The Great Simplification with Nate Hagens - John Kitzhaber: "What Makes a Healthy Society?"

Episode Date: May 10, 2023

On this episode, former Governor of Oregon and ER Doctor John Kitzhaber joins Nate to discuss the shortcomings of the medical system in the United States. With health outcomes below average compared to other developed nations and healthcare spending at nearly 20% of GDP, creating medical systems that are less costly while also keeping people healthier is critical to the well-being of the country and its citizens. Dr. Kitzhaber's hands-on experience working in medicine and systemic perspective as a policymaker gives him a unique perspective on healthcare resource allocation, the effectiveness of medicine, and the real world effects of how we incentivize medical care. Can we extend our time horizons by making long-term investments in the most effective preventative care? How do we take care of more people with fewer resources available? Most of all, can we come together to think critically about how we can create a system that prioritizes holistic health, based in community and accessible to everyone? About John Kitzhaber John Kitzhaber has more than 40 years of experience in health care and health policy in both public and private sectors. He practiced as an emergency room physician for 15 years; served 14 years in the Oregon Legislature, and served three terms as Governor of the State of Oregon. Kitzhaber is the author of the groundbreaking Oregon Health Plan, through which hundreds of thousands of low- and moderate-income Oregon families gain access to health care. During his third term as Governor, Kitzhaber was the chief architect of Oregon's Coordinated Care Organizations, the first effort in the country created on a statewide basis to meet the Triple Aim—better health, better quality, lower cost—with a focus on community and population health. To watch this video episode on Youtube: https://youtu.be/Z4cjl77rj78  Show Notes & Links to Learn More: https://www.thegreatsimplification.com/episode/70-john-kitzhaber 

You're listening to The Great Simplification with Nate Higgins. That's me. On this show, we try to explore and simplify what's happening with energy, the economy, the environment, in our society. Together with scientists, experts, and leaders, this show is about understanding the bird's eye view of how everything fits together, where we go from here and what we can do about it as a society and as individuals. Today's guest is John Kitshopper, a former emergency room physician and also the former governor of Oregon. John and I discuss the medical and health care system in the United States, which may seem tangential to the great simplification, but health care is over 20% of the size of our economy. And we get lower health outcomes than many other developed nations. In the future, we're obviously in a resource and growth constraint and complexity constrained system.

We're going to have to create medical systems that use less energy and money while keeping people healthy. Dr. Kitshober has a unique perspective on health care policy and its real world applications. He's credited with some of the most outstanding reforms in the nation's health care system, including some that are still in effect in Oregon, including the Oregon Health Plan, and coordinated care organizations. John is currently active in health care reform advocacy, fighting for a system that prioritizes better health outcomes that meet the triple aim of better health,

better quality, and lower cost with a focus on community and population health. Please welcome Dr. John Kitshober. Governor, great to see you. Yeah, Nate, thanks for having me. You are welcome. You have been a governor of the state of Oregon. You've been an emergency room doc. And now among many of your other pursuits, you are working on trying to help the United States have a more sane, sustainable, viable health care system.

So it's quite the trifective experience. And I'm happy to have you here to share your wisdom and insights. maybe we could just start with an overview of the U.S. healthcare system. So in prior conversations, you and I have talked about this, how much of U.S. GDP is the health care sector, and how does this compare to other countries? Yeah, we're getting close to 19% of the GDP committed to health care. It's about twice the average of the rest of the OECD nations. So we're definitely an outlier.

about $12,900 per capita per year. I think the second one is Germany at about 7300. So there's a huge gap there. And, you know, the troubling aspect of this is not just the amount of money, but is our health outcomes. You know, we have the highest infirmatality rate among those nations, and we're about three years lower than the average life expectancy for the OECD nations. So we're spending a lot of money. We're not getting the population health outcomes in return. And why is that? Why is that? I think it's due to a number of things. One of them that doesn't get much play is that in a zero-sum budget, money that spent on one set of services is not available to spend on something else. So we spend a huge amount of money on an acute care

medical system that essentially fixes broken people. It addresses problems after the fact. It addresses problems after the fact. We spend almost nothing on early childhood, on children, families, and communities, on those things that could actually reduce the disease burden in the first place. And the more we spend on medical care, the less we have available to invest on the front end. And it's just this vicious cycle. So the USA is approximately 4% of the global population. But I've heard that we write around 50% of the world's medical prescriptions.

