The Government is Already Paying for Your Health Insurance, Buddy

About 18% of U. S. GDP every year gets spent on health care. Half of that, 9%, is coming from the government, which is about the whole cost of other countries’ public health programs. In other words, for what the U. S. spends on Medicare, Medicaid, Tricare, VA benefits, and the tax write-off for employer-sponsored plans, we could have free basic health insurance for everyone. This is why the co-authors of the 2023 book “We’ve Got You Covered” describe the current health insurance system as a total tear-down. We could have universal insurance coverage for all with no tax hike if we started building from the ground up. Chapters: 0:00 Announcements 0:58 Retcon — Costco cashier's $33/hr job and career security 2:49 Terms & Conditions — Political economy, Cost Sharing, Gatekeeping 7:45 The Big Pilcrow: “Americare… Just Enough” 8:08 Healthcare vs. health insurance — why this is really an insurance/payer fight 12:53 We have 5+ public health programs already 17:07 Health economist Amy Finkelstein's research: "It's a tear-down, not a fixer-upper" 19:55 The proposed system — universal basic coverage + letting “rich people rich" without letting them opt out 28:11What Americans would love or hate 40:44 This health world changed a lot since Obamacare 43:20 Executive Orders — Airport boarding pass warnings, living-roof bus stops 45:20 Spiritual Sponsors — Resurrection fern, Aunt Fern 46:42 Credits Donate to Optimist Economy: https://optimisteconomy.com Video-curious? Watch the Optimist Economy YouTube channel⁠⁠ https://www.youtube.com/@optimist_economy. We’re also on Instagram at ⁠⁠@optimist_economy https://www.instagram.com/optimist_economy or TikTok at ⁠⁠@optimist_economy https://www.tiktok.com/@optimist_economy. Chat with other Optimists on Substack. https://substack.com/chat/4604257?utm_source=pub-nav-bar Find utility with our merch: https://merch.ambientinks.com/collections/optimisteconomy Got economic questions, concerns, or executive orders? Send them to [email protected] mailto:[email protected]

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  ProPublica has broken some of the biggest investigative stories in recent history, from conflicts of interest at the Supreme Court to the deadly impact of abortion bans. Now, we're bringing our journalism straight to your ears on a new podcast, Paper Trail. Each episode, we take you inside a new investigation. We'll tell you how some of the best investigative reporters in the country know what they know and how the world changed in response to their reporting. I'm Jessica Lussenhop. Follow Paper Trail on your favorite podcast app.

• 0:35Speaker 01

  Love that we found the answer. Any more guesses for me? Yes.

• 0:48Speaker 01

  Hello and welcome to Optimist Economy. I'm economist Catherine Ann Edwards.

• 0:52Robin Rauzi?

  I'm editor Robin Rousey.

• 0:54Speaker 01

  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.

• 1:05Speaker 01

  Today, big old problem. It's gonna be a fun one.

• 1:08Robin Rauzi?

  Yeah, it is.

• 1:08Speaker 01

  We're talking about healthcare.

• 1:09Robin Rauzi?

  We are. Health insurance specifically.

• 1:11Speaker 01

  Health insurance, 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.

• 1:23Robin Rauzi?

  Okay.

• 1:24Speaker 01

  First up is announcements. I don't think we have any, other than we always appreciate a review. Sassy or the better. We can move right into Redcon.

• 1:34Robin Rauzi?

  Right.

• 1:35Speaker 01

  The question from our shift worker episode, is Starbucks a restaurant or drinking place?

• 1:42Robin Rauzi?

  I looked that up, and it is a limited service restaurant, not a drinking place.

• 1:46Speaker 01

  Okay.

• 1:48Robin Rauzi?

  Okay.

• 1:48Speaker 01

  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 $1 million 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 people through a checkout line up to four times as fast as someone who has just been hired. So.

• 2:31Robin Rauzi?

  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.

• 2:42Speaker 01

  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 waste. 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.

• 3:13Robin Rauzi?

  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.

• 3:23Speaker 01

  Yeah. Okay. Terms and conditions. What'd you look up?

• 3:27Robin Rauzi?

  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?

• 3:45Speaker 01

  Jesus, I don't know. I saw it on the outline. I was like, oh, my God, I'm so excited. Robin's gonna explain to me what political economy is.

• 3:52Robin Rauzi?

  Yeah, I mean, I.

• 3:53Speaker 01

  I've never understood it.

• 3:54Robin Rauzi?

  Okay, well, there we are.

