The Checkup with Doctor Mike - Former Head of Medicaid Exposes America’s Insurance Crisis

Episode Date: July 2, 2025

I'll teach you how to become the media's go-to expert in your field. Enroll in The Professional's Media Academy now: https://www.professionalsmediaacademy.com/Follow Chiquita Brooks-LaSure here: https://x.com/TheLaSureSideThe Century Foundation: https://tcf.org/00:00 Intro01:25 Medicare13:10 Medicaid16:18 Obamacare19:33 Looking For Insurance?27:15 Prior Authorizations / Denials32:25 $1 Trillion Budget39:04 Skyrocketing Prices46:15 Pharmacy Benefit Managers54:40 Doctors Rejecting CMS59:12 Expanding Primary Care1:02:04 HHS Budget Cuts1:09:20 Surprise Billing1:10:50 Misconceptions1:12:32 New Administration1:15:14 Magic Wand1:20:30 AI1:21:27 Doctors vs. Insurance1:22:18 Dream Pick1:23:20 Senate ConfirmationHelp us continue the fight against medical misinformation and change the world through charity by becoming a Doctor Mike Resident on Patreon where every month I donate 100% of the proceeds to the charity, organization, or cause of your choice! Residents get access to bonus content, an exclusive discord community, and many other perks for just $10 a month. Become a Resident today:https://www.patreon.com/doctormikeLet’s connect:IG: https://go.doctormikemedia.com/instagram/DMinstagramTwitter: https://go.doctormikemedia.com/twitter/DMTwitterFB: https://go.doctormikemedia.com/facebook/DMFacebookTikTok: https://go.doctormikemedia.com/tiktok/DMTikTokReddit: https://go.doctormikemedia.com/reddit/DMRedditContact Email: [e-mail] Producer: Doctor MikeProduction Director and Editor: Dan OwensManaging Editor and Producer: Sam BowersEditor and Designer: Caroline WeigumEditor: Juan Carlos Zuniga* Select photos/videos provided by Getty Images *** The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional **

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Make the most of it at Best Western. visit bestwestern.com for complete terms and conditions. 16 years ago in this country, if you were a woman and you wanted to buy individual coverage, you would pay more than a man the same age. If you had something wrong with you, some health condition, an individual market plan could charge you more or say, we're not going to ensure that part of your body. So, yes, I know. So crazy, right? On this episode of the checkup, we're joined by Chiquita Brooks LaShore. the powerhouse who ran the Centers for Medicare and Medicaid services before passing the baton

to Dr. Oz. As CMS administrator, the job is literally to manage the $1.7 trillion program that funds Medicare, Medicaid, and the ACA marketplaces. These make up the largest portion of health care coverage in America. I thought given the confusion surrounding our insurance industry, it would be great to get an expert in who can teach us the basics and tell us. us the truth about what makes the system so broken and hopefully how to make it better. I admit the beginning of this conversation can feel a bit overwhelming with all the different partitions behind Medicare, but I urge you to push through as we get into some truly eye-opening discussions about the cuts facing America's health care system, surprise billing loopholes, and why that

some patients with insurance sometimes pay more for medication than those without. Please welcome Chiquita, Brooks Lashore, to the Checkup podcast. Let's talk about this. sexiest subject that exists in healthcare insurance. I think most people just literally let out aside. Yes. And I understand why they feel that way. I understand why they feel that way because I'm a doctor and I see the struggles my patients have. I see my billing department and how they struggle to try and get care covered for our patients. And I also have seen it from the small business side for trying to get insurance for my employees. It's complicated. So I'm hoping that today we can start structuring this in a way where by listening to the conversation, at least we'll have a better grasp of what insurance is, what we can expect, how the government plays a role, how CMS plays a role in it.

Where would be a good place to start? Like, let's zoom out as much as possible and talk about what is the United States system of health insurance. So we in this country have a very fragmented health care system. We have many people, most of us, are covered by employer-sponsored insurance or employer-sponsored coverage. And some of that is because after World War II, when wages were capped, a lot of employers started offering better benefits to attract employees. And so most of us get our coverage through an insurance company, through our employers. And the federal government

has some rules around employer-sponsored insurance, but for the most part, employers make a lot of decisions. And they make those decisions usually as a way, as you said, to lure better quality workers

as a form of capitalism, I guess we could say. I know, for example, the big financial institutions oftentimes will brag that if you come to join our institution, we have this great coverage, look how happy all our employees are

that have this level of coverage and they're able to negotiate better with insurance companies based on the number of employees they have. So for me, I'm at a disadvantage having much fewer employees than like let's say J.P. Morgan has a random example. So that makes it a bit tricky

from my end, but not from the consumer end. Okay, so we have insurers. What's the next segmentation there? So the next piece in terms of insurance coverage in our country is government-sponsored insurance. And CMS runs most of the government-sponsored insurance, runs Medicare, which Medicare covers almost all of the seniors in our country. So if you have, if you hit the age of 65 and you have worked 40 quarters, so basically 10 years,

then you are eligible for the Medicare program. Medicare also covers some people, with disabilities. So largely, that's the next biggest insurance company in the world. That is the Medicare program. And it covers millions, over 70 million people in this country. And CMS runs the Medicare program. Some of it is what we call fee for service, where basically if you are a doctor and you say you will take Medicare, any person who has Medicare can come to you and you can bill the government for your services, and sometimes people enroll in Medicare Advantage, which is an insurance company that is providing Medicare benefits, and those rules can be different than the Medicare program. How does one know if they're in Medicare or Medicare Advantage, and how do they choose to be

in one versus the other? So when you enroll in Medicare. Let's run the hypothetical. I just turned 65. I need to, I was getting my insurance from my employer. employer. I retired. I'm 65. What do I do? So you need to sign up for Medicare. Sometimes your employer will help you with that process or you go to Social Security Administration, which a lot of people don't realize that you actually enroll through the Social Security Administration.

And you choose. So if you don't choose anything, you are in what we call traditional or original Medicare. And that's fee for service where you will as I said, yeah, if your doctor provides, we'll take Medicare, you can see them. See them. Right. You also, if you're in traditional Medicare, should choose a Part D plan. And that is prescription drug coverage. So that is a separate step that you also need to do if you're in traditional Medicare.

Meaning you have to enroll in that? You do. And does that cost money? or is that just a checkbox when you're doing the application? It costs money. So sometimes you can enroll in a very low premium plan. And there are another set. This is for traditional original Medicare.

There's something called Medigap insurance, which some people also choose to enroll in. And that can help with cost sharing. So sometimes you'll hear people talk about Medicare F, G, those are medigap plans they are not technically medicare they are a different type of coverage which also helps with cost sharing medicare their traditional form of medicare is free so i'm not paying anything if i sign up for that it's not it's not completely free so part a um which covers hospitalization and sort of a very basic set of services is free if you've worked

for 40 quarters, but part B, which is seeing the physician, like outpatient care? Yes, yes. And a certain set of services, that has a premium that is attached to it. So every year, and often people just get it taken out of their Social Security benefits. So you can automatically get your Part B premium taken out. So if you're in traditional Medicare, you're paying that premium, but then sometimes people will enroll in Medicaid.

