Navigating the Intricacies of US Healthcare: A Comprehensive Insight with Industry Veteran Greg Vigdor

Parker Condit: 0:01

Hey everyone, welcome to Exploring Health macro to micro. I'm your host, parker Condit. In the show I interview health and wellness experts and by the end of each episode you'll have concrete, tangible advice that you can start implementing today to start living a healthier life, either for yourself or for your loved ones. And that's the micro side of the show. The macro side of the show is discussing and having conversations around larger systemic issues that are contributing to health outcomes here in the US. So an example of that would be understanding financial incentives in the US healthcare system. So if you understand how insurance companies and healthcare providers are paid or compensated, you start to have a better understanding of how certain decisions are made, and that's something we discuss in today's episode. My guest today is Greg Vigdor. Greg spent his career as a healthcare executive and two of his more prominent roles were serving as president and CEO of the Washington Health Foundation and later the Arizona Hospital and Healthcare Association. He's now an author and largely retired from that healthcare executive part of his career, and he's using his storytelling skills as a vehicle to teach and inform people about so much of what he learned during his tenure as a healthcare executive. Today's conversation sort of in the theme of this show, from macro to micro. This conversation sits more on the macro side of things. Today we end up discussing the history of health insurance and how that's shaped the current healthcare system, what a patient centric future looks like, how misaligned financial incentives lead to worse care, what needs to be done to rein in healthcare costs and spending, and what patients can do to be their own best advocates. And I'm well aware that healthcare and health insurance are boring, but those two things are also it's like the biggest government expenditure and it's also biggest national expenditure each year. So if you don't love your health insurance and you don't love the healthcare that you get in this country, it's important to learn about these particular topics so you're more informed and you can make better decisions moving forward. So, without further ado, I hope you enjoy my conversation with Greg Vigdor. Greg, thanks so much for being on. I want to start by just getting a better view of like patients within the healthcare system. So could you just briefly describe how you think of the patient role within the US healthcare system?

Greg Vigdor: 2:21

Sure Parker, and thanks for having me on, really enjoy your show and glad to be a part of it. It's really an odd thing to say that patients are really a secondary thing in the American healthcare system and you can't have a healthcare system without patients. But really the patient is more of a commodity than really the central feature of the system and a lot of the defects and a lot of problems we have, I think, at least to my thinking and experience really revolve around that defect. So unfortunately the patient is not the center and we need to somehow make them more of the center in order to really, I think, improve things and fix things in some cases.

Parker Condit: 2:59

Yeah, it's kind of a strange thing where, kind of within the healthcare system, people aren't referred to as people, they're referred to as lives or attributed lives. Yes, they're kind of just units within the system. They sort of represent a metric of how much money that unit can represent for a particular system. Yes, and outside, learning about it it was like that was very disheartening, and we'll get into more of that throughout this conversation, I'm sure.

Greg Vigdor: 3:25

Yeah, and it's disheartening to a lot of the people in the system trying to provide care.

Parker Condit: 3:29

Sure, yeah, I imagine that as well. Can you just write briefly how we got to the situation where I understand where healthcare and health insurance started? It did start from kind of a good place. I think it was like a hospital in Texas. That was one of the original places where it started. But so how did we get to this point now where we are, where people are just lives, they're sort of just units within this almost inhumane system? It feels like?

Greg Vigdor: 3:58

Yes, I think it doesn't matter history, but I start the history before really health insurance became a thing. Okay, and I'd go back to even 125 years ago if you got sick and you saw healthcare it was really something that you wouldn't expect a good outcome from. Our scientific understanding of what we could do to the human body and spirit was really limited, and what really sparked everything was the beginning of scientific discoveries around things like the germ theory of disease that infections can spread and can kill you, and that being somehow brought into an institution where there are even more germs and unsterile conditions was that was what was going to kill you, not whatever you went in for. And then we also saw that with anesthesia, where suddenly you couldn't really take care of people and do things like surgery because the pain was too extreme and suddenly we had a way to knock people out and take care of them. So these discoveries around the turn of the century, 20th century, really started to shift things. But one of the shifts was really that how to take the whole system into the future more scientifically. And a lot of it was around medical education, where physicians were still able to go out there and just hang out their shingle and say I'm a physician, I'm going to take care of you. And the medical profession itself stepped up and tried to make itself a true profession and started to really govern this a lot around medical education and requirements to become a physician, and they approached this and again, most of this is really good news from scientifically. When they did it, though, it went to the logical extreme of really starting to break down the body parts and the dysfunctions. So early on, patients became not whole units but heads or hearts or skin or all the specialties and now sub specialties that we have in education developed around that, even if you've ever been to observe an operating room procedure, the entire patient gets covered except for the one place where they're working on. So there's this disassociation that happened with that whole phenomena scientifically and that really sort of sparked the beginning of this different role for the patient and how we view them as a clinical thing rather than a whole person. What, then, really took it to its extreme was really the advent of third party payment mechanisms, whether it was private insurance or not, for profit insurance like the historic Blue Cross, blue Shield plans, or then later government programs like Medicare and Medicaid and others those essentially dealt with patients not as patients but, as you described it, units were. Somehow they were factored into how do you get paid for that care? And in many cases the actual care had very little to do with the payment. In fact, the origins of Medicare when it first started was a cost reimbursement system. So it was not like there was a specific unit of the patient, it was just you would load up all the care that you provided, the cost of that care for Medicare patients in a facility and say you're going to pay me this for that. So it was disassociated. Those routes just kept extending and extending and getting more complicated and it's left us in this position where the patient is this third party thing rather than the central part of the system.

Parker Condit: 7:21

That's great. I appreciate that pretty concise backstory to what is a very robust topic. I do want to get to the future at some point and wondering if we're going to get to a more holistic view. But I want to go to, I guess, the bifurcation, because if you look outside the United States it's not necessarily the case where there is this individualized each body part is treated individually. There is a bit more of a holistic approach. If I look at Europe, it's a little bit better and it's not also specialized. Do you know why there was that split? Did it come from how things? Was it the education that you were speaking to that encouraged that specialization here in the US?

