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- [00:00]
A
Love that we found the answer. Any more guesses from me? Yes. Hello and welcome to Optimist Economy. I'm economist Kathryn Ann Edwards.
- [00:17]
B
I'm editor Robyn Rousey.
- [00:19]
A
On this show, we believe the US Economy can be better. And we talk about how to get there one problem and solution at a time. Today, big old problem. It's gonna be a fun one.
- [00:33]
B
Yeah, it is.
- [00:33]
A
We're talking about healthcare.
- [00:34]
B
We are. Health insurance.
- [00:35]
A
Specifically health insurance. How why ours is so bad, really what we can do for the future. This is the episode where we fix healthcare in the US should take a cool 15 minutes. Okay, first up is announcements. I don't think we have any other than we always appreciate a review. Sassier, the better. We can move right into retcon.
- [00:59]
B
Right.
- [01:00]
A
The question from our shift worker episode, is Starbucks a restaurant or drinking place?
- [01:07]
B
I looked that up and it is a limited service restaurant, not a drinking place.
- [01:12]
A
Okay.
- [01:13]
B
Okay.
- [01:14]
A
Redcon. For real. The Wall Street Journal had an article on shift work that ran the day after we recorded the last episode. And it is about a man who works at Costco who has spent the majority of his career there, who earns $33 an hour, who has a very predictable shift, who has over a million dollars in retirement. He has traveled to Europe with his family a few times, and the article is about how people like him who are seasoned, treated well, paid well, are the key to Costco's success because they can do things like move a checkout line up to four times as fast as someone who has just been hired. Yeah, so.
- [01:56]
B
And he's also mentoring other people and trained other people. You know, they've tried to promote him, but he likes being a cashier, and he's incredibly valuable to them because he models how great cashiers work.
- [02:07]
A
You know, people hold up such myths in our economy, and they'll say something like, you know, for our grocery store to be competitive, we have to pay as little as possible and have this shift arrangement that's as mean and, like, cuts down on weight, you know? And yet you can see, like, Costco paid people money and still have a store. So maybe blaming low paid employees are not a strategy that's actually successful, but you keep leaning on it. Hey, try something new. Pay people. Think about it.
- [02:38]
B
Exactly. I shared that story on our substack. I can't remember if I shared it in the chat room or if I shared it as a note, but I shared it on substack with a gift link, so if you didn't get a chance to read it, it's really worth reading.
- [02:49]
A
Yeah. Okay. Terms and conditions. What'd you look up?
- [02:52]
B
Well, actually, I wanted you to help me. I hear this term political economy all the time, and I don't understand entirely what it means. I looked it up, and I think it seems like it's the interdisciplinary study of how political systems and economic systems interact with each other. Is that right?
- [03:10]
A
Jesus, I don't know. I saw it on the outline. I was like, oh, my God, I'm so excited. Robin's going to explain to me what political economy is. Yeah, I mean, I. I've never understood it.
- [03:20]
B
Okay, well, there we are.
- [03:22]
A
I mean, I think I. I took it as shorthand for this is. Okay, so this is like a truly, like, arrogant economist perspective of, like, there's economic policy that we know and need and study, and then there's the politics of getting that enacted and put in place.
- [03:39]
B
Hmm.
- [03:40]
A
So, like, an example, like, there's the economics of taxes, and then there's the political economy of tax policy. So, like, the economic of taxes is pretty straightforward. The political economy of tax policy is, I feel like, is just politics. Okay. I'm like, rich people really don't like taxes, and poor people need them so that we can have social service investments. And it gets into, like, do you think that the government should help people in need or invest in the economy? Or do you think people should just have their own taxes? But, like, that just feels like politics about the economy and not actually like something special. Okay, so that's. That's where I am. Political economy, to me, is how politics shapes economic policy, but is not actually the economy.
- [04:28]
B
I'm. I'm looking this up and what it says, it integrates insights from both political science and economics to study the interaction between politics and markets. So instead of treating economic activity as something that happens in a, you know, in a perfect, ideal economic world system, like you said, tax policy, government institutions, other political environments and systems influence the economics.
- [04:51]
A
Well, I mean, not to, like, show my true colors here, but I generally associate political economy with, like, needless obstacle. Like, paid family leave would be really good. But the political economy is that women might need to stay at home with their kids, and that's what rich voters feel like. Political economy is like some bull that gets in the way of doing really good things. Political economy, well, but it could be
- [05:18]
B
things like government regulation of an industry leaves markets, like in health insurance, like we're going to talk about today. That was a transition. Did you like it?
- [05:28]
A
Oh, that was the transition. Okay.
- [05:29]
B
Okay.
- [05:29]
A
I could also see it as like, economic policy creates political constituencies.
- [05:36]
B
I love how you're like, I don't know what it means, but then you're going to keep telling me what you think it means.
- [05:42]
A
I'm giving you my interpretation of it a la Modern Ballet. Okay. Cost sharing is my term and condition.
- [05:49]
B
Yeah, cost sharing.