Extra one. And then where is Part C volunteer? There is a Part C. Okay. So Part C is Medicare Advantage. So basically Part C is A and B together. So Medicare Advantage is, like I said, you choose an insurance company. So every year, Medicare has an open enrollment in October,

and it basically said, what Medicare is saying to you is you can choose a new Part D plan if you're in traditional Medicare, or you can choose a Medicare Advantage plan. So every year you can make this decision as a Medicare beneficiary. However, once you choose Medicare Advantage, it's very hard to go back to traditional Medicare. So it's a big decision and often people choose Medicare Advantage because Medicare Advantage often is providing additional benefits like Medicare Advantage will often pay the Part B premium for you. Sometimes it offers additional benefits like, again, the cost sharing might be different. You might get additional services like a card to buy groceries or things that. that help Medicare enrollees.

But you also have to know that you can't see any doctor that you want. You have to see a doctor that participates in your Medicare Advantage plan. And each Medicare Advantage plan is run by a different insurer that has a different set of doctors in it. That's right. Got it. And is Medicare Advantage free or is it have a premium that you have to pay? It can have a premium. some Medicare Advantage plans offer $0 premiums.

And that's a big part of, there's a big debate in D.C. Among the federal government of why is Medicare Advantage able to offer people free coverage? A traditional can't. Can't, yes. And what is the answer to them? So I would say a couple of things.

One, Medicare Advantage plans get paid in a way that makes it easier for them to lower their co-pays. So things like they limit the doctors that participate. They also get paid in a very specific way that causes them to sometimes get paid more than fee for service. And so they're able to use those savings to lower costs. Why then have the original Medicaid still? I would say a couple of things.

One, in my opinion, we should improve traditional Medicare because it's a public good that you can see any doctor that wants to participate in the Medicare program. And there is a certain entitlement that you have to get the care that you need that traditional Medicare provides. And I personally think that we should continue to have both options available. So if you're a senior and you are comfortable enrolling in Medicare advantage, I think that that's fine and should be a choice that every Medicare beneficiary has. But traditional Medicare, if you have a serious illness like cancer, maybe you want to see whatever oncologists you want to see. We have people most of who are older who live in different parts of the country. So say you live in Ohio and you during one part of the year and then you live in Florida.

or down south, do you want the difficulty of finding out does your plan participate in both states? These are the kinds of things that come up that if you're in traditional Medicare are less of an issue because all you have to do is know that you have a doctor who will take Medicare, which most doctors in America will take Medicare. Are the insurers that are part of Medicare Advantage being subsidized by the federal government? They are. So they, basically based on fee for service they offer and tell the federal government how to how they bid they bid and say this is how much it's going to cost me to provide these benefits and then whatever they save they can um some of it they use for profits and some of it they use to lower cost for people and is that transparent so we in the biden harris administration really worked to increase the transparency of of exactly what Medicare Advantage plans are offering.

So really wanting them to detail in more specifics, like what are using these extra dollars for? So you are telling seniors that you give them gift cards or, you know, dental coverage. That's a big one that a lot of plans do. And so some of the things we said is, well, we want to see are people actually using them? Are they aware?

Are they aware? Because if you don't publicize it and you have it, Yes, yes. Do people actually get those benefits? So those are some of the types of things that we really worked on and trying to increase the transparency. And so there is some, certainly, and I think more continues to be needed. Summer's here, and you can now get almost anything you need for your sunny days delivered with Uber Eats. What do we mean by almost? Well, you can't get a well-groom lawn delivered, but you can get a chicken parmesan delivered. A cabana? That's a no, but a banana. That's a yes. A nice tan. Sorry, nope, but a box fan, happily yes. A day of sunshine? No. A box of fine wines? Yes. Uber Eats can definitely get you that. Get almost, almost anything delivered with Uber Eats.

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find fabulous for less. Okay. And then how does the next component of Medicaid come into the equation. So Medicaid is the next, um, next big program that is a, uh, a public program. And it is jointly administered by the states and the federal government. So the federal government pays a portion, states pay a portion, but it's really states that administer Medicaid. So Medicaid isn't called Medicaid in a state. It's called names like BadgerCare and Medi-Cal and, you know, all the states have their own names. for it. A lot of people in America don't, they are on Medicaid and they don't necessarily know that that's the program. And so we have over 70 million people who are now covered by

Medicaid and CHIP. And it is a program that is really designed for, originally, was designed for low-income people. It originally, it was created in 1965, along with Medicare, covered low-income children, very, very low-income parents, people who have disabilities and some lower-income seniors. Over time, Medicaid coverage has grown to include more people. And the Affordable Care Act really designed Medicaid to cover everybody who is under 133% of the poverty level. So that was one of the core things. Different states have made decisions about whether to what we call expand Medicaid or not. But basically, it is a program that millions of low-income people rely on

and more and more middle-class families who fall into one of two categories. Have kids with high needs, disability born with something wrong with them. If you think about the NICU, a lot of the children who are there, are people in children's hospitals, a lot of the children in America are taken care of by, who have health issues are taken care of by Medicaid, and then a lot of our long-term care. So people in nursing homes, often Medicaid is one of the primary payers for long-term care services in our country. What about individuals who, let's say, you're 40 years old and you end up on dialysis?

Where does the coverage come from there? So if you are a 40-year-old on dialysis, you will probably end up in Medicare because Medicare has a special level of disability for certain illnesses and stage regional renal disease. So at some point, you probably will qualify for Medicare, but if you're not, if you're not on Medicare, you're most certainly on Medicaid. Got it. So if you're an individual who, who's seeking, and is there another part of this that is just individual plans?

Yes. So those are the big ones, the two, you know, the behemists to say. And then the Affordable Care Act really changed health insurance in our country. And it's hard to believe for, I think, some people who are a little bit younger than I am. But 16 years ago in this country, if you were a woman and you went to, buy individual coverage, you would pay more than a man the same age because women use more health care services. If you had something wrong with you, some health condition, an individual market plan could charge you more or say, we're not going to ensure that part of your body.

So, yes, I know. So crazy, right? They would write insurance plans. I would say, we won't insure your lungs because you had lung cancer. Or that. That was, you know, really how the individual market operated. States could make restrictions, but you as a person, you could even be deemed uninsurable. And there were many, many people who would go bankrupt in this country because they couldn't afford something happened and they couldn't afford medical bills. And, you know, you were talking about being a small business owner. people would think I've got a health condition.

