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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Welcome to a special Health Affairs podcast episode. My name is Lauren Adler, and I'm thrilled to bring you a conversation with Elizabeth Popberman. Beth is one of the authors behind a new article series from Health Affairs Scholar, co produced by the Health and Political Economy Project and sponsored by the Commonwealth Fund. This series dives into what a quote unquote political economy approach to health could really look like, especially at a time when our nation faces huge health challenges, from rising health care costs for patients to unaddressed social factors and stagnant and unequal life expectancy. The authors in this series describe some potential responses, covering ideas from social insurance to greater public provision of health care services to a focus on frontline care workers.
Loren Adler:Check the show notes for a link to the series at Health Affairs Scholar. Our guest, Elizabeth Pop Berman, comes from the University of Michigan and is the author of the book Thinking Like an Economist: How Efficiency Replaced Equality in US Public Policy. Pop Berman wrote an article for the series titled Advancing a Political Economy Approach to Using Lessons from US Antitrust and Climate Policy. We'll talk about that and more. Beth, welcome to the show.
Elizabeth Popp-Berman:Thanks, Lauren. It's great to be here with you.
Loren Adler:To start off, before we dive into the article itself, what is a political economy approach to health? And how do you think this is different from, you know, what we might think of as the standard approach to health care policy or the economic style of reasoning you describe in your book?
Elizabeth Popp-Berman:Yeah. I mean, so when I think about what a political economy approach to health is, right, I think of an approach that takes a pretty broad lens to what health means and that kinda centers power and politics and economics and thinking about the conditions that that enable or that shape health. Know, so that means not only having affordable access to to medical care, but people have the economic security that allows them to, pursue the kinds of behaviors that enable health. Right? Do they have a physical environment that promotes health?
Elizabeth Popp-Berman:Do they have chronic stressors in their life? Like, racism, we know has a has an ongoing income, ongoing effect on health. And and I think more generally, just, do we have a health care system that prioritizes profits at the expense of more human centered care? And so I think this is a pretty hard shift to make because we do have an orientation, especially in policy conversations, really towards thinking about, how do we get people access to affordable health care, which is obviously super important, but that that's kind of the main lever that we think about, through which people through which we try to improve people's health. And so it's sort of partly about zooming out from that.
Elizabeth Popp-Berman:The way I'm thinking about this more generally, does grow out of of, this book that I wrote a couple years ago, thinking like an economist, which talks about the rise of of what I call an economic style of reasoning about policy making. And so this is something it's historical, kind of focuses on change from the nineteen sixties to the nineteen eighties, and it covers, multiple policy domains. So it covers health. It covers antitrust. It covers environmental policy.
Elizabeth Popp-Berman:And so, really, the book argues that over the period of a couple decades, really, you kind of have an advance of of of a new way of thinking about policy problems that really understands good policy to be policy that's either efficient or it's cost effective, and that kind of understands the role of government as being a way to make markets work better. And so what that meant in a space like health is that you get kind of this shift from thinking about broad potentially universal programs. So conversations about Medicare that you were having in the nineteen sixties or in the nineteen seventies, conversations about universal health insurance, which were happening even under the Nixon administration, and towards a focus on expanding access cost effectively, right, and leveraging market mechanisms. And so that's kind of an approach to the health policy space that by the nineteen eighties becomes dominant. And then you can kind of see really, I mean, really up to the present, but certainly through the Clinton health reform efforts, through, the Obama administration and the Affordable Care Act.
Elizabeth Popp-Berman:And, you know, and it continues to some extent to the the present. And so really, the thing that I'm trying to say here is that in some of the other policy areas that I look like look at, like antitrust and environmental policy, you see a shift towards taking a little bit of a broader lens on the policy domain and thinking a little more broadly about solutions. We don't see the same kind of, shift in health policy, at least not to the same extent. And so what this article is doing is partly exploring some of that variation across those spaces and thinking about, what we can learn from it.
Loren Adler:You know, I don't think anyone would argue that there are policies outside of the the sort of pure health care coverage landscape that would affect people's healthcare. And certainly there's a lot of focus on prevention and the sort of other policies that affect health. But you brought up antitrust and climate policy, and that's where a big focus of your article here is talking about the sort of major shifts in those two arenas that happened over the last decade. And that might be helpful if you could walk us through those changes and explain why they matter.
Elizabeth Popp-Berman:I think in those policy spaces, see in that in the in that longer historical period, you do see kind of a rise of, broadly speaking, economic reasoning about the policy domain in the in over the same time period. Right? So that in antitrust starting in the nineteen seventies, you have a consumer welfare framing for thinking about antitrust becomes really central. When people really start to understand the purpose of antitrust as as being primarily and really only about, you know, are we keeping prices sufficiently low for consumers? You know?
