Healthcare History: John McDonough on America's Wrong Turn

SPEAKER_01 0:00

Welcome to Civics and Coffee, a History Podcast. The show all about United States history, delivered to you in the time it takes to enjoy your morning cup of coffee. I'm your host, Alicia, a historian trained in United States history with a passion for telling both the known and unknown parts of America's past. So grab your coffee and get ready for some bite-sized history. Welcome back, everyone. I don't often get the chance to chat with folks who are researching social welfare history. So I was delighted to sit down with John McDonough to chat about his recently released book, America's Wrong Turn, which dives into the history of health policy in the United States. I hope you all enjoy the conversation. Hello everyone. Joining me today is John McDonough. He is a professor at the Harvard T.H. Chan School of Public Health and author whose latest book, America's Wrong Turn, U.S. Healthcare in the Neoliberal Era, explores the history of the fractured American healthcare system and will be the focus of our conversation today. Welcome, Mr. McDonough.

SPEAKER_00 1:13

Thank you so much, Alicia. Great to be with you.

SPEAKER_01 1:16

So great to have you. I'm so interested in diving into all of this book. There's so much to cover, but we'll start with can you share a bit about your background as it relates to healthcare policy and how it motivated you to write this book?

SPEAKER_00 1:32

Yeah, well, it's a long story now because I just turned 73 in May. So I get a lot of history. My health policy for me began in 1985. I was 32, 33 years old and had gotten elected to a seat in the Massachusetts House of Representatives. And just by accident, I happened to get appointed to the Joint Committee on Health Care and had no real prior knowledge of it. I said to one person who suggested I ask for it, I said, but I don't understand the difference between Medicare and Medicaid. And they said, Don't worry, we'll tell you. And I fell head over heels in love with it just instantly. It's so compelling, it's so important, it's so big, it's so political, it's so everything in terms of something that could keep me going. So I started in health policy February 1985, and I'm still doing it more than 40 years later. And I haven't been bored a single day because every day there's just something happening. It's like, oh my gosh, I didn't see that coming. And my goodness, it's all it's all so interesting. So I spent 13 years in the legislature, became chairman of the Joint Committee on Healthcare for a while, uh, became a kind of a national expert on states and health policy. And in 2003, I took a different job as executive director of a healthcare advocacy organization in Massachusetts called Healthcare for All. And in that role, I was the leading consumer voice on what became the big Massachusetts health reform law of 2006, when they created a near-universal coverage scheme that was led significantly by Governor Mitt Romney, a moderate Republican, who decided that he wanted to leave a mark on policy in Massachusetts by making this happen. And so I was deeply involved in that now and very involved with Senator Edward Kennedy at the time, who was also deeply involved in the Massachusetts health reform process. And so in 2008, he recruited me to come to DC and to work on his staff at the Senate Health Education Labor Pensions Committee because he thought, and a lot of us thought, that there'd be another big chance coming for universal health care in 2009 or 10, regardless of who got elected president. So I worked in the U.S. Senate for under two years during the writing and passage of the Affordable Care Act. And then after that, I ended up at the Harvard Chance School of Public Health, where I've been since 2011 doing teaching, writing, consulting, research, all different, all different kinds of things. But so the consistent theme has been deep level meaningful involvement in US and state, and also since at Harvard global health policy, because as interesting as it is outside in the United States, it's just as compelling outside as well, all across both individual countries and looking at sections of the globe and the whole globe as well. It's it's just and it's so important and so fascinating. And you can get things done. Good things can happen. You can work your tail off and lose everything and nothing happens, but you can also work your tail off and you find, wow, some amazing stuff has happened. And so that's that's a little bit of my story.

SPEAKER_01 5:36

Yeah. I definitely want to ask you about the the international perspective, but as your book's title suggests, you kind of frame this in this neoliberal neoliberalism era. And so for those that you know might not be aware, what is neoliberalism and when did it gain momentum in the United States?