I remember talking to a friend of mine and her father was about to leave his company and wanted to start his own business. But the idea of trying to buy insurance with health conditions was really a barrier for people. And so President Obama, along with the Congress at the time, created the Affordable Care Act, which put regulations on the individual market

so that everyone needed to be covered. if you wanted to buy it, which was a very big change. And then also put federal subsidies, tax credits, to make it affordable. Because if you allow everyone to have coverage, then the sickest will probably be the ones who can buy it. The premiums go up. So you need to subsidize it to make it affordable. And are you subsidizing it for the individuals or for the companies themselves to make

sure that the prices come down? For the individual market, it is, it's the, the, the, the, the, People themselves get the tax credit, but the money goes to the insurance company. So now, if you buy insurance in the Affordable Care Act, through the Affordable Care Act, you enroll health care.gov or say one of the state websites, you might even have a broker who helps you walks through the process with you. You'll enter in your information and choose a health care plan, and then the federal government will send that money to the health care plan when you enroll. Got it. To make sure that the cost is stabilized for you versus someone who needs a higher

level of care. Right. Got it. Now, if you're a person who's, let's say, not employed, not falling into the Medicare, Medicaid bucket, what are some tips to actually get good insurance? Because if you're an average individual, if you're just coming into the workplace, you're over 26, you're no longer on your family plan, and now let's say you're 30, you're working your first job. When you're 30, you're entering the insurance market. It's scary. So what are some tips for them? So that is where you would want to go to health care.gov or one of the state websites. And you could always go to health care.gov first. And the thing is, you're on a sliding scale on the tax credit. So the more money that you earn, the more you're going to. end up paying. So you as a person are paying. But the Affordable Care Act and subsequent laws have made coverage more affordable last year when I was still CMS administrator. We could say that most people, four out of five people, could find a plan for $10 or less. So if you're

27, right? $10 a month premium? Yes, $10 a month. And so if you're a 27-year-old, you know, and relatively healthy, you're sort of thinking, how much do I need health care? Well, there are reasonably priced plans for you for most people who are looking for coverage. Got it.

Now, I've seen in this insurance market something that happens where the premiums perhaps are well controlled, but then the cost ends up shifting to another form of payment. So either the premium may stay the same, but the co-pay goes up, the deductible goes up, the percent coverage of cost sharing goes up. How does one decide what is the best route? Because I know you were telling me you had some family that was going through this process as well. It can be challenging to try to think about what's the best plan for you. And I think, and everyone needs to make that decision, obviously, you know, thinking about their own situation. I would say a couple of things. You want to think about sort of your, what's the

most important thing to you, right? Usually if you pay a higher premium plan, you might have more cost sharing that's taken care of. So you'll pay less when you go to the doctor. And you want to kind of trade off. Does this plan let me see the doctors that I want to see? That's one I think probably the most important thing, the doctors that you already have a relationship with. Then you're thinking about how much do I pay in a co-pay for what services I need. So you might pay more for hospitalization because you think I'm not going to go to the hospital. Nothing right now in my own profile suggests that I'm going to need the hospital this year. But if you are somebody who knows that you have health needs where you might have a hospital, maybe you choose a plan where the

hospital co-pay is more. And for a lot of people, prescription drugs is really an important consideration. So looking at what we call a formulary on a plan. So the drugs that I'm taking, are they covered? Can I afford it? Those are the types of things that we want to think about when we're choosing coverage. Makes sense. Now, has there been ever any ventures from CMS, perhaps to make this process simpler in terms of creating more clearly defined buckets of this is considered a high co-pay plan but low deductible plan and creating almost titles for them or perhaps some algorithms where I mean AI is is valuable for the simple fact that it can reason quickly within the set of rules you put for it like it's not going to come up with some

brand new idea but it can follow a formula so if that formula is you enter your age, your medical history, your records, and then it could say, well, if you want to save the most based on how often you're seeing the doctor now, here's the best plan for you. Has that ever been brought into conversation? There's definitely been a lot of conversation about how can we make it simpler for people trying to make these decisions. And some of the things that we did during the last four years, some of which are going to be undone, so I will say that caveat, is really calling putting more standardization. So saying these types of benefits, these types of plans are a standard plan. So you will know if you're

choosing this plan, some consistency about whether I'm choosing a plan from X company or Y company or Z company, they are going to provide this set of service. And that was one way that we were trying to make it clear to people that these standard benefits will be offered to try to help. And that's true. That was something that we did both in marketplace coverage, affordable care act coverage, so health care.gov, as well as Medicare Advantage. Now, as someone who's going to select these individual plans, right?

Like for me, it's a small business. I'm basically shopping in that same market. So we should stop for a second and say the small employer market is a little bit different. It is like the Affordable Care Act market, except that there are not the subsidies for people in the same way. There are some subsidies, but they're really limited. And so an employer, yes, like an employer is choosing, here is the plan that I'm going to offer to my employees, for example. And one of the more frustrating things about that. that process is if I want to guarantee the best coverage for my employees, even if I pick the

top tier plan, like the most expensive plan, it's still not as good as the plans as some of the bigger companies like the J.P. Morgan. Like, I can't buy it. It's not available to me. How come? That would require more government regulation than we have right now. So what is the regulation in place that's preventing that, or lack of regulation that's preventing? The biggest thing is that the private sector is negotiating directly, right? So with insurers. And so insurers are making decisions about, or making decisions about how many lives you can bring a larger employer is able to spread risk more easily, right? And so for a small employer, what we, the Affordable Care Act did was limit some of the risk, but it's still a smaller risk pool compared

to the large risk. Makes sense. And then for, if I'm trying to get the best plan possible, and there are all these different insurers, how do I, like, as someone who, let's say, might not have a doctor selected or is seeing specialists that they have a relationship with,

you see three different names of insurers. What are you supposed to make sense of that with? Like, is Oscar better, is United Health better, is this better? What should one look for in a situation like that? So these are really good questions. And I think it's one of the things that makes our health care system a little bit more complicated than some other, than other systems. I would say things like prior authorization.

This is one of the most. It's the bane of my existence as a physician. It is. And, you know, I will tell you, I heard so much about both from people and from doctors about how frustrating. about how frustrated they were about prior authorization. There is, and just to say what that is, it's about an insurance company saying you need to go through certain hoops before you can give this drug, perform this test.

And there is a place for prior authorization because, you know, there was a time when doctors were prescribing too many things or too many services, health care costs are going up. So there was a sort of a, let's impose some prior authorization, but it has gotten out of control. Right. The pendulum has swung too far the other way because with checks and balances, you want it to be where it's catching fraud and preventing fraud, but not to the point where it's impeding care. Right. And I feel like we've had swings in health care, like even with the opioid crisis as an example. That's right.

We've overprescribed opioids in the past. Then we've limited it so abruptly where now patients who truly need the medications have difficulty accessing them. So we have to find that healthier balance. So you were saying how does the prior authorization's impact selection of a brand? So I think really when you're researching your company, like really looking at are there stories about prior authorization? Well, that's hard to make a judgment call off anecdotes. It is hard. And as a scientist, I don't know if I would recommend that.

Because there's stories of all sorts of things, right? Is there a place I can look like a resource that says the prior authorization rate, and the denial rate is x um you know i don't think that there is and i do think that that is something um you know that we need to like a mandated statistic yeah that's transparent well the theory that i had and again i'm so far removed from being an expert any of this as you could tell the questions i'm asking it would make sense for cms instead of having brokers broker these, even Medicare Advantage, the individual market, having that role be filled by a CMS employee as someone who understands the plans and what would be best for an individual,

because that takes away some of the shadiness, if you will, creates more transparency and honesty in the system. Is there a reason why that's not happening? Because it seems like a great idea. So this is, it is. And, you know, actually, we had talked about this and thinking about, you know, what work we could do at CMS about really trying to create this transparency. I would say a couple of things. One, not all of that data comes to CMS. So a lot of these questions, especially in the commercial market, CMS doesn't get that data. The federal government doesn't get the data.