Is that because we're sicker, we're less tough, or because doctors too easily write scripts or some combination? Well, I do think there's a cultural aspect about America. You know, it's the fast food, quick return, you know, instant gratification. So I think there is a belief or a culture to some extent that says, well, we can just fix it with a pill. At the same time, you know, we've got very limited price regulation. on pharmaceuticals, and we're one of only two nations in the OECD that allow direct-to-consumer advertising, a very low barrier in terms of getting new drugs on the market, and it's just incessant

advertising. You know, ask your doctor whether this drug is good for you, and then, you know, on the end, it's this long list of potential complications that they run through so fast that you can't actually understand them. Yeah, but they scare the crap out of me. When they say that could result in liver failure, all this other stuff. How can people, like, actually be marketed after all those warnings at the end? It sounds horrible.

Yeah, I'm not, you know, I'm not an advertiser, but I think the primary message is visual. It's the, you know, it's the happy people suddenly recovering from rheumatoid arthritis or some kind of skin disorder. And I don't think they pay much attention to the tagline. And, you know, if you've got a problem and it's a real problem to you, and you think that there's a way, some simple way, that you can cure that without actually having to make much change in your own lifestyle, you're going to go to your doctor and you're going to ask for that medication. So I didn't know this, what you just said earlier. In all the nations in the OECD, we're one of two nations that even allows television marketing for pharmaceuticals.

The rest, there's no advertising. That's my understanding. Yeah. My understanding is that the direct-to-consumer advertising is allowed in the U.S. and in New Zealand. But I venture to guess, and I'd have to check this, that the New Zealand health care system has more stringent price regulation. And because the U.S. market is so big, because the direct-to-consumer advertising is allowed, a lot of these drugs are marketed first here in the U.S. Because the profits can be astronomical. If you compare the price of the same drug in Canada and the U.S., there's just a stunning difference in price.

then why is that it's because we don't really regulate drug costs we allow the direct to consumer advertising and most other nations restrict the price of medications they have more more stringent controls over the price of medical goods and services so last year we were involved in this survey in the state of Wisconsin where we people about their well-being and what well-being meant to them and they ranked like 10 different things in their life and a very common response from people was I'm afraid to get sick because if I get sick I won't have the money to pay for the health care costs and I read somewhere John that it's estimated that almost half of cancer patients in the United States

will have to file bankruptcy in the process. Is this an extrapolation of what you just said between the U.S. and Canada? It is. I think the actual number of percent that actually go through bankruptcy is much smaller. I think it's four or five percent, but over half of them have actually been in collections. And I think the second leading cause of bankruptcy in the U.S. is inability to pay a medical bill right after unemployment, you know, which is to me just unconscionable in a wealthy nation like this.

The fact is that the price of medical care is becoming increasingly unaffordable for individuals, for government, and for businesses. Okay. So you've long been a champion of this issue. In 1994, you got primary legislation implemented in Oregon that was a different way to provide health care called the Oregon Health Plan based on ranking health services by their necessity and their effectiveness. And when the budget wasn't enough to cover all of them, only to cover whatever was the most. most effective on the list rather than pushing out coverage for entire people in an effort to increase coverage and accountability. Can you give a breakdown of the thinking behind this plan? Was it politically difficult to implement? What were the major setbacks? How did you get it pushed through?

Were there a lot of compromises that had to make? What was the public largely supportive of this or what? Well, it's an interesting story. It actually started earlier than that. It started when I became Senate President in 1986. In those days, the Oregon legislature met every other year. And in between sessions, there was this thing called the Emergency Board, chaired by the Senate President and the Speaker of the House that managed the state fiscal affairs. And Oregon, like all states, has to operate on a balanced budget. We can't deficit spend like the U.S. Congress can.

And about halfway through the interim, the budget went out of balance, and a big chunk of it was in the Medicaid budget. So we gathered together, and we took a few votes. we rebalanced the budget and one of the things we did was drop 4,300 people from coverage. Now, to me, it seemed like kind of a sterile accounting exercise. None of us really thought much about it. I went back home to my town, Roseburg, and began practicing again in the emergency room. And about six months later, I started seeing some people in the ER who'd lost coverage

because of that accounting decision we'd made in Salem. And one of them was a middle-aged man who had suffered a stroke because it could no longer afford his blood pressure medications. And I remember thinking as I walked his wife up to the intensive care unit that I was just as responsible for his stroke as his hypertension because I'd made this decision to drop him from coverage. So what I realized at that point is the way we manage cost, at least at the state level in the healthcare system, when the cost gets too high, we drop people from coverage. In other words, we rationed people or we cut what we pay providers and at some point they stopped trying to see people who are on Medicaid in this case. or we increased co-payments and deductibles to the point that they're really no longer covered. So we came back and the next year, Oregon stopped covering Medicaid transplant program.