Elizabeth Popp-Berman:Do producers have the capacity to raise prices above a competitive level? And so that's, you know, one important issue, but kind of excludes a lot of things that were historically part of the antitrust conversation. So, you know, questions about other ways that corporate consolidation might lead to concentrated power or downstream effects of of consolidation, like impacts on of small business loss on communities and things like that. What happens though is that by the twenty tens, I think you're getting a lot of questions about the limitations of that approach. And so I think you've got the rise of, platforms.
Elizabeth Popp-Berman:You've got, you know, Amazon, Facebook, Google. If you think, oh, if Amazon controls 40% of all sales that are happening online and it's got all this information about sellers who use its platform, right, but it's also competing them, then what does that mean about competition? Right? You've got questions about, what's the role of platforms like Facebook in conveying political speech. And if and if these platforms are really important for political conversations, but the the algorithms are shaping what people see, you know, how do we how do we think about that as a new kind of problem?
Elizabeth Popp-Berman:And then I think there's evidence in other spaces. Like, for example, there's a growing body of evidence that that concentration is also having an effect on wages. Right? That that there's less competition for employees. And so concentration's potentially keeping wages down as a in in addition to potentially having an effect on prices.
Elizabeth Popp-Berman:And so, you know, so there's kind of this accumulation of of new kinds of questions. And in reaction to this, you get this new Brandeis movement that is kind of political economy centered, it takes this more expansive view of how should we think about competition, how do we think about ensuring that markets are working well. Is it more than just focusing on consumer prices? At the outset, you know, when this when this conversation is starting to take off, it seems pretty marginal to the mainstream of antitrust debate. And so, you know, 2015, '20 '16, you're starting to see articles about this, and there's a lot of pushback.
Elizabeth Popp-Berman:It's kinda seen as beyond the pale, and it doesn't really feel like a perspective that is going to have a big impact. But it does not take that many years. It's it's by 2020 that when, Biden is elected, and is starting to look for a different approach to some kinds of problems. You see him, do things like appoint Lena Khan to lead the FTC. All of a sudden, this approach that had been quite marginal becomes, you know, effect a de facto, the main approach that the White House is taking.
Elizabeth Popp-Berman:You have this kind of shift in in antitrust policy. You have really sort of a parallel shift in in climate change with a shift from thinking about cap and trade as kind of the only viable approach to policy change to saying, okay. Well, if we can't achieve that politically, what are the other options? You know, which which ultimately leads to the embrace of of industrial policy under the Biden administration. And these are pretty significant shifts in how people think about those spaces.
Elizabeth Popp-Berman:So in both of those areas, you have what start out as pretty as changes that seem like they're pretty much outside the mainstream that within a few years end up, becoming much more part of the ordinary policy mix within Washington.
Loren Adler:I think that just leads to the natural question of what changed, right? What is it? What are the factors that sort of helped drive these shifts? Mean, antitrust shift, agree, felt pretty sudden almost in how quickly it bubbled up. The climate one feels a little different in some ways and that you're still sort of dealing with the relative prices of clean energy versus not as clean energy.
Loren Adler:It's now just through just focused on dropping the prices of clean energy through this sort of inflation and reduction act approach here. But, you know, I'm curious, you know, having studied this, you know, what what what are the sort of the main factors here that you think kind of drove the these these pretty sudden shifts?
Elizabeth Popp-Berman:Yeah. And I think, you know, just to, like, pick up on your on your climate point too. Right? I think, I mean, I think you're right that fundamentally, you know, the fundamentally, the broad approach is still, okay. We're gonna think about how do we how do we how do we change the relative cost of these different forms of energy.
Elizabeth Popp-Berman:Right? And so it's sort of rethinking, that kind of piece. But I think the one piece that maybe is that is actually different that sort of part of new political alliances that emerged is that, you know, environmental justice conversations were really sort of embedded into policy making as well. And so there was also, a very, explicit acknowledgment that, you know, climate impacts are more likely to follow marginalized communities, that that that's something that we need to address directly. And so, you know, so I do think you're right that maybe the shift was a little more abrupt in in antitrust policy, but, I do think you see it in both in both areas.
Elizabeth Popp-Berman:As to as to why this happened, in both cases, in many ways, it's the product of a lot of political organizing and sort of coalition building that happens while people are not in positions of influence. That happens in sort of different spaces in the two policy areas. In antitrust, a lot of that organizing is happening in these relatively, elite policy domains. So you see think tanks like open markets, and you see spaces like Yale has this law and political economy project that was that was doing a lot of academic work around antitrust. And so it's this relatively intellectual elite sort of organizing that is kind of trying to shift the conversation.