So that would be, that's one barrier in terms of. So how does like the Kaiser Family Foundation put out a statistic like 17 or 18% of in-network insurance claims are denied? They might get that data from employers. But I mean like the federal government doesn't always get, we don't get everything. Well, it seems like because you're the primary payer, you should be able to demand the most. transparency we do but um for medicare and like we don't get it for all of the commercial market right so some of that stuff and i can't fully speak to what labor and um you know some of the other entities get but um and sometimes it's voluntary right like people are deciding to participate

in databases and things along those lines but in terms of what's mandated for the federal government. I guess maybe I'll back up and say the federal government sometimes does things that they're interested in, but for the most part, the federal government is consumed with doing what it is required to do. So most of my time was really spent with what has Congress told me that I have to do. It's not like you have infinite power to say this is a... The change that we're making. Yeah. Yes. So you're at the mercy of the, the, legislators and what they believe is valuable to be changed. That and also.

And I'm sure it's also a free flowing process where, you know, on week one, you're doing X and then four weeks later there's a new policy put forward. Now you're thinking about that implementation. That, but I would also just say, I mean, CMS and every agency, like they have a budget and, you know, it wasn't adequate to do the work that we had to do. And so a lot of your day is making sure all of those trained. run, if that makes sense, right? Like there are other ideas that, you know, may not be part of your core mission.

How does one institute a cost-saving measure for the budget that is put forth for CMS without harming people? Say that question a little differently. Let's say, what is the budget of CMS? It's about $3 billion. So $3 billion. How do we save on that budget without ultimately hurting people? people. It's, or is it always, no matter what budget you cut, there's always going to be someone

that's impacted negatively. From a, from a CMS budget perspective, I would say CMS is responsible for a trillion dollars a year, a trillion. Three billion dollars to administer. A trillion dollars is nothing, right? So CMS's budget, if anything, should be greater. Well, that maybe I'm confusing the budgets. Where, where is that, whose budget is that trillion budget that we're talking about? That's Medicare, Medicaid. Yeah, so that budget. Is there anything that you could cut there? Oh, oh. Yeah, sorry, I misstated the question. Got it, got it. I see. Certainly, there's always, there are always changes that you can make to, um, to think about how can we reduce costs. That doesn't mean that's exactly what we should be doing. So I would,

say a couple of things. The federal government states are always, is their responsibility and make sure those dollars are being used well. So sometimes we see things, sometimes there's fraud. The IG and CMS has a staff who are really focused on finding fraud. You know, we'll see improper payments and take actions. Sometimes people need to go to jail. Sometimes people just need to pay things back, there are a whole series of activities that are always under a way to find things like that. For example, during my time, something we saw were people not getting home care, like people, you know, fraudsters pretending to be providing services in the home, calling people up and ordering devices for them and then them not arriving. So there are things like that. There are

differing views on on payments and whether the federal government should cut Medicare Advantage payments. And some of that would take action from Congress, which cut payments to the subsidization for the insurers. That's right. So that is an ongoing debate. I think the challenge of doing that is that the Medicare Advantage plans are providing additional benefits and people want them. And so That's an ongoing discussion. I would say, and then Medicaid, wrongly, I would say the Congress right now is considering major changes to Medicaid and affordable care coverage, a trillion dollars in cuts over 10 years right now.

And I think those are going to be incredibly harmful to not just the millions of people who depend on the programs, but also just to our health care system. overall because hospitals are credibly dependent on Medicaid dollars. And, you know, again, for people who aren't on Medicaid, we want to make sure as a country that when people are sick, they get treated so that, A, we don't all pay more for them because of uncompensated care, but also because we just saw with COVID-19 pandemic

what happens when people are sick, The hospitals were just overrun, and then even people who needed routine surgeries that were really important, the hospitals were overwhelmed, and they couldn't get the care that they need. So does, like, I'm trying to view it from a practical perspective. If this program has created the size that it's created, it's a big program, it becomes very difficult to create cost savings within that program because of the dependency that is created from the hospital side, from the patient side. So how do you make cuts?

Because look, we could talk about fraud because it's a good story in the sense of like catching fraud is good. Everyone will agree. It's a 10 out of 10 issue. People will talk about it in press. But if you're thinking about percentages, I can't imagine that fraud is one of the more significant cost savings measures. Yeah.

So if you are thinking about trying to address this looming, growing program, where can you make cuts or improvements in order to make it more effective? Well, one of the big things that we were able to do was get drug negotiation in the Medicare program. And so last year, we CMS negotiated for 10 drugs, lower prices for people who take them, but also to make Medicare more sustainable. In one year, the estimated savings are 1.1.5 billion. for people, and then $6 billion for the program. And prescription drugs are not the only health care issue in our country, but it is probably

one of the most painful ones. And I think A, it's painful because seniors are taking more drugs. They're more dependent on them than say medicine is more dependent on therapies in a good way, right? There are a lot of therapies that are working. but it's actually having a significant impact on people's lives in terms of really having to choose between paying for their prescription drugs or their housing or food. And so I think that prescription drug spending and getting a handle on it is one of the most important issues in health care, in part because we have these therapies that should come to market.

but they're and some of them are going to be cures but they're really expensive and as a payer you're you don't want to pay two million dollars or what have you but it is the best thing for the person and really the health care system would probably benefit in the long run but we've got to get no and no provider I mean the federal government will have to pay for it if you know it meets all of the standards and what have you. But getting those costs under control is a really important part of spending. So how do you prevent, let's say, me and the team here, we come up with a cure for type 2 diabetes. Like, boom, we have it. Here's the cure. And I, because no one else has this, I have this formula. I want to charge a million dollars a dose. And obviously there's a tremendous

benefit to society to have that. What rules are in place to prevent me from charging a million dollars a dose? Well, there really aren't. I mean, the only thing that now, if you want to charge a million dollars a dose, once FDA approves it and Medicare will cover your drug, it will depend on a negotiation of private companies like Medicare Advantage or the party plans or the commercial market is going to decide, do I want to cover your drug? So on the commercial market side, the commercial market will decide whether they want to... So it's a market force economy. And it's crazy that there's no government intervention to some degree.

Because, again, within this health care space, it needs to be a true collaboration between government and private sector. Because in order to have it successful, you need both parties, at least getting along to some degree. And the fact that there are no checks is a bit weird. How come that never was established? Is there been pushback from the pharmaceutical side of things? Yeah. So I would say, and there are government. So in Medicaid, there is government intervention.

Like Medicaid gets a much better price. But, and, you know, DOD negotiates drugs. VA negotiates drugs. But when Medicare... But that's simply because of the amount that you're buying. So it's like still in the company's best interest to negotiate. But if I have the one cure, it's no longer in my best interest to lower price. That's right.