Very small part of the budget. It wasn't an intentional decision that got lost, I think, in the larger budget for human resources. And six months later, this little boy named Kobe Howard showed up who had acute lymphoblastic leukemia and his doctor wanted him to get a bone marrow transplant. And of course, the state was no longer covering the percentage. procedure. So he was eligible for Medicaid, but the program didn't cover that particular service. So they went to private fundraising. This became front page news, not just in Oregon, but around the country and even abroad. And he eventually died tragically. He was not in remission. He hadn't found a match yet, so it's

questionable whether the procedure would have saved him. But it was a very legitimate and moving human tragedy. So in the wake of that, there was an emotion made to refund the transplant program for eight people who application is pending. And I opposed the motion. Not because transplants don't have merit, which they do, and not because we couldn't afford it, but at the same time, there were 300,000 Oregonians who didn't have any coverage at all. Many of them children. They weren't eligible for transplants. They weren't eligible for immunizations. So it seemed to me that we needed to be more accountable in the way we made these resource allocation decisions. So that led to the Oregon Health Plan, which did a couple of things. It prevented the legislature from rationing people.

We put the eligibility in statute, so we couldn't do what we had done in the Emergency Board of the year before. Secondly, we prioritized health services from the most important to the least important in terms of the health benefit to the entire population being served. And then we estimated the cost of each element on the list with an independent actuary, so we couldn't manipulate payment anymore. So the legislature just had to make a resource allocation decision and decide how far up or down the list they wanted to fund. Now, it's important to note that we didn't prohibit doctors from providing things that were below the line, if you will. It just made it more clear and accountable connection between the cost of health care and the benefit. It was not particularly controversial inside Oregon. It was wildly controversial in Washington, D.C.

We needed a waiver to pass it. Some of the biggest opponents were Senator Al Gore, Henry Waxman, the Children's Defense Fund, who cried rationing, right? as though the 300 kids who couldn't get access to anything weren't being rationed. And if you looked at the list, services for children and maternity care were very high because they're very effective. In any event, we finally got a waiver. President Clinton gave us a waiver. We implemented in 1994. We increased payment a bit, so we had a lot of people vying for that population.

We've used that list now for 30 years. It's updated every two years. when the vote to pass this in Oregon was 30 to zero in the Senate and 57 to three in the House. So we had broad-based support inside the state, and I think it was more the sensational nature of an individual in need rather than the needs of the entire population that drove the opposition in the nation's capital. So that was quite successful in both keeping people covered and saving money, but as you point out, it would be highly controversial nationally because, our culture doesn't like the concept of rationing. Rationing is kind of against the American narrative. Personally, and you and I have worked on some other fiscal cliff and other issues, I think the concept of rationing is unfortunately going to become more necessary in the future. What are your thoughts

on this and what sorts of imaginative ways could there be to make rationing of basic needs more fair and effective? Well, a couple of thoughts. First, conservatively, 25 cents on every dollar in the health care system is wasted in terms of it does not produce a positive health outcome. Overpricing, over-utilization, poor care coordination, unnecessary care, et cetera. So I think there's more than enough money in the U.S. healthcare system to provide everyone in America with all the services they need that could possibly actually help, you know, and improve their health. I don't think that's the problem. I think the problem is that we have, we've got an hyperinflationary delivery system that spends almost nothing on prevention.

And we need to reform the system and reallocate those resources. The fact is, we have always rationed care. Usually not intentionally. The man that had the stroke, we rationed care for him. He was never on the front page of the newspaper, so no one really cared. He was invisible. What the legislatures, what legislative bodies do is they focus on the immediate and the visible and the dramatic. And they do it at the expense of needed services that aren't being delivered to many other people.

It's just a crazy and unaccountable way to develop public policy. Is it possible to host a space where all the interlocking agents and aspects of the health care system, payer, provider, labor, long-term, long-term care sectors come together to coordinate and have a real conversation about the whole system and how it works and this 25% overage that you described. And what would be the first step towards doing that? Well, I've done that twice. I've had two direct experiences. One was with the Oregon Health Plan where we convened after that emergency board debate about the transplant. I gathered together a group included hospitals, doctors, insurance companies, organized labor, and consumer groups. And we developed a set of principles that we all agreed to.