Greg Vigdor: 8:05

I think it's a little bit more of the finances in this case, because the scientific discoveries were happening all over the world, including some of the medical education approaches. We might have taken a more aggressive approach to setting it up the way we did. I think a lot of the European countries modeled us after that, but it was really more on the financial side. If you remember, when we had the real boon to all this, it was post-World War II America. We were able to go all in in terms of what I call the age of more more healthcare services, more health insurance, more everything, because suddenly healthcare was a good, because we discovered that positive things could happen out of the battlefield experiences of the scientific discoveries. Most of the rest of the world was devastated and did not have the resources that we could put into it. They had to take a more practical approach. I think that's part of the reason why they probably more emphasize the specialties where you're more likely to get at the holistic view of the patient, primary care, for example. I think their systems are actually built much more on that. Maybe there's other cultural reasons, given our difference in global histories, where they would reach that conclusion more than the high age of specialization that we have really reached in the United States.

Parker Condit: 9:20

Okay, yeah, that actually does make more sense that the resulting outcome of the war and just the circumstances of each of the countries. We had the flexibility to do so and, like you said, more practical sense in Europe. Can we speak to what you think the patient role is in the future? What will the patient look like? I'll let you set the timeframe, but if you're optimistic, what do you think the patient role will be in the future?

Greg Vigdor: 9:48

I try to be optimistic all the time. I'm struggling a bit lately with this very question because I think we're about to have a bit of a battle over where the future of American healthcare is going, and this is to me the core question If is it gonna be one where the patient is empowered and put in the center of the system, or is it gonna go even further, to the extreme of? There? Are these other entities, corporate entities that are really gonna be in control of our healthcare and will be sort of put more in the position of having to deal with what we get? So I don't know the answer to that. A lot of what I've been writing in my novels is essentially setting up the battle and trying to figure out what happens with it. I'm about in my third book and I have to start to answer this question for it, and I truly don't know what I'm gonna put in the book yet. The analogy I make to make this understandable. So a bit like I think one of the better analogies for the healthcare system is the airlines industry, and when I first started flying, flying was a fun thing, and it was. It might actually, but pretty expensive relatively speaking, but it was something you're worth paying, because the experience itself something you took a good thing out of. All these things happened to the airline industries and suddenly flying became most of the cases when I had to do it really expensive and really inconvenient and really clear that no longer was the passenger the central unit in that experience, and I think the airlines industries are still struggling with trying to figure out how that's gonna work. And what we're starting to roll into, I believe, is where there's not that many air carriers and they're the ones that are gonna hash out this answer, not the American international flying public. I think that's where we are in healthcare, maybe a little bit behind the airline question, but not in terms of the inconvenience and the unhappiness about the experience of being a patient.

Parker Condit: 11:36

Yeah, so I do wanna take a detour if you happen to know this, but I've heard that airlines now are more they operate more like banks than they do actual airlines, because they're not making a ton of money off the actual tickets, it's more their credit cards and their frequent flyer programs. Is that correct?

Greg Vigdor: 11:53

That's my understanding too. I'm not an airline expert, but I truly believe that.

Parker Condit: 11:58

Okay, yeah.

Greg Vigdor: 11:59

And I think it's the same follow-up phenomena when your central unit isn't the passenger but something else and strange things start to happen and middle people start getting involved in that that are affect the transaction of what should be the true customer to the system offering the service.

Parker Condit: 12:15

Right, we're gonna end up. So this is something that came up on a recent episode. That's not out yet, but I did record recently. It was like for every healthcare dollar that comes in, how much is actually going to providers or practitioners or clinicians, the people providing the care, with like direct touch points to the patient, and I think it was I wanna say it was 32 cents, so there's like 68 cents of I don't wanna say waste, because it's not all waste, but admin and middle men and the inefficiency is staggering. Where there are nursing shortages, there are physician shortages, there are staffing issues, it's because not enough of the money from each healthcare, every healthcare dollar, is going to the people providing care. That's right.

Greg Vigdor: 12:58

And it's unlikely there's shortages of these middle people that are transacting a lot of the money.

Parker Condit: 13:04

Well, no, it's the biggest industry in the country for a reason because there's so much opportunity to make money if you can insert yourself into the system in some way. Exactly so. You spoke about corporate entities. Can you describe or can you talk about what some of the biggest corporate entities are in this space?

Greg Vigdor: 13:22

Well, there's so many of them now. It's a bit of what to me also happened during the COVID experience. While we were focused correctly on trying to figure out how to deal with that catastrophe in so many different dimensions, what was happening was the healthcare system itself was getting more and more consolidated in all directions. So horizontal consolidations, so hospitals, which historically have been community-based institutions, and it started to become more prominently part of major healthcare systems across regions or the entire United States. More and more individual community hospitals were basically bought up I might have described it some other way but were bought up by bigger systems, and then the bigger systems bought up even bigger systems, bought up by even bigger systems, and so that's just one example Physicians being purchased by hospitals and health systems. When I started my career, it was common but not the majority of the physicians that were employed physicians on a system or a hospital staff. They were independent practitioners. Now it's flipped entirely where it's harder and harder to find an independent physician. So they're starting to get incorporated, but it's not just happening there. Also, all these entities are going into not just care models, from acute care to secondary care, to primary care, to nursing home, types of care, residential care. They're going up and down that unit, but they're also getting to the insurance and the financing side as well and really blurring their identity. Then the last piece I'll just throw in to why it's hard to track all this is that there's now private entities that had nothing to do with healthcare in the past Amazon, for one, and other just commercial entities that are in venture capital saying we want in on this game. We can see there's big money to be had and they're coming in with their own model. Some of these are pharmacy based, some of them are just based in nothing but the desire to make profits. Because they see what's there, they're coming in and starting to say we're gonna create our corporate thing to get into the future and get into this playground where there's profits to be had. That's what's going on right now. It's a little hard to follow it because there's so much of it going on and most of it isn't very public.

