Healthcare Reform: Price, Primary Care, & Access

Episode

[00:00:00] Erik Sunset: You know, we sit here every week and talk about healthcare like it’s some kind of unsolvable riddle, like it’s the Kennedy assassination, like nobody’s ever thought about this before. And yet, here’s the thing nobody wants to say out loud, everybody already knows what’s wrong with it. Ask a doctor. Ask a patient who just got a bill for a Band-Aid that costs more than their rent.

Ask a primary care physician who’s closing up shop because Medicare pays them less to keep you alive than a hospital gets for one scan. They all know. They’ve known for years. So why hasn’t anything changed? Well, that’s what we’re going to get into today because it turns out the problem was never a mystery.

The problem is that fixing it requires somebody, somewhere to actually lose something, money, leverage, maybe a talking point, and nobody in Washington wants to be that guy in an election year. Lucky for us, my next guest isn’t running for anything, at least not that we know of. Marc Ryan is back, and he’s not here to [00:01:00] pull any punches.

Let’s get into it

Erik Sunset: All right. Welcome back to The DocBuddy Journal. We are really fortunate to once again be joined by Marc Ryan. Marc is the chief solutions officer with Lilac Software. Marc, thanks for making another appearance on our show.

Marc Ryan: Great. Nice to be here, Erik. I love doing these, as you know, periodically,

Marc Ryan: thank you

Erik Sunset: here. Same here. And let’s, l- let’s maybe go back in time and address something that we haven’t totally covered yet for our listeners. I’m not sure that we’ve ever covered that you run a blog and your own podcast that can be found at healthcarelabyrinth.com, um, of course, on the leading podcast apps as well.

Erik Sunset: This is a healthcare reform series, of course. But give the audience a little more context there. What, what, why did you do this, and what do you cover?

Marc Ryan: Yeah, sure. Great. Um, you know, in addition to my work, uh, formerly at Lilac, now with Medisolve, [00:02:00] uh, which purchased our company, I have been for a number of years now, I wrote a book back in 2020 called… 2022, called “The Healthcare Labyrinth.” And then shortly, a couple years later, I decided to just sort of build on that book and create a website that people can go to, largely a lot of industry leaders, right?

Marc Ryan: Health plans, providers. it’s healthcarelabyrinth.com. I do a newsfeed five days a week on the weekday. I do two blogs a week, and I do a podcast once a week. And it’s just my way of giving back, making sure everybody… I try to keep it simple, but sometimes it’s complex stuff. So average Americans, uh, industry experts can read what’s going on in the news, get a little bit of my opinion on it. And for those that like the podcast format, I just sort of take a blog and blow it out a little and, and do a little more discussion on it. So that’s sort of what I’ve been doing since, I think, about ’23, ’24 now, so.

Erik Sunset: Um, and I’ll [00:03:00] attest to that, Marc. You are absolutely a content machine. You never miss a beat. It is, uh, it is very impressive. Very impressive indeed

Marc Ryan: Well, thanks

Marc Ryan: so much.

Marc Ryan: Thanks

Erik Sunset: And in, in these blogs and in your podcast, you talk, uh, regularly about a possible grand bargain between the parties. Can we break that down a little bit?

Erik Sunset: Explain what it is and why that would hopefully make sense for our nation, America.

Marc Ryan: Yeah, Back in 2024, I had sort of my first installment of a healthcare reform proposal taken a lot from my book, but then updated for now. We’re in now 2026, not much change has happened. If th- if anything, things have gotten worse on the affordability front. So I once again did a, uh, four-part blog series, five-part podcast series, which is now out there on both the blog tab and the podcast tab, or on the podcast is on all leading podcast, uh, apps and sites. But basically, it’s a [00:04:00] deep dive into my proposal, refined a bit on healthcare reform, I talk about the need for a grand bargain. It seems like no matter who’s in office, it doesn’t matter if it’s a Republican or Democratic president or a Republican or Democratic House or Senate, um, in the end, we really make no progress on healthcare reform. And again, affordability and costs continue to increase. year that somebody’s in control, they’re promoting their own agenda, and frankly, neither of which, whether it’s the Republican or the Democratic agenda, is right for the country. I happen to be a Republican, but I sort of go up the middle here, and I’ve sort of cultivated a plan that is a true compromise, responds to both parties’ concerns, and I think lays out a strategy to get to a point where we are not an outlier on healthcare spending our outcomes, which are among [00:05:00] the poorest in the developed world, get better over time. I know we’re gonna jump into that, but the three pillars are simply, um, price reform, pivoting to primary care and care management, and thirdly, true affordable universal access. This does not have to be a socialized medicine scheme. It does not have to be a single-payer scheme. Those are two prominent features in other countries. It can be a private scheme, which also is in other developed countries and has been very successful. And so that’s really what I’m aiming for in this reform series, and I figured it was a really great topic to bring to your audience, Erik

