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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.
Friends, welcome to another very special episode of A Health Podyssey, the kind of episode where instead of digging in on one specific recent health affairs paper, we occasionally get to welcome a luminary from the world of health policy to talk about the big issues facing our field. Today, we are honored to welcome the one and only Doctor. Ashish Jha. Most recently, Doctor. Jha served as the Dean of the School of Public Health at Brown University.
Rob Lott:From 2022 to 2023, he was the White House Coronavirus Response Coordinator. And previously he served as a professor of global health at the Harvard TH Chan School of Public Health. And of course, over the years, he's been a regular contributor to the pages of Health Affairs. Doctor. Ashish Jha, welcome to A Health Podyssey.
Ashish Jha:Doctor. I am thrilled to be here. Thanks for having me here.
Rob Lott:Well, let's jump right in then. And perhaps I thought we could start with the, quote exit interview phase of this conversation. Tell us a little bit about your time at, Brown University, Dean of the School of Public Health, from about July 2023 when you returned from the White House through the 2025, when you left the university. How did your work in the White House, your focus on COVID, shape your subsequent efforts, your vision and philosophy as dean for the School of Public Health?
Ashish Jha:Yeah. Well, first of all, thank you again for having me here. And I'm delighted to sort of start with my time at Brown. I came to Brown in the middle of the pandemic or early days of the pandemic in September 2020, left, of course, for about sixteen months in the middle to go to the White House. And to your question, even before then, but certainly after, I thought a lot about what is public health education, what does it need to be at this current moment?
Ashish Jha:And one of the things I often talk to my faculty about was that we were in Rhode Island. We are. I mean, school is in Rhode Island, which is a pretty blue state. And it was really important to me that we were not necessarily trying to build a great public health school for blue states of America, that we weren't just trying to train the next generation of leaders who would go work in a Rhode Island or California or Massachusetts, that they were going to go work across the country. And that meant one of our strategies was bringing in faculty, often practitioners, who had worked in red states, who had worked with governors and mayors who thought differently about public health.
Ashish Jha:This is not about red and blue per se. It is about different visions of what is public health, what is the proper role of public health. And America is an extraordinarily diverse country in that question, among other questions. And so we really spent a lot of time making sure we were training our students to think broadly and deeply about a range of different ways of doing this. Of course, another really important thing that came out of the pandemic was the importance of high quality science that was relevant and quickly translated.
Ashish Jha:So we put a lot of investments in hiring great scientists. But we built a new Washington DC office right when I came back because science that sits in the journals Health Affairs, by the way, would be one of the exceptions, which actually has a great translation arm.
Rob Lott:Very kind.
Ashish Jha:And most scientific journals don't. And so you could write great papers that have lots of relevance, no one will read it. And so we set up a Washington DC office just when I came back to really start engaging the policy audience, bringing our faculty and students into Washington, and having them work directly with policymakers. So there was a bunch of ways in which I feel like my experience at the White House really shaped how I thought about the role of public health.
Rob Lott:With your departure from Brown, it was announced that you would lead an initiative that aims to bolster the nation's defenses against emerging pandemic and biological threats, obviously building on your work over many decades, but especially your time in the White House. Where do things stand on that effort these days?
Ashish Jha:So let me tell you a little bit about what motivated that departure. When I was at the White House, I became clear, at that time it was just emerging intelligence, now more widely known. I became aware of really what the biological threat landscape looked like. And obviously, I've been worried about natural pandemics for a long time, but what was happening between the synergy that comes from synthetic biology, CRISPR and other forms of gene editing, and increasingly artificial intelligence, there is very good evidence that we're seeing the building of a whole new generation of biological agents, biological weapons, not to put too fine a point, by both state and non state actors. And our country is not ready for those.
Ashish Jha:Just they're not. We don't have this right surveillance system. We don't have the strong medical countermeasures we need. We work on some of those issues inside the White House. But after I left, I continued engaging with people inside the Trump administration.