Parker Condit: 15:41

Yeah. So a few other corporate examples of like companies that you wouldn't expect to be getting into the space. Walmart is one. They're gonna be implementing primary care in their location because they think about their demographic and they think they're already here we can provide primary care or some sort of care right within the store. Another one would be Best Buy. They're getting into the hospital at home and remote patient monitoring space because of their Geek Squad capability and they have the infrastructure to get people set up in home. So, yeah, there's a lot of these things that you probably, unless you're really plugged into this, you probably wouldn't be incredibly aware of. But yeah, there's a lot of consolidation and that's a big concern for me as well. Can you actually describe the difference between, like, what exactly is a health system For people who aren't incredibly plugged into the space? For just a lay person, what is a health system? Then maybe we'll sort of unravel the consequences of what's happening.

Greg Vigdor: 16:36

Well, it's a somewhat fluid concept in the eye of the beholder. So a lot of this came from the hospital world, where they wanted to stop being identified as just an acute care institution in the belief by the leadership that that would limit their role into the future, whether it was financial or even if it was population health-based, that they wanted to be seen more as somehow getting out of just a sick care business into something more. So they would describe themselves, self-describe themselves, as a health system instead, and a lot of marketing executives gave them branding advice. So that was a good thing to do and they would invent these new names, which ultimately usually included the phrase health system in it, and it became whatever they were. But there are other health systems that really truly have come into this with. Their notion is they are a health system, they're a conglomerate health care corporation, whether they're investor-based or not-for-profit-based, where they are trying to take a broad view of all facets of what it takes to provide healthcare and basically put themselves into a leadership role over that transaction and series of transactions.

Parker Condit: 17:45

Yeah, unless you're paying attention to stuff or you live this stuff at work every day. It's just two words that you hear and they're not super complicated independently. But then you sort of dive into it and you're like are there also payers sometimes and they provide care and they're a hospital, but they have specialty groups and primary care. It can all get very confusing.

Greg Vigdor: 18:05

And the most frustrating thing in the consumer perspective is whenever you experience, and I shouldn't say whenever. Usually, when you experience it, you go. It's many things, but system was not exactly the word that came to mind. In my personal experience, it seemed totally detached, in fact.

Parker Condit: 18:21

So yeah, very much Part of the oddity of healthcare. Yeah, and what you're alluding to is the lack of interoperability and coordination amongst providers who, in theory, are under one umbrella or one system, where they should be able to coordinate and work together easily, and that is usually not the case, right?

Greg Vigdor: 18:39

even when you just walk down the hall.

Parker Condit: 18:42

Yeah, it's like we're gonna take your vitals again. It's crazy.

Greg Vigdor: 18:45

We need your patient information. You have to fill out another form. It's like I was just down the hall doing that.

Parker Condit: 18:50

Yeah, exactly, it's a. Yeah, I'm sure that's an experience that resonates with a lot of people listening because it's oh so common, which is bizarre. So if we wanna talk about kind of the future being more patient-centric, having a patient at the center of their healthcare experience instead of them being plugged in and spun into the existing system, how can patients be better advocates for change and be drivers of change for that particular future?

Greg Vigdor: 19:20

So I think there's a number of fronts on how this battle is going to play out, and my optimistic part you asked about earlier is that there are some technological pieces that will allow us some new ways of thinking about the industry, sort of like how the internet spurred a number of changes to the Americans economy and to other sectors, and then that will activate it. But I think we're sort of waiting for that and the opportunity is find that. But it's not just all wishing for that to come. I think there's two tracks to this. One is that I think patients and consumers to take it a little bit broader have to empower themselves. They need to try to take control of their health care, even though everything they deal with in the health care system is trying to suck that desire out of them. So you just got to find your ways to do it. One of the things I was proud of back when I was the CEO of a very active Washington Health Foundation is we developed a whole series of what we called health home tools, and these are free tools, are actually still on our website and you could just take them and use them as a consumer and try to activate and empower yourself to say I'm going to try to take control of my care experience. So, for example, primary care visit and especially with physicians becoming part of these bigger systems where you'd go in and you'd have maybe some embarrassing thing you really want to take care of. But then the first time you're seeing this provider and you walk in and their head is buried in their machine, they're typing notes, they're just asking you questions and they're going like I've got 10 minutes, I'm going to get you out of here. And that's sort of the transaction. We created a really simple form where you could fill it out and you give it to the physician and it says what things do I want to get out of my visit? And you can put on there that it's some communicable disease or something whatever and you've passed it to them. They've had to take their eye to the computer, they're looking this document and effectively created a contractual commitment between the two of you that that's what you're there for, not whatever it is they're going to send you to. And again, that's the type of thinking we tried to do that in over 30 different ways of how people could really just sort of take control of the experience they find themselves in at the moment and sort of assert their empowerment over the situation. But I think that's the type of thing that people need to do. Maybe it's just really insisting upon that because they're not into health home tools and things like that. But I think people just have to really take it upon themselves to say this isn't a system where I'm in the center and I want to be in the center. Maybe it's around caregivers who provide that support that people are feeling particularly vulnerable. So there's a whole front to that. But the other side of this, I do think it's clear that part of the ways we're going to unravel this will require a role of government activity, and I mean in terms of policy, whether it's legislation or regulation or court based law. There is going to be an engagement over this at some level, for no other reason than the impact of Medicare and Medicaid on the structure of American healthcare. But I think it's way more than that too. So there will have to be a coming together of trying to solve this, and I don't think it can be in our typical political boxes, because those were captured long ago in the partisan wars. So it's trying to figure out where you can get in the game politically to to affect change that you would like to see for you. Again, we have not been really good at trying to create those opportunities historically and we tend to go back into our partisan corners around this very issue because it's very activating in terms of politics. But I think there's a way for people to gain engaged. Part of what I've been trying to do in my books is bring some common knowledge and understanding so people can find where they agree on these issues rather than where they disagree, and I think there's actually substantial areas of agreement, but they just have not yet found their political basis for moving into the future. So those are the two big fronts I think we can work on while we hope or dream for some technological shift that really takes the industry to a new place into the future.