And, but Medicare did not have the power to negotiate when the drug benefit was created. It was created in 2003. And, you know, it was just at the mercy of the legislation. So, you know, the other, that was just something Medicare was not permitted to do. Like there is, you shall not. negotiate written into the law, and it wasn't until the law was changed, and we were given the authority to start negotiating for the top 10. And then a lot of these medications that are breakthroughs, a lot of them come on the work

that's done by the NIH that's perhaps government funded, because we can't expect pharmaceutical companies to spend billions of dollars in something that probably won't work, but has the potential to work, right? Because that's what the government does, right? They invest in things that perhaps aren't super profitable in order to help the most amount of people. But a pharmaceutical company will only do it if it is profitable. So the fact that we fund so much of the work that ends up being used in the future by pharma, I know we have the Bidol Act as a potential way to get some of those patents back. Are there any avenues to say, well, this drug was developed based on the work that was done at the NIH, we are going to pay less for this medication as a result.

In the drug negotiation law, there is the ability for, or the requirement for the drugs that are being negotiated by the Medicare program to take that into account. So now that's something, but this is a new, you know, a new program. And again, we had the, we did it for the first time last year. Now the Trump administration will move forward and we'll see how they approach it. And I want to be fair to drug companies. They take on a lot of risk, right? They try and many of their drugs don't work or, right?

Exactly. And so, but this is a challenge, right, that we, that, you know, they can charge what they work. Well, I think the issue is, and we say the word transparency so often, but we're probably not transparent about why we're saying transparency. It's that a lot of these private institutions, the more they can be less transparent, the less power we have from a government side or from a consumer side of things. Because if I call 10 plastic surgery offices because I want a nose job, I can very easily compare prices and decide who I want to go to based on reviews and that price.

But if I don't have that for medical imaging, for pharmaceutical medications, it becomes a lot trickier to do that. And then on the government side, it makes it harder to say, well, which company should we fund, which company is a good player in this space? We're relying on anecdote to hear that, as opposed to true statistics being served to us as part of the reporting process. So I think improving that will allow us to better call balls and strikes as a simple metaphor. I definitely think it is true that more transparency is needed in the health care system. and it's really challenging. I think, though, it's hard, in my mind, in my opinion.

Healthcare is not as much of a commodity as it is buying a car and making decisions. It's hard sometimes to know the tradeoffs and what makes sense when you're in a health crisis. And so that's, I think, one of the challenges about our prices, you know, really trying to figure out how we make our health care system work better, because sometimes you're not in a position to know what's the best treatment for you. You need your doctor to tell you. Well, that's true, but I think about it in the way that, let's say, my job has changed. I get a report that shows how often I'm prescribing certain controlled substances, benzodiazepines, opioids, in comparison to other doctors in my specialty, perhaps other doctors in my area. And it's done so to see if I'm an outlier. Yeah.

And there could be a reason, totally logical explanation for why I'm seeing more of this patient population, and that's why that's happening. But if we don't have that same data, we're expecting that of individual physicians, but if we don't have that same data from insurers to say, hey, what's your prior authorization rate? What's your denial rate for coverage? It's hard to decide who's doing what and make sense of it all. So I think that's the level of transparency I would be seeking. Yes, and I think that having that information for doctors, having that information for providers, I think would help considerably.

My only point was just that it is hard sometimes as a consumer to make sense of all of this. Yeah, I mean, it's hard for me as being in this space. I can only imagine hard for you, as you were saying with your family. So it's very hard. continuing on the conversation of these prior authorizations, pharmaceuticals, there exist this world of pharmacy benefit managers. PBMs, they're very shady industries that have been created seemingly out of nowhere. Can you break down very simply for the audience? What is a PBM? Why they were intended to exist and what they're doing now that perhaps they're frowned upon to some degree.

So I would say that the PBMs are offering a service that the health plans did not want to, or I shouldn't say didn't, but didn't take on. So health plans manage services across the board, right? They manage the relationship between doctors, the relationship between hospitals, you know, doing the negotiation. And when you say health plans, you mean insurers? Insurers, yes. And so PBMs are the middle. men between the insurers and people and the drug companies in terms of costs. And so the understanding how drugs are paid for in our country is one of the most

complicated things in the world. So often it's the PBM who's in between the pharmacist, the doctor, and the health plan in terms of drug coverage. And one of the things that people are very frustrated with is that they don't know what the PBM is doing exactly with the costs. So how much are they paying for the drugs from the drug companies? How much are they charging the insurer? How much are they paying the pharmacist is sort of their middle? Well, I think the simple thing that I would look at is have they,

become successful financially and they've become billion dollar industries by the way that I explained it the other day on a different podcast was they're a coupon company that have become a billion dollar coupon company and the goal of this coupon company is ultimately to make the system more efficient and somehow it's become less efficient as a result at least to some degree through some people's eyes and I think one of the more confusing parts that I feel government intervention should play a role in, is how in the world can there be one entity that owns the same parts of this equation? Like you described, you have the pharmaceutical company, you have the insurer, and you have the patient, and you have the pharmacy. But now through

vertical integration, you have one giant company owning all of these things, pushing money into different pockets, calling it savings, and then multiplying that profit. So how is that allowed? So there are really restrictions of how much CMS can get involved in the contracts between these different entities. And there was bipartisan legislation to really look at PBM transparency and give more authority to really understand what's happening. And it, you know, we'll see if a future Congress considers and really tries to address these issues.

What happened to that bipartisan? It fell apart. It was included in legislation, I think, I want to say, at the end of last year. And then at the last minute, didn't get through. Got it. Yeah, because I remember talking about this. This is a while ago, maybe five years ago, maybe even longer, seven years ago, at the J.P. Morgan Health, conference ages ago saying this is the most complicated thing ever for me as a provider to

understand what's being charged to my patients because they'll come in to their pharmacy to pick up a medication with their insurance card and it'll be $100 and then they'll say oh that's a lot of money I don't think I can afford it and then another patient comes in saying I don't have insurance and it's $20. I'm like wait wait wait you're paying with cash and it's it's more expensive if you're covered, then if you have no coverage? Like, I don't understand how that scenario is even possible. Yeah. So this is the source of a lot of frustration.

And I shouldn't even say frustration. I would say anger. And I would say also real concern about our ability for pharmacies across this country to stay open. So you talked just a minute ago about vertical integration. This is a huge issue where pharmacies that are part of vertical integration sometimes are doing better than what we say are community pharmacists, like your local, especially in rural areas. And again, I would say there's bipartisan interest and concern around this. But basically the scenario talked about where maybe someone with insurance is paying more is because there really aren't rules around the discounts that.

the drug company gives. So sometimes drug companies, they're negotiating with the PBM about their placement on a formulary. And so sometimes it goes to lower the premium, like the discounts for the drugs. I really am trying to think of how to explain this simply. It is a struggle. It's because they are negotiating different prices with insurers, then they're probably making a different designation with a relationship with a pharmacy. That's right. And to me, I have rules as a physician, even though I work at a community health center, but I know in private practice, I can't charge my patient who has United Health $150

for a visit to see me, bill United Health $150, and then say, oh, you're paying cash, I'll give you a discount. $50. That's illegal. Yet the pharmaceutical companies, the PBMs are doing exactly. that and deciding different prices based on who negotiates things better or perhaps if they don't have insurance at all. So it feels weird that we have all these mandates for us as physicians as individuals, but yet these rules don't apply to the bigger companies. Is it because our lobbying

power isn't as strong as in reality? I mean, you know, this is a really, I can see from that point of you. It's, it's hard to say, but I think that sometimes in public policy and in health care, particularly, things have to hit a tipping point. And they are hitting a tipping point. They're hitting a tipping point. Right. I mean, I think the prices of prescription drugs, and I would say, you know, it's frustration on both sides, right? The companies, they want people to use their drugs, right? So there is an incentive for them to come to the table. But it has been really challenging. And I think that often status quo is very attractive to many, many parts of the healthcare industry. But it's too problematic, right? Like how frustrated our doctors?