Ashish Jha:There are, I think, some excellent people both in the White House and the Department of Defense who understand this risk. But ultimately, last fall, I came to conclude that as a country, we were moving too slowly on building these defensive capabilities and decided that actually what needed to happen is we needed a new effort, new initiative. So a colleague of mine from the White House, from the Biden White House days, and I started a new company called Bio Radar with the goal and purpose of building the Bio Radar our country needs. We've just published a piece in BMJ. Again, I hate to advertise an alternative journal, but there are others out there that We're do good
Rob Lott:all friends inside the little corner of the world.
Ashish Jha:Yep, that lays out both the problem and the solution we're trying to build. So the company's fresh and young, but what we're really trying to do is cultivate an entire network of companies, for profit, nonprofit, working alongside governments, cities, states, the nation, the federal government, to build the biointelligence our country needs. I have to tell you, Rob, there are very few things that keep me awake at night. This is one of them. The threat of a engineered pathogen used against our population to me is very, very high.
Ashish Jha:And as a country, we are not moving quickly enough to bolster our defenses.
Rob Lott:Shifting gears, I want to ask you a little bit about the multi part series that you are in the middle of publishing in The Boston Globe and on your Substack as well, where you've really zeroed in on health spending as a serious problem, and also lay out some solutions that can help. And, before we get to sort of the substance of your recommendations, I'm wondering if you can walk us through the thinking that sort of led you to embrace this subject as, your current project, your sort of first project after, departing Brown University. Of course, you're not the first person to raise many of these issues. So what are you hoping to add to the conversation with these people?
Ashish Jha:Yeah. Look, I think a lot about what happened last year with the One Big Beautiful Bill. It was one of the first times that Congress passed a law that will result in fewer people being insured. Usually when Congress acts, it has tended to expand coverage or maybe make not much of an impact. But I thought a lot about what has changed in the politics that allows for Congress to pass a bill and get signed into law that actually will result in millions of Americans losing coverage.
Ashish Jha:And the reality is, in my view, the reality is that what has changed in the politics is that health care spending has now crossed a threshold where it is putting such a burden on our federal deficit, state budgets, individual budgets, that people are starting to make those kinds of trade offs. I think that is a terrible trade off to have to make. I don't want to be in a constant debate of, should we be running 3,000,000,000,004 trillion or $5,000,000,000,000 deficits every year or multi trillion dollar deficits, or should we be covering more people? We need to be covering more people. We need to not be running these massive deficits.
Ashish Jha:Health care spending has been a topic lots of people thought about for a long time. And I am constantly surprised at how simplistic many of the solutions are that people bring up. And with all due respect to friends across the political aisle, across the political spectrum, people who are like, oh, it should just be market driven. Everybody should just go into a health savings account with a high deductible health plan, catastrophic plans. That'll solve it.
Ashish Jha:Well, what I point to them is that since the Affordable Care Act was passed, the number of people with health savings accounts and catastrophic coverage or relatively skinny coverage has gone way up. We have not seen a bending of the cost. There are other people who say, oh, the solution here is very simple. We just need a single payer plan. I have lots of explanations for why I don't think that's the right solution for America.
Ashish Jha:It's not something like, oh, I'm against government run health care. I try not to get into sloganeering. I think about, substantively, I don't think that's going to be a solution that's going to work for And so I was talking to friends who had been in the Biden White House, people on the Hill. And what I heard from them was a real hunger for concrete policy actions. No silver bullets.
Ashish Jha:I told them they are I don't have a silver bullet. Maybe somebody else has. Only. But a set of things that federal policymakers can take or state policymakers can make that will substantively bring down health care spending or at least slow its growth. And someone said to me, well, could you write a piece on that?
Ashish Jha:And I said, unfortunately, I can't write one piece, 800 words, that's going to do it justice. So I went to the Globe with what I thought was a crazy proposal that I thought there's no way they'll overtake it. And I said, how do you feel about a multi part series, a nine to 10 part series? That's a lot of real estate to ask I laid it out. And I told them the only thing, if I'd be honest, I would not be politically constrained by what's going to offend my friends on the left or right.
Ashish Jha:And the only thing I can promise is every policy idea will annoy somebody because it will harm somebody's revenue. Otherwise, we're into magical thinking and unicorns. And I don't have any of those. The Globe has been a fantastic partner. They are up for it.
