Iowa, I mean, not Iowa, Idaho,
Utah, Missouri, um, lots of other state,
North Carolina, uh, uh, the legislature
eventually caved and, and adopted it.
Lots of states, the populace
has said, "We want that."
So I think that tells you there's a
recognition healthcare is a right,
universal coverage is the right way to go.
Um, so the question is how.
I will ⦠Maybe I'll
answer that question now.
So, um, I don't, I'm working on the
full-blown thing, but I've written
in Bulwark, um, look, getting
healthcare is too complicated.
Um, we have literally, um, hundreds
of thousand ⦠We have thousands
of insurance companies and hundreds
of thousands of different offerings.
We have to radically simplify.
So my proposal is- People who
get employer-sponsored insurance,
like myself, you stay there and
the employers figure it out.
Everyone else, Medicare, Medicaid,
the exchange, the uninsured, vets,
Indian Health Service, just everyone
else, that's 175 million Americans,
go into a separate exchange.
That separate exchange, the, I call it the
American Exchange, uh, limited choices.
We know too many choices, you guys
are experts in behavioral economics.
Too many choices paralyze people, and
they make bad choices where they're paying
too much for the product they're getting.
Limited choices of six options,
where one of the options is
a modernized Medicare option.
So people on the left who want a
Medicare buy-in or a public option,
they get that public option.
Other people who don't want a public
option, want private insurance,
can get private insurance.
But then you also have to
standardize across them.
The same benefits, the
same, uh, uh, out-of-pocket
co-pays and things like that.
The same payment for surgical and other
procedures, so you can have bundled
payments and drive more efficiency.
You need toâ¦
A lot more standardization.
One of the things that we're reas- One
of the reasons we're paying 18% of GDP
and others aren't, is we don't have
standardization, which dramatically
increases administrative costs.
The last element that I would add
to that is, um, uh, not one year
annual re-enrollment contracts.
That is a terrible idea.
First of all, most people think it's
onerous and just a distraction, and
second of all, it leads to lots of
churn, and churn is bad for, uh,
persuading insurers to do long-term
investments in prevention, in chronic
disease management, and other things.
So those are the elements of it.
One exchange, limited number of
choices, standardization of choices,
and I should also say, um, constrain
the, uh, uh, payment of deductibles
and co-pays no more than 2%.
This idea that you're, got high deductible
where you're paying 5, $7,000 before
insurance kicks in, that's not insurance.
That isn't.
Um, so those are the kind of elements
I would have, uh, in a reform system.
Kevin: Zeke, I'm curious to bridge, you
talked earlier in this conversation about
you need the problem clearly identified.
We've got that.
You need the solution.
Sounds like you're working
on an option for that.
I was reading an article over the
weekend about a, a gentleman who may
or may not share the same last name
as you, who was biking across New
Hampshire, uh, potentially to, to show
that he is physically fit enough for
a, a run for a certain office in 2028.
Do you- Actually, I don't think
Zeke: that'sâ¦
I don't actually think
that's why he's doing that.
I, I mean, I think people just
screwed up the psychology.
Kevin: Fair enough.
Um, that was the Wall Street
Journal's take, I think- Yeah, I
know, I know ⦠on, on the scenario.
Um, I, I think- If
Zeke: you have any doubts, I can assure
you, having ridden with him and run
with him and horsed around with him,
he's plenty fit and plenty there.
For sure.
Kevin: Um- I, I'd be curious how you
think about the 2028 presidential
campaign and, and the moment.
It, it feels like we are, we are
building up to a ACA-like moment in
time for another really meaningful
policy shift in this country.
And if you were advising a presidential
candidate, somebody thinking about what
that election looks like, how big do
you think this topic's going to be?
How do you think this, this
builds up to that conversation?
Zeke: You've anticipated exactly my
thinking about it, which is, look, I don't
know if it's 2028, and the main reason I
don't know, while I think the pressure is
gonna build up, I don't know whether it's,
you know, healthcare's gonna be t- one
of the top two issues, which it has to be
if you're gonna embark on a big reform,
or whether we're gonna have to wait till
2032 where multiple other things are
gonna happen, including we're gonna be,
you know, looking down at the, uh, trust,
the Medicare trust fund being bankrupt.
My suspicion it's a little later
for that reason, and the second
reason, uh, well, three reasons.
The second reason being that,
um, affordability of everything
else, uh, food, energy,
housing, is gonna dominate 2028.
Um, and so I think it, it, while
healthcare's part of that, you know,
the public says they're worried about
healthcare, I suspect the worries of
other things, just getting f- literally
getting food on the tables might dominate.