SPEAKER_00 6:00

So that is probably the most frequent question. I can't tell you the number of people who said, John, this is a great idea. I think you got a real book here, but please don't use the word neoliberal in the title because nobody knows what it is. Very, very few people know what it is in the United States. Outside of the United States, you go to a lot of different countries, pick one at random, Chile in South America. Their country was taken over by neoliberal economic policies after the 1973 coup. So the short form is that coming out of the World War II experience, it was a big fight between communism and fascism and liberal democracy. And the United States and Great Britain were kind of the leaders of the democratic open societies. And there were people who never liked Franklin Roosevelt and the New Deal. They thought that it was too far left, and they were some of the people who were conservatives during the 1920s and so forth, a much more open free market period. And so they developed this line of thinking that turned into neoliberalism, which said, listen, we hate communism, we hate fascism, but we see the New Deal and Franklin Roosevelt as a slower boat ride in the same direction. And it's going to lead to the loss of freedom and autonomy. And we need something that is more open, free market, and less government involvement. And their hero, their icon in history was a guy by the name of Adam Smith, who, in many ways, some people consider the first economist back in the 18th century in Scotland. He wrote a book called The Wealth of Nations. He wrote a number of different pieces. And for many conservatives of the neoliberal persuasion, they looked and they said, you know, we think that Adam Smith had the right analysis. He talked about the invisible hand of the market. You just kind of let the market work, you stay out of it, and everything will be fine. That's a great oversimplification of what he said. But nonetheless, he also was one of the first people to talk about the role of self-interest, that everybody's just trying to look out for themselves and just let people do that, and things will be great. A real oversimplification, but he was their hero. And so in the post-World War II era, people who became the neoliberals, they had a big conference in 1947 next to Lake Geneva on a mountaintop, and they formed a society called the Mount Pelerin Institute, which was intended to be a global. There are about 15 nations represented there, a lot from the United States. Milton Friedman was there at the original meeting in 1947, a young, conservative, leaning economist. And they couldn't come up with a name. The one they could most agree on is neoliberal. And they came out thinking they were going to use that, but there was a problem because when people heard the word liberal, they thought of Franklin Roosevelt and the New Deal. And so, what is this neoliberal? Does this mean your new version of FDR and so forth? And it took too much explaining to do. And they dropped it after a very short period in the 1950s, but it lived on around the world, around the globe. This became a global force. And it was pretty below the radar screen in the US in the 50s and the 60s. But in the 70s in particular, these folks really gained a huge amount of prominence. Milton Friedman being their leading writer thinker, but others, Robert Bork, James Buchanan, a whole host of folks, a lot of whom came out of the University of Chicago Economics Department. And a lot of their people who followed their message were called the Chicago boys. And people who really gravitated from the political world included Barry Goldwater, the presidential candidate in 1964. He had a huge loss. He lost 44 states. He won only six states. But he gave an aggressive, assertive, free market platform that said, this is the way the world should be. And while people laughed and thought it was a joke because he did so poorly, the true blue conservatives thought it was a magnificent, wonderful moment because it was the first time since the 1920s that they heard someone stand up in a way that they appreciated for capitalism. And so that gave them a big lift. Another big lift came when Ronald Reagan became governor of California. He gave the nominating speech for Barry Goldwater in 1964. So there was this movement that was growing that culminated in 1980, the presidential election. Jimmy Carter had one term under his belt, was trying to get re-elected, a deeply unpopular time, stagflation, the Iran costage crisis, so many things like that were going on. And there was a sense that the New Deal had run out of gas. And the Friedman, Reagan, neoliberal movement said, we have the real ideas, we know where to go, we know what should happen. And Reagan won, and that started then the implementation of neoliberalism as the ruling, governing politico-economic philosophy of the time. And lots of people think, well, an era ends when the president leaves office. The truth is, like with FDR, the FDR era went from 1933 all the way up to 1980. And then what succeeded it was the new Reagan era that didn't just go through 1988. It went all the way up to 2020. And that's the analysis of a political scientist from Yale, Steven Skaronik, who has created this idea of longer regimes. And so that's where it, that's where it came from. And so a lot of the ideas that percolated and that kind of ruled in those four decades came straight out of the neoliberal movement in different ways. And it also became a global phenomenon. Just one example and then I'll stop. The World Trade Organization, created in 1994, is the kind of the epitome of neoliberalism on a global scale. Basically, that the economies have to run for the benefit of corporations. So a lot there.