They were fairly broad principles. I wrote a couple of them down here for you. All citizens should have universal access to a basic level of care. There needs to be a clear and transparent process to determine what that basic level of care should be. The health care delivery system must encourage the use of services and procedures. procedures that are effective and appropriate and discourage over treatment. So we had a set of those that we all agreed on. They're fairly broad, fairly general, hard to disagree with. And then the condition for being at the table is that you couldn't just say no. If someone proposed a way to

reach those principles and you didn't like it, you had to offer a couple of other suggestions that worked for your particular industry that still fit in those principles. And we met twice twice a month in my office for about a year. And it's very interesting as people begin to get to know each other, as trust began to build, things that were hard lines began a little bit softer. And then you could almost feel a point at which people thought, wow, we're going to really do something important here, something big here. And at the end of the day, we produced Senate Bill 27, which created the Oregon Health Plan and had that broad bipartisan support. We did the same thing in 2012 when we created what's called coordinated care organ.

which actually did change the delivery model and try to reduce the total cost of care. And how effective has that been the coordinated care organization in increasing community health outcomes and reducing long-term medical inflation since that time? It's been quite successful. I mean, it came out of the depths of the Great Recession, where if we wanted to maintain coverage for everybody on Medicaid, with no new resources, which we didn't have. Providers were looking at a cut of about 37%. So we sat down and figured out how we could look at the delivery model to get more value for each dollar spent. And the result was these coordinated care organizations,

which are community-based organizations with local providers, a local governing board, and their goal is to look beyond the narrow clinical model and focus more broadly on community health. They operate within a global budget, budget, a fixed budget that can grow at only 3.4% per member per year, and they have to meet rigorous metrics around quality, outcome, and patient satisfaction. So in the first, we operated under waiver, we needed another waiver, which we got under the Obama administration. In the first

five-year period, all of the coordinated care organizations operated within the 3.4% growth cap. They all met the quality and outcome metrics stipulated by the waiver. We enrolled in additional 380,000 people under the Affordable Care Act, and we saved about $1.1 billion over that five-year period. They're still up and running, and it's a marvelous change in the delivery model. Is this, in good part, due to your political civic acumen, or is it also related to the fact that Oregon is a relatively low population state, so relative to California or Illinois, or New York, there's a lower threshold to get something progressive like this through. You know, I think it's a little bit of both.

There's no question that being a medical doctor gives you a certain credibility, I guess, in the debate. And being a governor also helps you convene the parties. I mean, you do need a convener. And Oregon is a small state. I mean, you can list on two hands the number of people that have to agree on any given issue to actually get things done. I would argue that it is progressive in the sense that it expands coverage. and manage, but it's also conservative in the sense that it manages costs,

public sector expenditures. And Medicare Advantage, not perfect, but it operates on it, which is in almost every state, right, it's becoming the majority choice in Medicare. It operates on a very similar manner. It has a fixed budget that's given to determined by counties. And then they're rated. It's called a five-star rating system that measures quality. It's got some real problems.

You're able to go in there and game that system through what's called risk adjustment and charge more than you should be getting. And there's been a couple of lawsuits on that. But if you could fix that part of Medicare Advantage, it's not dissimilar to the coordinated care organizations. So it's not like an unknown entity in red states and blue states. They're all doing it. So healthcare is a big drain on our national. budget and we're going into more and more debt. We're over 31 trillion already, but I think

healthcare, just like climate change, to address it, we have to deal with the corporate and moneyed interest. I assume there's a lot of lobbyists in the healthcare thing in D.C. Yeah, I think of the top six lobbies, four of them are, I think the National Chamber of Commerce is number one, but pharma, pharmaceuticals are next. I think, The American Hospital Association is in there, Blue Clause for shield, the AMA. Yeah, it's a huge lobby organization for sure. So technically smart policies, such as the ones that you described, that reduce the cost spent on medicine or whatever other industry actually decrease the contribution of that industry, healthcare, to GDP. And so in a culture, in a global culture, but particularly the United States,

where we measure our success solely through the metric of GDP, these health-efficient policies that you're describing actually look like it's making the country worse. So how do health, health care, and well-being fit into the growth model at the core of the entire system? Well, first, as you know, I disagree with the validity of using the GDP as a sole measure for success and progress and wellness. back in the day, right, to look at in Nepal, to look at alternative metrics? Absolutely. Right. So a couple of comments on that.

First of all, the health care system has very little to do with health. As I mentioned earlier, it's an after-the-fact acute care system. I prefer, I wrote this down here, the World Health Organization definition of health, which is a state of complete physical, mental, and social well-being, not merely the absence of disease and infirmity. So the health care system doesn't produce much health on a population basis, as we've discussed earlier. It's reflected in our population health outcomes compared to other industrialized nations.