And then the, the last thing is what
I mentioned at the start, which is we
don't have a plan that enough of the
health policy experts have agreed on that
politicians can then adopt and adapt.
And, um, I, so I think in
the absence of that policyâ¦
Now, maybe we will over the next two
years get a policy that, you know,
my policy or some other policy that
people will agree on, but I suspect
we're gonna need a little more debate.
And that suspicion is because, you
know, I, I think people forget,
um, uh, to get to Medicare, what
Medicare was first proposed in 1957
and adopted in, uh, 1965, okay?
Hmm.
That gives you the, that's a sort
of eight-year window that it took.
Um, now it could have
been adopted in 1960.
There, you know, um, uh, there were
some debates that actually came to a
vote and, and didn't pass the Senate.
I think, uh, similarly, you know, it was
2005 when Romney- uh, care, uh, came in,
uh, 2009, '10 when the ACA was passed.
That's a five-year win- I think
you need those kind of windows.
Anyway, that's my, you know, suspicion.
Once you have a plan or the outlines
of a plan, you still, you know, you
need to begin vetting it, having the
country debate it, and things like that.
Yep.
So.
But I think you're right.
I think the pressure's gonna
build and people areâ¦
I mean, it's amazing.
People are pissed off.
And when we did the ACA, it was,
you know, the middle class, the
upper middle class was still pretty
confident in their sy- their plans.
Now they are pissed.
I was just at a friend's house
and he's like, "You know, these GI
doctors, all they wanna do is scope me.
They don't wanna talk to me
about, you know, my problem."
And it's like, uh, and
th- they're, you knowâ¦
A- and by the way, it took four
months for me to get a scoping date
because they're scoping everyone.
Mm-hmm.
And so he, you know, this is a
guy who's got plenty of resources.
Um, so it, it, I think that kind
of anger at the system is now
infiltrated the upper middle class.
And when that happens, then,
then there's a lot of pressure on
elected officials to do something.
Martin: We are at time,
and so I'm- Oh, what?
Are you kidding?
If you have a couple more minutes, we
would love- I have a couple more minutes.
Great.
So you, we've been talking a lot
about AI recently in the HTN Slack,
and just generally, obviously,
you, you, you can't go two feet
without running into an, an AI.
You wrote a JAMA article, co-authored
a JAMA article with this framework.
I'm curious, where are we at in terms
of this being a technical problem that
we need to solve versus this being an
adoption problem in terms of, like,
what's your, what's your view on w-
where the, the clinical AI is at at this
Zeke: moment?
I, I, I think it's both.
It, it's not so much technical.
We, what we need is to get a lot of the
models that have, you know, there's a lot
of work been done i- into more real-life
clinical scenarios where we're not testing
them on patient actors or by, via, uh, a
text chat box, but where you're actually
got a voice and people are interacting
with it, and they're also interacting
with, uh, the messiness of the real world.
Now, some of the bots have
been tested in that scenario.
Um, more need to be tested,
and they obviously tested.
They need to be tested in a supervised
sense that there's someone overseeing when
they're interacting with real patients.
I th- and, and they are gonna
be constantly improving.
It's not like this is a plateau.
Um, I think by 2030 you're gonna have
plenty of, uh, of AI, clinical AI
that really can diagnose patients,
establish a differential, order tests,
diagnose patients, and establish a
guideline concordant care pathway,
and even autonomously manage patients.
S- uh, um, I, and then you are
gonna have this regulatory issue of
what, mainly what's the liability,
but also what's the compensation.
I think once we have some of those,
um, AI tools, you're gonna have aâ¦
Actually, that's gonna, in my opinion,
be a big push towards getting more
value-based payment because you don't
want someone to ka-ching, ka-ching,
ka-ching for every time AI's involved.
That would just drive
costs through the ceiling.
On the other hand, if, uh, healthcare
providers have an incentive to implement,
uh, AI because it'll drive costs down,
I think that would be, uh, the right
way, uh, to get it really adopted
because then, then the providers, the
doctors and hospitals see it in their
interest to actually implement it.
So I think that's, that's
the way we're going, frankly.
Kevin: Zeke, I'd be curious,
healthcare seems toâ¦
I, I hear this, this talk track
from CMS leadership currently.
Healthcare has a tendency to incentivize
the adoption of new technologies that
ends up driving up costs rather than
driving them down over, over time.
I'd be curious how you think about
that from a policy perspective,
perhaps in what you're thinking about,
um, uh, in the, in the years ahead.
But how do you- W- w- what's your
thought on how we actually make sure
AI is deflationary versus continuing,
um, the historical trend of inflating
costs with new technologies?
