Focusing on care not just coverage; economist argues for bigger solutions

Summary

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Consider This from NPR

Episode Summary: "Focusing on Care Not Just Coverage; Economist Argues for Bigger Solutions"

Air Date: December 7, 2025
Host: Miles Parks
Guest: Craig Garthwaite, Economist & Director, Program on Healthcare at Northwestern University's Kellogg School of Management

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Main Theme

This episode addresses America's ongoing health care debate, focusing on the Affordable Care Act (ACA) subsidies showdown in Congress and significant barriers to true health care access. Rather than tweaking coverage or arguing about who pays, guest economist Craig Garthwaite calls for bold, supply-side policy changes—like expanding the health care workforce and rethinking Medicaid—to make care both more efficient and accessible to those in need.

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Key Discussion Points & Insights

1. The Health Care Coverage Debate (01:10–02:30)

• Context: Millions face higher ACA premiums if Congress doesn't extend subsidies, tied to this year's government shutdown negotiations.
• Current Proposals:
  • Democrats want a 3-year subsidy extension.
  • Republicans propose a lower premium/HSA plan.
  • Bipartisan suggestion: 2-year tax credit extension with limits.
• Craig Garthwaite’s Critique:
  • The debate is stuck on "who pays" (demand-side), not "how much care do people get or how much does it really cost" (supply-side).
    • Quote (02:33):

      "If the subsidies expire or they don't, it'll change the cost of health care. That's not true. All that's going to change is who pays for it. Does the federal government pay for it or do individuals pay for it? ... What we do care about is how much are we spending on health care overall and how much care are people actually getting for the money we're spending?" – Craig Garthwaite

2. Solutions for Affordable, Efficient Health Care (04:34–09:03)

• Recent Study:
  • Aspen Economic Strategy Group’s research argues practical, scalable reforms can make care better and cheaper, if implemented.
• Garthwaite’s Recommendations:
  1. Ease Restrictions on Foreign-Trained Doctors (05:00–05:57)
     • Bring in reputable, credentialed physicians from abroad, asking them to serve low-income/Medicaid patients.
     • Increases supply, improves access, could lower costs.
     • Quote (05:18):

       "...we want to increase the supply of people who can provide medical services. ...As a physician, you have to primarily concentrate on targeting low income patients and particularly patients who are on Medicaid..."

  2. Expand Scope for Nurse Practitioners and Physician Assistants (06:41–07:47)
     • Allow mid-level providers to practice independently; research shows excellent outcomes in primary care.
     • These providers often spend more time with patients and cost less.
     • Already used in value-based care settings.
     • Quote (06:52):

       "For a lot of primary care, research has shown that [mid-level providers] provide exceptional care for individuals... for primary care, I think that's often what people want. They want to be able to sit down and talk..."

  3. Leverage State-Level Flexibility (09:17–10:11)
     • States can experiment with Medicaid via waivers and program design, offering space for practical innovation.
     • Garthwaite sees promise here versus waiting for Congress.
     • Quote (09:53):

       "State Medicaid agencies actually can obtain a lot of flexibility to implement these. ...Let all these states experiment. ...They can be the laboratories of low income coverage and figure out what's the best way..."

3. The Broader Problem with Medicaid (10:11–11:16)

• Historical Context:
  • Began small (1965, for the very poor/disabled/widows/orphans).
  • 1990: ~20 million enrollees. Last year: 80 million+, including children, seniors, half of all U.S. births.
  • Not designed for current massive, diverse use; struggles with scale and effectiveness.
• Parallel to ACA Expansion
  • ACA further expanded Medicaid enrollment.
  • Most current debates (premium/tax credits) are about "who pays," less about total system costs or care access.
  • Quote (11:46):

    "Most of the debate ... is not about the cost of health care. It's really just about who pays for it." – Craig Garthwaite

4. Shifting Focus: Coverage Isn't the Same as Care (07:58–09:03)

• The critical problem isn’t insurance coverage alone, but whether people can actually find and receive care—particularly primary care—when they need it.
• Need a "supply-side" focus:
  • Who actually delivers care?
  • How do we ensure enough personnel and access points for all, not just the insured?
  • Quote (08:36):

    "...Coverage ... is a necessary but not sufficient condition for getting access to health care. ...We'd like to see the debate focus more on what actually gets people care. And that has to be a supply side conversation..."