A lot of the new technology actually just takes money that's being spent on medical care and takes it as a profit. A lot of these are publicly traded companies, venture capitalists, private equity funds. So it doesn't really reduce the cost of medical care. It just takes more of the profit out. and I would argue drives up the cost of medical care. So the way you deal with the question you're talking about, if we're going to continue to use GDP as a measure of success,

is you reduce the spending, the waste and inefficiency in the health care system. We need a health care system. There are acute problems that need to be addressed. There are chronic conditions that need to be addressed. But you take the difference and you spend it on the front end. You spend it on primary prevention in the very earliest years of life where the seeds, most of the seeds for chronic conditions are, are planted. So you are doing two things. You're spending the money. It's running through the GDP,

but you're spending it in a different way. It's like comparing the cost of a college education with cleaning up the oil spill and the Gulf. They're not the same. And I would argue that spending on primary prevention and health is not the same as spending after the fact on illness, right? Secondly, if you begin to make those investments in primary prevention, you will reduce the cost of medical care in the long term. And you can use those resources to invest in a transition to a cleaner economy, for example. Boy, it's really overwhelming. Yesterday, I did a podcast with Dr. Robert Lustig, and he said that 97% of Americans have some sort of metabolical dysfunction in their mitochondria. He blames it on sugar and processed food as the core culprit.

But what a mess because not only is it the monetary drain on economies, but it's the physical and almost psychic and spiritual drain. If people are sick and not well, we're not as creative or pro-future or able to work in our communities. And also, you know, how much of, you'll know the answer to this. I heard somewhere that like 50% of an individual American's lifetime health care costs are in the last six months of their life. Is something like that true or not? Yeah, obviously we spend a huge amount on end of life care, if you will, on the complications of aging.

But the metabolic issue is very interesting. One of my projects right now is looking at primary prevention. We know there's a new field called epigenetics, so it's about a decade old, maybe a little older, that has demonstrated that poor nutrition and toxic stress from housing insecurity, from economic insecurity, from unsafe neighborhoods, alters the genetic expression in the unborn child, which dramatically increases their risk of risky people. behaviors of addiction, of behavioral problems, mental health disorders, learning disabilities. In utero.

And that's passed from general. In utero. And then those problems are either amplified or modified based on the environment of which the child lives, right? So if you want to really bend down the curve and improve the life expectancy and the full participation of people in our economy, you begin to invest in the first thousand days of life. you begin to identify the conditions of a justice that exist before conception and during pregnancy, and that's where the resources need to be spent.

It's been estimated that 70 to 80 percent of chronic illness, including addiction and behavioral health problems, are planted, are set in place in those very early years. But if we were to care about that, and if we were to prioritize that, like many other things that you and I have talked about in the past, it would really, require a longer-term horizon because any politician that would vote for what you just said, we're not as a nation going to see the benefits of that for 10 or 20 years from now from the babies are just being born, right? That's absolutely right.

And one of the problems with the political system is it does operate on a two-year event horizon and you can't grow a tree or raise a child in two years. So the project I'm working on right now is trying to figure out a delivery mechanism. So it's not just about money. It's taking that money and making sure it gets to the right children and families at the right time and the right amount for long enough to make a difference. What does that delivery model look like? We're calling it a child success model that we're trying to design and needs to be nested in the community. It needs to be owned by the community so it can outlive changes in the executive branch of the partisan makeup of the legislature.

It's a governance issue as well as a resource allocation issue. But if we can crack that nut, I mean, the human potential and the cost save, downstream cost savings in social services and a criminal justice system and health care could be staggering. Are there other countries that are doing that sort of investing in child and in utero in the first thousand days? Short answers, I don't know. I know there are most other OECD nations do a much better job of spending on the social determinants of health, if you will. If you look at the OECD nations and you look at their total spending on health, which includes medical care and social investments, we're all about the same, roughly, but the U.S. spends vastly more in medical care and far less on social services than these other nations.