Parker Condit: 23:23

Yeah, those are great points. I think patient empowerment has come up quite a few times on here. I'm a huge patient advocate and I very much fall on the side of things where it's like you. Even if the system that we're currently in is not necessarily working for you and its best capacity, it's still your responsibility and you have to make the most of it. It's unfortunate that, like learning about healthcare and learning about the healthcare industry is not more interesting, but it's kind of why I do this show to try to make it more accessible, to understand the nuances of the system, and the more you know about the system you're operating in, you can make better decisions, if not for you, but maybe in a caregiver capacity as well.

Greg Vigdor: 24:01

It's why I write my books. The same reason is that I thought well, I've spent 40 years of my career trying to do this the normal way. Now I'm trying to write entertaining novels. Whereas you read the entertaining story, you're getting this real experience of what it means in terms of American health policy to change it.

Parker Condit: 24:17

So I definitely the next question after this one is definitely going to go into the idea of using story to educate people, which I love because people learn through stories and it resonates with people. But as far as the government activity is concerned, I think collectively most people in the US they're not thrilled with the healthcare system and at the very least, that's something they can agree on. Like, not many people are kind of go through a healthcare experience and they come out of it and be like that was awesome, I love the care, I love how much I paid, I love how easy it was. Not many people have that. So a very common goal or talking point at least to be something needs to change. But on the political side it's like you said. It's very tricky with the partisan issues on both sides and sort of the talking points that have become established. Do you have any resources that you can point people towards, that people can get involved or learn more about what can be done from a healthcare and government perspective?

Greg Vigdor: 25:15

Well, of course, my books, but beyond that, I think there's a fair amount of conversation beginning on this front, sometimes at national level, but sometimes even at the community level, around things like a hospital being proposed to be purchased by a bigger system, where these issues start to pop up. So that's some level you might engage in, start to learn about this, but it's again it's hard to activate right now. I think the hope is to build a movement there. You go back about 20 years. There actually were some things going on, but most of those seem to have faded away, including some of the ones we did with the Washington Health Foundation way back when one of the proudest things that I was ever involved in was us engaging every Washington state county in a conversation at the community level about healthcare, where our goal was to find areas of agreement, and we found violent agreement and across the political spectrum. But the hard part was activating it into somehow creating the change, because it started to again bifurcate back to the two political parties and the differences. So I think part of what needs to happen is a movement gets built, both the local level, the state level and the national level, where there is exactly what you're asking about is where are these places where I can engage, rather than with my typical candidates and my typical political party nonsense, and where can I find real solutions that actually would mean something to me and my family and the people I love?

Parker Condit: 26:41

Okay, great, yeah, I think it's really helpful and one of the questions I'm going to ask later sort of like what are the consequences of the sort of consolidation and like what happens to a local community hospital that did operate independently is now part of a system. But I want to get back to one of the things. Very core to you is being an author, right? So we are going to link to all of your books in the show notes and in the description on YouTube. But I think the idea of kind of sneaking the vegetables in, so you're kind of teaching people through story the ins and outs of the health care system, so can you kind of just go through. If you were always in or you were always drawn to writing growing up, did you always have this sort of literary act or was this something later in your career you decided was a good vehicle to help share these stories?

Greg Vigdor: 27:33

It was sort of an odd thing that I discovered in the in the pandemic. So I had left my last position as the CEO of the Arizona Hospital Association in 2019. And I was going to take a little bit of time off because I had worked since I was a little kid and said, well, just enjoy some time able to go back to work. And then the pandemic hit and it's like I'm not sure I'm ready or anybody's willing to get me involved in the craziness that was going on. So, instead of sitting on, what do I do? And I went back to when I was a kid. I always had this dream of writing the great American novel, and when I was, you know, five years old, I think, I was writing draft novels. So I said, well, why don't I pick that up and just sort of do that just as a bucket list type of thing? And then I did it and I sent to a couple friends. They said this is pretty good, you should try to publish it. And it was about healthcare. Because I said was I had no idea how to write a novel or short story. Even so, I was just sort of making it up as I went along and then I started to realize that there I had an act for, but the beginning it was I'm going to write about things that I know about, because it's hard enough to write. If I have to make it up to that's just a row too far. So I started writing about healthcare, just naturally because of that. And that's where I started to realize a couple of things. One is, which is it is these stories that in my career, what I had learned as a healthcare leader and executive was that everybody had a healthcare story, oh yeah, and if they didn't have one, they would soon enough. And so the way to communicate, even back when I was engaged in the trench work and politics, was to tell stories. And I said, well God, this is a vehicle for me to keep on the work that I had been doing. And getting back to the work that I had been doing, and I was like I'm going to write a book about healthcare. And I was like I'm going to write a book about healthcare, but now just in this concept of being an author. And so I started to explore that and I've written my second book and I've sort of found that there's a place for this. It's very natural to people. People have really different ways of thinking about what I was doing and this instead seems very comfortable and engaging to do and maybe can have an impact Totally.

Parker Condit: 29:41

It's cool that I'm finding this kind of as I grow older. Life is very cyclical and some of the things that you were just naturally drawn to in childhood or early childhood just end up circling back to. It's nice to see that for you, sort of the literary and creative outlet of writing has circled back and what seems like a very has become like a very nice outlet for you in this time. So I do kind of want to move, move past that and go on to the healthcare system a bit more. So we've already kind of gone over like the enough of the backstory to do this, but so let's just go to more recent history of the Affordable Care Act. Can you briefly describe what that initial intention was and what the results have been thus far?

