Alan Sager is the author of the book The Easiest, which focuses on health care reform. He is a professor at Boston University's School of Public Health.
Q: What inspired you to write The Easiest?
A: Two things. First, while in grad school, a little over 50 years ago, I decided that winning affordable health care for all Americans was the easiest job in the U.S.
Not easy—just easier than housing, education and training, environment, personal and neighborhood security, or any of the others.
Because we already spent enough on health care. Even in the 1970s, U.S. spending was enough to pay for the health care that works for everyone who needed it.
Since then, real health care spending per American—adjusted for inflation—has grown more than five-fold.
How many Americans know that health care spending is triple all education spending? That it’s six times defense spending? That it grows by another 1 trillion dollars every few years?
Or that it’s double the rich democracy average? Other nations have more doctor visits and hospital admissions and live longer—while spending one-half as much.
Why do we spend so much, get less care, and worry about rising premiums and co-payments? And allow an insurance company clerk to decide whether we need an MRI or whether our family doctor can remain in-network?
And second, I’ve been wondering what it would take to win affordable health care for all. If we are spending enough—and I’m convinced we are—where does all the money go? How can we find ways to better use the huge sums we spend on health care? How can we get more family doctors, keep needed hospitals open, and win better long-term care and mental health care? And finally cover the costs of fixing our teeth, eyesight, and earing?
It will probably take a crisis to provide the political and financial impetus to fix health care. But a crisis is not enough. It’s very complicated to organize, deliver, and pay for health care. Reforming it is even harder because so many moving parts need to be coordinated. And a crisis is not a time when citizens, caregivers, payers, and politicians will be patient.
So that makes it essential to figure out, in advance, what a crisis in health care will mean and—especially—how to use the opportunity afforded by a that crisis to squeeze out fat and recycle it to win solid, affordable coverage for Americans, and also financial security for all needed doctors, hospitals, and other caregivers.
Q: What do you think of the current impasse over the future of health care in this country?
A: Right now, we have two dysfunctional political parties. (The French, always competitive, outshine us: They have three dysfunctional political parties.) Both U.S. parties have extreme elements that are driven by ideology, not pragmatism. Many citizens lack good information because large numbers of reporters at TV stations or newspapers narrate stories about what they believe instead of reporting objectively about what is actually happening.
No one in U.S. health care is accountable for anything that happens outside the building where they work. No one is accountable for covering all people, containing cost, identifying needed hospitals and paying them enough to stay open, persuading enough doctors to go into primary care by boosting their incomes and cutting their paperwork, making prescription drugs affordable, or anything else.
Millions of people lost Medicaid coverage a few years ago and millions more will lose it when Trump’s budget cuts take hold—mainly after the 2026 midterm elections. Millions of others will lose their federally-subsidized ACA coverage if Trump and Congress fail to agree on extending the enhanced subsidies that were enacted during Covid.
Some people think U.S. health care is in crisis today. We have big problems and they are getting worse. But these are the storm clouds that arrive in advance of a hurricane, not the dangerous storm itself.
Q: How do you think we got to this point, and what do you see looking ahead?
A: Some six things matter here.
First, we gradually and accidentally built very costly ways to raise money, cover people, and deliver health care. U.S. health care may look like it was designed by the North Korean KGB to waste money and cause Americans to lose faith in our capacity to fix problems. But it wasn’t. It was crafted by good people who made the best decisions they could at the time. But they made mistakes.
Second, a big mistake has been to put faith in competitive free markets to shape health care. I happen to like those markets because they spur innovation and greater efficiency that cuts cost, and reward delivering the things ordinary people need and want to buy. But we don’t have a competitive free market anywhere in health care. None of its seven requirements are remotely satisfied—or can be.
Third, an equally big mistake has been to rely on government regulation to repair damage stemming from market failure. Antitrust action has been weak. Regulations to protect patients from high prices, inadequate networks of doctors or hospitals, surprise bills, and theft have been badly-designed political compromises and hard to enforce. Federal or state governments rarely put their arms around health care problems and work seriously to fix them. Instead, we have rhetoric like “value-based payment,” “accountable care organizations,” and other over-sold reforms that do little good. Government involvement in health care too often resembles the work of the guy with the wheelbarrow and shovel who cleans up in the wake of the circus parade.
Fourth, without either a functioning free market or competent government, health care suffers anarchy. No accountability. For anything. For example, consider primary care—the widely acknowledged, deep, and worsening shortage of family doctors. It’s simply no one’s job to address this crisis. Not the job of Medicare, Medicaid, Blue Cross, other insurance companies, medical schools, teaching hospitals. And good primary care is strategic: It saves money, builds trust in health care, coordinates specialized medical services, and promotes continuity of care over time.