• 3:56Speaker 01

  I mean, I think I took it as shorthand for, okay, so this is like a truly 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.

• 4:14Robin Rauzi?

  Hmm.

• 4:15Speaker 01

  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. Like, 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 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 where I am. Political economy, to me, is how politics

• 4:58Speaker 01

  shapes economic policy, but is not actually the economy.

• 5:03Robin Rauzi?

  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.

• 5:26Speaker 01

  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.

• 5:51Robin Rauzi?

  Well, but it could be things like government regulation of an industry leaves markets, like in health insurance, like we're gonna talk about today.

• 5:59Speaker 01

  Mm-hmm.

• 6:00Robin Rauzi?

  That was a transition.

• 6:01Speaker 01

  Or I could see it.

• 6:02Robin Rauzi?

  Did you like it?

• 6:02Speaker 01

  Oh, that was a transition. Okay, okay. I could also see it as like, economic policy creates political constituencies.

• 6:11Robin Rauzi?

  I love how you're like, I don't know what it means, but then you're gonna keep telling me what you think it means.

• 6:17Speaker 01

  I'm giving you my interpretation of it, à la modern ballet. Okay, cost sharing is my term and condition.

• 6:23Robin Rauzi?

  Yeah, cost sharing.

• 6:24Speaker 01

  Cost sharing sucks. So a cost sharing would be your co-pay, your co-insurance.

• 6:34Robin Rauzi?

  Deductibles.

• 6:35Speaker 01

  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.

• 6:54Robin Rauzi?

  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 healthcare. 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.

• 7:20Speaker 01

  Yes, it does do that. Also, it makes it harder for poor people to get healthier.

• 7:25Robin Rauzi?

  Right.

• 7:25Speaker 01

  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.

• 7:53Robin Rauzi?

  Right.

• 7:53Speaker 01

  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?

• 8:10Robin Rauzi?

  Nice, nicely done. Perfect.

• 8:12Speaker 01

  Okay, great. We'll come back for the big pill crow.

• 8:20Robin Rauzi?

  Okay, we're back with the big pill crow. Again, if you're new here, the big pill crow 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 healthcare in the United States could look like. Does that sound like a fair summary, Catherine?

• 8:40Speaker 01

  I think so.

• 8:42Robin Rauzi?

  Okay. I guess I want to make a distinction between healthcare and health insurance. You know, 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. And so that's what health insurance should be doing. Healthcare is the actual delivery of medicines and medical treatments. 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.

• 9:18Speaker 01

  Gosh, I do that all the time. I'm like, health consurance.

• 9:21Robin Rauzi?

  Care assurance.

• 9:22Speaker 01

  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

• 10:07Speaker 01

  in the US, 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.

• 10:15Robin Rauzi?

  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.

• 10:44Speaker 01

  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 healthcare 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 two obvious ones is we have Medicare, which is a basically un-gate-kept

• 11:29Speaker 01

  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 you turn 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

• 12:13Speaker 01

  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.

• 12:19Robin Rauzi?

  You're saying you can't supplement it, right? With wraparound?

• 12:22Speaker 01

  You can't supplement Medicaid.

• 12:24Robin Rauzi?

  Okay.

• 12:25Speaker 01

  Which is a problem.

• 12:26Robin Rauzi?

  Okay. So we have Medicare, we have Medicaid.

• 12:28Speaker 01

  Yeah, so now we have the VA.

• 12:30Robin Rauzi?

  Right.

• 12:31Speaker 01

  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 to government sites 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, VA, TRICARE. Coming in number five is your employer-sponsored health insurance plan.

• 13:14Speaker 01

  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 a Medicaid, which means that it's another form of public health insurance. So that's number five.

• 13:57Speaker 01

  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.

• 14:24Robin Rauzi?

  So in other words, the federal government, you're saying the federal government's fingers are all through healthcare already?

• 14:28Speaker 01

  Yeah, I mean, I think that people, you know, 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 not getting people healthcare 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 healthcare, even though we have government healthcare, basically in all these different forms. Because if the government is paying for your health insurance premium for a private plan, that's government healthcare. You just don't want to call it that. Like, it's from your employer, but like, hell, if the government didn't put the thumb

• 15:13Speaker 01

  on the scale, you wouldn't have it.

• 15:15Robin Rauzi?

  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 say about this current system.

• 15:31Speaker 01

  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.

• 16:07Robin Rauzi?

  Yeah, but Switzerland's a country of 10 million people. Like, it's not even, it's like a tiny little country.