Erik Sunset: Yeah, I’m so glad you did. I mean, listeners of this show will have, uh, uh, hopefully heard your prior episodes, Marc, where we’ve, where we’ve touched on this. They’ve heard me harping on it and lamenting sort of the state of healthcare in the US. There’s so much that needs to happen to, to fix it, but there’s no magic wand, and you [00:06:00] and I have talked about sort of the lack of, if you could push any button, which button would you push?

Erik Sunset: You need more than one,

Marc Ryan: Yep

Erik Sunset: button, at least from my estimation. So what– that’s a great place to start. Walk us through, uh, the elements of healthcare reform, and I think starting with price, since that’s gonna be front of mind for everybody that’s a participant in this US healthcare system.

Marc Ryan: Yep, absolutely. And I will give everyone an admonition. Uh, some of this is controversial, right? Uh, and it, it offends some payers, it offends some providers, but the reality is, on the price issue, you really have to begin to make progress. And a former hospital board member, former health plan executive.

Marc Ryan: I’ve been on both sides. So I’m not insensitive to the fact that you have to be deliberate about this, but you gotta start, and you gotta start executing. And I really go back to the point that healthcare prices in America range anywhere from two times to multiples beyond that, depending on what it [00:07:00] is. When I look at the bout, the double, I’m referring to the aggregate cost in the system. In round numbers, taking the average of developed nations and looking at our costs in various stats, usually percentage of gross domestic product tied to the healthcare system, we are about double, maybe a little bit less, but double is a good number to work on, right? And so our prices are double, our costs are double. When you start going into hospital pricing or other provider pricing or things like that, in premium pricing, for example, we are many folds greater, right? And that has driven, uh, uninsurance rates up. though we made progress under the exchanges, we still have between twenty-five and thirty million people uninsured, and that’s really a tragedy in a very wealthy nation. then more to the point, we have what I call a growing unin- [00:08:00] underinsured problem. in many ways, that underinsured problem is between double and triple what the uninsured problem is. so if you look at the combination of uninsured or underinsured, we’re approaching twenty-five percent to a third of the country that either don’t have insurance or even if they have it, can’t afford to use it, and therefore they are not seeking out the care they need to stay healthy, right? And so what high price does. It essentially means people get sick, and it doesn’t mean savings. It means greater costs in the healthcare system.

Marc Ryan: because people are seeking care at higher and higher levels of care, much more expensive levels of care. And so the secret in my mind to price reform is this.

Marc Ryan: Number one, we do need to impose site neutral payments. let me back up a little. Site neutral payments basically say in the Medicare program, [00:09:00] you are gonna be paid the same amount, uh, as a provider regardless of where that is furnished, whether it’s in an outpatient hospital, an outpatient-owned facility perhaps of a hospital, a freestanding ambulatory center or imaging center, or a doctor’s office It– you’ll be paid the same throughout there. Right now what we have is much higher prices for some basic services at hospital outpatient and other owned hospital facilities, and that’s a problem that really drives costs. Now, it’s not just a Medicare fix, it’s also a commercial fix because commercial or employer coverage is basically based on multiples of the Medicare rate.

Marc Ryan: So when you’re paying too much for some of these services at different sites, you– i-in Medicare, you’re paying even more it comes to, uh, employer or commercial coverage. So first, site [00:10:00] neutral payments would help. And again, I’ll go back. I was on a hospital board. I’m not seeking to destabilize hospitals here. You can phase this in over time and begin to get that savings, and it will work. It will bring down price in Medicare, it will bring down price in the employer and commercial world, and those are the two biggies out there, right? next, believe, and people are gonna start yelling, “You’re a socialist, Marc.