SPEAKER_01 14:15

Yeah. Well, and so this is a book, right? That's neoliberalism, its impact to U.S. healthcare policy. But ironically, your book begins, or surprisingly, I should say, your book begins by comparing the United States with how it sits among other nations across a variety of metrics. And so I'm curious why was this important to include and what conclusions did you draw from this research?

SPEAKER_00 14:45

So it's awfully hard to judge any country in terms of how effective its health and medical care system is without at some point looking at other countries around the world because they're all facing the same challenges, and they all then respond to the challenges in their own unique way. So, for example, we take pride in the United States, a lot of people do, that we saw a significant drop in the rate of people without health insurance in the United States. And starting really with the Affordable Care Act in 2010, it went from about 16% on insurance down to below 8%, the lowest it had ever been. So that sounds great until you look at every other advanced democracy in the world. And this is without exaggeration, every one of them, France, Britain, Japan, South Korea, you name it, 99 to 100 percent of their citizens have health insurance. And we still have seven to eight percent, although we know with the Trump administration cuts that are coming, it's gonna be going up significantly. We'll have that data later this year.

SPEAKER_01 16:14

And so another kind of idea that you tease out in the book is this idea of financialization of the US. So can you expand on this and and how it impacted health policy?

SPEAKER_00 16:27

So financialization is something that has happened across the globe, and it really had its birthplace here in the United States and in the 1970s. In 1970, specifically September 13, 1970, in the Sunday New York Times, Milton Friedman, the Chicago school economist, wrote a column in his typical provocative style. And the headline says it all. The headline was a freedman doctrine, the only purpose of the US for-profit corporation is profits to shareholders. And his thesis was this was a time when there was a lot of discussion about the role of corporations. Should they do things to deal with societal problems? Should they deal, should, and and should they care about their their customers, their patients? Should they care about their workers? Should they care about the communities in which they reside? Should they care about the environment? And Friedman's answer is no. They should follow the law, but their job is just to make as much money as possible for the shareholders. And that the people in charge of the company, the people who count, it's not the CEO, it's not the board, it is the shareholders. The shareholders have to rule. And that became a philosophy, and it got its own little tagline, which is called Maximizing Shareholder Value or MSV. And it really did. It was an op-ed that triggered a movement, a movement in corporate America, a movement in business schools, a movement all across the country. And one element of that was the financialization. So what we see then is we see companies that are existing, producing goods or services in communities all across the country. And what we find then is larger companies coming in and buying them up, absorbing them, swallowing them up, not to create better products, but to maximize the economic value from the company, to squeeze it out, to take it unto themselves, and