And I think that is one of the reasons that we see those poor population health statistics that are rather embarrassing. So one thing that I learned recently is that processed food with fillers like corn syrup and sugar and things like that is cheaper. And that real food, which is healthier, that's not processed, if you ate your entire diet with real food, it's like three times more expensive. So there's an income and wealth inequality aspect of food, which leads to the health issues you were just describing, yes? Absolutely. And when you bore down, and we're going to get to this point here in Oregon, if we're able to continue this project, we're going to discover that economic insecurity, poverty, along with racism, is a major driver of this problem. If you don't have enough money, you don't have access to healthy food, affordable housing,

child care, a safe neighborhood. And those are all factors that drive stress and cortisol levels in the pregnant woman. But we're going to have to step back. And if we can get consensus that we need to make those investments, we need to do more of a full cost accounting. Look at this problem. Over a 10-year period, if you made those investments, they are going to pay for themselves, six, seven to one in terms of reduced costs in the health care system or in the social support system or the criminal justice system. So the solution's there, right?

It's a matter of taking a 10-year view and, I think, budgeting framework, developing a process to reallocate resources from the back end to the front end and an effective system to actually deliver those resources to get the outcomes that you want. So I don't know if you've followed what's happening in the last month or two with advanced artificial intelligence. what about all these new tech venture capital ideas of using tech and AI to squeeze the current inefficiencies out of the health care system and in turn boosting their returns? Isn't this an inherent problem that if these companies are successful, they're still taking more

money out of the system and not prioritizing the health outcomes? Yeah, I think that's right. And I think if you if you stop, step back and ask your, of what produces population health, only about 10% of your lifetime health status is a result of involvement with the U.S. medical system. The rest of it's your behaviors. It's your environment, physical environment. It's the social determinants of health, right?

And that AI doesn't address any of that, right? And it doesn't really change the underlying incentives inside the delivery system. In fact, if the U.S. didn't spend so much on health care, there wouldn't be so many companies involved in startups that are trying to grab a piece of that pie. I'm not saying that these technologies aren't amazing, but ultimately that don't have much to do with health. They have to do with changing the way we do, making an inefficient system, making a hyperinflationary system, no less hyperinflationary but more efficient. So you know a bit about my work because of our interaction in the past. And I'm anticipating, this is a little bit of a,

of a rabbit hole off of the main thrust of our conversation. I'm anticipating a tougher times economically. Our energy and material throughput in coming decades will not follow the same trajectory of the prior 50 years. And when I think about doctors and nurses and healthcare with that alone, irrespective of the things you were just saying, I think we're going to have to get 80% of the medical health, benefits with 20% of the resources. I mean, I just went in for a little procedure last week and

there was disposable plastic and all these fancy machines and just tons of stuff that was single use and gone. And I just wonder, and I'm not talking about a dystopian future, but I wonder if, A, can we get a majority of our health benefits with a much smaller input? And B, is the emergency doctor or the medical version of McGiver going to be a really, really valued social skill in coming decades. Do you have any thoughts about all that? Oh, for it begin. I don't disagree with you, and I don't know the percentages, but let's start with this.

I think you can actually do it in health care. So let's say 25%, I think it's higher than that, 25% of the health care budget you could get, get rid of, and it would not affect the, you know, the, you know, the, the, the, the, the, health of the population, right? Then you go to the point, the fact that 40% of Americans adults have one, at least one chronic illness, and 60% have one and 40% have two. And chronic illness accounts for about 80% of the health care budget. So if you begin to make early investments and reduce the incidence of chronic disease, childhood obesity is a great example. Those kids are going to grow up and have type 1 diabetes, which has huge comorbital.

abilities, right? Rental problems, circulatory problems, et cetera. So you take the 25% out, you begin to reduce the chronic care burden, and you can probably get there, right? I mean, but it requires systemic change. And, you know, I don't want to leave your listeners with the idea that I'm not a big fan of entrepreneurship or private equity or innovation. What if we could, what if we could say, if you can figure out a way through technology to actually reduce the cost of the healthcare system over time by 6% a year, and you get 1% of the savings, what's 1% of $4 trillion? It's a lot. I just think that, you know, the investments in R&D in this country are not on prevention. It's not on delivery system reform. It's on new, fancy medical interventions to deal on the back end. So reforming an entire health system is obviously an enormous undertaking. I mean, how do we even begin?

Is it something that needs to be addressed from the bottom up, top down, or both? And do we first start by thinking about the goals of the health care system? I mean, what if we publicly stated the goals aren't to generate GDP, but to have an outcome of healthier populations, is it possible to have this conversation? I remember the vitriol when Obamacare came out in our public conversations. I mean, how do we even begin to start this process, John? I don't think you can do it in the United States of Congress today.