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Notable Quotes & Timestamps

• On the limits of current debate:
  "[All that's] going to change is who pays for [health care] ... not the cost itself. ...What we do care about is how much are we spending ... and how much care are people actually getting." – Craig Garthwaite (02:33)
• On foreign-trained doctors:
  "There is a readily available set of people who have graduated from reputable, credentialed medical schools abroad ... allowed to work here as a physician ... to primarily target low income patients on Medicaid." – Craig Garthwaite (05:18)
• On mid-level providers:
  "For a lot of primary care, research has shown that they [mid-level providers] provide exceptional care for individuals. In addition, they're a lower cost input ... And for primary care, I think that's often what people want." – Craig Garthwaite (06:52)
• On Medicaid's expansion and complexity:
  "It has become this sort of unwieldy program that was never designed for the size and the scope of the patient population that it's currently covering." – Craig Garthwaite (11:04)
• On the real policy priority:
  "If the actual cost of health care goes down, we can provide care to far more people more efficiently. And that's ultimately what we want." – Craig Garthwaite (11:53)

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Memorable Moments

• Garthwaite’s Realism on Congressional Prospects (09:17):

  • "You're talking to an economist, so you can't be more cynical than I am. I think I've lost almost all faith in ... Congress..."
  • Points out the opportunity for states to innovate, even if Congress stalls.

• The "Coverage Isn’t Care" Message (08:36):

  • Turns the spotlight from abstract insurance coverage to actual, practical care delivery—arguing for policies that would materially affect Americans’ experience of the health system.

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Important Timestamps

| Segment | Timestamp | |----------------------------------------------|------------| | Rising ACA premiums & subsidy debate | 01:10–02:30| | Craig Garthwaite: “Who pays” vs “real cost” | 02:30–03:12| | Solutions overview | 04:34–05:57| | Foreign-trained doctors | 05:00–05:57| | Mid-level providers | 06:41–07:47| | Coverage isn’t care (supply-side focus) | 07:58–09:03| | Realism about congressional action | 09:17–10:11| | Medicaid’s history and scale | 10:11–11:04| | ACA parallels & true reform | 11:04–12:09|

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Conclusion

This episode uses current legislative battles as a jumping-off point to probe a deeper flaw in the U.S. health system: confusing insurance coverage with health care access. Economist Craig Garthwaite lays out pragmatic, actionable reforms—expanding the provider pool, empowering mid-level practitioners, letting states be creative—to drive real access and efficiency, urging policymakers to focus less on who pays and more on ensuring Americans get the care they need.

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Transcript

[A]

Hi there. It's Miles Parks. Okay, I know it's Sunday, but real quick, we do have to talk about last Tuesday. It was Giving Tuesday this week. And it's not too late to support Consider this and everything you love from npr. This was a difficult year unlike any other for NPR because federal funding for public media was eliminated as of October 1st. That means NPR is now operating without federal support for the first time in our history. But NPR's commitment to you has not changed here at Consider this. We're going to keep bringing you a deep dive into one of the day's major news stories and what it means for you. But we need your help to do it. And we are so grateful for everyone who has already stepped up to give, like Catherine in Montana who says, I absolutely adore NPR and every podcast they produce, I listen to up first and Consider this every day. Thank you for all you do. Thanks, Kathryn, and thank you if you've already made your gift or if you're an NPR supporter. If not, sign up today. Support public Media and get perks to NPR's podcasts, including bonus episodes of Consider this. Sign up at plus.npr.org.

Millions of Americans could see their health insurance premiums skyrocket in the new year if Congress doesn't extend subsidies to the Affordable Care Act. The debate over that funding was at the heart of the government shutdown this fall. The deadline has passed to keep the government open. Federal agencies millions of Americans now face higher health insurance.

[B]

At the heart of the government shutdown.

[A]

Is a debate about health care.