Elizabeth Popp-Berman:In in climate, it's a lot more grassroots. You know, a big sort of landmark moment in climate policy was the failure in 2010 to pass Waxman Markey, which would have been the big cap and trade bill. That was a moment that also fractured the environmental movement, in part around the issue of environmental justice because it was sort of excluded from the cap and trade stuff. And so over the course of the twenty tens, you have a lot of those grassroots, more youth based, more environmental justice leaning organizations starting to organize by the later part of the decade. It's this sort of bottom up kinda organizing that starts to bring some alternatives onto the table.
Elizabeth Popp-Berman:There are things that, you know, beyond just sort of this general idea of organizing advance, there's some other things that the spaces share. One is that, you know, both of these movements were pretty good at linking their issues to concerns that are sort of broadly resonant to the American public. Right? Things that are resonant throughout American history. And so in antitrust, you've got sort of like a fear of concentrated power.
Elizabeth Popp-Berman:Right? Which is sort of an theme that that has a long historical past to it. And you've got arguments about the the fairness of the playing field. In climate, the the key thing is connecting the idea of climate policy to jobs, right, which had not really been the case in the past. And so industrial policy becomes a way not only to reduce carbon emissions, but to create good green jobs, and that's super important.
Elizabeth Popp-Berman:And so I think in both of these spaces, people are really effective at building what the political scientists call issue networks around their issues that sort of cross different sorts of organizations that brought different constituencies together and that put people in a good position to when the politics, change to be able to advocate for change. And the one last thing I'll mention is that I think another, factor that was critical for both of these was they both, had a really visible youth aspect to them.
Loren Adler:I mean, the antitrust world sort of bleeds a little bit into health care policy. Obviously, some of the antitrust, action was focused on health care. Obviously, I'm a little biased by my own research sort of touching on that intersection here. But I think this leads to of the two real natural questions here. One is sort of, why haven't we seen similar transformative changes in health care?
Loren Adler:And then, you know, what are how do you adapt these lessons from climate and antitrust policy? And how do you funnel those into health care? You know, certainly, there are plenty of plenty of similarities.
Elizabeth Popp-Berman:I mean, I think I I think there is sort of one big difference in the policy spaces that is is is is one reason you don't see the same kind of change. And I think that is really the success of the Affordable Care Act because I think in both antitrust and climate policy, you had kind of a long buildup of increasing concerns that don't really resolve themselves. You know, in antitrust, you kinda have this fifty year old paradigm, new issues are emerging, you know, you get sort of growing number of news stories or whatever about it, but nothing nothing really major has has changed. And so there hasn't really been any any resolution to these building concerns. In climate, I mentioned wax and marquis, and that was a real moment of hope for the environmental movement during the Obama administration.
Elizabeth Popp-Berman:And then when it failed, people were just sort of crushed and wondered, you know, is this the wrong strategy? How do we rebuild this? You know, where do we go from here? And so there was this real period of of soul searching. But by contrast, I think in in health policy, you have the Affordable Care Act passed in 2010, and that's quite successful.
Elizabeth Popp-Berman:But one thing it does over the next decade is that health policy conversation is pretty heavily oriented towards thinking about the Affordable Care Act. You know, it's either defending it or it's challenging it or it's it's trying to expand it, but, you know, that becomes a very, core focal point in health policy in a way that doesn't open itself up to, sort of broader questions about, well, are there things are there more fundamental changes that we want to be, thinking about? You you you do see one movement that is somewhat aligned with health policy, which is that kinda mid twenty tens, you start to see some conversation about the care economy. And this is sort of initially coming from the space of people who are, really focused on childcare and early childhood education and who are interested in kind of organizing, workers in that space for better conditions, but kinda gradually opens up to consider a lot of different kinds of care and starts to incorporate some health policy concerns into that. So that's maybe something that, we can come back to, but I think it's sort of the closest thing to a movement that is analogous that is really, near the health care space.
Elizabeth Popp-Berman:But I guess then second part of your question was, what the lessons are for how we might think about house policy.
Loren Adler:Yeah. And right. I think just to build on that. Right? I think I mean, you make a good point.
Loren Adler:Right? Had cap and trade passed, you probably would not have seen the sort of big push towards the sort of industrial policy approach. That also tees up both the Affordable Care Act and cap and trade policy, both were trying to improve their domain, but had created both winners and losers. I think part of the industrial policy approach on climate and part of that was let's create fewer losers and let's just sort of make it all about let's just throw money at things and make it so it's predominantly winners in this situation. I'm sort of curious, I mean, both broadly, how these lessons might be adapted towards health policy.