I think it has just become too dysfunctional and truly about the next election cycle. So I think the approach needs to be at the state level. What we need from the federal government is flexibility to innovate. And let's say a state level, like Oregon makes some coordinated care organizations, for example. If you could feed that to Washington and California and have a regional approach to health care, you've got, just think about it for a second. You've got three governors, six U.S. senators, 68 members of Congress, either the third or fourth largest economy in the world. I mean, you can reach a tipping point that way. And I think the question

we should ask is this one, is the purpose of our health care system to finance and deliver medical care or is it to keep people healthy? There are two completely different things. And most of the things that keep people healthy, most of the things that drive longevity and quality of life are not in the health care system. They're established much earlier. And, you know, that's the conversation we need to be having. Yeah, there's the tentacles of the superorganism are just embedded throughout various

sectors of our society. I've read that more than a quarter of FDA employees that approved drugs in the past now work at or consult at pharmaceutical companies. So how big is that conflict of interest within the higher echelons of the health care system? It's a big problem. It's not just restricted to health care. I mean, I think I read an article recently. I think it was two-thirds of the members of Congress in 2019, the class of 2019, who either were defeated or retired. went to work for some DC-based lobby company.

So that revolving door, I think, is a real problem. It's a problem in the financial industry. It's a problem in the health care industry. You know, it is a real problem. That's why I think, you know, that the reform is going to have to start at a local or regional level. I just don't see how it's going to get through Congress. So we started at a local and regional level and come up with pilots of examples that work and then other states or other communities say, hey, look at what they're doing in,

Roseburg. Let's try that because, well, here's another way to frame it. We can either change the healthcare system and then that rolls over into maybe changing GDP or we change GDP as a cultural goal and then fix the health care system. Of all the things that we might be able to change, I think health care actually might be one because it affects all of us every day. And a lot of people, like you said, 60% have one chronic disease and 40% have two. Is that possible? Yeah, I think the health care system is the avenue into addressing some of these larger issues. It affects every single person in the country. For the vast majority of people, it's increasingly unaffordable. If you're a small business, it's almost totally unaffordable. And in Oregon,

and it is the single largest all funds expenditure in the state budget, and it is the second largest general fund expenditure. It's huge, right? So I do think that's the place. And if you look at the healthcare industry, it reflects sort of the corporatocracy that we see across the nation that's causing all sorts of problems. And, you know, people want to be healthy.

They don't want to be sick. No one wants to stand up in an acute care hospital. So I think it creates a space for a different conversation. Not that it's going to be easy. you know, it is a big industry now, but I do think that it offers a much more personal entree because health is ultimately intensely personal. Sickness or death occurs one person at a time.

It occurs to you, which makes it different than almost anything else. Well, on that note, take off your policy and politician hat and put on your ER doc hat for a moment. For those listening or watching this podcast, what are three, personal recommendations you would give to people who live in this society for their own personal health. I know there's not a one-size-fits-all, but do you have any general advice? Well, I can think of two, and these are from, I guess, partly experienced. One of them is, I think cardiovascular exercise is really important. I run at least three hours a week or inside,

outside I like to run up in the woods. Recently, I've been attacked by a barred owl who thinks I'm seriously? Oh yeah, yeah. He's actually very cool. I know right where he is, I wear my hat and watch for him. He comes. Do you think he's protecting his family or something? Or he's playing? Or what do you think? You know, after the first time he went over and just brushed my hat with his wing and then he landed. And I thought he was maybe, you know, going after a mouse or something. And then I read this article about this increase in owl attacks in the northwest. Apparently they're very territorial. But he's pretty cool.

He's a giant, beautiful bird. Anyway, exercise, I think, is really important. It has lifetime benefits. The other thing in this may sound a little soft and fluffy, but for the last 35 years, every morning I find 10 minutes, no matter where I am, and I just sit. And I try to just be aware of my breath. I try to be aware of my surroundings. I try not to think.

and just sort of center. And I think that my days are always better when I have that opportunity just to kind of let go of things that I think are really important. And just take that time. It doesn't, you can do it anywhere. It doesn't require resources. It just requires a little bit of discipline. And I think it's a marvelous contribution to your long-time health status. You're like the 10th or 12th of my guests that have mentioned something about the benefits of slowing down and meditation.

Okay. tougher question, Governor. If you were, granted, you've already said that you think this needs to start at the community level, including some of the initiatives that you're working on. But if you were suddenly health czar of the United States, what would be a couple things that you would try and implement right away if there was political support? Yeah, I would, I think this, I think the thing that I would do immediately would be to move away from fee for service reimbursement, which is volume-based, the more you do, the more you get spent

to what I call value-based capitation, that is a global budget that can grow at a fixed rate that is linked to quality and outcome metrics. That is the future. That is the way we need to go. We need to change the incentive so that you get paid more by keeping people healthy rather than being paid more by doing more. It forces efficiency in your supply chain. It just changes the whole dynamic.