Greg Vigdor: 30:34

So the original intention was to do major health care reform for the nation, coming through the federal government, around basically three fronts, two of which are usually forgotten now. First was around access to health coverage, essentially in using this managed care competitive model to achieve that. That's the one most people center in on, although they might not resonate with those terms. But it was also to somehow reform the financing and delivery such that care got way more efficient and productive. In terms of the cost question, which is the driving problem for most Americans, there's all sorts of other problems, but the cost is just horrific and has always been getting worse. It's just how much worse. So it was supposed to do some real things around that. And the third though and this is really forgotten was it was to really reinvigorate public health in America, and there are provisions that finance that and we're trying to really sort of get that sort of on a new territory. So the second two never really happened, in my opinion, or they were fits and starts and reasons why they just went away and they weren't good reasons. They're more political reasons. So most of the focus has been on the first question, where I would sit back. People ask me what do I think about and I said well, it's the closest we've come in this country to getting everyone into the system. And if you can't get everyone into the system, you don't really have a system when it comes to health care, because you just go to the emergency room. If you're completely shut out and you get in and that sort of triggers a whole series of consequences for why the system starts to break apart, including some of the price transparency questions you were asking. It just flows through and makes the system a mess. So the Affordable Care Act did more to close that gap than any other action we took aside from Medicare historically and so that was a good thing. That it left some people out and it didn't deal with the cost question in a real, pragmatic and useful way or the public health question and the health improvement question in a real, effective and pragmatic way were the failings. But the most important thing to me about the Affordable Care Act was that actually happened in past, because at the time the political convention was that health care and health care policy was the third rail of American politics from the Clinton experience and other experiences at the state level, and then if you tried to do something about that that you would just get burnt, and you would get burnt horribly in terms of political consequences. And instead President Obama and I was involved in some of this behind the scenes decided to do this anyways, and certainly had consequences to it politically, but got it done. And we're getting to this point now and I'm not sure about this, but it seems to be getting to this place where the fact that this is a fabric of the American health care system, these coverage provisions, might now finally be something that even Republicans accept, even though, oddly enough, the model that we adopted was a Republican, conservative model, which brings another whole line of question you probably don't want to go into. But it really said that there's a way to deal with this politically too and somehow come to resolution on these really thorny questions, and up till then people had said don't go there, it's just going to be the way it is and we have to accept the consequences.

Parker Condit: 33:55

Yeah, it's interesting that from a political standpoint there are so many things that can be done but there's such like hot button topics where it's like, if you want to get reelected, it's not a wise political choice to even address it. So I think that's kind of what you're alluding to with any sort of major health care reform or policy.

Greg Vigdor: 34:13

That's right, but it happened in the Affordable Care Act. That was beyond notable, that was amazing.

Parker Condit: 34:20

So the good is that it's now like part of the fabric of the US health care system. It did remove access. What are some of the or feel free to speak to any other the upside that you've seen and any of the downside you've seen come out of it.

Greg Vigdor: 34:36

So the upside I believe one of the core ones as it evolved was really how Medicaid moved from basically an adjunct welfare program to non intact families to a true health care system insurance program. It's really not insurance, since it's government based, but it really is a coverage program. That really now is somewhat sophisticated in terms of how it's approaching that question, rather than somehow sort of trying to add health care onto what were welfare benefits.

Parker Condit: 35:09

Okay, I didn't realize that was that's what it used to be.

Greg Vigdor: 35:12

And it's really become a vital thing for so many people in America, and especially with the Affordable Care Act expansions, that's where this really started to take on a different character, because so many people were covered and they weren't the people that were usually in the political ads. You found out it was your next door neighbor who had been covered in their work for 25 years and then suddenly got cancer and were tossed out and had nowhere to go but the Medicaid.

Parker Condit: 35:41

Oh, interesting.

Greg Vigdor: 35:41

Okay, and your neighbors, your family members. It just became a central fabric to somehow make sure we're taking care of those people and get them coverage when they needed it most, and Medicaid in most states has become that and just an essential part of the system. So I think that's actually the core thing that's happened, not just that there's coverage, but that Medicaid itself has advanced into becoming something that it did not used to be before the Affordable Care Act.

Parker Condit: 36:10

Okay, yeah, I appreciate you sharing that because I know so little about Medicaid, just because learning about the healthcare industry in and of itself is hard because it's so big and convoluted, right. And then you get to Medicaid and it's a it's like dual funded from a federal government and then it's also like a state independent as well. So like every state's Medicaid is different. So I saw I'm like, oh, it's 50 different versions to learn and I kind of just ignored it.

Greg Vigdor: 36:35

It's mind numbingly complex.

Parker Condit: 36:37

Right, yeah, yeah. So it's a ton of work to fully understand Medicaid, but it's nice to. I appreciate you explaining. That was one of the one of the things that came out of the ACA that I would not have known about either. Is there? Has there been any downside that's come out of this?

Greg Vigdor: 36:53

I do think that there was a great missed opportunity and both the effectiveness question about how it is we get the cost question answered, and also this public health question, which there was a mechanism set up to try to do better and, if anything, we've slid far further in terms of our approach on that because of the craziness of the pandemic experience. So if we had done more with that at the time, I think maybe we could have managed our way through the pandemic on public health, and we really have never really addressed the cost question effectively. So it's it's tempered some, but it's really not an answer, it's not a solution and and I think we know what a lot of the solutions would be in terms of making care more affordable we just don't have the courage and the commitment to do them, including things like getting the patient more in the middle of the equation.

Parker Condit: 37:43

Very much so yeah, there's most of the money that's been is spent on a small portion of the population, so it's it's just treating the sickest and oldest people in the country, and I think a lot of those resources just need to be reallocated earlier in life to prevent getting to that point. But that's much easier said than done.

Greg Vigdor: 38:03

Well, there's a lot of research on that around the social determinants of health, where that, at best, healthcare as a way to produce health is eight to 10% of what your investment should be. It should be all these other things which are much more about the person and their social circumstances and society that they live within. Yep Community building. In terms of trying to create productivity in healthcare.

Parker Condit: 38:26

Right, but it's, yeah, it's counterintuitive. It's like, yeah, it blows people's mind when you hear that, like eight to 10%, I didn't even know it was that low I had. I had always thought of it around 20% as far as, like, the clinical care you receive contributing to your overall health. So, even lower than I would have expected, even lower, yep, yeah, so it's pretty alarming and it's those other things. Can you just talk a little bit more about social determinants of health for people that aren't familiar with that, because people probably just think of the typical things. When you think of your health, as far as what your doctor tells you to do, the prescriptions, you're on the quality of the hospital, you can go to your cholesterol level, your glucose level. So what are these other factors that are contributing as well?