[B]

Do they continue offering services and hope to recoup payments from Medicare later? A group of Senate Democrats have defected to agree to a deal with Republicans to end the government shutdown.

[A]

Eventually, the government did reopen with the promise that Congress would hold a vote on those subsidies by the end of the year. The the problem is so far there is no consensus in either chamber on what an extension might look like.

[B]

We are working to deliver to Speaker Leader Thune and Speaker Johnson a plan which I think could get 60 votes, which gives the American people the power.

[A]

And they can choose a lower premium and an hsa.

[B]

We're working on that. And I'll give them a piece of.

[A]

Paper probably by email tonight. That's Republican Senator Bill Cassidy speaking about a Republican health care plan on FOX News. Democrats proposed their own idea as well, hoping to just extend the subsidies for three years. And and a bipartisan group of senators offered up a plan that would extend the tax credit for two years with some limitations. But economist Craig Garthwaite, he wants the US to think bigger when it comes to health care.

[B]

It's a frustrating thing, I think, for economists as we watch this debate where, you know, they're saying if the subsidies expire or they don't, it'll change the cost of health care. That's not true. All that's going to change is who pays for it. Does the federal government pay for it or do individuals pay for it? And while that's an important question, it doesn't get it. I think we do care about, which is how much are we spending on health care overall and how much care are people actually getting for the money that we're spending?

[A]

Consider this. If the true cost of health care goes down, more people get access. And several solutions to make health care both more efficient and more affordable at scale could be right in front of us.

From npr news, I'm miles parks.

[C]

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[A]

It's Consider this from npr. Hi, I'm Miles Parks. New research from the Aspen Economic Strategy Group. Coverage isn't an abundance agenda for Medicaid argues that solutions to make healthcare both more efficient and more affordable already exist and they should be expanded. Craig Garthwaite is the director of the Program on Healthcare at Northwestern University's Kellogg School of Management and one of the authors of the study. He joins me now. Welcome.

[B]

Hi. Thanks for having me.

[A]

Yeah. Thanks for being here. So your paper says it offers a roadmap for structural reforms to America's healthcare system would make health care more affordable. The first of these recommendations is to ease restrictions on doctors who have been trained in other countries. Can you explain how that would work?

[B]

Yeah, I mean the idea would be that we want to increase the supply of people who can provide medical services with. If we have more people who are intentionally coming here with the goal of treating low income Americans, it'll provide more access and ideally lower costs. There is a readily available set of people who have graduated from reputable, credentialed medical schools abroad who could come here and we could develop programs that say we will. In exchange for you coming to the United States and being allowed to work here. As a physician, you have to primarily concentrate on targeting low income patients and in particularly patients who are on Medicaid, which is our nation's insurance program for the low income and the disabled.

[A]

Is there any risk, I guess, in terms of people who receive this coverage, you know, having the care being different for people who are lower income versus higher income?

[B]

I think the first thing to recognize is we already have different levels of care or different sites of care for people who are lower income or higher income. In the United States, lower income individuals are often going to clinics that concentrate on them. The vast majority of individuals on Medicaid are treated in facilities that primarily concentrate on low income individuals. And so we want to do is recognize that reality and provide the most efficient way to get people access to care. With the idea being that perhaps the biggest problem that low income Americans face is not that they get a different level level of care, it's that they're unable to find care at all.

[A]

So this study also mentions the idea of expanding the pool of providers by allowing nurse practitioners and physician assistants to practice independently. Can you explain that bit of it a little bit more?

[B]

Yeah. So we, we have a ready made set of providers. These mid level providers who have advanced training, they are not doctors in the sense that they have an MD or a DO degree, but they've gone through a lot of advanced training and for a lot of primary care. Research has shown that they provide exceptional care for individuals. In addition, they are a lower cost input that can be more readily deployed across the healthcare ecosystem. You can often spend more time with a mid level provider than you can with a doctor. And for primary care, I think that's often what people want. They want to be able to sit down and talk to a doctor about the things that are concerning them. And so this can again augment the healthcare workforce. We see a lot of use of mid level providers among Practices that are already engaged in what we refer to as value based care, but practices that are trying to, you know, make more money by making people healthier. And we think that there's a real place for that in the Medicaid and low income population.