- [05:50]
A
Cost sharing sucks. So a cost sharing would be your copay, your coinsurance deductibles that collect into deductibles. So cost sharing is you paying when you consume health insurance through some kind of structure. And it is a integral part of the US Healthcare system. That sucks.
- [06:20]
B
Cost sharing, I mean, has a specific purpose that you haven't really explained, which is it's to get people to meter their use of health care. That the fear is that if it's totally free, people will just go to the doctor for fun and we will swamp the healthcare system. And if you. If you ask people to just have some skin in the game, that they'll make responsible decisions about how much healthcare they consume. And it does do that.
- [06:46]
A
Yes, it does do. That also makes it harder for poor people to get healthier.
- [06:50]
B
Right.
- [06:51]
A
So the alternative to cost sharing is gatekeeping, the idea that your health consumption is brokered through your primary care doctor. It's like you have to get a referral to go someplace else or to go beyond your primary care doctor or a set of doctors. So one of the ways that we kind of limit healthcare consumption is by putting a price tag on it that can be hefty. The other way would be we just make you go through doctors before seeing other doctors.
- [07:18]
B
Right.
- [07:19]
A
But I think the general feel of terms and conditions is that healthcare has to have some limits, and where those limits come from are tough to navigate in our political economy. How did I do?
- [07:35]
B
Nice. Nicely done. Perfect.
- [07:38]
A
Okay, great. We'll come back for the Big Pilcrow.
- [07:45]
B
Okay, we're back with the Big Pilcrow again. If you're new here, the Big Pilcrow is the centerpiece of our podcast where we talk about a new idea. And this week we're going to talk about health insurance and what sort of possible futures for health insurance and health care in the United States could look like. Does that sound like a fair summary, Katherine?
- [08:06]
A
I think so.
- [08:07]
B
Okay. I guess I want to make a distinction between healthcare and health insurance. We've talked a lot about what the role of insurance is in terms of protecting people from risk. Insurance, at the end of the day, is designed to make you not go bankrupt when something bad happens. That's what health Insurance should be doing. Health care is the actual delivery of medicines and medical treatments. And we talk about them in the United States sometimes like they're one and the same, but they're not necessarily the same thing. They're two sort of separate systems that are tightly, tightly intertwined. But you can look at them a little bit in isolation.
- [08:43]
A
Gosh, I do that all the time. I'm like, health insurance in care, who knows? Like, I always do that. But yeah, I mean, you're right. It's a good distinction to start with that when we talk about. I mean, like, let's not beat around the bush here. We need to have public health insurance. But I think when people hear public health insurance, they get tripped up because they think that that means public health care. Those aren't the same thing. Your insurance is how you pay for the care that you receive. And your insurance can be public and your care can be private. In fact, that's. That's how Medicaid works. That's how Medicare works. Those are both public insurers that reimburse private providers. It's not like everyone on Medicaid goes to a government clinic or anyone on. Everyone on Medicare goes to a government clinic. I mean, it's just this idea of government doctors has just like a specter of doom and fear in the. Which I don't think anyone, anyone would want unless they were in the military or va and they get great healthcare for free. So.
- [09:40]
B
Right. Yeah, I think that's the thing. Like, people, and I'm not immune to this. When you hear discussions of potential changes to the quote, unquote healthcare system, it's most likely that your thoughts about the way the healthcare system works has to do with how you interact with doctors and medical clinics and how you receive care. But one of the big things that's broken about the healthcare system is really just about how it's purchased, how it's paid for.
- [10:09]
A
Yeah, this is an insurance fight. I mean, hopefully people get better care if the insurance is not so poorly organized. But yeah, this is really like a payer fight. So health care versus health insurance is a good. I think a good starting point. The one that I wanted to start with was you already have public health insurance to some degree. And I think that there's this fear of, like, the government taking over something. But I'm like, no, y', all government's there for most of it. It's like we're running an experiment of, like, five different types of public health insurance, and now we just need to, like, pick A winner and get rid of the rest because the overlapping system is also not doing us favors. So there's the. The two obvious ones is we have Medicare, which is a basically ungate kept fee for service. Whatever you want, you go get health insurance system paid for through payroll taxes that are collected as part of FICA that you get when 65 in the US it has very good coverage, some pretty massive out of pocket spending. So most people have a supplemental Medicare plan. In addition, the second one we have is Medicaid, paid for mostly by the federal government, run through states, is often delivered via a private provider. So like your Medicaid provider in a state is Blue Cross Blue Shield or is Aetna. It's almost entirely HMOs. They have pretty strict caps of how much they spend. Their coverage is negotiated to be quite low. And if you have Medicaid, you can't have any other type of insurance. So there's no wraparound plan. It's like a one or zero. It's intended for low income Americans and children and those with disabilities.
- [11:45]
B
You're saying you can't supplement it, right?
- [11:47]
A
With wraparound, you can't supplement Medicaid.
- [11:49]
B
Okay.
- [11:50]
A
Which is a problem.
- [11:51]
B
Okay, so we have Medicare, we have Medicaid.