Well, I don't, I think no one is winning except the big companies. And I'm not saying that as someone who's like anti-capitalist or something. I came from communist Russia. So I very much don't want that system. But what I just see is that doctors are getting burnt out and having moral injury. Patients are upset because their things aren't covered. They feel like they're spending less time with their doctors. So it seems like a loss, loss, loss.

And there's only one winner. And ultimately it needs to get redefined in a healthier way where I'm not saying no industry. Industry can absolutely thrive in a system. They just need to thrive in a more balanced system. my guess is my thought. But perhaps I'm an idealist in that regard. I want to ask you if CMS ever thinks about an issue that I see in my community, let's say even in Brooklyn, where I grew up. You can get protein at home or a protein latte at Tim's. No powders, no blenders, no shakers. Starting at 17 grams per medium latte, Tim's new protein lattes, protein without

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Oh, hi, buddy. Who's the best you are? I wish I could spend all day with you instead. Uh, Dave, you're off mute. Hey, happens to the best of us. Enjoy some goldfish cheddar crackers. Goldfish have short memories. Be like goldfish.

Doctors who were the best at their specialty, family medicine, cardiology, dermatology will oftentimes say, I'm not dealing with Medicare. I'm not dealing with Medicaid. I'm going to accept either the best private insurers or cash only for my services. How does CMS deal with some of the talent leaving the pool of the doctors that are working within this sector to actually deliver care? How do we keep them in the system? What's harming that relationship. So to answer your question, did we think about this? Yes. In Medicaid, which is where I would say there's the most concern about doctors not taking Medicaid, some of the things that we did were try to strengthen the rules for requirements for states and manage care companies that

participate in Medicaid to have a certain level of network adequacy. And while we did not mandate that states pay more money to doctors, that is part of the implication that to have an adequate network, you're going to need to make sure that you are creating an environment where doctors want to participate in the Medicaid program. There are some states where Medicaid participation with doctors is stronger than another's, and part of that can be how the state pays them and how the state reimburses them. In Medicare, CMS has less authority and ability to the payments are dictated really by Congress. And so payment is absolutely one key way that you get providers to participate.

But that is something that CMS has little control over. We certainly thought as an agency about what we could do about provider burden. And that's a piece of whether you want to participate, just you as a physician, you as a hospital, like the level of paperwork that you are getting from the insurance companies. And so that is something that we really did think about provider friction. And, you know, I was talking about prior authorization. That's something that we took steps within our authority to really try to make it easier for providers. So those were a couple of steps. Yeah, because I see organizations that are trying to help everyone, and they'll open up a practice

very wide-eyed, bushy-tailed, excited to help everyone. And they say, I'm going to accept Medicaid. I'm going to accept Medicare. I'm going to accept private insurers. And I'm going to try and balance this in a way where this is sustainable for me as a business. As an individual practice, that's near impossible. And that's why we're seeing these rates of individual practices drop that are run by physicians.

They're joining large groups so they can better spread apart this risk. And also what ends up happening is once you become known in a community for accepting that coverage. And while everyone else is not, the amount of people that end up coming to you with the worst quality or lower reimbursing insurers, it makes your business model falter. Are there any ideas about how to manage this in the future to get like some bright ideas of saying, well, okay, we are working on the Medicare side of things, but we also have some sort of say in relationships with these private insurers through Medicare Advantage, through the individual market, to say if you want to participate in that, we have to create a balance that if you're using this physician services for Medicare, you also have to send them pay. within that insurance network or there's been little innovation there. There have been times when people have thought of tying the markets. CMS's ability to do that is limited. But certainly there have been times when states have thought about that

and it may be that we see a future Congress that would take a step like that. There are things that CMS cannot do without congressional approval. Got it. For me, as someone who's passionate about primary care and someone who's seeing primary care on the down swing, seeing residents perhaps not as excited about pursuing primary care because of the burnout, the lower reimbursement rates, actually, I find it funny when anti-vaxxers will accuse pediatricians, family medicine physicians as doing this for the money, like pushing the vaccines for the money, when they clearly haven't looked at who

are the lowest paid physicians. We're literally at bottom of the list. I worked with Senator Chuck Schumer on this a lot to try and improve the residency training for primary care, boosting primary care, not because I'm passionate about it because I love it, but because I do. But it's also because I see the benefit for not just society, but also the cost savings of it. If I, as a good primary care physician, can keep my patients out of the hospital, out of the emergency room,

if I can manage their chronic health conditions without flare-ups, if I can make sure that if they have a risk in their life, that I can mitigate, therefore decreasing the need for a surgery for future medications, I would save money. I would make their lives better. But yet we're not thinking about primary care as much as we should. Has CMS ever thought about this and what has been happening in the background there? Yeah, so this is definitely something that so many people are thinking about about the fact that we need to have more and more of an emphasis about primary care in our country. One of the ways that we thought about this was really around what we call models, which is basically when CMS does something a little bit out of their authority in a test case scenario. And there have been a number of models that my predecessors tried, that I tried, and I'm sure, you know, future administrations will think about, about how can we pay more for primary care? How can we encourage whether doctors to engage in primary care?

and not so much CMS, but other agencies at HHS do a lot of work to encourage people to go into primary care. So like the HRSA, well, what HRSA did, we'll see how HRSA survives in this administration of taking care of community health centers where you see a lot of emphasis on primary care and grants for that grants for people to, you know, as they pursue their education, because it is a real issue also just with doctors making decisions, which, of course, they can choose which speciality to are you worried with the current cuts that the HHS is facing, that there's going to be harm to these CHCs and other perhaps primary care ventures? I think that I'm really concerned about the cuts to HHS. I think, um, You have so many people who are dedicated to trying to improve our health care system.

And some of the things, some of the things we're talking about, they're public goods. And there might not be a financial incentive to make sure that there's community health centers operating. But it is a public good to make sure that when you need health care, that there is somewhere to go. But see, I think there is an incentive. Because if through a community health center, you're minimizing the use of ER space. Oh, totally. Like I think there is so much.

I just think it's overlooked. Yes. In many instances. And I should say people, I think, in a bipartisan way, love community health centers. But there are just so many things that HHS does that are things that we need. And I think that to, it's not that any, any administration has a right to look for efficiencies to make sure they're, you know, being thoughtful. But that's not what we saw. That's not what we're seeing. There isn't a thoughtful approach to what do these people do, what harms are going to be, what are going to be the impacts.