Greg Vigdor: 39:10

Yeah. So it's really getting away from thinking about healthcare as a sick care phenomena and what it is you would do to produce your own and society's health, because really that's what we aspire for is to be healthy, not to somehow manage our disease processes. And when you start to think about it from that point of view, you get to well, what creates that health? And, again, medical care. 8% to 10% is usually what has been out there as the the the factor that could really make a big difference. But you start to get to a number of different things. So environmental hazards, for example, pollution badness, housing, bad housing will lead to bad health outcomes, bad nutrition. There's a whole set of these that are important to understand as physical and personal relationship questions. It's sort of, what can you contribute to yourself? How much are you responsible for your own health? And I've always sort of, just as an offhand, said that probably about half of these determinants are things that are under your own personal control and the usage you somehow have to take care of and not count on society to really be the one doing it. They can help you get there. But the really things like do I, am I watching my weight? Am I eating right? Am I getting my preventive health care services? The list there's a pretty good list of things you can pick from, and my smoking is actually probably on top of the list. So there are all these other factors, both the manner that the person can take responsibility for or are subject of social questions like the environment or housing or transportation. Poverty, health disparities based on race and ethnicity is part of the thinking about all this. These are all the factors at play and it's there's, I think, really good grounding now to that. We know where it is. We would go in terms of making the investments to solve these things, but we just don't have the political will to get there and changing the health care system being part of it, and many of those other systems, like pollutants and housing. Those are other political hotspots where we're just reluctant to really get in and do what needs to be done.

Parker Condit: 41:21

whatever one thinks from your ideological point of view, the answer should be yeah, it's you talk about like community building or anything that's like the direct environmental factors, that where people live, and you wouldn't necessarily think of that when you're thinking about health care originally, you're probably thinking more along the lines of like, oh, I need to, I know I need to exercise, I know I need to eat better, but what about having like a safe, supportive community to live in? So that's where a lot of these things and it's like how do you, how do you sort of reconcile that? Do you take money? Do you take dollars that would be allocated towards patient care and allocated towards community development and green spaces? It's tough to crack, but there's a lot of people working on this now and it's a much more. It's a much more public conversation, which, at the very least, is progress, but the healthcare system moves in a staggeringly slow pace.

Greg Vigdor: 42:14

So progress is kind of painfully slow to come by. You asked about lost opportunities. Going back to the Affordable Care Act, this is one of those which I believe we know that the ability to do that is really at the community level and bringing together community coalitions. There was even a movement that was described as the healthy communities movement, that this was what it did, what it was really actively doing back then and it was looking to be a big part of the next wave of the solutions and instead the Affordable Care Act didn't really give that resonance. It gave resonance to the other things that really weren't going to advance. What you were just describing the ability to somehow tackle these things more collectively at the community level in nonpartisan ways.

Parker Condit: 42:54

I think that's a huge point that a lot of people miss is that when you're trying to make change at the community level, it can't be coming from on high, from the federal government. It can, but it's probably not going to be effective. There needs to be organic growth within the community. There needs to be those leaders of people who live there who resonate with the residents and they are part of that community and it's like they become a leader and they become sort of a pillar to kind of lift everyone else up. But it has to come at that like organic sort of grassroots level. I think it's been proven many times you can't just throw money at a situation where there's not buy-in at the community level. So that's kind of circling back to what you talked about earlier of that local political buy-in. It's a great place to start getting involved and kind of getting a better understanding of these community initiatives. What are your thoughts on the single payer system? Do you think we're moving in that direction? Do you think it would help? Do you think it would just further politically divide our country?

Greg Vigdor: 43:51

Well, I've been willing to rethink a lot of my political assumptions over the last five years, but I don't think I've changed on this one, which is I've never seen it as a possibility for the United States. It's just not how we're wired. Canada is wired that way. I have a lot of Canadian friends and whether they like the Canadian healthcare system or not, they understand where it comes from culturally in the way they approach the world. That's not America. That's not how we roll Very much so. I just don't see it happening. I just don't see a confidence in the government being the one to come up with these answers, in at least whether it's real or perception. It's just not our way. We were always going to come up with our own unique solution to somehow drew upon these other forces of the marketplace or community or other things, and that's what I think we're grappling with.

Parker Condit: 44:41

Yeah, we have a very weird blended healthcare system here where there's parts of it are government funded, parts are private, other parts individually funded. I had a guest on previously who spoke, who was originally Canadian, lives here now, but he spoke about how Canadians speak in general. It's a lot more we, it's a lot more collective language and that's, I think, what you're alluding to. Then here in the US it's more me. I individually focused, leading to solidify your point of I think it'd be hard for so many individuals in this country to adopt a single payer system or vote somebody in who would be able to implement that.

Greg Vigdor: 45:20

Yes, even state level systems seem to be a bit too government based for people, although that is a viable option. To think of it that way.

Parker Condit: 45:30

Very much so. Is there anything you've changed your mind about? You have a long history operating and working within the US healthcare systems. Is there anything you've seen over the past few years where you're like I used to think this and now you've really changed your mind within the US healthcare space?

Greg Vigdor: 45:46

There are a few that I think. The central one for me is the role of money and a financial opportunity in the system. I've always known it had its good parts as a social incentive, but also some of its dangers, I think. Historically, I believe you could manage that because of the tradition, history of not-for-profit in healthcare. What I've been watching over the last few years has really given me pause about our ability to control that phenomena, as I've watched venture capital firms and some of these hospital consolidations and health system consolidations that are never described as being about money. But I've been doing this for too long to not understand how to read the press releases. Let's be real yeah, exactly, it's really about money and it's clearly about scale and it's clearly about marketplace investments beyond the actual healthcare product itself. So I've really started to question what that is going to do to our capacity to come up with what we need to be a uniquely American solution. It just seems to have so much juice right now in terms of people believing there's major amounts of money to be had from this system. That seems to me to really threaten the ability to counter what we should be after, which is how we produce a healthcare system that's producing health for the American people.