Anarchy is why up to one-half of this year’s $5.6 trillion in health spending is wasted. Clinical waste is probably biggest type of waste—care that isn’t needed at all, care with high cost but low value, incompetent care, or uncoordinated care.
Administrative waste is almost as great. One cause is enormous mistrust between payers and caregivers that gives rise to chronic fights over upcoding and downcoding, prior authorization, improper bills, and more. Another cause is the complexity created by many payers, each with their own rules, incentives, penalties, covered services, prices, and other requirements.
Then comes high prices—for prescription drugs, devices, CEO salaries, and many types of care.
Theft and fraud probably make up the smallest type of waste—but even this amounts to a quarter-trillion dollars yearly.
This waste is deeply embedded throughout health care. It can’t simply be sliced off. Only a crisis can blast it loose.
Fifth, under conditions of anarchy and high waste, U.S. health care—insurance companies and caregivers—have become addicted to more money to finance business-as-usual each year.
Sixth, some reformers have given up on trying to fix health care. Some believe that belief in the market blocks reform; others believe that hospitals, doctors, drug makers, and insurance companies have a lock on most federal and state politicians. Many reformers have come to believe that spending more on the social determinants of life—income, housing, environment, criminal justice, and the rest—would do more to prevent illness and combat threats to health and disability than would working to improve health care itself. They might be right. But the money to finance that higher spending on the social determinants hasn’t materialized.
And it won’t—until we get health care costs under control. U.S. health care has become a sponge, absorbing money we could otherwise spend on many other things we value—such as building housing to push down rents, job training, vacations, national or neighborhood security, or saving for retirement. So real health care reform is strategic—essential to fixing health care and also to making it possible to address other problems.
Q: What do you hope people take away from The Easiest?
A: Seven ideas.
First, U.S. health care is addicted to more money each year to finance business-as-usual.
Second, up to one-half of health spending is wasted. Each year.
Third, as the saying goes, when something can’t continue, it stops.
Fourth, U.S. health care has no back-up plan. It is unprepared for discontinuity, for crisis.
Fifth, a health care crisis is very likely. Economic, political, and international threats could lead Congress to freeze federal Medicare, Medicaid, ACA, and other spending at the bottom of the next recession. Hospitals and doctors and drug makers might then try to raise prices charged to patients who are privately insured through their jobs. But the employers who pay for that insurance would resist—since family health insurance premiums will soon approach $30,000 yearly. Patients could then worry about whether they’d be able to get needed health care and, if they got it, who’d pay for it.
Sixth, at that point, doctors, hospitals, and other caregivers would be ready to abandon business-as-usual and embrace reform. Patients and employers would sign on. Politicians would go along.
But, seventh, this crisis would go to waste if we didn’t prepare well in advance to cope with it. Health care is very complicated. Reform is even more complicated. So we should begin now to design and test ways to use the opportunity presented by crisis to blast loose the money that’s now wasted and put it to good use.
The crisis might never materialize. U.S. health care might continue for years to struggle forward under the increasingly heavy burdens of higher costs, higher premiums and taxes, primary care shortages, long ER waits, soaring drug prices, and the rest.
But it might materialize. Planning and testing real responses to crisis amount to taking out a very-low-cost insurance policy. A few million spent yearly for five years could help avoid health care meltdown. Surely, once the plane’s motor stops, it’s too late to start sewing parachutes.
Among the key planning and testing jobs are—
√ How to capture the money available today and put it to good use? Lots of the pipes through which money now flows would need to be connected differently. This is a serious plumbing job.
√ How to cap spending and cover all people. These jobs are complementary. No rich democracy has done one without also doing the other.
√ How to identify needed caregivers—doctors, hospitals, long-term care, mental health, dental, and the rest? What are the gaps between current availability and need? How to fill those gaps?
√ How much money do caregivers require to efficiently deliver needed?
√ How to pay caregivers in ways that allow us to trust them carefully?
√ At heart, the jobs of slashing clinical waste and administrative waste are complementary. Both entail a few key strategic and concerted decisions by governmental and private payers to cap spending, cover all people, and sustain needed caregivers. Hospitals get budgets and doctors are paid in financially neutral ways.
√ Caring for all Americans with the huge but finite dollars and clinical capacity already available entails putting our money in doctors’ hands under arrangements that allow us to trust them to spend it carefully. That’s essential—because doctors’ decisions about how to diagnose and treat us—patient-by-patient—control almost 90 percent of health care spending.
√ So we have to pay doctors well, so they stop thinking about their own incomes. So they act wholeheartedly as altruistic fiduciaries—weeding out wasted low-value care and making sure all of us get the care that works.
--Interview with Deborah Kalb
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