• 16:14Speaker 01

  They're all rich.

• 16:16Robin Rauzi?

  Anyway.

• 16:17Speaker 01

  And that tiny little rich country still needs a heavy hand of government regulation and rulekeeping, and like, the government still has its fingerprints all over that system of like keeping prices in check and deciding how things move. I mean, it's...

• 16:32Robin Rauzi?

  And maintaining a huge amount of competition. I mean, think about that. That's the size of LA County. We have 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?

• 16:49Speaker 01

  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, à 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.

• 17:18Robin Rauzi?

  Like Medicare for all? Like, that would be bad?

• 17:21Speaker 01

  I don't know if like Medicare for all, like what they think that means.

• 17:25Robin Rauzi?

  Yeah, I think it's young people who aren't in Medicare, and they don't know what Medicare really is.

• 17:30Speaker 01

  Because Medicare 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?"

• 18:02Robin Rauzi?

  Yeah. She's also, I think, she's a recipient of a MacArthur Genius Grant. Like, she's been recognized for putting out a lot of really interesting ideas.

• 18:11Speaker 01

  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 You 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.

• 18:47Robin Rauzi?

  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 is 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 teardown. We have to start over. That's her take.

• 19:13Speaker 01

  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, you know, before you buy it, they're basically saying like, "You will spend more money fixing it than you ever will having to just tear it down and rebuild, so this is a teardown." It's such a like clear metaphor. I'm almost surprised it came from an economist. We struggle with words. I was like, "Oh, that conveys it perfectly." Like, our health insurance system is a money pit. Tear it down and rebuild it.

• 19:44Robin Rauzi?

  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.

• 19:53Speaker 01

  Yep.

• 19:54Robin Rauzi?

  And I think that sometimes the Medicare for all thing is like, "Let's just have everybody move into the living room." And you're like, "No, no, it's a teardown." Just to extend the metaphor.

• 20:03Speaker 01

  If we all sleep in the living room for two years.

• 20:06Robin Rauzi?

  If we all just get in the garage, it'll be fine.

• 20:09Speaker 01

  But when you say "tear down," what you really mean is a teardown of the payment side. Like, health insurance.

• 20:15Robin Rauzi?

  Yes.

• 20:16Speaker 01

  It's a payment issue. How we allocate insurance and risk and copayments and co-insurance and cost-sharing and coverage, that is the teardown. How do we tear it down?

• 20:30Robin Rauzi?

  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 two-thirds 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.

• 21:12Speaker 01

  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 automatically on it. 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 gate-kept 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

• 21:55Speaker 01

  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.

• 22:22Robin Rauzi?

  And she thinks this is totally possible.

• 22:24Speaker 01

  Oh, yeah.

• 22:25Robin Rauzi?

  Catherine also thinks it's totally possible. I think it sounds outrageous. Like, how could we possibly do this? But...

• 22:30Speaker 01

  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.

• 23:11Robin Rauzi?

  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 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 a universal, basic coverage all the time, that just wouldn't happen.

• 23:46Speaker 01

  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

• 24:27Speaker 01

  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 England, 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.

• 24:53Robin Rauzi?

  Yeah, you just top off.

• 24:54Speaker 01

  I mean, it's the difference between flying JetBlue versus, you know, first-class on British Airways. Like, 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.

• 25:28Speaker 01

  Honestly, I thought it would take us a lot longer to explain, but it's really not that complicated.

• 25:35Robin Rauzi?

  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, when there is care available, and treatments that are available

• 26:15Robin Rauzi?

  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.

• 26:25Speaker 01

  I did some, like, landscape work of, 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, like, give rich people, you know, basically rewards in other ways, and other ways to make their healthcare, it's more palatable. I mean...

• 27:05Robin Rauzi?

  Yeah. 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.

• 27:15Speaker 01

  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 US, 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

• 27:58Speaker 01

  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 an 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 gate-kept from receiving it, and people who are not gate-kept from receiving it. And they just, they go wherever. Unifying

• 28:41Speaker 01

  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?

• 28:53Robin Rauzi?

  About a universal, an automatic, universal, basic care system. Yeah.

• 28:57Speaker 01

  Yeah.

• 28:57Robin Rauzi?

  Okay. 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.

• 29:07Speaker 01

  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.

• 29:17Robin Rauzi?

  Yeah. I think so, too. Highly unlikely to have medical bankruptcies. I think we'd like that.

• 29:23Speaker 01

  No medical debt.

• 29:25Robin Rauzi?