then to go on and conquer other companies and other industries. And that's what we mean, so that an organization really doesn't exist anymore. It's not about making computers or making shoes or making uh uh making cookie cutters or whatever it might be. It's about making money. And that's the financialization process. When Wall Street is not just the financial servicer of American capitalism, it is the controlling engine of it, and it is taking over sectors and it is determining what needs to happen, not in terms of what Americans need, but in terms of where they can make the most money. And that emerged in the 1980s with a particular form, something called the LBO or the leveraged buyout. Some people may remember there was a famous book written about that process in the late 80s called Barbarians at the Gates. And it was about the takeover, the competition to take over RJR Nabisco, not to build up or improve their cookies or tobacco products or whatever, but to take it over to be able to extract the value. So there are two things that Wall Street can do or that the financial community can do. It can invest and create value in something new. That's what venture capital actually does a lot. Venture capital gets a bad rap, but they actually are risk takers who go in for emerging companies and they build them up and they try to make them succeed to their initial public offering and then they take their money and run and move on to the next conquest. But they've actually done something and left something of value behind. The LBO, which disappeared in the late 80s and re-emerged in the 90s as private equity, is not about value creation. It's about value extraction. It is about taking the financial assets. So a corporate hospital has its own physical plant. It also has real estate, the land on which it resides. And so private equity will come in and say, we know what to do. We will sell your land and your buildings to something called a real estate investment trust, R E I T, or a REIT. And the REIT will give us a lot of money, a lot of money. And we'll give some of it to you, maybe if we feel like it, but we're going to pay off our investors with that. And we're going to use it for whatever we want to use it for in terms of turning it into its highest and best use in terms of bringing more money back. And the hospital itself is maybe, maybe they got some money to do a little fix-up or something like that. But from that point on, the hospital has lost all of its real property. It is now a tenant of the real estate investment trust paying monthly rental payments that are far more expansive than whatever they got out of the deal because the big benefits from the selling of that went to the private equity firm. So that's the kind of stuff that goes on in financialization. That's what started with LDOs and private equity. And in this century, private equity, particularly in the second decade, began to say, hey, we see golden opportunities in health and medical care in the United States. And they've gone in like gangbusters, so that today there is literally no element of the U.S. healthcare system, hospitals, nursing homes, physician practices, home health agencies, hospice agencies, veterinarian practices, dental clinics, you name it, private equity is in there, and they are doing their best to get in there with nice promises, but they're after value extraction through financialization. And that's a big part of the crisis that I try to lay out in my book.