Marc Ryan: You’re a socialist,” right? But I believe we should have national and regional price setting all lines of business And what I mean by that is we essentially determine what a service should be reimbursed at fairly, similar to how Medicare fee-for-service works, but again, we have to adjust some prices downward for site neutrality. But basically equalize rates across all lines of business, all this price shifting and things like that that occurs, [00:11:00] and pay fairly to providers to earn regardless of the type of member they have, Medicaid, Medicare, or commercial. And I think you could do it in part regionally, in part nationally. And let me push back on the critics that say you’re a price fixer and you’re going back to the Nixon days, right? Well, the reality is fixing is not a good idea in a competitive Marcet. By the way, healthcare is not a competitive Marcet, so it doesn’t… It, it makes a lot of sense for the government to intervene or states to intervene on this issue. So I think regional or national price payment schedules across lines of business would simplify things going on between lines of business. And by the way, we spend tens of millions, a hundred million, hundreds of millions of dollars over time in administration because we don’t have uniform pricing. [00:12:00] And so administrative cost is huge, and we would also be attacking administrative waste and inefficiency if we did this, this price scheme. Now, what I will tell you is in the developed world, even in private healthcare delivery systems, prices are indeed set at sort of regional or national bases, whether it’s, you know, a medical service or a drug, and therefore, this is proven. It works. We’re not some socialist price fixer here because, uh, you know, it’s really not a free Marcet.

Marc Ryan: Healthcare is not a free Marcet, I don’t care what you say. So that’s sort of in summation the two major points really related to price. There’s a third one. Consolidation is out of control. Consolidation, whether it’s health plans or hospitals and health systems, or providers, or even the impact of private equity, uh, in healthcare sometimes, um, is a bit out of control.

Marc Ryan: [00:13:00] We need a real understanding at what consolidations are doing how it really is raising price and in some cases, how it’s not actually improving care. It might be hurting care

Erik Sunset: Well, I, I just wanna give the audience a chance to collectively gasp and collect themselves after hearing about regional or national price setting. But on the other, on the other end of that, Marc, you know, a rose by any other name smells as sweet. Wouldn’t that address the need for transparency in pricing as well?

Marc Ryan: absolutely would. You’re exactly right, Erik, right? Suddenly you have transparency. You can’t really have real price transparency when you have different lines of business costs, different pa- plans paying providers different things, having different costs with payers. Uh, you can’t really have price transparency, and you can’t actually ask the patient to take stock and seek out efficient care in the current environment [00:14:00]

Erik Sunset: Absolutely not. I mean, there’s some really nice downstream effects with, with access and affordability there, and just being able to make a good choice as a consumer. And your, your points are really well made and well understood here, Marc. Um, so coming back to our, our core here, um, on your last point, what all has happened there?

Erik Sunset: Because there, there’s an understanding in the news that the Trump admin has proposed some things on that front. Is that gonna be enough? Obviously, hospitals are going to oppose this. Are their concerns valid? Should we care what the hospitals think about fixing healthcare in the US?

Marc Ryan: Yeah, Well, in many ways, I think the Trump administration’s approach on this, the incremental approach, the right move, right? Because again, we don’t wanna destabilize hospitals and health systems. We don’t wanna cause, you know, layoffs. We don’t wanna cause all those kind of things. encourage hospitals over time to become more efficient, and I think many of them are trying that, but many of them aren’t.

Marc Ryan: They’re [00:15:00] living off the old world. So, uh, basically what the Trump administration is doing is on select services, slowly but surely introducing the concept of si- site neutrality. In 2026, they did it on infusible and administered drugs, and now in ’27 they’re proposing to do it on imaging. starts.

Marc Ryan: Maybe I would go a little faster, and maybe that’s part of their plan, but they wanna, like, allow people to dip their toe in the pool a bit here. But doing it over time, protecting hospitals and protecting jobs and protecting things going on in the healthcare system makes sense. But let’s set that on a schedule and get to a point where we have an implemented site neutrality. I think that’s the right move. So I really applaud the Trump administration for f- you know, going down this road. They tried it in Trump, uh, ’45. It was sort of undone under Biden. They’re now doing it again in Trump ’47. They de- they deserve [00:16:00] congratulations, and even though the hospitals are opposing it, you gotta give them credit for being pretty incremental about this, recognizing potential some fallouts that could happen if it’s too aggressive

Erik Sunset: Yeah, as you point out, healthcare is not a free Marcet. It’s… There’s probably a, a better economic definition of it, but it’s, it’s a u- There’s utility in it. It is a utility. It’s a public good. I’m, I’m sure somebody much smarter than me has the exact, uh, terminology. So it makes sense not to shock the system, uh, as it were.

Marc Ryan: Absolutely

Erik Sunset: Um, next,

Erik Sunset: next I we wanna pivot to, uh, primary care and care management. Uh, this is something that we’ve talked about, um, with your prior appearances, Marc, and on this show in general. But as a part of your healthcare reform plan and platform, uh, tell us about this and why it’s essential.