Parker Condit: 47:09

Yeah, it's very strange. I've been learning a lot more through work about remote patient monitoring and accountable care organizations and those are groups that are supposed to help with patient coordination amongst a lot of practices and also control costs. And then so you kind of speak to them and you find out what they really care about. And it's star ratings are incredibly important and most people listening have probably never heard of a Medicare star rating before. But it matters to lots of these groups because they need to check certain boxes and it's how good the reimbursements are and how much they can control costs and then somewhere down the line, patient outcomes are included in there. But it's so strange to see these massive systems where it's like, even if you can improve patient outcomes but you can't do the above, they're not necessarily going to care. So the financial implications can't really be understated. Yes, well put, or, sorry, overstated. They can be understated. Yes, they can be yes. Is there anything else you'd want to share about this topic? I know we've kind of covered a lot and we just kind of just I always end up kind of bouncing around because the healthcare system is so broad, but is there anything else you want to share around, anything that we've spoken about today.

Greg Vigdor: 48:27

Well, when I had, it's one of the possible questions you sent to me, which was if I was president for a day, what would I do? And gets to your last point, because I think a lot about this, is something I think a lot about, for what I put in my books too, and the one I came to, if I had to pick one, was to basically flip the paradigm you were talking about on its head and say why don't we have a clear set of national health goals in this country and hold people accountable to them the system itself, politicians, healthcare providers, healthcare insurers. So, for example, one of them would be I would think would be about cost. And let's say that the cost of the system isn't going to go up more than you know 3% a year, take a number. And if it does go up more than that, that there's consequences to that, including clawbacks in terms of money that was paid to providers and others. Similarly, if you think about it, not just around money, but around how to produce health. So what if, just to pick one variable you might look at, to what would mean good health, is the receipt of proven preventive clinical care, things like well, it used to be common knowledge that vaccines were good. I guess I shouldn't use that as my example right now, but breast cancer screenings I think that's still a safe territory to say. That's probably a good thing for most women of a certain age to have them, and it's really effective in terms of catching things early, both for the person and the system in terms of cost. And we say that there's a the ratio of, and there are these variables that are out there. Calculate this of how much you get that as a population. Well, what if we said that's our national health? Goal is to make sure that you know we're in the top quadrant of countries across the nation in that. And then if we weren't, then there are consequences to it. And I think what you'd find in the healthcare system is certainly around the clinical part of the system is that they respond very, very well to clear metrics and the sense of where they are in terms of those metrics. And if you really want to create change in the healthcare system, I think we have learned very clearly from the patient safety movement that that's what you want to do is give the healthcare system clear metrics and goals to get to, and if you do, they will usually get there.

Parker Condit: 50:41

Yeah, that's a great point. So you just you gave a very concrete example of what I was vaguely describing with star ratings. These ACOs are doing things for star ratings because those are the metrics they need to check off. Right, there's a checklist of things you need to do and it's all going to contribute to your star rating.

Greg Vigdor: 50:56

So that's exactly right.

Parker Condit: 50:58

No, exactly. Yeah, you'd like to see patient outcomes a little bit higher or weighted a little bit more heavily, but no, I think that's a. I think that's a great way to.

Greg Vigdor: 51:07

Yeah yeah. Collectively, from our sense of what we think we want to achieve in America. Maybe it's the end of cancer, right? You can just imagine. Let your imagination go crazy with what if you had 10 health goals for the nation. What would they be? Yeah, eliminate smoking, reduce smoking Again. I could riff off of this for about a half an hour.

Parker Condit: 51:26

Sure, yeah, no, and like kind of going back to the individualistic nature and sort of the, I guess like the culture of America, if you sort of set forth a goal of like us being best at something, yes, like if we set some like best health metrics of like worldwide, you know, maybe we'd strive towards that a little bit more instead of just trying to be best in other things. But as a country we love being best and the greatest and everything. So, yeah, if we could circle around health goals, that'd be, that'd be a great thing to do.

Greg Vigdor: 51:56

So our Washington Health Foundation, way back when we did a healthiest state in the nation campaign for a number of years, it was predicated on exactly the thinking you're talking about. We can chat about that at some point.

Parker Condit: 52:06

Yeah, yeah, definitely. So it sounds like you did a lot of interesting work there. What are some of the other initiatives you did? So you had like sort of the access to education that you did for helping people empower themselves, healthy state in the nation. What are some other things you did there?

Greg Vigdor: 52:21

Some of it was just basic work. I was really proud of the programs we ran in the Seattle King County area that were basically helping to get people who needed health coverage or a way to manage their health care experience, support early patient navigators there was just staff who would answer the phone and work with people and providers to make sure that matches were made where people who needed care would able to get access to system just block and tackle work. We did an awful lot with the health of communities movement, trying to help sponsor that, not just in Washington state but the national movement and trying to give it some legs and some juice. We did an awful lot in terms of the rural communities in our state and then also that spread nationally too, of trying to help give rural communities usually ones that had hospitals in them that were the center of not just of the health care system but the local economy a way to imagine that they had a future instead of where they were headed when we were doing this work, which was essentially toward closure. So we're really proud of that work Just a whole series of more individual local community initiatives wrapped up in this bigger political question of how do you create a movement for bigger health reform across not just Washington state but the nation.

Parker Condit: 53:37

Yeah, was that one of the more progressive states as far as health care is concerned?

Greg Vigdor: 53:43

Certainly was. I spent more of my time in Arizona now I spent a little bit of time up there still, but certainly we were always trying something new and different. Sometimes it seemed like that was the point was to make sure it was new and different, and I think some success I think some the word is successful, but certainly a hotbed for trying to figure out a different way to do things.

Parker Condit: 54:03

Yeah, I mean. Yeah, you need to be creative. You need to think differently to drive innovation, especially in such a complex system as health care. So I'd love to circle back to your books. You have a third one that is going to be written. I'm confident and can you just tell me about the first two, the basic story of them and which parts of the system that the parable goes through in each of your books?