And I think that what we've seen of the last couple of months will have devastating impacts to so much of our health care system. And so to answer your question more specifically about community health centers. I don't know that it will specifically affect primary care or CHCs. I do feel quite clearly that we've lost a lot in our scientific community. It is really undermining the work of scientists, this stopping of NIH grants midstream, creates so much uncertainty and it it doesn't just pick up in a dime like they say oh sorry I well you call them back and now getting them back is 10 times harder that but even like the money that went to private entities I heard another doctor talk about how you know if your grant funding stopped and

then it resumes it's not like you just pick up that work are we creating an environment where scientists want to do business in the United States. I mean, this is a place where people have from all around the world have wanted to come. So I think to some of those changes can have a real lasting impact on what health care in our country looks like, really concerned about FDA. I mean, some of the things that the experts at FDA do to make sure that we have drugs, not just that they're safe, right, that they're approved, but looking at the facilities, making sure they're safe. I mean, these are really important jobs.

Yeah, it's scary. In looking at the new head of CMS, there's a new venture that those who are receiving some sort of government aid from an insurance perspective need to contribute either by working, taking care of a loved one. Have you seen that venture put forth? feelings on it. I would say that if we have learned anything over the last couple of years, it's that when we don't have everybody in this country having health insurance and health coverage, it affects all of us as a community. I mean, you don't have to, you can only care

about yourself and you should care that other people aren't sick and dying and affecting your environment. It has an impact on the rest of us. Funding insurance can be selfish in a good way. It can be selfish. You really can be selfish. You can really say, you know what? I want to be able to go to the hospital and I want there to be a place to have a baby.

You know, as in my job, I traveled around the country and talked to people. I went to Wednesday where one out of three days, you can't travel. over this past. This is the past that you need to get to the hospital. We have hospitals across this country that are closing and they need financial support. And one of the ways to get it is by making sure that everybody that goes through their doors has health care. So I would say that, first of all, we really want to make sure that we have a basic level of coverage for this country. The second piece about about work requirements or all of this is what we have seen time and time again is that when you put people through red tape, you lose not only the people

that you think don't deserve it. You lose other people. Of course. Which is what marketers do so well. That's right. And why some of those prior authorizations and denials work in some insurance companies' favors. Yes. So those are the things that I would say. First of all, I believe that again, it's the right thing to do for all of our sakes, not just for the millions of people. And also just the coverage numbers, CBO, the Congressional Budget Office, whose job it is just to look at the data and see what they think, thinks that 16 million people are going to lose coverage as a result of these changes. that is a lot of people that think about who those people are. The people who depend on Medicaid are, you know, they are children who have high needs. They are children who just are low income and just trying to go to school, right, who are key to whether our economy is going to work, whether healthy kids grow up to be adults that go on the job.

some of the people that are in what's called the Medicaid expansion, they're parents who make 40% of the poverty line whose kids have a birthday. And then all of a sudden they're no longer eligible for insurance coverage because their child, you know, aged out of them, the parents qualifying for health care. And then it's seniors and people with disabilities. And so, you know, the toll of those people losing coverage. And that's just on the Medicaid side. The Affordable Care Act, this bill changes affordable care act coverage,

makes people pay back thousands of dollars back if their incomes go up, which is not what we want, right? We don't want you get a better job and then you have to pay the government back. Money you didn't get. The insurance company got it. Right. Right. At the end of the year.

Yeah, that's so messy. You know, something my patients struggle with. at times, and I know there's been some legislation put forward about surprise billing. Now, no one wants to receive a ridiculous bill. I frequently give some strategies about negotiating these things, fighting them, telling my patients how to adequately handle that to the best of their ability. But I know that we had this no surprise billing, was it legislation passed forward? But it was missing teeth from my understanding to the point where a lot of these cases are

held up in court or perhaps not fully executed. What is the state of the surprise billing rules? So there have been a number of court cases that have, which caused during my time CMS to have to issue new regulations. And I would say, you know, this is, as with all things in health care, making changes take some time and the courts really ruled against the Biden administration in terms of some of the choices that we made, which did make it harder to enforce. But we went forward with really trying to help between the negotiation, settle these cases between providers and insurance companies and, you know, to the best of my acknowledge those that work continues. Okay. What do you think is the biggest myth or

misconception surrounding CMS or Medicare perhaps to the average person? Oh, such a good question. I think many people don't know what CMS is. They've never heard of those initials. Yeah, tell us what does CMS stand for because now we have a celebrity at the head of CMS with Dr. Yes, I think now people will start to know. Maybe you can know what it is. So Medicare, sorry, so CMS stands for the Centers for Medicare and Medicaid services. And it's not well known, in part because there was really the focus on let's brand Medicare, right? So most people in America know what the Medicare program is. But CMS runs Medicare, Medicaid, the Affordable Care Act, and it does something else that a lot of people don't know. And that is, looks at the health and safety

of tens of thousands of facilities across the country. So your nursing homes, your dialysis centers, hospitals, all are required to meet certain standards that are set forth by CMS. How did CMS get that role? It seems like not a role. You know, I don't know exactly when it happened, but it comes from if you want to get Medicare dollars, we need to make sure that you are meeting Medicare standards.

So that's the hook, right? Like we're not, CMS is not responsible for, if there's a private hospital that says we don't want any Medicare dollars. So if it's sort of the, when you're the money, you get to decide, you get to be involved. Sure. So somewhere that happened. Got it.

Are you confident this new administration, Dr. Oz will do a good job running CMS? I think that CMS has such an important mission and that everyone there seems committed to executing the best way. I am incredibly concerned about some of the steps, particularly this House bill, which now is being debated in the Senate about the effect on people. What part of the bill is concerning? The biggest issue is really losing that level of coverage. for it's going to be destabilizing for those families. It will be destabilizing for states, who, many of whom are struggling right now to pay, to make sure that they are supporting the Medicaid program in the way that we need.

I think it's going to be really hard on a lot of hospitals, particularly in rural areas. And again, I think that health care has become. become a more important part of our economy. As I said, the bankruptcies in this country, many of them are because people can't afford their medical bills. We don't want to be in a world where people are going bankrupt over medical bills because it's not, then you can't work. You can't, you know, take care of your relatives. Well, that's why I was thinking about those CHCs, these community health centers. If they're keeping people healthy, they're keeping people to work for. So again, it's beneficial. It's absolutely beneficial. You know, you, you know,

you really, I came to health care. It wasn't my top as a kid. Like, it wasn't my top issue. You mean you didn't want to run CMS as a kid? That was not on my bucket list. But the more I started to, you know, in college and in my graduate school, sort of understand how fundamental health is to the pursuit of the American dream, the more I really began to appreciate that it's pretty fundamental. Like, I think education is so basic. Like, we cannot, you cannot pursue the American dream without having an education.

And we as a society have decided we're going to educate our children. I see health now really the same way that it's fundamental. You cannot, you know, you can't provide for your family if you don't have your health. You can't go to school and learn anything if you don't have your health. So it's just pretty basic. I have a magic wand. Okay.

And I'm able to, let's say double for simplicity's sake, give you another $3 billion and run CMS. What are you using $3 billion for? Well, I would update a lot of our systems, which I think is the, at least exciting. The answer, I know. But honestly, the best answer, because I know how ancient those Windows 3.0 NT systems are. I would, we would be updating the IT systems and really making some, some changes there. Because, you know, data is really important.

