The David Frum Show – "Architect of Obamacare: Health Care Is Still a Mess"
Date: December 3, 2025
Host: David Frum (The Atlantic)
Guest: Jonathan Gruber (MIT professor, principal architect of Obamacare)
Episode Overview
This episode dives into the persistent problems of the American healthcare system, as David Frum is joined by MIT professor Jonathan Gruber, a principal architect of the Affordable Care Act (ACA/Obamacare). Together, they discuss why healthcare in the US remains staggeringly expensive and inequitable, unpack how political and structural shortcomings have kept reform elusive, and explore the unique social forces shaping health outcomes. The episode also confronts how misinformation continues to shape public policy debate, and ends with Frum’s reflections on democratic responsibility and societal recovery in reference to the book They Thought They Were Free.
Key Discussion Points & Insights
1. The Two Core Challenges in U.S. Healthcare: Cost and Disparity
[11:01]
- Expensive, Unequal, and Inefficient: Healthcare spending (~18% GDP or ~$5 trillion/year) outpaces other countries, but results lag, especially in lifespan and infant mortality.
- Disparities, Not Just Averages: For affluent Americans, health outcomes match those in peer nations. But for disadvantaged groups, outcomes are far worse.
- “A white baby born in the U.S. today has the same infant mortality rate as one born in Scandinavia. A black baby... worse than one born in Barbados.”
—Jonathan Gruber, [11:01]
- “A white baby born in the U.S. today has the same infant mortality rate as one born in Scandinavia. A black baby... worse than one born in Barbados.”
2. Health, Healthcare, and Socioeconomic Factors
[12:41]
- Healthcare Isn't the Biggest Driver of Health: Genes and behavior matter more than care. Still, Medicaid expansions have saved tens of thousands of lives.
- “Health care is third; that doesn’t mean it can’t play a huge role... But the real driver is socioeconomic conditions.”
—Jonathan Gruber, [12:41]
- “Health care is third; that doesn’t mean it can’t play a huge role... But the real driver is socioeconomic conditions.”
3. What Healthcare Disparities Look Like
[13:31]
- Being Uninsured = Lack of Preventive & Maintenance Care: Emergency rooms must treat all, but the uninsured lack routine and chronic care management.
- “You won’t get preventive care. You won’t get maintenance for your chronic diseases... That is the major disparity.”
—Jonathan Gruber, [13:31]
- “You won’t get preventive care. You won’t get maintenance for your chronic diseases... That is the major disparity.”
4. What Other Countries Get Right
[14:48]
- Universal Coverage & Price Regulation: Other industrialized countries (e.g., Canada, Switzerland, Germany) ensure universal coverage and tightly regulate healthcare prices. The US alone allows prices to be set (imperfectly) by market “forces.”
- “There should be government regulation to help determine the prices. Every other country in the world learned that lesson. We have not.”
—Jonathan Gruber, [14:48]
- “There should be government regulation to help determine the prices. Every other country in the world learned that lesson. We have not.”
5. The Myth of a Pure "Free Market"
[15:34]
- Medicare's Role Is Real, But Limited: While Medicare sets patterns, outside of its realm there is little price governance. The coding system is not fully controlled by Medicare, and vast parts of healthcare costs remain unregulated.
- “There is no regulatory mechanism that drives the vast majority of the spending in the U.S. today.”
—Jonathan Gruber, [16:10]
- “There is no regulatory mechanism that drives the vast majority of the spending in the U.S. today.”
6. Drivers of Out-of-Control Costs
[17:22]
- Not Everyone Is Overpaid: Primary care doctors and nurses are not highly paid compared to peers abroad. The real drivers: overpaid specialists, executives, and—uniquely—middlemen like pharmacy benefit managers (PBMs).
- “It’s our specialists, our executives, and in particular the vast array of healthcare middlemen... that’s the big, a big driver of the costs.”
—Jonathan Gruber, [17:22]
- “It’s our specialists, our executives, and in particular the vast array of healthcare middlemen... that’s the big, a big driver of the costs.”
7. Broken Markets and Entrenched Interests
[18:48]
- Structural Dysfunction and Lobbying: The healthcare market failure was clear half a century ago, but entrenched private interests (e.g., PBMs, insurers) now defend the status quo.
- “The rest of the world’s learned that lesson. We haven't. Now … it’s hard to get rid of [the lobbies]. That is the fundamental challenge going forward as we think about controlling healthcare costs.”
—Jonathan Gruber, [18:48]
- “The rest of the world’s learned that lesson. We haven't. Now … it’s hard to get rid of [the lobbies]. That is the fundamental challenge going forward as we think about controlling healthcare costs.”
8. "Skin in the Game" & Consumer Cost-Sharing
[19:49]
- Consumer Cost Controls Help—But Only Marginally: There's evidence that making consumers price-sensitive curbs some waste (especially in low-value care), but this is not the root problem.
- “There is a room for consumer skin in the game, but...it’s not the primary driver of spending...most spending is not places that are consumer price sensitive.”
—Jonathan Gruber, [19:49]
- “There is a room for consumer skin in the game, but...it’s not the primary driver of spending...most spending is not places that are consumer price sensitive.”
9. Why Shopping for Healthcare Is a Mirage
[21:23]
- Opaque Prices Undermine Consumer Choice: Even within a city, costs for procedures like knee replacements can vary wildly; pricing is murky and non-transparent.
- “It’s hard to shop when you don’t know the prices...before we’re ever going to have a consistent role of consumer shopping as an important determinant of our healthcare system.”
—Jonathan Gruber, [21:23]
- “It’s hard to shop when you don’t know the prices...before we’re ever going to have a consistent role of consumer shopping as an important determinant of our healthcare system.”