Greg Vigdor: 54:28

So the first book is called the Theory of Irv and they're all medical detective stories. With the heart of them there's something bad that happens to somebody usually a death and then the central protagonist, irv Tinsley, gets involved in investigating it and he's kind of a creative problem solver with a public health and health systems background and he gets in there and tries to unravel it and, as any good novel would, things go from bad to really worse and then even worse. So the core of it is to make it a really entertaining story that people would just like to read for entertainment and go like well, that was a good book to read. I really enjoyed that. So I just try to keep it moving, with crazy things happening, including some unique things that happen within the health care system that only someone with as much time and experience and watching things go wrong like me could even imagine, even though they were probably built on things that I actually saw. But then meanwhile I cut into that some real questions about policy in the future of America, and overriding theme are these big questions of health care reform. But nobody really wants to read that, or very few people want to read that in that construct, so I folded in the first book, the Theory of Irv. I do it around a lot of historical fiction that describes, through some of the characters that are involved in the novel, in contemporary times, going back to their grandfathers, of how they were involved in early efforts to try to make this thing work and why it went off the rails. And I'll cut in with personal stories from all the characters that they were experienced in their own health care world and how that helped derail their life. Because, as we talked about earlier, everybody has a health care story. So trying to really humanize the stories and make it clear that we're all dealing with this. So the first book really tried to sort of take you through the history of health care policy and why it got that way and offer up some solutions. The second book, the COVID Murders, is essentially the same framework, except it really explores the COVID period a little bit about COVID itself but much more about what's happening to health care reform while we're dealing with the consequences of the pandemic and one of my friends told me it's the scariest book she ever read because she said it really seemed so accurate that what we're really doing is raising questions about the future of the American health care system, which is exactly what I was doing, and so it really leaves the end of that book. Even though we resolved the medical detective story, the bigger question about the future of American health care is just hanging, and that's the topic of the third book, which is right now called the health care civil war.

Parker Condit: 57:03

Okay, what are some of those big questions that arose specifically out of the COVID period?

Greg Vigdor: 57:10

I think it's the scale, it is this consolidation movement and just how much that really took on steam while we were paying attention to the pandemic and it and it. There was just a lot of it. Not only that, but there was a lot of the money that, for me, as I watched it, that went to the to help support hospitals and others around taking care of COVID patients, which was so necessary. We've never been so overrun with demand, but the way that money flowed is my take on it was it flowed more to these large, large entities than really the small entities that really needed it. Many of these larger entities were already sitting on humongous cash reserves and so to me, all it was doing was capitalizing the effort to consolidate more and more and acquire more and more. So my take on what happened, I believe, is we've gotten way more consolidated, partly because of the government money, and consolidated partly because of the screen that issue provided to allow this to happen without anybody really paying attention, and that we've really got to come to grips with that scale question in terms of where we're going, and it's really a battle. I think the battle of the future of American healthcare now is over control and it's control with these systems. It's control around ideologic agendas of different stripes, and I think we have to somehow grapple with those issues in order to figure out how to get to the system that we want. It's no longer what we were dealing with the Affordable Care Act around just the inputs of healthcare and how to make it affordable. I think it's fundamentally who is in control of our healthcare. We've been talking about trying to make the patient be in control of their healthcare, and I'm not sure that's possible in the way the war is set up right now, and we've got to find a way to somehow shift the battle front to where we can win.

Parker Condit: 58:56

Yeah, I definitely don't disagree with you. What are the consequences for? So people can understand what are the negative consequences of all this consolidation?

Greg Vigdor: 59:05

Well, I think it's just that the power shifts to fewer and fewer entities and more removed entities To me, I've been in this system a long time and one of the core precepts of it was healthcare is a local matter. It's a community matter. That is so not the case in so many communities in our nation right now. It has shifted dramatically, where these questions not only are being answered by a few people. Those people are hundreds or thousands of miles away from the community and don't have any understanding, or in some cases, even much concern, over what the people in the community think about it, and that's not a good thing in my point of view. Maybe others would argue that it's a great thing and, like the airline model, that somehow that's all going to work out. I'm not buying that.

Parker Condit: 59:54

Yeah, that's a great point. Yeah, the consolidation is definitely a concern. I mean, I just look at the Medicare Advantage market and it's like United and Humana they own half the market already and it's like nobody's really like is that just going to happen, where it's going to be two vendors for Medicare Advantage probably consolidate to one at some point. I don't know, but it's yeah, the control issues definitely a concern Is there. Do you have any resources you can point people towards? We're definitely going to link to your books but any resources for anything that we've spoken about today that you do? You have trusted resources on where you kind of go to for this type of information?

Greg Vigdor: 1:00:34

Yeah, so we talked a lot about empowerment. So those Washington Health Foundation tools that we have are available on our website I'll use people can see our little URL. I don't know if I'll get it there, but our website has those free tools available and if you sign up for our blog we'll actually send you one of the models that we use just so you can get a feel for them. There's and I try to read a lot and try to find new resources out there. I found the. The Atlantic actually has been running a lot of useful healthcare commentary articles in the last six months or so, so that's one source I've been looking to. Kaiser Family Foundation typically has some really good articles and analysis of issues, but I think it's some of this is trying to. It's actually the best thing is really shows like this and what you're doing. I think that's actually one of the best ways for people to get information about sort of an alternative view of where we're going and what we might do.

Parker Condit: 1:01:30

Yeah, that's probably a good point. I do think there's there's a lot of power and sort of like decentralized communication now and you know, it's kind of the ability of anyone to have a platform. So, yeah, hopefully people kind of appreciate the, the work that goes into this and kind of guess, like you coming on here. So do you have anything else you'd like to add before we close out?

Greg Vigdor: 1:01:48

No, I just enjoyed this and thanks for what you're doing. I'm going to make sure people know about your blog and my network knows about you, and I think that is how we grow this organically and find a solution that we're all willing to at least accept, if not believe in.

Parker Condit: 1:02:03

Very much, greg. I really appreciate you coming on. You've been a great guest, lots of. I learned a lot today. I'm hoping our listeners did as well. Again, we'll have all the information, all the links that we talked about and that came up during the show. They'll all be linked in the show notes. But thank you so much for coming on, greg. It was a real pleasure.

Greg Vigdor: 1:02:20

Thanks for the opportunity.

Parker Condit: 1:02:22

Well, to those of you still here, that's all for today's show. I want to thank you so much for listening. I really hope you enjoyed today's conversation. If you want to learn more about today's guests, please visit our website exploring health podcastcom. There you can find show notes for today's episode, links to the guests and our full episode archives. If you enjoyed today's show and you want to hear more, make sure to subscribe on your favorite podcast platform. I really appreciate each and every one of you listening Until next time.