SPEAKER_01 23:58

Well, and in your book, you also talk about Medicare and Medicaid's establishment. And so I want to talk about how did these programs, they're monumental, they're bedrocks of what we now know as the social safety net. How do they run up against these emerging neoliberal ideas after their creation in 1965?

SPEAKER_00 24:21

So there's there's a core neoliberal idea. It's straight out of Milton Friedman, but it's also out of, it's also out of the Heritage Foundation from Washington, D.C. And that is that you know, the the best thing to do, if you can, as a firm conservative, neoliberal, whatever you want to call yourself, is to shrink government as much as possible. And so that might mean, first of all, cutting taxes everywhere. Don't worry about deficits because we'll create a crisis for the other side and tough luck. Um, or eliminating programs, shrinking government and getting it out. But then there's another approach to say there are some programs where it's just not going to sell. That dog won't hunt. You can't just get rid of this program. So, therefore, when you can't get rid of it, what you should attempt to do as much as possible is to privatize it. So to take it out of the hands of government employees who manage it, and as much as possible, to give it away to the private sector with government oversight to make sure that it doesn't. So Medicare and Medicaid, Medicare, of course, is federalized medical health insurance for senior citizens, senior citizen citizens, and for and and many disabled people. And Medicaid is for lower income, it's for the poor. It's for poor, low-income Americans, and Medicare is all federal, and Medicaid has federal in charge, and states actually run the program. And in Medicare, let's just focus on that for a moment. There came the time in the 1970s when we had a new phenomenon in American medical care, and it was known as the HMO, or the Health Maintenance Organization, which said, Hey, we provide both the insurance and the provider medical care together in the same organization, pay us a capitated single payment for every patient, and we guarantee you that we will provide better care at lower cost. And that was the deal. And for a while in the 70s and 80s, policymakers fell in love with managed care and the HMO. And including a lot of Democrats, including Democrats, including me. I got into the legislature in the mid-1980s, and I had been part of the Harvard Community Health Plan, our standout HMO since 1976 when I got out of college. For a lot of people, Harvard Community Health Plan, HCHP, some people said it stood for horrible care for healthy people. So I was a healthy young person and I didn't mind. But so I came in to health policy, and a lot of people said to me, this is the answer. Capitation and managed care are the answer. If we can only spread that across the system, all the problems, all the dysfunction will disappear and we will have something. And it didn't turn out that way. But in those early years, in the 70s and 80s, the HMOs came to the federal government and said, Hey, why don't you let us get into Medicare and let us enroll people in Medicare, their own free choice, if they want to, to come in, and we will provide you, the federal government, with better care at lower cost. And in the 70s and 80s, into the 90s, managed care HMOs were not known very well. And people didn't understand them, particularly the older generations who were aging in to Medicare, and there wasn't an interest. But in the 90s and then beyond that, managed care, its practices, uh, its rules and how it works have become ubiquitous in the US healthcare system. And as people became more comfortable, and as the Medicare private insurance programs got more sophisticated with the help of Republicans in Congress. Democrats, we had this period in the 80s and 90s and into this new century where it was very easy to tell Democrats versus Republicans. Republicans loved managed care and HMOs because it was the private sector, and they hated traditional Medicare called A B, fee for service, because it was run by the government. And Democrats hated Medicare managed care because it was run by the big bad insurance companies and loved it because it was run by government. Today, Medicare private coverage is now called Medicare Advantage. And over the years, particularly in the last two decades, since 2003, when the Republicans modernized Medicare-managed care into Medicare Advantage, it has grown. And today, today, 55% of Medicare enrollees are not actually in the old-fashioned government-run Medicare program. They are in privatized Medicare. And lots of people who are in it think it meets their needs. It's great. It usually meets people's needs until they start getting sick and having needs because they find that to get into the managed care, it's essential that they have a closed panel of providers. But when you get serious illness, then you start seeing those things, which is why we see this movement of people away from Medicare Advantage into traditional Medicare when they can do it. But now Medicaid has also been privatized. Medicaid is privatized even to a greater extent than Medicare. So state governments decided they were scared about managing this big program themselves. They needed somebody who wasn't scared of it. And so they started to contract with private for-profit commercial HMOs and other managed care organizations to provide a not a voluntary, mandatory, this is how you're going to get your care. If you want Medicaid, you do it, but you're going into an HMO. And so right now, today, 80% of Medicaid, non-elderly, non-disabled, are in managed care, private commercial insurance, and 55% of people in Medicare. And voila, that's what we mean by privatized health insurance.

SPEAKER_01 32:37

Well, and you also discuss in the book the transformation of the Supreme Court as it relates to antitrusts and corporate power, beginning with the Nixon administration. So what happened and how did this factor into later healthcare policy debates?