And the ability to make sure that we can make good decisions and make changes when one of the reasons why Congress would always say, why does it take you so long to do things? It's because the IT systems are out of date and need to be updated. That would certainly be a priority. So a billion dollars for that? Yes. And then really trying to strengthen,

I think a lot of our ability to do oversight and back to the facilities and the nursing homes and things along those lines and be able to expedite a lot of the things that people ask us to do. Now, the reason why I'm saying all of those things is because that's money that's for the staff and for the operations.

So those are, I would say, kind of the key areas of really being able to respond to the things that people need. Remind me the cost of Medicare and Medicaid? A trillion. So if I can take 10% of that and that's a huge amount and put that towards CMS, does Medicare and Medicaid be better. Yes. If those dollars is spent well, absolutely. Because I think people will ultimately get help better as well. The quality of care will go up. The oversight will go up. So it seems like the funding issue, we're throwing money at the wrong thing, the thing that perhaps feels better or perhaps

has good intentions, but the outcomes aren't there. Why do we miss that? You know, I think, well, I would say a couple of things. One, the two are divorced, right? Like there's a different appropriations process, then the dollars, the over a trillion that is spent on Medicare and Medicaid flows regardless of the budget process. But when CMS's budget is being debated, it's against NIH and CDC and FDA. And so I think people often miss that it's important for CMS to have a budget that... We need to create a sex your name for CMS. I think that that's true. We need to make it something so it's like, if this is broken, it doesn't, like the power button or something.

Yes, I like that. Because if it doesn't work, you're not turning anything else on. So I think that's a good first step. And it's funny because we're talking about a title change, but those things matter. They matter a huge amount. These conversations matter. Absolutely. Because without the understanding of how things work, ultimately the funding gets incorrectly placed.

The transparency is lacking. And once those things break down, then you just have further problems down the line. Yes. No, you're right. Well, maybe with Dr. Oz, CMS's profile will change. You know, Tommy Thompson, Secretary Thompson, and the Bush administration changed CMS's name. So maybe it's time for some rebranding.

Do you think it will help CMS the fact that Dr. Oz is a physician? I think that there have been times when there have been physicians. where I think people have really appreciated that. I don't think it's either or, but it's always good to have everybody's lived experience, I think can be helpful to their role. And I was not a doctor. I brought a different type of experience to the role. And I think being a doctor certainly brings, you know, a perspective.

There are things that even as a doctor you don't experience. It's about the insurance industry. And so I think, you know, it's also that learning curve of learning what CMS is, it does, as you said, some of the things that, I mean, I could go on and on about some of the things. Does CMS impact residency training spots? It does. So just, yes, funding for that. It does. It flows through CMS.

But where does the money from that come from? It comes from Congress. So it's like, it's called GME. and we have limited ability to change it. But like when you were saying, you worked with Senator Schumer on the legislation. Yeah, it was on the omnibus bill. Yes.

So they gave money to CMS and it said, put more money in a primary care. So it was earmarked for that. Yes, it was earmarked for that. Okay. So we need to improve that as well in addition to all the... Yeah, so there are all these like little things

that CMS does. People sometimes you think I'm responsible for that. Oh, man. And GME needs to update. I mean, medical schools need to update. Like the whole AI change of information transfer is leading to drastic questions that are being asked of how necessary is college. How necessary is it for doctors to know the Krebs cycle, you know, like these little minutia points that you don't work with in every day versus is it more valuable for a doctor to know these chemical formulas or is it more important? for them to learn how to use AI in a way that's going to help their patients.

Yeah. Those are good questions. I'm not saying that one is definitely better than the other, but those are questions that need to be discussed from the education standpoint for sure. Absolutely. Yeah. What's your relationship like with your doctor? Oh, it's fantastic. You have a primary care doctor? I have both a primary care doctor and an OBGYN. She delivered my daughter who's just turned 11 and I just saw her a couple of weeks ago. I love them both. I will say. I really do. So that's good that you have a continuity of care in that sense.

I do. Now the harder question, what's your relationship like with your insurer? Are you happy with your insurance plan? I am, but I... Really? Yes. I've yet to see the person say that. I...

Is it because of your history in your position? No. No. They're not aware. No, they don't know. Okay. You just go through, are you still employer-based? I am, but through my spouse.

Got it. Okay. But isn't this complicated? that it's it has to be dictated based on your family situation which changes it is based on your employment situation which changes that's right it's really challenging and you know a lot of people when they left the administration like this is a you know a big transition and of figuring it out when you're when you lose your job last question which is hard oh okay not yourself who would you put in charge of CMS today?

Oh. Oh, I can't. Who comes to mind? That's hard, right? See, this is the beauty of podcasting. I can put you on spot. But if you want to say past, that's fine, too. Oh, yeah.

I have no idea. What a good question. It has to be, yeah. It could be anyone. Is there anyone who you see that they're innovating, they're doing good work, that you would love to see them get a chance? to make some change. Yes, this would take a lot more thought.

I think that this is a very hard question. Well, I can only imagine how hard it is to enter the presidency and then say, okay, let me nominate all these positions that I know very little about. Yes, but there are plenty of people who are weighing in on people that they think are good ideas. But yes, it is. It is, you know. What's the Senate confirmation like? That was stressful for you.

It was stressful. You know what, though? I really, I would say afterwards, it forged me in the fire. And so it was actually really good training for my job. Okay. Got it. It prepared you for the bureaucracy and complications of press. And to really, so I met with senators until I got confirmed. And you really are establishing relationships and helping them to understand where you're coming from. and also to listen to what they have to say. Sure. Because senators call the CMS administrator quite a bit. Really?

Yes, yes. Wow. Yes. And what do they ask for? Well, many of these things, I would say, really come around to what's going on in their state, like what's going on with my Medicaid program or what's going on with my hospital.

So just a lot of questions about. my hospital is having X, Y, Z issue. Can you look into this and trying to cut through the bureaucracy? And yeah, I think that's one of the things that probably was the most surprising how much time I spent with members of Congress listening to their concerns, nursing homes, also a big, big issue that I spent a lot of time. Or it could be their bill, like something about health care and that they're concerned about and want my perspective.

But yeah, so that's why it was good because I went through a process. Where you got ready for that. Yes. Well, thank you for your work. Everything that you've done. Thank you for the open and honest conversation.

I think I learned a lot. I hope the audience learned a lot too. Do you want people to follow along with your work, your organization, anywhere you'd like to push the audience to? Sure. I am at the Century Foundation, so you can take a look there, and I am on X at the LeShore side, and so you can follow me there.

Perfect. Thank you so much. Thank you. Huge thanks to Chiquita for traveling to New York City all the way from Washington for this interview. If you found it interesting, you might actually find my interview with Dr. Elizabeth Potter also really interesting. This was just a few episodes ago. She's in a very public battle with the health insurance industry.

Scroll on back, check that one out. Also, make sure to follow. or subscribe as it's the best way to find our newest episodes. And if you really like this episode, give it a five-star review, leave a comment. It helps our podcast find new viewers. And as always, stay happy and healthy.