Consider This from NPR - Focusing on care not just coverage; economist argues for bigger solutions

Episode Date: December 7, 2025

New research from the Aspen Economic Strategy Group argues that the subsidies-or-no-subsidies approach to the Affordable Care Act debate is too narrow. Co-author of the paper 'Coverage isn't Care: An Abundance Agenda for Medicaid' Professor Craig Garthwaite tells NPR’s Miles Parks that solutions to make healthcare both more efficient and more affordable at scale are right in front of us. For sponsor-free episodes of Consider This, sign up for Consider This+ via Apple Podcasts or at plus.npr.org. Email us at [e-mail] episode was produced by Avery Keatley, Jeffrey Pierre and Henry Larson. It was edited by Sarah Robbins. Our executive producer is Sami Yenigun.Learn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

Hi there, it's Miles Parks. Okay, I know it's Sunday, but real quick, we do have to talk about last Tuesday. It was giving Tuesday this week, and it's not too late to support consider this and everything you love from NPR. This was a difficult year, unlike any other for NPR, because federal funding for public media was eliminated as of October 1st. That means NPR is now operating without federal support for the first time in our history. But NPR's commitment to you has not changed.

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And thank you if you've already made your gift or if you're an NPR plus supporter. If not, sign up today. Support public media and get perks to NPR's podcasts, including bonus episodes of Consider this. Sign up at plus.mpr.org. Millions of Americans could see their health insurance premiums skyrocket in the new year if Congress doesn't extend subsidies to the Affordable Care Act. The debate over that funding was at the heart of the government shutdown this fall. The deadline has passed to keep the government open.

Millions of Americans now face higher health insurance costs. At the heart of the government shutdown, is a debate about health care. Do they continue offering services and hope to recoup payments from Medicare later? A group of Senate Democrats have defected to agree to a deal with Republicans to end the government shutdown. Eventually, the government did reopen with the promise that Congress would hold a vote on those subsidies by the end of the year. The problem is, so far there is no consensus in either chamber on what an extension might look like. We're working to deliver to Leader Thune and Speaker Johnson a plan, which I think,

could get 60 votes, which gives the American people the power, and they can choose a lower premium in an HSA. We're working on that, and I'll give them a piece of paper probably by email tonight. That's Republican Senator Bill Cassidy speaking about a Republican health care plan on Fox News. Democrats proposed their own idea as well, hoping to just extend the subsidies for three years, and a bipartisan group of senators offered up a plan that would extend the tax credit for two years with some limitations. But economist Craig Garthwaite, he wants the U.S. to think bigger when it comes to health care. It's a frustrating thing, I think, for economists, as we watch this debate, where, you know, they're saying if the subsidies expire or they don't, it'll change

the cost of health care. That's not true. All that's going to change is who pays for it. Does the federal government pay for it or the individuals pay for it? And while that's an important question, it doesn't get a, well, I think we do care about, which is how much are we spending on health care overall and how much care are people actually getting for the money that we're spending? Consider this. If the true cost of of health care goes down, more people get access. And several solutions to make health care both more efficient and more affordable at scale could be right in front of us. From NPR News, I'm Miles Parks.

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Science Delivers.com. This message comes from Bloomberg Weekends the Michelle Hussein Show, a podcast featuring conversations with world leaders, business titans, and cultural icons. Make sense of the world with this one essential conversation every week. Listen on Fridays, wherever you get your podcasts. It's Consider This from NPR. I'm Miles Parks. New research from the Aspen Economic Strategy Group,

coverage isn't care and abundance agenda for Medicaid, argues that solutions to make health care both more efficient and more affordable already exist and they should be expanded. Craig Garthwaite is the director of the program on health care at Northwestern University's Kellogg School of Management and one of the authors of the study. He joins me now. Welcome. Hi. Thanks for having me. Yeah, thanks for being here. So your paper says it offers a roadmap for structural reforms to America's health care system that would make health care more affordable. The first of these recommendations is to ease restrictions on doctors who have been trained in other countries.

Can you explain how that would work? Yeah, I mean, the idea would be that we want to increase the supply of people who can provide medical services with if we have more people who are intentionally coming here with the goal of treating low-income Americans, it will provide more access and ideally lower costs. There is a readily available set of people who have graduated from reputable, credential, medical schools abroad who could come here and we could develop programs that say we will, in exchange for you coming to the United States and being allowed to work here as a physician, you have to primarily concentrate on targeting low-income patients,

and in particularly patients who are on Medicaid, which is our nation's insurance program for the low-income, the disabled. Is there any risk, I guess, in terms of people who receive this coverage, you know, having the care being different for people who are lower income versus higher income? I think the first thing to recognize is we already have different levels of care or different sites of care for people who are low. lower income or higher income in the United States. Lower income individuals are often going to clinics that concentrate on them.