Loren Adler:And do you think there's something to that approach to health policy where, you know, using less trade offs and using money to kinda primarily create winners?
Elizabeth Popp-Berman:Right. So I mean so maybe so maybe there's sort of two ways you can think about what the what the potential lessons are. Right? I mean and I think in one is just sort of how do you think about the kinds of actions that people took in these other spaces that sort of built the momentum for for having sort of the people and the energy in place to try to motivate these kinds of changes once the political environment was right for them. You know, in that vein, you've got the question of, like, how do you think about building issue networks that are gonna help you advance the kinds of approach to the policy domain that you want?
Elizabeth Popp-Berman:These issue networks that were built during this time when they really did not seem particularly likely to be effective end up being quite important down the road. And so, you know, 2016, '20 '18, even though, you know, whenever AOC came out and started talking about a green new deal and it got some press, it did not really seem like we were in the moment when there was gonna be, some kind of major environmental legislation in the next few years. I think another lesson is thinking about how to build networks across different kinds of policy spaces and really thinking about how issue networks can align, the interests of different groups. The climate movement, one way that they they did that effectively was sort of by figuring out how to realign kind of the more traditional climate groups with these younger, more environmental justice focused groups so that they could bring different sets of political actors to bear when they're actually trying to accomplish policy. I mean, I do think that's a space where it's worth thinking about how these kinds of care economy movements that, again, have been based more on the childcare, early childhood education spaces, but they obviously have a lot of affinities with health care.
Elizabeth Popp-Berman:And that I think those kinds of frames have the opportunity to bring in people who are interested in advancing the interests of particular professional groups. Right? So physicians or or nurses. You know, in terms of thinking about, you know, can are there ways to align interest by basically creating incentives for everybody? I mean, I do think, yes, of course, that that is always one strategy.
Elizabeth Popp-Berman:But there's always a question too of do you actually you know, if if part of the motivation for doing something like the inflation reduction act was to create policy change that was gonna be really durable by kinda giving new people interest in maintaining it. Yeah. I think it also raises some questions of of is it actually gonna look like that in the end? Is that actually where we are in terms of is it gonna be as resilient as people hoped it would?
Loren Adler:That makes a lot of sense. Right? And you do see some of this in health care, the long term care arena. Obviously, you know, the workers and the home health aides, have gained a lot of, attention there. In the antitrust space, you know, particularly under Lina Khan's FTC, there was a sort of renewed focus on the effects on doctors or nurses of the sort of financialization of healthcare.
Loren Adler:And there's evidence that hospital consolidation can suppress nurse wages, for instance, so sort of go into this sort of broader arguments here. You know, I think before kind of coming back to sort of how lasting these are, your article also kind of focuses more broadly on the sort of corporate consolidation and financialization of health care. You know, do you think there are ways that this political economy approach that helps address those specific issues?
Elizabeth Popp-Berman:I think there's definitely spaces where even, you know, a fairly traditional approach to antitrust has a lot of of of potential to hit on some of these issues. Right? I mean, like you mentioned, we've got increasing evidence that hospital mergers and certain other kinds of consolidations are driving prices up. They're potentially affecting wages. You know, there's some evidence about their their impact on health.
Elizabeth Popp-Berman:And those seem like places where, you know, a fairly standard approach to antitrust enforcement that's maybe aggressive, but not especially novel could do quite a bit. But I think there's other places where, you know, we have broader economic issues that are gonna be hard to address. And I don't know, you know, I I don't know what the what the policy solution is to this, but we've, you know, we've kinda developed this system that is extremely complicated, very, you know, complex mix of public and private actors. We've got a lot of people who are very sophisticated in their ability to figure out the maximum way to to profit in this market that's just inherently you know, it's got a lot of agency problems. It's got a lot of information problems.
Elizabeth Popp-Berman:And so, you know, what do you what do you do about that given the size of government as as a buyer in the health care market? There's a lot more that we can do to think about how to ensure the prices are reasonable. And, honestly, you know, I think we need other ways to think about evaluating what fair prices look like in health care markets because I think it is pretty clear that as the market's currently functioning, you know, prices are really sort of the the competitive mechanisms that you would like to see keeping prices down are not really proving very effective.
Loren Adler:That seems like a light statement, given how health care works. You kind of teed this up a little bit, but even more broadly, you know, we're obviously in a political climate right now where this sort of care economy or the change you're describing doesn't seem terribly likely in the next few years. And sort of, you know, does that change how you're thinking about these issues at all?