Marc Ryan: Sure. Well, you know, it goes along a little bit with price reform, right? So he- here’s the big problem beyond price. [00:17:00] We are not emphasizing in our system upfront care or primary care. if you look at the other developed systems, they, uh, have a lot of focus on primary care And care management at the primary care level, uh, providing resources with primary care to manage disease states and things like that. when I talk about that upfront care, when you do have a disease state, you might actually need both a primary care physician and a specialist. I’m not arguing it’s all primary care. But unless we infuse primary care, and unless we really think about upfront care management, even with price reform, we probably don’t a- achieve the outcomes we want because we’re still going to be having all of this exacerbation of disease states at more expensive settings, right? So you gotta really pivot to primary care and care [00:18:00] management. As you know, I’ve criticized health plans even though I’ve been in there by saying plans got obsessed with prior authorization and utilization management, which has huge friction with providers. actually a bit wrongheaded. You always need some of that, and I’ll always say that, right? if we invested more in care management, more in primary care through health plans, we would be so much better off, and the savings potential multiples and multiples of what prior authorization probably saves along the way. So we need to, uh, as part of this pivot to care management and primary care, we need to have a primary care agenda nationally. We need to infuse primary care and stabilize it. need to, uh, basically begin the process of teaching primary care physicians and the system as a whole that we need to begin to manage disease states at [00:19:00] a more local level, at a provider level, at a low-cost level, provide the kind of infrastructure at that level that we need. We talk a lot about the fact that primary care is, is exhausted in several ways. There’s burnout among primary care physicians, and there’s financial exhaustion because they can’t even run a primary care practice anymore because they’ve been dealt hard blows over decades on the primary– the Medicare, uh, primary care physician and other physician rates, a real drop of about a third since 2001. so they’re financially exhausted because they can’t even run a business, and consequently, many of them sold out to health systems, plans, private equity. They’re now employees uh, it’s not necessarily the truth that these entities are emphasizing primary care. In some cases, they’re [00:20:00] using their new employees to divert services to higher cost settings, which exacerbates that price problem. So we definitely have to pivot to primary care, infuse it. We have to get back to independent practice primary care over time, because I think those are the independent, unbiased guys who are going to tell you when and if you need to go to a more expensive setting, right? Right now, that doesn’t occur.

Marc Ryan: There are all these perverse incentives where some of these docs, now over 50% of them live, uh, that is not necessarily right for the person or the healthcare system. again, second leg, infuse primary care, get a Medicare doc fix moving, and really emphasize care management for those with disease states through primary care and specialist infrastructure

Erik Sunset: Marc, we need a lot of help on that front. The independent primary care physician and their practice has been the [00:21:00] core, the spine of American healthcare for so long. The profession’s dying, and I’m not gonna climb all the way on top of my soapbox, but we’re in big, big trouble there unless things change really quickly.

Erik Sunset: It’s still not being reported on cable news. It, it will be at some point alongside the anesthesia shortage, but people just have no idea what a tenuous situation we’re really in

Marc Ryan: Yep.

Marc Ryan: Absolutely

Erik Sunset: of that,

Erik Sunset: sorry to on you there, but a big, a big part of that is another point we wanna cover, and that’s around Medicare pay.

Erik Sunset: Um, all these investments that we’re talking about here, is, is that going to provide relief? It’s obviously a zero-budget offset, um, item in front of Congress, uh, but Medicare just does not reimburse,

Marc Ryan: That’s

Erik Sunset: for– in particular these primary care physicians how we need them to, um, and more broadly speaking, you know, anybody at all how they need to be reimbursed

Marc Ryan: Yeah, absolutely, Erik. And, you know, back to the point, 2001, a real drop in coverage, uh, for physicians in Medicare, uh, of [00:22:00] one-third. I mean, that is amazing. No wonder they’re selling out to different entities, and they can’t make a financial go of it. And over decades, the formula has never been fixed right. Uh, they’ve had temporary overrides called doc fixes, but then they unravel usually the next year, so you’re getting a one-time bump up, and then you’re seeing your revenue drop again. In 2024, we saw a drop in, in Medicare payments. In 2025, we saw it. In 2026, the One Big Beautiful Bill Act did give a 2.5% positive. in 2027, if you look at the proposed rule from the Trump administration, will be a negative 1% because that two and a half percent goes away. And so you can’t expect doctors to function well in that kind of system. I will tell you, there is a brand-new bipartisan Medicare bill in [00:23:00] Congress that would begin to fix this.