Ashish Jha:We're about halfway through. We've laid out a bunch of ideas. Some of them have come from the political right. Some of them have come from the political left. I just want to put out concrete ideas that I think can make a
Rob Lott:Great. Well, that's definitely what I've sort of taken away from your pieces so far is really strong focus on solutions and specifics. Now, of course, your starting point is the soaring level of health care costs. And, I will say readers of health affairs will know that at the same time, there was this period from between 02/2009 2019 where national health expenditures, the growth slowed to less than half of the historical rate. And we've of course published a number of pieces attempting to sort of pick apart that slowdown, decompose the different forces driving it.
Rob Lott:I'm curious how you reconcile that slowdown with your own understanding of sort of the fundamental drivers of spending and the problem we're trying to solve.
Ashish Jha:Yeah. Look, I think there's a lot of debate about that slowdown. And of course, people are fans of the Affordable Care Act. And let me be very clear, I was supportive of the Affordable Care Act. I think the insurance expansion has saved thousands of lives.
Ashish Jha:I think it's been terrific. And there are people who want to give the ACA credit for that. I think the evidence on that is pretty weak. I do think there's a little bit of evidence that the ACA may be slowed down spending in the Medicare program for a period of time, but it's probably not more broadly. And of course, now that spending has picked back up in the last few years, the critics of the ACA are now blaming the ACA.
Ashish Jha:And I just feel like none of this is useful. My best understanding of what really happened in 2010 and 2019, I mean, maybe there's some policy things, but also we didn't see a whole ton of new innovation. We didn't see a whole bunch of new blockbuster drugs, a bunch of new. And that actually, I think, was part of the reason we saw that slowdown. But we are not in that era now.
Ashish Jha:GLP-1s, for instance, are extraordinarily effective and should be much more widely used. They are going to, in the short to medium run, drive health care spending way up. We're seeing these multimillion dollar cures, cures for genetic therapies. We should be employing them. They are going to drive health care spending up.
Ashish Jha:So I think that whatever I mean, again, we can just debate what caused that slowdown. That may be our past. That is not our future. Our future is going to be accelerating health care spending Depending on who you talk to and including some of the numbers published in health affairs, I think we're looking at between $70 and $80,000,000,000,000 of health care spending over the next decade. That is an extraordinary amount of money.
Ashish Jha:And we have got to do something to at least try to slow that down and at least not be wasting I'd rather spend the money on a cure for sickle cell disease than spend that money giving it to a hospital that is billing extra because we have these crazy side of payment rules. Let's focus on what really matters. And even if we have to spend money on it, if there's things that are saving lives, let's do that. If there are things that are just administratively wasteful, let's not do that.
Rob Lott:That's a great starting point. I want to ask you a little more about some of the underlying sort of existential, forces driving your your approach to this series, but before we do let's take a quick break. And we're back! I'm here talking with Doctor. Aashish Jha about his, ongoing series in the Boston Globe addressing, health care spending and potential solutions.
Rob Lott:And you alluded to this in, your earlier comment, and in your introduction to the series, you write, quote, the mystic diagnosis is not just technical, it's ideological. On the political right, the reflex is to blame government. On the political left, the instinct is to blame the market and corporate profiteering. That story is also simplistic. And I guess the the reality of this sort of simplistic interpretation, in my sense, is a result of the kind of human impulse, political leaders especially, to embrace the most simplistic explanation of any given problem.
Rob Lott:And credit to you to, for telling a more complex and nuanced version for taking eight or nine, entries in the series as opposed to boiling it down to just one. But I'm curious how you think about how we can engage others to do the same. How can we get our leaders to let go of the simplistic version and embrace something more complicated when politics sort of encourages the opposite?
Ashish Jha:Yeah. It's a fantastic question, Robin. I've thought a lot about this. And one of the things that makes me feel more optimistic in answering that question is, look, there is the public persona that political leaders often have to toe. And so if you're on the political right, you have to start by blaming government.
Ashish Jha:And you have to start off by saying, this is the government's fault. And by the way, there are truth to that. There are some bad CMS policies that are making things worse. And those are not policies that were created by the Trump administration or the Obama or the Biden administration. They've been around for a long time and should be fixed.