The vast majority of individuals on Medicaid are treated in facilities that primarily concentrate on low-income individuals. And so we want to do is recognize that reality and provide the most efficient way to get people access to care with the idea being that perhaps the biggest problem that low-income Americans face is not that they get a different level of care. It's that they're unable to find care at all. So this study also mentions the idea. of expanding the pool of providers by allowing nurse practitioners and physician assistants

to practice independently. Can you explain that bit of it a little bit more? Yeah, so we have a ready-made set of providers, these mid-level providers, who have advanced training. They are not doctors in the sense that they have an MD or a DO degree, but they've gone through a lot of advanced training. And for a lot of primary care, research has shown that they provide exceptional care for individuals. In addition, they are a lower cost input that can be more readily deployed across the health care ecosystem. You can often spend more time with a mid-level provider than you can with a doctor. And for primary care, I think that's often what people want. They want to be able to sit down and talk to a doctor about the things that are

concerning them. And so this can, again, augment the health care workforce. We see a lot of use of mid-level providers among practices that are already engaged in what referred to as value-based care, right? But practices that are trying to, you know, make more money by making people healthier. And we think that there's a real place for that in the Medicaid and low-income population. Can I ask broadly about these changes? I mean, how radical are some of these changes, or are there ways or levers in place already to allow for some of these changes to more easily be applied? In many ways, certainly on the idea of foreign trained doctors and mid-level providers, already have experience with various kinds of programs that have different residency requirements

or different what are referred to as scope of practice laws for the mid-level provider kind of dictating, you know, how much prescribing behavior might they have independently. So we're really talking about expanding sort of an existing set of tools, but really targeting it on a population where we know there is an identifiable need for more access to care. And I think that's where Tim and I, Tim Layton is my co-author on this, where we start with this, which is the title of the paper, which is coverage isn't care. There's so much discussion, so much of the debate we're going to have in Congress over the next two weeks is going to be about insurance coverage, which is good, but it's a necessary but not sufficient

condition for getting access to health care. And I think we'd like to see the debate focus more on what actually gets people care. And that has to be a supply side conversation where we think about who's providing the care and not just what economists refer to as the demand side of conversation, which is who's paying for the care. I don't want to be cynical. I hate being the cynical voice here. But I guess when you look at the current landscape in Congress, how realistic is it that they would take on some of these things as opposed to the sort of tweaks that they're negotiating to the current system right now? Well, you're talking to an economist, so you can't be more cynical than I am. I think I've lost almost all faith in the idea that Congress will do good government and pass laws anymore. The nice thing about this, though, is that a number of the things that we're talking about here can actually be accomplished at the state level. We have seen state governments be more active, but Medicaid, it's important to recognize is a program that while it's jointly funded by the state and the federal government,

it is administered at the state level. And through waivers and other processes, state Medicaid agencies actually can obtain a lot of flexibility to implement these. And I actually think that's a wonderful thing about America. It's what we thought about, you know, the founders thought about for the country is let's let all these states experiment, right? They become, as we often refer to as the laboratories of democracy. Here they can be the laboratories of low-income coverage and figure out what's the best way to provide true access to health care for low-income Americans.

I feel like your paper touches on this idea that Medicaid didn't start out covering many tens of millions of people. It wasn't really designed initially that way and that we've kind of ended up there. Can you explain that for people who don't know the history of this thing? Yeah, so Medicaid comes out of the Great Society programs in 1965. It is intended as a very small program for the very, very poor and disabled and widows and orphans. Even if you go to 1990, right? So now we're only talking 35 years ago. There were only 20 million Americans that were on the program.

If we go to last year, there were nearly 80 million Americans on the program. It includes kids. It includes seniors in nursing homes. It includes half of all births in the United States. And so it has become this sort of unwieldy program that we, was never designed for the size and the scope of the patient population that it's currently covering. I mean, is that a similar problem to the Affordable Care Act more broadly, too, and that it is this kind of massive thing that is doing a lot of different things? I guess I'm just wondering,

are there parallels there? Yes, yeah, no. I think the Affordable Care Act has a bunch of things attached to it. One part of the ACA, we should note that is relevant here is it involved a very large increase in Medicaid. So one of the reasons that a lot of people are on Medicaid is because of the ACA. On the ACA insurance exchanges, which is the debate that's going to happen in Congress, you know, that primarily is just providing a relatively standard insurance product to people. And most of the debate, I will note there, is not about the cost of health care. It's really just about who pays for it. And your paper basically is arguing, like, if we fix some of the broader issues here,

then the actual cost of health care could go down. Yes. And if the actual cost of health care goes down, we can provide care to farm more people more efficiently. And that's ultimately what we want. We as a society wants people to get access to the health care they need, and we should focus on providing that in the most cost-efficient manner. That's Craig Garthwaite of Northwestern University's Kellogg School of Management. Thanks so much for talking with us. Thank you for having me. This episode was produced by Avery Keatley, Jeffrey Pierre, and Henry Larson. It was edited by

Sarah Robbins. Our executive producer is Sammy Yenigan. It's Consider This from NPR. I'm Miles Parks.