Elizabeth Popp-Berman:Yeah. I mean, I think it does. I mean, obviously, on the one hand, like yes. I mean, with the exception of possibly, you know, antitrust again, kind of bumping up against the health care space as being a a spot where where it's a little bit more open yet as to what exactly the policy approach is gonna look like. But, you know, most of these changes are not gonna be things that are that are on the table in the next few years.
Elizabeth Popp-Berman:Looking back at what the lead up to change was during the Biden administration, I do think it's important to remember that things can change pretty quickly politically, that organizing, that sort of, laying the groundwork that's happening now is still really worth doing even if it takes a while to have a payoff. I also think the other thing that's that's useful to think about is that, you know, crises are often opportunities as well. And so if it seems like we're in a moment where where there's sort of threats to parts of social policy that are providing access to people or where there seems like things are really under attack, you know, that's also a time when people are sometimes willing to step back and say, wait. Maybe we need to think bigger about this. Maybe we need to think differently about this.
Elizabeth Popp-Berman:You know, that can actually be helpful in kind of broadening the scope of debate. You know, I think the main consideration that I have that's sort of a a new thing is that it does seem possible that, that the Trump administration may be successful at hollowing out some of our our state capacity. Right? So we just don't have the administrative ability to administer some kind of complex new program. And so I do think it makes sense as we think about, moving forward that perhaps it makes sense to consider simple programs over more complex programs that we really, need to recognize the administrative capacity may be a real issue even if the political climate changes in the future.
Loren Adler:The administrative capacity question is somewhat new this time around, right, the sort of large scale firings of federal workers. And, you know, there's plausible cuts to Medicaid, state Medicaid programs that are on the table right now, which sort of can touch on state capacity here. That sort of maybe the Medicaid discussion here maybe touches on a little bit of a question you alluded to earlier, which is, you know, yes, we had these changes in climate policy and antitrust, and we're talking about these potential changes in health care. But, you know, even if you are successful, how lasting are these changes? Right?
Loren Adler:The Affordable Care Act had many near death experiences. It has survived, but that does not have to be how it ended up. You know, the Medicaid expansion is still under, you know, still under debate and may get may get drawn back and hasn't happened in Florida or Texas. You know, the inflation reduction act, clean energy subsidies are certainly on the table for the reconciliation package this year. An antitrust, I assume, can basically change on a whim depending on the administration.
Loren Adler:So I'm kinda curious how you think about how lasting these changes are. And, right, is there anything you think that can be done to make changes more lasting?
Elizabeth Popp-Berman:Think to one extent, right, some some policy areas are much easier to reverse under a new administration than others. So anything like antitrust, that's mostly the changes happening. In the executive branch, obviously, you change administrations, you change priorities, and you can take things in in quite a different direction. I think even something like the inflation reduction act, well, I mean, to to some extent, I think the, jury is still out there. Right?
Elizabeth Popp-Berman:Obviously, it created a lot of new economic interests in, renewable energy that weren't there before and that potentially, may result in pressures not to, repeal it from people who otherwise might be supportive of that. However, will that be enough to prevent parts of it from being repealed? You know, we will still I think we have to we have to see. I think, you know, the way to think of this, one, it's a it's a, you know, it's a long term project. It's not it's not a short term.
Elizabeth Popp-Berman:So anything you do, I think, is subject to reversal. So one question is, you know, how do you build both the politics and the sort of broader, motivation for for, carrying a particular agenda forward even though, of course, you know, the short term politics of it are gonna go go back and forth, and you might make a change in one, administration only to see it step back later. I mean, and maybe that's, you know, kind of a good note to bring it back to is that another way to think of this is, you know, it's a it's a project, I think, that goes beyond just thinking about policy space to sort of thinking about civil society more generally. Yeah. That that I think there's space for nonpolicy actors as well to really think about how do we create a civil society network that says, you know, this is what you know, what does it look like for Americans to live in a world that allows them to be healthy, right, and that gives them good options for care when they're when they're not healthy.
Elizabeth Popp-Berman:And that building that capacity outside of policy spaces is also something that in the long run can create more lasting change.
Loren Adler:That's a that's a good point, think. That seems like a good good positive note to to end on here. So I wanna thank you again, Beth, for sharing your time and insights. And again, Beth is a professor at the University of Michigan and to check out her article and the rest of the series on health and the political economy at HealthAffairsCholar. Please check out the show notes or you can look it up on HealthAffairsCholars website.
Loren Adler:And thank you again, Beth, for taking the time.
Elizabeth Popp-Berman:Thanks. It's great to be with you.