Marc Ryan: It’s not perfect. It would basically tie future increases, not address the past, but tie future increases to, uh, the medical inflation index, so to speak, minus one percentage point. Why minus one percentage point? Well, I don’t like it, but you know what? It’s a positive increase that’s, that would be guaranteed. It adjusts some of the other perverse, uh, spending requirements that steal money from people, uh, within the system. We won’t go into those details, but it tries to address that as well. It also would begin experimenting with capitation for primary care physicians in Medicare. So this is all very good signs. I would not attack the bill because it’s insufficient. I would embrace the bill because maybe we’re finally beginning to get somewhere here. tell you that some other, uh, [00:24:00] healthcare lobbies may oppose it because it could be expensive, and they may see it as stealing from their prospects of funding in the future. But I think it’s gotta pass. It begins to set the course, and once you get that in place, uh, then you start doing some of the other reforms I’ve talked about, about infusing primary care and things like that

Erik Sunset: Marc, you’re so much closer to this than, than I am, but what’s your sense around the, uh, the emotion in this bill? Are we in a place where we have to do something, anything? Anything at all has to become a positive for, for Medicare pay, or, and I’m not, not saying that the current bill as it sits didn’t have a lot of thought put behind it, but is this a, a more thoughtful approach or I guess a more we gotta do something now and anything will work?

Marc Ryan: I, I, I don’t think it’s a grand fix, which many people look for. And in some ways that’s good, because a grand fix, would be [00:25:00] probably years in the making to really make it work?

Marc Ryan: So this is sort of just saying, regardless of some of the other formulas, we are gonna base it on inflation, which is probably the fairest thing right now to do to stabilize. It’s not, again, as I pointed out, a perfect solution, but it begins progress in the right way, and it stops, hopefully, of the further erosion that we would have here. So again, I worry about the prospects because it could be deemed expensive, right? um, people have to understand how important it is and how it will actually help reduce costs over time, in the healthcare system.

Marc Ryan: We have to start changing the paradigm, even if it’s little by

Marc Ryan: little

Marc Ryan: here

Erik Sunset: Sure. Yeah, d– maybe done will be better than perfect, um, in this particular instance. We get there.

Marc Ryan: Yep.

Erik Sunset: Um, and then access. You know, this is a, this is a core, uh, tenet of, of any healthcare dis-discussion. [00:26:00] Excuse me. But, uh, the last thing we wanna cover, or one of the last things we wanna cover is affordable universal access.

Erik Sunset: We’ve talked about it on this program before. We talk about it on this program regularly. Um, so let’s, let’s dive in. I’ll shut my mouth and, and get your thoughts

Marc Ryan: Sure. So this is the third pillar. We got price reform, we have pivoting to care management and primary care, and so affordable universe- universal access is the third pillar. here’s my view on all this. progress under the Affordable Care Act, expanding Medicaid and creating the exchange program, we have not done enough to reduce the uninsured rate, and more importantly, the mechanism is imperfect because we have rising unaffordability. you can go and maybe blame the on this, right? You could theoretically say, “Oh, if you– if the subsidies, the enhanced subsidies didn’t [00:27:00] expire, you might have a different story.” My argument is, I’m not sure that’s true. If you look at the data, rising unaffordability n- notwithstanding that issue of enhanced premium subsidies.

Marc Ryan: So Democrats are gonna be beating the drum and saying unaffordability is tied to the expiration of the enhanced subsidies. It’s really not accurate, right? It’s a small part of it because we see unaffordability rising in the employer coverage world, which takes care of about one half of the nation, right? It has nothing to do with 20-some million people in the exchanges. unaffordability has everything to do as well, in addition to the exchanges, with employer coverage. And so when we’re sitting at somewhere over $9,000 a year for an individual and $27,000 a year for a family, more and more is being put on the backs of families in terms of premiums, in terms of [00:28:00] deductibles and cost-sharing, it’s very quick to understand why there’s unaffordability. And so that’s what we really have to keep an eye on. My view of the world is in the access world, is we do find a way to guarantee everybody The ability to access the healthcare system and have it affordable based on their income. So the concept of sliding scales premium like we have in the exchange exists. I disagree with the Democrats that some people should get absolutely free care. My view is everybody should have some skin in the game somewhere, right? No matter what your income level is, there’s gotta be some skin in the game. It promotes accountability. But I’m also a believer where I think the Republicans are wrong in that we do not have affordable access today. And when you’re asking people, uh, to spend 10, [00:29:00] 15% of their income on healthcare, it’s just impractical and it breeds the underinsured affordability crisis where people don’t access their healthcare, stupid decisions i- in terms of health, but that end up being what they have to do because they can’t afford it otherwise, paying the rent or buying groceries or whatever. it creates fallout, it creates greater costs. So let’s create a system that is truly affordable, that’s based on income with some skin in the game for everybody, but provided at a level that it incents access to healthcare systems with reasonable cost-sharing, reasonable deductibles, and reasonable premiums.