Zeke: Again, I think so as I said,
I think you have to give it to the
providers to use and not have a fee
for service arrangement under, or that
reimburses for the implementation of AI.
I think that's absolutely critical if
you're gonna make sure it doesn't explode.
And similarly, on the administrative
side, you know, you can't have the
providers just adding more codes and
the insurers just doing more denials
and, and, and, and a race there.
That's one of the advantages, in my
humble opinion, of moving towards more
value-based payment, but also, um,
uh, standardizing a lot of the bills,
reducing the number of codes you can
use so a lot of this gaming goes away.
So that, that's the way I would
see it as, as really important.
Martin: I think where I wanna end is,
so I mentioned earlier, but you wrote
a book called Eat Your Ice Cream.
Yes.
We're in this weird cultural moment
where the very affluent are spending
lots of money on research chemical
peptides- ⦠stack transfusion stuff.
And I'm curious what you make of
this, you know, sort of moment
where people are, there's vaccine
hesitancy, but then there's also people
injecting themselves with Chinese
research chemicals, and then- Yeah
you know, you come out with this
book saying basically like, "Don't
do stupid stuff," and, uh- ⦠don't,
you know, and, and you can live
a long, health, uh, healthy life.
Zeke: Uh, well, of
course, I think I'm right.
Um, uh, but I do, it, so, you know,
there's a long historical tradition about
focus on wellness, and it's not constant.
Uh, between about 1880 and 1914, the
start of World War I, there was a big
burst of interest in, uh, wellness, um,
and much the same vaccine hesitancy.
Then it was about smallpox vaccines.
There was a big interest
in vegetarianism then.
There was a big interest
in exercise back then.
Spas like Baden-Baden in Germany and,
uh, Saratoga Springs in the United
States, uh, uh, flourished at that time.
It's almost identical to the
current moment- Mm ⦠um, in
terms of wellness interest.
My hyp- underlying hypothesis, a lot
of this is driven by, um, uh, you
know, the fact that the world seems
like it's spinning out of control.
You know, you've got, then in 1880s,
you had an industrial revolution.
Now we have AI.
Uh, you have people
worried about the future.
We had a lot of immigration then.
We have a lot of immigration now.
Similar moment.
You also had income inequality,
and people wanna hold onto
something they can control.
And it turns out wellness is, you
know, I can control what I eat, I
can control my exercise, et cetera.
Um, and, you know, damn the
state if they're gonna tell me
what vaccines I need to take.
Um, uh, so I think that's a large
part of what's driving this.
Um, by the way, you can also
find way back then in 1909,
I've got a quote out of the St.
Louis Post-Dispatch, "Researcher says
that with scientific advances, humans
are gonna be able to live to 150 years."
Could have been written yesterday.
Um, so I think, I think that's actually
what's going on, and I think, you
know, this idea that we're gonna
live ever longer is a delusion of
people like Bryan Johnson and others.
Why do I say that?
You know, we've got more people living
into their 90s than ever before.
We've got more centenarians
than ever before.
But it turns out the top 120,
roughly, um, hasn't budged.
You haven't had people living to 130.
You think you would get that
sport of nature, just the, uh,
odd person who can get there.
Hasn't changed.
Um, a- as Jay Olshansky out of, uh,
University of Illinois in Chicago says,
and I think quite persuasively, um, w-
we may get more people into their 90s
and 100s, but we're not gonna get past
that, and I think that's pretty true.
And I would just note that, um, recently,
unfortunately, uh, Craig Venter, who, uh,
helped, uh, sequence the genome, um, and
was a big believer in, like, whole, you
know, sequence your genome, whole body
MRIs, and all of these tests, um, died at
79 of a complication of treating cancer.
He didn't detectâ¦
Or maybe he did detect his cancer.
I don't know the ins and outs of it.
But he, he couldn't prevent his cancer,
and he couldn't prevent an unfortunate
outcome of the treatment of his cancer.
So, you know- Yeah ⦠all these guys
who are sure in their 40s and 50s
they're gonna live to 150, um, I've
already made a bet with Bryan Johnson
it ain't gonna happen, uh, for him, so.
Martin: Will be interesting
to follow up with that.
And thank you so much for your time today.
This was, was really great.
I lo- I love
Zeke: interviewing with you guys.
Martin: Yeah.
We'll have you back- This was fun.
We'll do it again ⦠a- anytime you want.
Anytime you want, uh, we'd love to chat
about your policy plan and ice cream.
Great.
Have a great rest of your day.
Take care, guys.
See you, guys.
Nice chatting.
Bye.