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

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.

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..."

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)

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.

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|

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.