Marc Ryan: Now, to go a little bit of a step further here, what what we really need to do is, um, is also create less entry points. propose to keep [00:30:00] the employer coverage system as the foundation. It’s a pragmatic decision on my part. I don’t wanna go to socialized medicine. I don’t wanna go to single payer. I don’t even wanna do what the private healthcare systems do in other developed worlds where there’s sort of a national healthcare structure. I think for practicality purposes, we keep employer coverage, let it be the foundation. Price reform will give employers relief, will give people relief, uh, and emphasizing primary care further reduces costs over time. So, I think the employer coverage foundation is a good one. you have to make sure that coverage is seamless. And I actually go back to all people, uh, of Richard Nixon here. Richard Nixon in 1974 proposed one master social safety net program people who were not in employer coverage would go into with affordable universal access [00:31:00] tied to their income, and they automatically move there if they change jobs and they don’t have coverage through another employer. it’s sort of a guarantee, and then you’re with an employer system, one social safety net There’s debate about whether Medicare should be part of that one social safety net or does that stay the same? I think it can stay the same. Uh, there’s pros and cons of each. But for people under 65, you’re in your employer, mandated types of benefits, there’s subsidies that come from the government to even help you afford in the employer world, and then you have that one social safety net. That, again, reduces administrative costs and brings real affordability. And this, again, was something that Richard Nixon proposed in 1974. really saw the light of day too much given the Watergate scandal and his resignation. But I think there’s something in there that makes a great deal of sense. And by the way, [00:32:00] you know, a lot of the other components like the exchange, like Hillary Care, like some other proposed reforms have some of those elements already. I just think you gotta make it rational, build it out, go that way because without affordable universal access, price reform and pivoting to care management still doesn’t work. And in conclusion, I think all three of them have to come together. They reinforce each other. They provide the price reduction, they provide the right focus, and they provide affordability, and they allow people to take stake in their healthcare. Today, people wanna do that financially, sometimes they can’t afford to do that.

Marc Ryan: And I happen to believe that everybody deserves, and I think most people do, to lead a very healthy life. And I think it’s gonna pay huge dividends, not only in healthcare costs, but quality of life throughout the United States, and it’s going to really, I think, uh, be, [00:33:00] you know, really game changing. And that’s why, again, I, I sort of put this, uh, podcast and, blog series together to reinforce some of the ideas I had in my book

Erik Sunset: So, well said. Um, I- I’m gonna ask you to be in a difficult position here. I want you to play devil’s advocate against your own points, just because I, I’m not sure that I’m qualified to. I didn’t hear anything revolutionary. I didn’t hear anything talking about, “Oh, we, we need to do it how Canada does it. Oh, uh, Britain does it so well.

Erik Sunset: We need to adopt how Britain does it.” And whether you like those systems or don’t like those systems, there’s pros and cons to each. So here’s where the devil’s advocate bit comes in. Because we didn’t, I didn’t hear anything that, you know, made the hair on the back of my neck stand up,

Erik Sunset: who’s opposed to, uh, reevaluating and reforming our system sort of along these lines?

Erik Sunset: Who says, “Nah, that, that’s not gonna work”?

Erik Sunset: What do they say?

Marc Ryan: Well, I, I think unfortunately, [00:34:00] Capitol Hill is in a divided standoff stance, right? They’re sort of the old dual world in the Wild West where they’re pointing guns at each other, readying to fire, and it’s primarily based on ideology, right? And so, you know, in talking about the Democrats, my criticism of them is they believe that the answer to healthcare problems to basically just add more and more money to government programs, add more mandates in the current system, and they think somehow that’s gonna provide affordability.

Marc Ryan: It’s not. It’s a broken system. so adding more and more dollars may help for a tiny bit somewhere somehow, but the, the grotesqueness of the current system then adapts and undoes some of what was done. So the idea that spending your way out of this healthcare crisis is gonna work is just wrongheaded [00:35:00] just doesn’t work. Let me go over to my own party and criticize my own party. I believe there are some people that are a little bit different, but generally a separate ideology dominates the Republican Party, and the Republicans sort of treat healthcare as a commodity. If you’re making enough money, you can afford healthcare, and let’s do some innovative, quote unquote, stuff that sort of lowers the cost of care somehow by having limited plans and skimpy plans and things like that.