- [11:53]
A
Yeah. So now we have the va, right, which is basically free health insurance that you get like a basic health insurance plan that you can access only if you are a veteran and only at VA approved sites. So it's kind of closer to almost, I would say the UK of like this is a government doctor employed by the federal government giving you healthcare at a government site for people who are eligible. Similar to the VA is Tricare, which is the health insurance plan for active service members. They have around 10 million people insured already. So that's Medicare, Medicaid, Virginia TRICARE. Coming in. Number five is your employer sponsored health insurance plan. Now it is seemingly private because it's your private employer and you're a private citizen and you go out and you get some type of private health insurance. However, this provision is not possible without an incredible subsidy from the federal government. The amount of money that your employer pays for health insurance is not subject to the income or payroll tax. And not collecting income and payroll tax dollars on the size of your private health insurance plan adds up to be around half the size of Medicaid. So just putting the thumb on the scale to get employers to provide health insurance, that's half of Medicaid, which means that it's another form of public health insurance. So that's Number five, I think five and a half are all the ways that the government provides health care outside of the insurance model. So this would be community health clinics, traveling community health clinics covering emergency care, which you're not allowed to deny someone admission to a hospital for emergency treatment, even if they don't have insurance. Like, the government will pay for all that somehow. It's not really an insurance plan, but it's them picking up for care outside of the insurance system. So I say five and a half.
- [13:49]
B
So in other words, the federal government. You're saying the federal government's fingers are all through health care already?
- [13:54]
A
Yeah, I mean, I think that people, you know, they, they say, like, the government can't do this or like this isn't the government's jobs. Like both are incorrect because the government is doing this and it is its job because as you point out, insurance as a risk reduction mechanism is getting people health care that they need. So that I think is like the shortest version of the problem is that we have a certain American resistance to having government health care, even though we have government health care basically in all these different forms. Because if the government is paying for your health insurance premium for a private plan, that's government health care. You just don't want to call it that. Like it's from your employer. But, like, hey, the government didn't put the thumb on the scale. You wouldn't have hits.
- [14:41]
B
I think the fear about government sponsored healthcare is you won't have enough control over your healthcare. I don't know. Anybody who's been to a doctor in this century knows that it's difficult to navigate already. I don't know what it is we're trying to save out of this current system.
- [14:56]
A
All right, So I think the optimist bent to how you and I have introduced this is whatever system comes next. We have a base for like three different choices here. And we can go, I think, in multiple directions. I think the dream policy for conservatives is to go Switzerland. Switzerland has only private health insurance. It is incredibly, incredibly, incredibly tightly regulated. There's like more than 60 private health insurance providers. And they have essentially like a blossoming marketplace where people pick their health insurance and it's kept under regulation.
- [15:33]
B
But Switzerland's a country of 10 million people. Like, it's not even. Like, it's a tiny. It's like a tiny little country.
- [15:40]
A
Like they're all rich anyway. And that tiny little rich country still needs a heavy hand of government regulation and rule keeping. And like, they. The government still has its fingerprints all over that system of like keeping prices in check and deciding how things move.
- [15:56]
B
I mean it's, and maintaining a huge amount of competition. I mean, think about that. Like, that's the size of LA County. We have like, like five health insurance companies. You know, if we had six insurance companies, can you imagine? Or 60. Oh my God. Anyway, so what would the liberal equivalent be on the international stage?
- [16:15]
A
I don't think liberals have really decided what they want because I think there's clearly one camp that's like, we need single payer a la England in which you have government doctors, basically the va, but for everybody. And then you have people who are more on the Canadian side of like, well, what we really need is like almost like Medicaid, but for everybody and allow wraparound plans. And then you have people who are like, actually just give everybody Medicare, which in terms of cost is the worst case scenario.
- [16:43]
B
Like Medicare for all. Like that would be bad.
- [16:46]
A
I don't know if like Medicare for all, like what they think that means.
- [16:50]
B
Yeah, I, I think it's young people who aren't in Medicare and they don't know what Medicare really is because Medicare
- [16:56]
A
also has a ton of problems. So given all of this, you and I did some homework to see what health experts have recommended. And we went to Amy Finkelstein, who is an economist at mit. I have never met Amy. I know several of her students. What I have heard about her is that she is just this like, very quietly, most productive economist you'll ever meet. I'm like, what did you do last year? Like, I wrote four books. Like, wait, what?
- [17:29]
B
Yeah, she's also, I think she's the recipient of a MacArthur genius grant. Like she's been recognized for putting out a lot of really interesting ideas.
- [17:37]
A
She is a health economist researcher. So she evaluates the health effects of changes to public and private insurance in the US and she put this into a book called We've Got yout Covered. And it was very formative for me for thinking of what comes next for healthcare. I think it's a pretty technical book. It's a really easy read, a good explanation. But they very much say, like, we cannot figure out the politics of this. Like what we have gleaned from studying the US Health system and studying other healthcare systems. This is what it should look like. Making it work will be hard, getting there will be harder.