Ashish Jha:But that is the tendency on the outside. And of course, on the left, they love beating up billionaires and big corporations and private equity and the boogeyman of the hour. Behind closed doors, I find policymakers much more reasonable, not only their staff, but the political leaders themselves. They are open to solutions. They are open to compromises.
Ashish Jha:They know that they have to have a public face that is going to be aligned with their thing. But behind the closed doors, I found a lot of political leaders very open to concrete solutions. This is particularly true at the state level, where governors, they have to balance a budget. And they know that if health care spending goes up and their state employees are paying more and if Medicaid is paying more, they're going to have less money for other things. So I am trying to give people concrete ideas that, at least behind closed doors, I feel I get a lot of reception, not always on Twitter.
Ashish Jha:But I'm not writing for the Twitter audience. I am trying to write for people who are actually going to make decisions. And so far, I have to say, I've been very heartened by the response from policymakers, including some Republicans who have reached out to me privately and said, thank you for saying this. This makes it much easier for me to push on this. And I'm happy.
Ashish Jha:If I can help facilitate better policymaking, or at least conversations, I'm thrilled.
Rob Lott:Well, that's great. Good to hear you've heard some positive feedback. Earlier, you alluded to telling the folks at The Boston Globe that you're probably going to piss off a few people every step along the way. Have you gotten any calls from frustrated folks saying you've gotten it all wrong?
Ashish Jha:Sure. Gotten those too. And what I have offered every one of them is a guest column on my Substack. I'm like, please, tell me exactly why I got it wrong. And you don't have to just send me what you want to write.
Ashish Jha:I will post it, and I'll tweet about it. And try to promote your views on this. And look, I am not arrogant enough to believe that I have all the solutions to American health care spending. I have a bunch of ideas. I think they're grounded in evidence and science and data.
Ashish Jha:But I think it is much more important to engage in a substantive debate and try to figure out how to move this agenda forward. The other part I think that's really important to model and this is not just about health care, but this is about a moment we are in in our country is we turn every disagreement into a personal, I hate you. You're a terrible person. It turns out there are plenty of people with whom I disagree strongly on health policy who are wonderful people that I don't hate at all. In fact, I like them a lot.
Ashish Jha:And I am trying to encourage through this like a real discussion that says, please disagree with me. Disagree with me on substance. Don't call me names. That's not useful. But disagree with me on the substance.
Ashish Jha:And if you really disagree, I actually want to give you the forum to write in your words why I'm wrong.
Rob Lott:Great. Well, one thing I've liked about your pieces, and we sort of alluded to this earlier, is the sort of focus on specific recommendations. But obviously, as you know, from your time, as the national coronavirus response coordinator and in other roles, there's a really big distance between, knowing solutions that we can be fairly confident will make a positive difference in actually implementing them. And I'm curious how you think about how we might begin to close that distance.
Ashish Jha:Yeah, it's a great, it's a very good question. I think it's a bit of a corollary to that conversation we had about sort of political leaders often behind closed doors do want to solve problems. Not every one of them, but many of them. What I found when I was at the White House is I often had ideas of something I wanted to implement or do. And it was helpful if somebody from the outside who had credibility was saying it because it gave me a little bit of political cover.
Ashish Jha:So I could walk into a room and say, hey, here's this thing that Eric Topol or Mike Osterholm or whoever is saying. I had actually been thinking the same thing, but look, then I can use that to give people the sense that there's outside credibility for a policy. It's not just an internal one. So I am never I'm not naive enough to think that someone's going to read this series and be like, oh, here are eight good ideas. Let's go implement them all.
Ashish Jha:It's not how America works. But I am hoping that a few of them have been talked about. Maybe this piece helps nudge one of them over the finish line. Maybe this piece takes one of the pieces takes somebody who hadn't really thought about a strategy or a political solution and say, oh, can we actually do this. Okay, if we can't get real competition happening in our markets, maybe we can put in price caps.
Ashish Jha:And then initially, a lot of people in the conservative right are like, oh, that's a terrible idea, except Indiana's doing it. They're like, oh, Indiana's doing it. That's interesting. So I'm hoping that implementation happens when you bring a bunch of people together around something. And again, my goal is just to advance that conversation, get more people looking at real solutions, and realize there's a lot of stuff we can do in bipartisan ways that we don't have to always be beating up on each other.