[A]

Can I ask broadly about these changes? I mean, how radical are some of these changes or are there ways or levers in place already to allow for some of these changes to more easily.

[B]

Be applied in many ways, Certainly on the idea of foreign trained doctors and mid level providers, we already have experience with various kinds of programs that have different residency requirements or different what are referred to as scope of practice laws for the mid level provider kind of dictating, you know, how much prescribing behavior might they have independently. So we're really talking about expanding sort of an existing set of tools, but really targeting it on a population where we know there is an identifiable need for more access to care. And I think that's where Tim and I, Tim Layton is my co author on this. We where we started with this, which is the title of the paper, which is Coverage Isn't Care. There's so much discussion and so much of the debate we're going to have in Congress over the next two weeks is going to be about insurance coverage, which is good, but it's a necessary but not sufficient condition for getting access to health care. And I think we'd like to see the debate focus more on what actually gets people care. And that has to be a supply side conversation where we think about who's providing the care and not just what economists refer to as the demand side of conversation, which is who's paying for the care.

[A]

I don't want to be cynical, I hate being the cynical voice here. But I guess when you look at the current landscape in Congress, how realistic is it that they would take on some of these things as opposed to the sort of tweaks that they're negotiating to the current system right now?

[B]

Well, you're talking to an economist, so you can't be more cynical than I am. I think I've lost almost all faith in the idea that Congress will do good government and pass laws anymore. More the nice thing about this though is that a number of the things that we're talking about here can actually be accomplished at the state level and we have seen state governments be more active. But Medicaid, it's important to recognize, is a program that while it's jointly funded by the state and the federal government, it is administered at the state level and through waivers and other processes, state Medicaid agencies actually can, can obtain a lot of flexibility to implement these. And I actually think that's a wonderful thing about America. It's what we thought about, you know, the founders thought about for the country is let's let all these states experimen. Right. They become, as we often refer to as the laboratories of democracy here. They can be the laboratories of low income coverage and figure out what's the best way to provide true access to health care for low income Americans.

[A]

I feel like your paper touches on this idea that Medicaid didn't start out covering many tens of millions of people. It wasn't really designed initially that way and that we've kind of ended up there. Can you explain that for people who don't know the history of this thing?

[B]

Yeah. So Medicaid comes out of the Great society programs in 1965. It is intended as a very small program for the very, very poor and disabled and widows and orphans. Even if you go to 1990. Right. So now, now we're only talking 35 years ago there were only 20 million Americans that were on the program. If we go to last year, There were nearly 80 million Americans on the program. It includes kids, it includes seniors in nursing homes, it includes half of all births in the United States. And so it has become this sort of unwield wieldy program that was never designed for the size and the scope of the patient population that it's currently covering.

[A]

I mean, is that a similar problem to the Affordable Care act more broadly too, in that it is this kind of massive thing that is doing a lot of different things? I guess I'm just wondering, are there parallels there?

[B]

Yes and no. I think the Affordable Care act has a bunch of things attached to it. One part of the ACA we should note that is relevant here is it involved a very large increase in Medicaid. So one of the reasons that a lot of people are on Medicaid is because of the aca on the ACA insurance exchanges, which is the debate that's going to happen in Congress. You know, that primarily is just providing a relatively standard insurance product to people. And most of the debate, I will note there, is not about the cost of health care. It's really just about who pays for it.

[A]

And your paper basically is arguing like if we fix some of the broader issues here, then the actual cost of health care could go down.

[B]

Yes. And if the actual cost of health care goes down, we can provide care to far more people more efficiently. And that's ultimately what we want. We as a society want people to get access to the health care they need and we should focus on providing that in the most cost efficient manner.

[A]

That's Craig Garthwaite of Northwestern University's Kellogg School of Management. Thanks so much for talking with us.

[B]

Thank you for having me.

[A]

This episode was produced by Avery Keatley, Geoffrey Pierre and Henry Larson. It was edited by Sarah Robbins. Our executive producer is Sammy Yenigun.

Let's consider this from npr. I'm Miles Parks.

[C]

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