- [18:14]
B
But I think they came at it from a real sense of like, we don't want to start with the politics of what's really possible. We want to say what's the ideal and how do we get there? And I think one of the things that it's really interesting that she says, I think in the book and in interviews, which is that our healthcare system, it isn't a fixer upper system, it's a tear down. We have to start over. That's her take.
- [18:38]
A
Yeah, that's the opening metaphor is if you were to pretend that her as a health economist is like your inspector walking through a house before you buy it. They're basically saying you will spend more money fixing it than you ever will having to just tear it down and rebuild. So this is a tear down. It's such a clear metaphor. I'm almost surprised it came from an economist. We struggle with words. I was like, oh, that conveys it perfectly. Our health insurance system is a money pit. Tear it down and rebuild it.
- [19:10]
B
Yeah. We spend something like 18% of GDP on healthcare in this country, twice as much as other industrialized nations, and we have worse outcomes. And I think that sometimes the Medicare for all things like is like, let's just have everybody move into the living room. And you're like, no, no, it's a tear down. Just to extend the metaphor, if we
- [19:29]
A
all sleep in the living room for two years, if we all just get
- [19:32]
B
in the garage, it'll be fine.
- [19:34]
A
But when you say tear down, what you really mean is a tear down of the payment side, like health insurance. It's a payment issue. How we allocate insurance and risk and co payments and coinsurance and cost sharing and coverage. That is the tear down. How do we tear it down?
- [19:56]
B
They propose essentially government funded universal basic coverage. This would give you, everyone in the country, a free floor of medical care. And they think probably 2/3 of Americans would buy some sort of supplemental coverage so that they got, say, access to nicer hospitals or shorter wait times or some other additional kind of coverage. But the same kind of if you have a disease or if you have cancer, you will get treatment, should be free and it should go to everyone and there should be no cost sharing. That's how I would explain it.
- [20:37]
A
Yep. The future of health insurance in the United States is that there's just one public health insurance plan. We're all on it, we're all atomic. We can't get off of it. And this is the basis for how healthcare is paid for in the United States. It's halfway between Medicaid and Medicare today. It has the aspects of Medicaid where you've got gatekept coverage through the primary care provider and it has Incredibly low out of pocket costs. But at the same time it takes Medicare's kind of example of allowing for wraparound supplemental insurance. You combine these together to have one public health insurance that's got the primary care provider that's helping you navigate the healthcare system. But the bill goes back to the federal government unless you buy, you know, your private, I want slightly nicer healthcare than that plan, in which case they split the payment. This coverage is about who pays. Private providers, you still have private doctors, private clinics, all of that. But we don't have the same type of tangled web of public and private health insurance coverage and payment and options. It's just the one.
- [21:47]
B
And she thinks this is totally possible. Oh yeah, Catherine also thinks it's totally possible. I think it sounds outrageous, like how could we possibly do this?
- [21:55]
A
But yeah, I mean if you collapse Medicare and Medicaid and no longer have a subsidy for employer sponsored plans, I mean, that is a lot of money to throw around. Her point is that the federal government already spends the equivalent of 9% of GDP on health insurance. And 9% of GDP is about what other countries who have universal coverage paid for by the government, that's about what they pay. So it's really just a, we are misallocating all of the money we spend and if we put it into a more efficient, simple single system instead of running like five to seven, then we just have one health insurance. It's government health insurance, it's basic. And that will cost the government the same amount of money or roughly the same amount of money.
- [22:36]
B
Yeah, in terms of tax dollars, it would be a wash. And we would have all of these beneficial outcomes because people who fall through Medicare, Medicaid, and there's just gaps in between them that people fall through and whether it's because they qualify for one and should qualify for the other, but they don't know to change or they lose eligibility. I mean, and those of us who are in the employer based markets, you know, you lose your job, you lose your insurance, we just drop people into these holes over and over again for no good reason. And if everybody had universal basic coverage all the time, that just wouldn't happen.
- [23:11]
A
Yeah, I mean if you have universal health insurance that you're automatically enrolled in when you're born and you're never allowed to unenroll in through your life, I mean there are no holes for people to fall through to end up uninsured. I mean, you're always covered. I feel like that part's like easy to understand. But what's kind of interesting is the supplemental coverage question, like what does this look like? Because it's basically saying everybody has insurance, but as Finkelstein notes, like rich people are gonna rich and you have to let them rich. You have to let them carve out some like rich version of this public system. All that matters is you give rich people the chance to augment the public system so that they feel better in it, which is fine. Like I don't think that instinct is bad, but you just, you can't let them opt out of the public system altogether because then the public system will erode because it'll be seen as welfare. Apparently this is a problem in how England does it because if you want to buy something above the public plan in Eng, you have to pay for all of it. Whereas I think in Singapore if you want to buy something above the public plan, you just pay net of that.
- [24:19]
B
Yeah, you just top off.