Marc Ryan: Well, by the way, I happen to believe that if healthcare is not a right, certainly not a privilege, and I believe many Republicans have that philosophy that it’s, it’s, it’s more of a privilege. Uh, y- you know, um, I think it’s more like a right, but I don’t think it’s a privilege. I think it’s, uh, somewhere close to a right. I don’t think Republicans believe that generally in Congress. I don’t believe Americans think that, by the way, [00:36:00] because I think they’re kind-hearted and wanna help their neighbors, but I think some of the folks in Congress believe that. And then number two, I don’t mind some of the innovation that the Republicans are proposing. I think there are new adaptable ways using technology in responding to how millennials and those younger want to access care virtually, and the priorities of care may be slightly different than the old world. So I’m good with that. But again, it’s not an answer to creating real affordability, and so that’s my criticism on that side.

Marc Ryan: So we gotta get out of the hard ideology. And to your point, Erik, reform proposal is not deliberately earth-shattering. is basic concepts and basic principles that can be implemented in favor of trying to get the two sides together to say you’re right, we need to com- compromise a bit [00:37:00] and there’s something in it for all of us, and let’s sort of move down that path.

Marc Ryan: Now, do I think that’s gonna happen overnight? I’ve followed politics all my life and have been in it. No, I don’t. I’m gonna keep doing my series every year or two until we start to make progress because, uh, the world we live in, uh, falls in upon itself every year creates even more challenges, not only for the healthcare system, but also for individual Americans

Erik Sunset: Again, there’s not a whole lot I can add there, uh, that’s, that’s of any value. But the, the final musing before we land this plane is who i- as a participant in the system, whether as a patient, whether you’re on the payer side, the health system side, the physician side, who’s looking around and saying, “We’ve got it, we’ve got it figured out.

Erik Sunset: This is highly sustainable. It’s good enough for everybody”? They just… That just can’t exist. Uh, as you say, it must just boil down to ideologies and, uh, and [00:38:00] opposition to compromise

Marc Ryan: Yeah. And, and I would say some of what I’ve done beyond Nixon was also pulled, and my book Well, documents this, from a bipartisan healthcare commission that has Democrats and Republicans on it that said, “We need to get together and talk about what’s true reform.” So are answers out there, but it’s getting to the center and thinking rationally and be- being willing to compromise, right? so there’s a number of different groups out there that, um, are willing to do that, I believe. by the way I also think, uh, both sides, maybe the more extremes part of the aisles should be part of this too. Because the truth is there are good things, uh, really across the middle, left, and right of the spectrum, right? I think you gotta create elements of all, of them, and I think I’ve built into my plan elements of all of them, to be honest with you, in some way or [00:39:00] another. Maybe not to everybody’s satisfaction. But get everybody together and talk about how to put some of those priorities in a system, and I think it can really work. Um, part of what I also concluded with in one of my… in both my blog and podcast series, is I said, back to the grand bargain, and we talked a little bit about it upfront, but think about it as a way to, even beyond healthcare, make people very happy. Um, if you look at the difference, uh, in a GDP percentage dollar sense between what we spend and what the average of other developed countries spend, could, over time, save $2 trillion in today’s dollars, and that’s only gonna inflate over time, right? We’re, we’re over $5 trillion in the, in the healthcare economy a year now. By 2036, we’re gonna be at about $9 [00:40:00] trillion. So that $2 trillion is savings now in today’s dollars. let’s just keep it at $2 trillion. Could you imagine how you could use $2 trillion that got freed up? Republicans might like to reduce taxes, right?

Marc Ryan: And make business more competitive. That’s a huge goal of theirs. I will tell you, Democrats would probably wanna augment social services. That will get pushback from Republicans. But the truth is, there is under-investment in many social service programs and public health infrastructure our world, and we saw that during the COVID pandemic. So maybe they’d be happy to do some housing initiatives and some public health initiatives with some of that savings. Some of it could just be saved in the healthcare system because we need that. by the way, can even set aside a sliver of it to do things a little different than other developed nations, right?