Rob Lott:The overarching framework of your series of articles is looking at health spending and tools to reduce it. Obviously, if we think about a framework like Don Berwick's Triple Aim, you know, there are other sort of legs to that stool there. Among them are things like quality, safety, the patient experience. Obviously, you served in the Department of Veterans Affairs working on things like quality and safety. And I'm wondering how you feel those pieces of the puzzle fit into the conversation you're having now with this series.
Ashish Jha:It's a great question. I struggled with this a little bit, and I made the decision to force myself to have the discipline of focusing largely on cost and spending. That's a decision, by the way. I'm not suggesting it's the only decision I could have made. But my general view on policy is the more specific and narrow you can be, the more likely you are to move the needle.
Ashish Jha:And if I got into let me write you 10 pieces on broader health reform. I would write two or three pieces on how we improve the quality agenda, how we reduce medical errors, how do we make information technology function better. I would be writing a lot about different ways of doing insurance schemes to improve access, all of which are critical issues. But I just felt like this is too big and we need more specificity. And so I've always believed that if you can't tightly define a problem, you can't solve the problem.
Ashish Jha:And if my problem becomes, I'm going to fix all of American health care, good luck, Godspeed. That is not going to happen. I feel like how do we slow down health care spending alone is an ambitious enough agenda. And so it's hard for me, Rob, because I spent most of my career if you look at the pages of health affairs, where I've probably published more than any other journal, almost everything was on quality and safety and access. And so to not write about that is actually hard.
Ashish Jha:But it is a discipline I have forced myself into because I thought the issue at this moment that is capturing the attention of all Americans is affordability and particularly health care affordability. And while quality and access and safety matter enormously, I wanted to focus on affordability and healthcare spending.
Rob Lott:Great. Well, thank you for embracing that discipline. And I think it was the right decision. At Health Affairs, I know our editors are constantly working with authors to sort of try and tighten their focus. So well done.
Rob Lott:Thank you for doing that. I have been trained
Ashish Jha:by some excellent editors at the Health Appear. So I think by people like Don Metz. You could tell Don that I have been trained for years in my interactions with him to be focused at this point.
Rob Lott:Oh, that's so kind. Thank you. Well, before we wrap up, I want to sort of circle back to reflecting on your time at Brown University, where we And as you said, this moment in time is particularly fraught. And I'm curious when you think about the conversations you've had with students and aspiring researchers and people early in their careers, what you tell them if they perhaps come to you feeling frustrated or daunted or overwhelmed about the prospects of the work that they aspire to do in the years and really decades forward. What's your advice?
Ashish Jha:As you might imagine, those conversations were happening a lot over the last twelve, fifteen months as we have seen a very substantial destruction of the CDC, pulling back of public health agencies around the country. A lot of students, junior faculty, prospective students asking, is this a time to be going into public health? And what I've said is that public health was never about the institutions. It was about the problems that we were trying to solve. And those problems are as stark and as important today as they have ever been.
Ashish Jha:And I don't actually believe that the number one job of public health leaders right now is to defend institutions. In fact, CDC had lots of problems. It needed reform. I don't agree with the way Secretary Kennedy is reforming the CDC, but I think it needed reforms. So instead of worrying so much about what is going to happen to our institutions, we need to build the skills to solve the problems that really matter.
Ashish Jha:And what I have said to folks is as long as you could focus on problems that matter to the American people and you work on them, there will be outlets, outlets for that work. There will be outlets for funding. There will be opportunities to go do the work. Worry less about what's happening to the institutions, which I don't love, but worry less about that, and focus more on the problems that really matter to Americans. And if you do that, you will be fine because those problems need solving.
Rob Lott:Great. Well, a great note to end our conversation today and perhaps send folks out into the world with a hint of optimism. Thank you so much, Doctor. Jha, for the work you're doing these days and for your service to the field and for talking with us here today. It was a lot of fun.
Ashish Jha:It was a lot of fun. It's always a delight to be back at HealthFairs, and thank you for the opportunity to come spend some time with you. It was great.
Rob Lott:Absolutely. Thanks. And to our listeners, if you enjoyed this episode, recommend it to a friend, leave a review, subscribe, and of course, tune in next week. Thanks, everyone.