- [24:20]
A
I mean it's the difference between flying JetBlue versus, you know, first class on British Airways. Like they're just, they're just very different experiences. But you will get from one city to another. How you get there is different. That was really helpful for me. But yeah, this system I think would be very reasonable that a universal public health insurance with basic coverage which would have the doctor gatekeeper in lieu of cost sharing, it would be you move through a primary care provider for specialty care. Honestly, I thought it would take us a lot longer to explain, but it's really not that hard. It's really not that complicated.
- [25:00]
B
Well, I think, you know, in the book she wants to show her work, right? Because they came at it from this idea of like, what does an ideal system look like? Are there just repairs we need to make to get from where we are to what this ideal system looks like? And then concluding. No, I think then they had to ask themselves like, okay, well, what's the social contract? What do our actions really show in terms of who we are as a country, in terms of wanting to care for our fellow citizens? And the truth is that we may think that we're hard nosed but that when people are sick, no one thinks that people should die. And when there is care available and treatments that are available for conditions that we have, and if we just acknowledge that we're not cruel, then you build a system to deliver care and not cruelty.
- [25:50]
A
I did some like landscape work of all right, what are other proposals for the US and what do they look like? And this is basically like within spitting distance of what every other person who has spent a lot of time in healthcare has proposed it is you have to have universal, free, basic coverage. You have to give rich people a way to differentiate their care, to give them the amenities they want. You can't let that differentiation involve skipping the line or opting out of the public system. But you can give rich people basically rewards in other ways and other ways to make their healthcare more palatable.
- [26:29]
B
I mean, she talks about like private hospital rooms versus shared hospital rooms. She actually did say shorter waits for people who buy supplemental plans would be likely.
- [26:40]
A
I would be against it, but yeah, that makes sense. What I've found through kind of reading through other plans is that the notion of specialty care in the U.S. i think people think of as being. We don't want to disrupt it. Like, it's so good here and it's so important here and that this is like the special part of the US healthcare system is how much we innovate. And I don't think there's anything about having basic health insurance gate kept coverage that prevents innovation. If you still have a private system of healthcare, this kind of just like eases the payment side and keeps the delivery side mostly private, but with some public kind of how it is now, and you make the payment public. I was reading a really fascinating kind of perspective of specialists who have said that like, they are burdened with Medicare patients. You know, you have a stomach ache and you're on Medicare, you can schedule appointment with a gastroenterologist, right? You have a tummy ache and you're on Medicaid and you call a gastroenterologist, you know, maybe the world's greatest gastroenterologist. And they'll be like, yeah, you need to get a referral to come here. Like, you need to go to your primary care doctor. Medicare patient doesn't have to do that. They can just call and schedule an appointment. And in some ways, the specialty care we want is being misallocated because there are people who are gatekept from receiving it and people who are not gatekept from receiving it, and they just, they go wherever. Unifying that would help specialists focus on what is in fact specialty care. So I did think, like, questions from this system would be, what would Americans love about it and what would Americans hate about it?
- [28:18]
B
About a universal, an automatic, universal basic care system? Yeah.
- [28:22]
A
Yeah, okay.
- [28:23]
B
Well, I mean, I think that if you're somebody who's gone through the churn of trying to enroll in public programs, the ease of this is 100 times better.
- [28:32]
A
You never have to fill out a health insurance application in your entire life. You just have health insurance from the moment you're born till the moment you die. And you never have to wonder if you don't have it. I think they'd love that.
- [28:42]
B
Yeah, I think so too. Highly unlikely to have medical bankruptcies. I think we'd like that.
- [28:49]
A
No medical debt.
- [28:50]
B
I mean, she talks about like huge levels of medical debt that people are carrying. Two thirds of those people have health insurance. It's not like the people who have health insurance now are getting out of their care debt free and a universal basic coverage system. You're going to get the care you need to survive or what's treatable anyway and not where you're going to wind up in an ambulance taking you to the wrong hospital and you're going to have a doctor who's out of network and then you're suddenly going to be sent a bill for $300,000. Network,
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A
network.
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B
Network is a word I, I'd be happy to never hear again.
- [29:28]
A
Yeah, same thing with coinsurance copay. Yeah, deductible. Like I'm just, I pay taxes, you give me health insurance. Like that's it. Like that's just the end of the discussion. I, I think the amount of money that will be freed up in people's budgets by not actually having to pay for health insurance and the cost associated with like beyond the premiums the CO pays the coinsurance, getting that down to zero, to near zero. I think that would, I mean, half of people in the US today who have private health insurance say they have trouble affording health insurance because those cost sharings have gotten so high.
- [30:08]
B
Yeah, they have trouble paying for the cost sharing piece of it.
- [30:12]
A
And you know what? Not having to rely on your employer or your spouse's employer is game changer. What a gift. Like, I mean it would probably do a lot for wages. Would help with some forms of discrimination. It would be a lot easier for us to move really aggressively on things like paid family leave if there's no employer picking up the tab for the pregnant woman. So it's like duck, duck, goose of who ends up picking up her tab and which, like, no, no, no, no. Like you could just take a break for six months from your job and your health insurance isn't part of it. They might have other incentives about your productivity or your pay or whatever, but like they don't have to pay for your health insurance. They're not like taxed for you having a baby because they're paying for your health insurance and you're not giving Them productivity in return. I think that makes a lot. I make. That makes a lot of, like, caregiving, paid family leave, periods of time off, extended time off. That helps with all of that to delink health insurance. Yeah, I think all those are great. And America, I think those are not just good things. Those are things Americans would really like for sure.