  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 gonna get the care you need to survive, or what's treatable, anyway. And not where you're gonna wind up in an ambulance, taking you to the wrong hospital, and you're gonna have a doctor who's out of network, and then you're suddenly gonna be, um, sent a bill for $300,000.

• 29:57Speaker 01

  Network. Ugh. Ugh. Network.

• 30:00Robin Rauzi?

  Network is a word I'd be happy to never hear again.

• 30:02Speaker 01

  Yeah. Same thing with co-insurance, co-pay, 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 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 co-insurance... 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.

• 30:42Robin Rauzi?

  Yeah, they have trouble paying for the cost sharing piece of it.

• 30:46Speaker 01

  And you know what? Not having to rely on your employer or your spouse's employer is

• 30:53Robin Rauzi?

  Game changer.

• 30:54Speaker 01

  What a [bleep] 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

• 31:37Speaker 01

  of time off, extended time off. That helps with all of that to de-link health insurance.

• 31:42Robin Rauzi?

  Yeah.

• 31:43Speaker 01

  I think all those are great. And America, I think those are not just good things. Those are things Americans would really like.

• 31:47Robin Rauzi?

  For sure. And also, if your health insurance is tied to your job and you take a sudden hit to your income and then your choices 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.

• 32:07Speaker 01

  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. But if 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.

• 32:50Speaker 01

  I think Americans would like shopping for health insurance that's a lot lower stakes.

• 32:55Robin Rauzi?

  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, 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, how care could be delivered. Once we stop worrying about how the money's shuffled around.

• 33:33Speaker 01

  That's 100%. So like, people focus so much on like, but all those new breakthrough technologies and treatments come from the US. 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 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. But what do we do? And she was like, oh, you'd be surprised how many hospitals don't have a crash cart and a maternity ward. Just like, don't have it.

• 34:12Speaker 01

  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.

• 34:55Robin Rauzi?

  Yeah.

• 34:55Speaker 01

  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. And decentralizing access to healthcare.

• 35:13Robin Rauzi?

  Mm hmm. Yeah.

• 35:14Speaker 01

  I think Americans would also really like.

• 35:18Robin Rauzi?

  Yeah. I mean, you know, we've just gotten glimpses of this in the last few years with clinics popping up in like 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.

• 35:32Speaker 01

  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.

• 35:43Robin Rauzi?

  Yeah.

• 35:44Speaker 01

  Okay. Things they'd hate.

• 35:48Robin Rauzi?

  Things they'd hate. I think there's something about the word basic that they would hate.

• 35:52Speaker 01

  Oh, yeah. We need to brand this differently.

• 35:54Robin Rauzi?

  Yeah. It needs, it needs a name.

• 35:57Speaker 01

  I mean, to be fair, it would not be called basic care. It would just be Medicare.

• 36:00Robin Rauzi?

  It would be called Trump care.

• 36:04Speaker 01

  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.

• 36:10Robin Rauzi?

  I mean, we, we still call it Obamacare, right?

• 36:13Speaker 01

  Yeah. Or it's just [bleep] social security. Where like you, you walk in with a social security number and like, that is your health insurance number and that's it. You just, that's something, okay, Medicare. This Medicare, Americare? Can we refer to it as Americare?

• 36:26Robin Rauzi?

  I like Americare.

• 36:27Speaker 01

  Americare?

• 36:28Robin Rauzi?

  I mean, if we're just gonna, you know, the political geniuses at Optimist Economy have decided it should be called Americare.

• 36:38Speaker 01

  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.

• 36:52Robin Rauzi?

  Okay.

• 36:53Speaker 01

  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. Cause 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.

• 37:36Robin Rauzi?

  Americare is probably not going to pay for that.

• 37:39Speaker 01

  Americare is not Amera luxury. So I think there'll be some adjustments to that part, especially older people. Did you see the note from production? Americare's just enough.

• 37:55Robin Rauzi?

  But just enough. Yeah.

• 38:00Robin Rauzi?

  The impression that I get from Amy Finkelstein is that people would still get supplemental cover. Most people would still get supplemental plans and they would, they could keep their big, big, biggie health insurance experience.

• 38:14Speaker 01

  Absolutely.

• 38:15Robin Rauzi?

  Like, that's a very American thing.

• 38:16Speaker 01

  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. What, okay, so Americare, I'm loving. What do we call the supplemental plan?

• 38:37Robin Rauzi?

  Ameraplus.