That's what we saw with the coordinated care organizations. So, John, I hope I can ask you a few more personal questions here. Given your lifetime of working with citizens on these issues, do you have any personal advice to listeners, not necessarily on the medical front, but at this time of global economic, inequality, economic, environmental problems. What do you recommend to people? I recommend that they don't give up. I mean, if we give up, it is an admission that we're powerless,

and I don't believe that. You know, I've seen over and over again people coming together in remarkable ways. I saw it. I was governor during 9-11. I've seen it during mega wildfires and floods. I saw it during the Great Recession. I was in central Oregon where the unemployment away was 20% and I saw an extension cord, two extension cords running from one house across to a neighbor's house whose utility had been turned off

because they couldn't pay the bill. We have that in us and I think we just need to tap it now and recognize that these are problems that we created and these are problems that we can fix. So don't give up. Be hopeful. And how would you change that advice for young humans who are teenagers, are in their young 20s who are learning about climate change and colonialism and inequality and this health care system that they're young people paying into, what recommendations do you

have for young humans or young Americans? Well, I guess it's sort of the same thing. I mean, I think that if you were, you know, my son's 25 and he looks out at the world that we're leaving him and is pretty stunned and not entirely delighted by the prospect. but you know, we deal with the cards we've been dealt. And I think the fact is that we may not be able to see the solution, but that doesn't mean we shouldn't strive towards it. I'm struck by a quote from the Vietnamese monk, Ticknod Han,

who said something to the effect of, when I lose my direction, I find the North Star, and I go north. It's not that I expect to reach the North Star, but that's the direction I want to go. And I think we need to have a picture in our minds and in our hearts of what the world should be like. Right. And then our compass during our lifetime is to continue to move towards that vision. And over the generations, we have done amazing things.

And we'll get through this. I don't think we know exactly how. It's going to require the new thinking, the new tools, the new ingenuity, the new perspective of the next generation. But they need to engage in this fray for sure. I like that. John, what do you personally care about most in the world? Well, I guess I care. I want to know in my heart that I have done everything that I could possibly do, no matter how small, to leave a healthy planet and a healthy society for my son and his generation.

Well, you've been working on all these things, ecology, climate, inequality, GDP, healthcare for a long time. So you've certainly been walking the talk as far as that North Star. If you could now, we're stepping outside of just the healthcare system, no longer health czar. But if you could wave a magic wand, there was no personal recourse to your decision. What is one thing you would do to improve human and planetary future? Well, of course, there are always consequences of your decisions. Well, I'll tell you what it is. If I can waive a wand, I would have everyone be able to, for just a moment,

move beyond the polarization and the partisanship and all the real and imagined differences we have and the voices on both the left and right that are exploiting them. And remember that we have two things in common. The first one is we share a common mortality. We're all going to be born. We're all going to die. That's the reality of our existence. And between those two events, we all walk a path, very individual path, but it goes to the same

destination. And I believe in my heart and from my experience that all of us in our own way want the same things as we walk that path of life. We want to find meaning and purpose and satisfaction. We want to be valued. We want to add value. And we want to all believe that we have an equal opportunity to succeed, to reach our dreams. No guarantee of equal outcomes, but an equitable opportunity to try. If we can remember that, if we can remember those common attributes of being a human being, I don't think there's anything we can't do. That's well said. Thank you so much for your time today, Governor. Is there anything that our listeners could do in their own lives, in their political

decisions, in their communities to help the kind of the efforts that you were talking about, your community models, or how can they learn more about it or get engaged, or what can people do listening to this that would like to contribute to changing the health care system? Well, I don't have an organization. I've got a blog that I could send you the link to what I post on periodically. But I just think, you know, I don't, I think we're much more empowered than we think. But we do have to get to root causes. And we've tossed to some of them about some of them today. And I think it's an exciting time to be alive. And, you know, someone said once that there's no survival value and pessimism. And I believe that. Yeah, I feel the same way. I mean, this podcast and talking to. thinkers like yourself and all the projects that you're working on is exciting. It's daunting, but it provides meaning and direction. Thank you so much and good luck with your projects in Oregon and we'll definitely continue the conversation. Great. Thanks very much for having me, Nate. I appreciate it.

If you enjoyed or learned from this episode of the Great Simplification, please subscribe to us on your favorite podcast platform and visit the great simplification.com for more information on future releases.