- [31:13]
B
And also, if your health insurance is tied to your job and you take a sudden hit to your income, and then your choice is to, like, try to maintain your health insurance by buying it privately, which is suddenly three times as expensive as what you've been paying. But, oh, by the way, you lost your job. That's not a great system. Nobody will miss that.
- [31:32]
A
Oh, yeah. And also, I actually think Americans would love shopping for supplemental coverage. Like, is it like, really sky's the limit here of like, it's. This is like private hospital room coverage or like, real things. You could also do, like private health insurer plan that's like. And if you get into any type of, like, physical accidents, like, we pay for a year of yoga, like, you can imagine a lot of these supplemental plans end up in, like, the wellness space where it's like, not actually health insurance because we've gotten that taken care of. And like, some of the private plans are just, like, out there making sure rich people don't have to be near poor people in the hospital. But then there's other plans that are just, like, adding, like, wellness benefits. I don't know. I think Americans would like shopping for health insurance. That's a lot lower stakes.
- [32:21]
B
I do think there's a lot of, you know, potential creativity that has been stifled by the current system. Right. Whether it's yoga or not, everyone should do yoga. But whether it's particular types of primary care, like local clinics for primary care, I don't know. It seems like there's a lot of other ways that we could be delivering care, but right now nobody gets to try those out because everything is tethered to can you get in network? You know, I think people could, including doctors and medical professionals, really have some interesting ideas about how care could be delivered once we stop worrying about how the money's shuffled around.
- [32:58]
A
That's 100%. So, like, people focus so much on, like, but all those new breakthrough technologies and treatments come from the U.S. but, like, I think we could use that type of creativity in how care is delivered without the same constraints we have. You know, I asked one of my friends who's just like one of the nation's, like, foremost experts on health delivery I mean, just like an, an absolute badass. And I asked her, like, just make it make sense to me how maternal mortality is so high. I was like, money's no object, what do we do? And she was like, oh, you'd be surprised how many hospitals don't have a crash cart and the maternity ward just like don't have it. The future of healthcare from that perspective would be you basically build a birthing center outside of a hospital and it's a vertically integrated. You only come here to give birth. It has prenatal classes, it has postnatal classes. If you are pregnant, you can just walk in and get help for whatever you need. And like their specialty is delivering babies and they do it at a certain place and it doesn't need to be attached to a hospital. And if there weren't enough places for people to deliver in a rural area, the government would build a birthing center and like put it like right where there's not a hospital. Those types of things can be hard to do in a for profit system that's like subsidized via like coverage and network and profitability of hospitals. There's also lots of like, interventions that do really well, like expanding, like what touch points of care and expanding clinics fits into this model where you're not walking in because you want to go see a specialist, you're just walking in because you haven't been to the doctor in a minute or. And decentralizing access to healthcare. I think Americans would also really like.
- [34:43]
B
Yeah, I mean, we've just gotten glimpses of this in the last few years with clinics popping up in CVS or Target or where they are trying to make some of the basic stuff really convenient. But I think we could have more of that.
- [34:58]
A
Oh yeah. I think all of those things Americans would like and the creativity of delivery that happens when you free up the payment side. I think Americans would really love. Love.
- [35:08]
B
Yeah.
- [35:09]
A
Okay. Things they'd hate.
- [35:13]
B
Things they'd hate. I think there's something about the word basic that they would hate.
- [35:18]
A
Oh yeah, we need to brand this differently.
- [35:20]
B
Yeah, it needs, it needs a name.
- [35:22]
A
I mean, to be fair, it would not be called basic care. It would just be Medicare. You get a Medicare.
- [35:26]
B
It's not called Trump Care.
- [35:27]
A
No, dude, if that's how we get it, I'm fine. Change the names when he dies. Like I don't care. But I mean like Americare or I
- [35:36]
B
mean, we still call it Obamacare, right?
- [35:39]
A
Yeah. Or it's just Social Security where you walk in with a Social Security number, and that is your health insurance number. And that's it. You just. That's something. But okay, Medicare this, Medicare Americare. Can we refer to it as Americare?
- [35:51]
B
I like Americare.
- [35:53]
A
Americare.
- [35:53]
B
I mean, if we're just gonna, you know, the political geniuses at Optimist economy have decided it should be called Americare.
- [36:03]
A
All right. Americare. America's free Universal Health Insurance, aka AmeriCare. We've identified lots of things Americans would love about it, things they'd hate now that we've taken care of the name. That was a great, honestly, great note, Robin.
- [36:18]
B
Okay.