Marc Ryan: Some of the criticism of other [00:41:00] socialized medicine and single-payer systems is that Um, they have waiting lists. They don’t have on-demand drugs. They don’t have on-demand technology. That’s one of the reasons I wouldn’t wanna go to a truly government-run system, single payer, socialized medicine, because the trigger there is just cutting off the tap, right, in so many different ways. But if we reformed our system and even invested a little of the savings differentiate us and said we are gonna be relatively on demand, we are going to give earlier access to drugs than maybe some other countries do, that would be another way to use part of that $2 trillion. So we got $2 trillion we save, and growing. So let’s get together and reform the system a- and craft the right system, and I think there’s win-wins in it for everybody; Democrats, Republicans, most of all, the American public who really struggles to pay for care[00:42:00]

Erik Sunset: Well, all, all three of those entities have, uh, have an election year, uh, ahead of them, Democrats, Republicans, and the American public. It’s a, it’s a midterm year. What, what are we looking at going into? How do you, uh, you know, if you, uh, polish up your crystal ball, what do you see happening in the midterms and what do you see happening as it relates to healthcare reform?

Marc Ryan: Yeah. it’s interesting. Um, since we last talked, there was some fallout on redistricting in states and things like that. And, uh, a couple of these Senate races have looked pretty interesting. Um, uh, I had proposed and I had predicted that the Democrats will likely flip the House, and I think that’s still likely, right? But I will tell you, because of gerrymandering, and I always say 90-plus percent of seats, the outcome is already known. you have about 40 seats truly in play, Democrats, if they do win it, and I [00:43:00] think they will, will not have a huge majority probably, the way things are trending. Even with the unpopularity of the president with the war and things like that, uh, this is going to be a tight majority. If things keep eroding, their majority will be a little more than not. this thing could be pretty close with Democratic control, and they could be in a similar situation as the Republicans in the House are in today with a fairly narrow majority, right? And the inability to lose a lot of s- uh, votes on given important bills. Senate, again, I still feel like there’s a better chance than not, although it’s getting much more to a toss-up, that the Republicans maintain control. Um, I think there are, uh… The loss in North Carolina will almost assuredly occur, and that should be a game with the Democrats. one time in Maine, appeared like the Democrat was probably gonna maybe [00:44:00] beat Susan Collins. was a scandal up there. There’s a new candidate. Susan Collins looks better potential now to keep that seat. In Michigan, there’s some weird stuff going on, and they have a pretty strong Republican candidate there to potentially flip it, right? So my view of it is that the Democrats likely win the House. While the Senate is pretty much, uh, in toss-up mode, I still feel like there’s some trends that the Republicans probably keep the Senate. I would say right now, and I’m sure I’ll change a little bit as we get closer, but I think we’re looking at a divided Congress going into the last two years of the president’s administration, where we probably have Democratic control in the House and Republican control in the Senate. And by the way, that might actually help on compromise. I’m, I’m a big fan of divided government because, uh, maybe it finally forces people to [00:45:00] get together think about doing the right thing. And I would say for the president’s sake, um, I think he might be willing to do that as Well, if it is a divided Congress.

Erik Sunset: Well, as you have pointed out,

Erik Sunset: right, right, as you pointed out before, uh, uh, Trump 47’s, uh, big, big thinker on his legacy and how people will regard him into the future. And now there’s a, there’s a path to be remembered by everybody fondly and probably a path to

Marc Ryan: That,

Erik Sunset: not be remembered fondly by a whole lot

Marc Ryan: the, now the generally the gridlock in Washington, you would say nothing’s gonna happen. But I have that hopeful aspect here that maybe a divided Congress could actually bring changes and hopefully in healthcare

Erik Sunset: We need him. We need him for all the reasons we pointed out and more. And for the and more, Marc, uh, where can folks get more of your content?

Marc Ryan: Sure, great. Uh, so I am at health- healthcarelabyrinth.com is [00:46:00] my website again. you can sign up to receive emails about when I’m updating and things like that. now also… Obviously, we still have our Lilac software site out there, lilacsoftware.com, but also metasolve.com is where, uh, the new company that bought Lilac is, and you can see some webinars and other features on the website there as well

Erik Sunset: Awesome. And you, you better believe we’re gonna put links to all of those destinations into the show notes. Marc, thanks again for joining us. This was a great chat, as always

Marc Ryan: Thanks so much, Erik. I appreciate it, and see you next

Marc Ryan: time

Erik Sunset: We’ll see you next time, Marc. And for all of our, all of our listeners out there, thank you for listening. Be sure you’re subscribed to both the DocBuddy Journal and Marc’s podcast on Apple Podcasts, Spotify, and YouTube so you always get the newest episodes of the show. Until next time, I’m your host, Erik.

Erik Sunset: Take care.