10. Public Health: Behavior, Policy, and Their Limits
[22:59]
- Changing Health Behaviors Is Hard: Smoking rates dropped only via a long, multifaceted campaign. Alcohol, sugar, and other behaviors are more complex targets.
- “It took 30 years to even get reversal on [smoking]...we need a campaign to recognize the enormous cost imposed. But let’s be clear, David, this is hard.”
—Jonathan Gruber, [22:59]
- “It took 30 years to even get reversal on [smoking]...we need a campaign to recognize the enormous cost imposed. But let’s be clear, David, this is hard.”
11. Polarization, Misinformation, and Public Attitudes
[24:37], [25:24], [27:07]
-
Personal Attacks & Public Confusion: Gruber describes the hostility he faced for his role in the ACA and how persistent top-down misinformation sustains polarization.
- “It was quite awful how mean people were...most people who do that are really misinformed.”
—Jonathan Gruber, [24:37] - “There’s a difference between being uninformed and being misinformed...We have a top down misinformation problem.”
—David Frum, [25:24]
- “It was quite awful how mean people were...most people who do that are really misinformed.”
-
The Never-Ending Fight Over Obamacare: The political game-changer was that the opposition never stopped, even after the ACA became law.
12. Individual Agency, "Deservingness," and the Role of Luck
[28:24], [29:23], [30:45], [31:33]
-
Cultural Beliefs in Health and Luck: Americans tend to see health outcomes as deserved, resisting the reality of genetic or random misfortune.
- “People believe that your health is determined by your hard work—until they get sick.”
—Jonathan Gruber, [29:23] - “Did I deserve that? Did I do something good? Am I better than my mother? Am I better than my daughter?...It is a lottery…”
—David Frum, [30:45] - “Most of health is determined by our genetics and we have no skin in the game on that.”
—Jonathan Gruber, [31:33]
- “People believe that your health is determined by your hard work—until they get sick.”
-
The Real-World Stakes for All: Gruber and Frum each recount personal stories underscoring that luck, not virtue, often dictates health.
13. Research Cuts, Innovation, and Economic Growth
[32:43], [33:13]
-
The Threat to Scientific Progress: Funding cuts to NIH and other agencies under Trump threaten future breakthroughs in genetics, medicine, and broader economic innovation.
- “That government funded science was what gave rise to every technology. We cut that back, we don’t just cut discovery, we cut economic growth.”
—Jonathan Gruber, [33:13]
- “That government funded science was what gave rise to every technology. We cut that back, we don’t just cut discovery, we cut economic growth.”
-
Policy Solutions: New initiatives, like the CHIPS and Science Act, aim to create regional technology hubs and tie science investment to local jobs.
14. American Individualism & Resistance to Scientific Evidence
[36:32]
- At Root: Attitudes, Not Just Policy: The U.S. focus on individual responsibility makes collective solutions and acceptance of luck difficult.
- “I think there is this notion in the American character of individual responsibilities drives everything.”
—Jonathan Gruber, [36:32]
- “I think there is this notion in the American character of individual responsibilities drives everything.”
Notable Quotes & Memorable Moments
-
“Healthcare is a broken market. The free market should not be determining the prices.”
—Jonathan Gruber, [14:48] -
“Once people understand this law, they like it better...What’s happened to public approval which has gone from underwater to 65% over time?”
—Jonathan Gruber, [24:37] -
“We have a top down misinformation problem.”
—David Frum, [25:24] -
“People believe that your health is determined by your hard work—until they get sick.”
—Jonathan Gruber, [29:23] -
“Did I deserve that? Did I do something good? Am I better than my mother? Am I better than my daughter?...It is a lottery…”
—David Frum, [30:45] -
“Most of health is determined by our genetics and we have no skin in the game on that.”
—Jonathan Gruber, [31:33] -
“When we teach American troops to kill in cold blood, we’re not just harming the victims of the killing...We are teaching American soldiers to commit crimes. And that’s not a lesson that they will forget.”
—David Frum, [41:35], from the book reflection
Important Timestamps
- [11:01] – Two core problems: cost and disparities in U.S. healthcare
- [13:31] – Why the uninsured suffer: preventive and chronic care denied
- [14:48] – What other nations do differently (universal coverage, price regulation)
- [17:22] – Real reasons for high costs: specialists, executives, middlemen
- [19:49] – Limits of "skin in the game": consumer cost-sharing's impact
- [24:37] – Gruber on personal attacks and enduring misinformation
- [29:23–31:33] – The myth of deservingness, the reality of health luck
- [33:13] – Cuts to public science undermine future healthcare and growth
- [36:32] – American ethos and challenges for science and public health messaging
Book Reflection: "They Thought They Were Free" by Milton Mayer
[38:20–46:29]
David Frum draws lessons from Mayer’s mid-century study of ordinary Germans living under Nazism, drawing a line to the culture of doing nothing in the face of wrongdoing. Frum laments a creeping moral degradation in American public life amid scandal and lawlessness, arguing for robust accountability and civic renewal:
- “For all that was required of most of us...that we do nothing. That’s what the Trump program requires of most of us. Just do nothing. Let us proceed.”
—quoted professor in Mayer’s book, cited by Frum, [42:42]
Frum urges listeners to recognize the passive complicity enabled by disengagement and find ways to recommit to foundational democratic values.
Tone & Closing Thoughts
The conversation is frank, occasionally caustic, but ultimately hopeful—asserting that understanding (and honestly confronting) the flaws in the American healthcare system is the first step toward meaningful reform. Both guests share personal stories, adding humanity to questions of policy, and express the conviction that citizens must demand better—both of their system and themselves.
For listeners interested in the intertwined challenges of politics, policy, economics, and culture in American healthcare—and the fate of democracy—the episode is essential, clear-eyed, and thought-provoking.