- [36:19]
A
Other things Americans would hate. I think Americans legitimately are a little bit pampered in the healthcare system where, like, if you are one of those people who have the golden ticket of high paying private insurance, you might just be like, accustomed to a certain lifestyle that takes some adjustments. Like, you know, in these other countries, like, it's pretty normal to deliver a baby in a room that has like five other women in it. And the idea that you have a private labor and delivery room is not standard because it's not necessary. Labor and delivery can be lucrative for hospitals, and so they want to, like, make sure patients deliver there. But, you know, a big, large, comfortable room with its own, like, private yoga space for labor and delivery, like Americare
- [37:03]
B
is not probably not going to pay for that.
- [37:04]
A
Americare is not Amera luxury. So I think there will be some adjustments to that part, especially older people. Did you see the note from Production Americares?
- [37:20]
B
Just enough, but just enough. Yeah. The impression that I get from Amy Finkelstein is that people would still get supplemental. Most people would still get supplemental plans and they would, they could keep their big, big, biggie health insurance experience.
- [37:39]
A
Absolutely.
- [37:40]
B
That's a very American thing.
- [37:41]
A
I mean, I get it, like, I'm mocking it as like, rich people are going to rich. But I also understand that, like, if you are in duress and you're vulnerable, like, you want to see those comforts that make you feel safe. And if you needed that, you could get the supplemental plan. Okay, so ameracare. I'm loving. What do we call the supplemental plan?
- [38:02]
B
Ameriplus.
- [38:04]
A
You are good. Oh, my God. Ameriplus. It's an Ameriplus plan. Robin, you're amazing at this.
- [38:12]
B
I'm done. I'm just done.
- [38:13]
A
Yeah, you're just done.
- [38:15]
B
I only ever have one idea, and then I'm done. Okay.
- [38:20]
A
I think rounding out things Americans might hate, I mean, they're, they're going to hate about this health insurance what all of us hate about all health insurance plans, which is what gets covered, like what treatments are approved?
- [38:33]
B
Yeah.
- [38:33]
A
What are you allowed to do in this insurance plan? And I don't think that has anything to do with public health insurance. Other countries who have private and public health insurance, they, you know, they struggle with this because it's just, it's hard to know what needs to be allowed. I think the good part about this system is that it moves that denial of care or coverage out of the hands of for profit private insurance companies and moves it over to basically a government system that you know, might respond to congressional actions or things like that. So I don't know if that one counts as like something to just hate about Americares because people hate that about all insurance everywhere. I think the kind of a, it's an interesting kind of like side quest question there of like what happens to the private health insurance companies in the US that we have if we transition to a public health insurance plan? Like what are they going to do?
- [39:22]
B
But you know, they wouldn't roll it out in one day. Like there would be a period of adjustment here. Like I don't think that we would pass this in July and it would start in January, do you?
- [39:32]
A
You know I, I think someone who is very involved in the health insurance system would be able to answer that better. I would say that enrolling people into a public health insurance plan, I think that just takes like a billing address. I think it's it the cost of setting up a new public health insurance plan and I think it's really the cost of winding down all of the other things that we have and how to be thoughtful about like people who work at private health insurance companies who might be out of a job. But I, I don't think scaling up a public payer is hard. I think scaling down all the existing payment systems through insurance web will be the tough part and how to do that best. Someone much smarter than me will have to tell you, you.
- [40:18]
B
Well, you know, I was pleased to hear Amy Finkelstein say that this is her life's work and that they just kind of keep working on papers and research and putting out ideas, really specific ideas about how this piece would work. And you know, I think a little bit like frankly a little bit like optimist economy. It's like we're just putting the things out there. It's the same way researchers do for the moment when, when the world is ready,
- [40:46]
A
you know, I'm going to talk about it and so I'm not going to talk about it lightly. So America's frustration with health insurance is tangentially related to a healthcare executive being assassinated in the streets of Manhattan, which is an unspeakable crime. I still can't fully wrap my mind around it, but I was talking to my friend who has spent her life in public health and health insurance, and she said that we don't live in the same world we lived in 15 years ago, because 15 years ago, the idea that the government was going to force people to have health insurance and make it easier for them to do so was met with these 2009 and 2010 town halls where representatives trying to expand health coverage in the US Were met with, like, death threats. And they weren't allowed to speak. They couldn't get a word in. The idea that you were going to touch healthcare. Sacrosanct. And, you know, Obama said crazy things like, no one would ever lose their doctor. And then to think about where we have gone in just 15 years. If you were to step back and look at it like someone reading a history book 50 years from now, you would just be like, this is an absolute stunning devolution.
- [41:59]
B
This is the breaking point.
- [42:01]
A
This system is breaking in front of us. And in 20 years, it will be really obvious to see, like, oh, we're worried about the transition to Americare and Ameriplus, but, like, we are living through the collapse of private health insurance, and that collapse is heading in all kinds of ways, not just in how much Americans are paying for it, but I think that this moment in time that we're in, I mean, like, Truman almost got healthcare in the 1940s. Roosevelt almost got it in, like, the 19 aughts. We've been close before, but I. I
- [42:32]
B
think we were close even in the 70s, right?