• 38:39Speaker 01

  You are good. Oh, my God. Ameraplus. It's an Ameraplus plan. Robin, you're amazing at this.

• 38:47Robin Rauzi?

  Done. I'm just done.

• 38:49Speaker 01

  Just done.

• 38:50Robin Rauzi?

  I only ever have one idea and then I'm, and then I'm done.

• 38:54Speaker 01

  Okay. 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?

• 39:08Robin Rauzi?

  Yeah.

• 39:08Speaker 01

  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, 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 Americare's 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

• 39:52Speaker 01

  we have? We transition to a public health insurance plan. Like, what are they going to do?

• 39:56Robin Rauzi?

  But you know, they wouldn't rule it out in one day. Like, there would be a period of adjustment here. Like, I, I don't think that we would pass this in July and it would start in January. Do you?

• 40:07Speaker 01

  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's less 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.

• 40:52Robin Rauzi?

  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, as the same way researchers do, for the moment when, when the world is ready.

• 41:20Speaker 01

  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. It's, 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

• 42:01Speaker 01

  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 was 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.

• 42:33Robin Rauzi?

  Mm-hmm. This is the breaking point.

• 42:35Speaker 01

  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, and not just in how much Americans are paying for it, but we just, 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 1900s. We've been close before, but I-

• 43:06Robin Rauzi?

  I think we were close even in the 70s, right?

• 43:08Speaker 01

  We were super close in the 70s. I don't know enough about those time periods to say 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 [BLEEP] state of the world.

• 43:25Robin Rauzi?

  Yeah.

• 43:26Speaker 01

  Bumper sticker. All right, y'all, well, we fixed healthcare. It was great doing business with you.

• 43:39Robin Rauzi?

  Americare's just enough.

• 43:41Speaker 01

  Americare!

• 43:42Robin Rauzi?

  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-

• 43:55Speaker 01

  So, I think Americare's just enough needs a jingle. Musically in kind, optimist, if you feel like Americare's 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.

• 44:15Robin Rauzi?

  Dude, this is like a Simpsons episode. Americare's just enough.

• 44:20Speaker 01

  Hey, a jingle does a lot. Let's not pretend Americans aren't who we are. It's gonna need some jingles. All right. Yeah. Okay, executive orders.

• 44:31Robin Rauzi?

  So, 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 can't believe how far I had to travel to get on the plane to come to Arizona. I felt like I walked to Arizona.

• 45:03Speaker 01

  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?

• 45:09Robin Rauzi?

  No, no, I flew to LAX.

• 45:10Speaker 01

  The Dulles Airport in DC, 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 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.

• 45:55Robin Rauzi?

  Mm-hmm.

• 45:56Speaker 01

  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, they do look dead the majority of the time, and then they're bright green after it rains. And there's something like, hmm, very lovely to look at and be like, oh my God, the green of the fern.

• 46:40Robin Rauzi?

  Well, inspired by your resurrection fern, my spiritual sponsor is my Aunt Fern.

• 46:44Speaker 01

  Oh.

• 46:45Robin Rauzi?

  Yeah, who is actually who I'm here to visit in Tucson. My aunt and uncle were married 10-ish years ago. 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.

• 47:03Speaker 01

  Oh. Oh my God, Robin.

• 47:06Robin Rauzi?

  I should say, they were, they were shacked up for a long time before they got married, but-

• 47:10Speaker 01

  Oh my God, living in sin?

• 47:11Robin Rauzi?

  Yeah.

• 47:12Speaker 01

  What'd she tell her mother?

• 47:13Robin Rauzi?

  But she's great. She's just really great, yeah.

• 47:22Speaker 01

  The Optimist Economy podcast is edited by Sophie Lawnd. 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.

• 47:34Robin Rauzi?

  Random, random jokes.

• 47:35Speaker 01

  Yeah, sass and jokes coming through the chat. Andy's feeling himself today, and so we got to snap that part out, too. Americare's just enough, that's you. Appreciate it. Video clips from the show for you to share are on TikTok, Instagram, Facebook, YouTube, or LinkedIn, and you can buy t-shirts and tote bags on our website, optimist economy dot com. New merch announcement coming soon.

• 47:56Robin Rauzi?

  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 at optimist economy dot 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.

• 48:33Robin Rauzi?

  That sounds like a threat. Sorry.

• 48:35Speaker 01

  We will thank you for your charity and your kindness and support. You believe in us, and people will goddamn know it. This has been Optimist Economy. So happy, so grateful. Love and light, love and light, and I will thank you.