- [42:34]
A
We were super close in the 70s. I don't know enough about those time periods to say that. That the devolution that we're going through is what they were going through. But this is incredible. So, yeah, it's going to be a hard transition, but I would welcome a hard transition over a state of the world.
- [42:52]
B
Yeah. Yeah.
- [42:54]
A
Bumper sticker.
- [42:59]
B
All right.
- [42:59]
A
All right, y'.
- [43:00]
B
All.
- [43:00]
A
Well, we fixed healthcare. It was great doing business with you.
- [43:04]
B
Americares just enough.
- [43:07]
A
Americare.
- [43:10]
B
All right, we'll be back in a minute for executive orders and spiritual sponsors. Actually, probably in a second, because there's probably no ad in this spot, but.
- [43:20]
A
So I think Americares just enough needs a jingle. Musically inclined optimist. If you feel like Americares just enough to write the jingle for our new universal health insurance plan that replaces Medicare, Medicaid, and private insurance. Y' all just, like, pick up that instrument and, like, go to town, dude,
- [43:41]
B
this is like a Simpsons episode. Americare is just enough.
- [43:47]
A
Hey, a jingle does a lot. Let's not pretend Americans are who we are. It's gonna need some jingles. All right. Yeah.
- [43:54]
B
Okay.
- [43:55]
A
Okay. Executive order.
- [43:56]
B
All right, so in the. In the long line of travel executive orders, if your flight requires. Once you get into the airport past security, if you have to walk a half mile through a tunnel under the tarmac and then take a bus to a remote terminal, they need to tell you that on your boarding pass because it takes a long ass time to get there. I mean. I mean, I can't believe how far I had to travel to get on the plane to come to Arizona. I thought, like, I walked to Arizona.
- [44:29]
A
I was like, were you flying out of Dulles? Did you. I was like, like, name names? Was this. Was this Dulles? Did Dulles hurt you?
- [44:34]
B
No, no, I flew out of LAX,
- [44:36]
A
the Dulles Airport in D.C. named after John Foster Dulles. The one that's out in Virginia. That's the one where, like, you could be walking for days. Okay. My executive order is going back to my common theme of plants, but I read about how. How much cooler, temperature wise, cooler public transit stops and bus stops are if they have a shelter that have, like, a living roof on top with, like, flowers and plants and stuff. So we just have to do that. Or maybe just, like, give me one so I can feel good about it. But I would like to see more plants and vegetation at bus stops to make them cooler and more pleasant. Trees, plants, flowers at bus stops, even in downtown areas where you could put on a living roof.
- [45:20]
B
Mm.
- [45:21]
A
Okay. So my spiritual sponsor is the resurrection fern, which is a plant that grows in Texas on trees. And it's called the resurrection fern because when it's not wet, like, if it hasn't been raining, the thing shrivels up small and brown, and it looks like your oak tree has a bunch of dead plants on it. And then once it rains, they, like, pop open bright green. And so then your tree is, like, covered in this, like, awesome green foliage. And they're called resurrection ferns because they do look dead the majority of the time, and then they're bright green after it rains. And there's something, like, very lovely to look out and be like, oh, my God, the green of the fern.
- [46:06]
B
Well, inspired by your resurrection fern. My spiritual sponsor is my aunt Fern, who is actually who I'm here to visit in Tucson. My aunt and uncle were married 10ish years ago though she was 75 and it was her first marriage. So I got an aunt, you know, in my 40s and she's great and it's been really great visiting her. Oh.
- [46:31]
A
Oh my God. Robin.
- [46:32]
B
I should say they were. They were shacked up for a long time before they got married, but.
- [46:35]
A
Oh my God. Living in sin.
- [46:37]
B
Yeah.
- [46:38]
A
What'd she tell her mother?
- [46:39]
B
But she's great. She's just really great. Yeah.
- [46:48]
A
The Optimist Economy podcast is edited by Sophie Lalonde. Our video production for social media is by Andy Robinson. We will snap this out. Had to add a credit to Andy this episode. He's also Captain Sass.
- [46:59]
B
Random random jokes.
- [47:01]
A
Yeah, Sass and jokes coming through the chat. Andy's feeling himself today and so we got to snap that part out too. America cares just enough. That's you. Appreciate it. Video clips from the show for you to share are on Tick tock, Instagram, Facebook, YouTube or LinkedIn. And you can buy T shirts and tote bags on our website, optimisteconomy.com new merch announcement coming soon.
- [47:22]
B
By the way, I got one of the women's T shirts and I'm going to tell you, they run a little small, but they're really great. Size up. If you are on substack, free or paid subscribers to Optimist Economy can join our chat room there. And if you have the means to contribute at whatever level is comfortable for you, we'll take your gift. Gift optimisteconomy.com and thank you to everyone who has contributed lately. We appreciate it. And I'm still tracking some of you down so that I can name you on this show. That sounds like a threat. Sorry.
- [48:00]
A
We will thank you for your charity and your kindness and support. You believe in us and people will God damn know it. This has been Optimist Economy. So happy, so grateful. Love and light. Love and light. And I will thank you.