SPEAKER_00 32:55

So let me just jump to the conclusion. There are some analysts who I who I admire greatly who say if you want to understand the American healthcare affordability crisis, it begins and ends with monopoly, antitrust, and corporate concentration. That's where it be, that's that's that's the bottom, probably it may be the most important factor of all. So America got into antitrust back in 1890 when Congress passed the Sherman Antitrust Act to go after the railroads, to go after the mining, to go after banking, to go after all of the big trusts that were creating monopolies, buying up their competition. And Americans through Congress looked at that and said, that's not good. That is not helping competition, that's reducing competition, and we need to stamp that out. And for purposes, if you get too big, if you get big naturally by yourself, by providing more products or better products, okay, go for it. But if you get big by buying up other companies, buying up competitors, trying to interfere with keeping a free market going, that's a role for public policy. And that's how it worked until the 1970s. And then the neoliberal Chicago boys came along. They had been working on this idea since the 1950s. They used to be big believers in antitrust. They said, yeah, we believe in the free market, but we need government to make sure that we protect a free market. But in the 1950s, they did a backflip and they went to the other side and they started saying, no, the problem is not big. If you're big, then you're big because you deserve to be big. And we should let you do what you want as long as consumers see some lower prices somewhere as a result of that combination. And so there's this name who was the lead player for the Chicago Boys neoliberal movement to re-engineer antitrusting the United States. And a lot of people probably will remember his name. The name is Robert Bork, B-O-R-K. And people mostly know Robert Bork because he was kind of a rambunctious, contentious guy who got nominated by Ronald Reagan to the U.S. Supreme Court in 1986 or 87. And he just had the worst confirmation hearing of anyone. He just didn't get schooled very well by the people who say this is how you get through this. One of the few moments when a nomination isn't withdrawn, it went down to defeat. But before all of that, before he became famous in that way, he wrote a book in 1977 called The Antitrust Paradox. And the antitrust paradox was the Chicago school version of how antitrust is a failed government program. And putting forward the what was called the consumer welfare hypothesis. And this book was popularized by the Chicago Network. It got into all kinds of places where it was influential. For example, in the 1970s, the neoliberal groups established a summer academy for federal judges. This was in the early 1970s, where they would teach them Milton Friedman, 101, Friedman would come and other people would come. And Robert Bork came and taught in that. And so they were grooming and teaching federal judges, this is the real way to understand antitrust. And so by the early 80s, when Reagan came in, the Bork line had been established. There were already federal U.S. Supreme Court decisions that made reference in footnotes to Robert Bork and the antitrust paradox. And as a result of that in the Reagan administration, it started before, understand it started even under Jimmy Carter. He wanted to show that he was different than traditional liberals of the New Deal era. So he was responsible for deregulating the airline industry. He was responsible for deregulating the interstate trucking industry, number of things like that. He didn't get a lot of credit for it, but he was really the first president who really engaged in this deregulation effort. But Reagan's people put it into this document. There's a document that is there all the time. It gets rewritten every several years, and it's the Federal Antitrust Guidelines. And it is a lengthy document that is aimed at federal judges and aimed at federal prosecutors and anybody and everybody else, but those are the two key audiences. And it's basically saying, listen, this is what we believe now. This is what we understand. This is what the evidence tells us. And so in early 81, Reagan's people started the process of rewriting the antitrust guidelines. It's done by the Federal Trade Commission, and it's done by the antitrust division of the Department of Justice. Those two, they come together, and they rewrote the guidelines to embed the consumer welfare hypothesis. No act of Congress, no regulation rewritten, not even a Supreme Court decision, although they showed their hands with the footnotes from the previous years. And that revolutionized antitrust policy over than the succeeding four decades. And even, you know, they all had their cases where they stood up in somewhere to like Microsoft or something occasionally. But for the most part, it was all throughout and across society. Go, go, go, in terms of joining together, merging, including very much in the healthcare sector, in the medical care sector. Hospitals, insurance companies. You know, there was a concern about what's called horizontal integration. Horizontal, where you've got all the hospitals in a particular area coming together or joining together, or a good number of them anyway. And that's that's one way, and that's the standard thing that people look for. Other kinds of consolidation, they don't even look at at all. So for example, the big corporate monoliths today are not horizontally integrated, they're vertically integrated. So you've got United Healthcare that started as an insurance company, and now it's got a pharmacy benefit management firm, it's got its own uh pharmacy benefit managers, it's got its own provider organizations through Optum of physicians and other medical professionals. It's got its own data firm that provides data to the whole healthcare industry, anybody who wants to pay their. So that, and then we've got with CVS, we've got CVS, you know, the pharmacy chain has its own insurance company in Aetna. It has its own provider networks with their Minute Clinics and other kinds of things that are now growing joint ventures with big uh nonprofit medical organizations. But so you have these, and these are the dominating, the dominant organizations. And then we also see it in the in the hospital health system space as well. So this is where now, you know, when when when Bork was writing, when they were thinking about this, they weren't looking at healthcare. That wasn't, I think, their main goal, but it got caught up, it could not resist the forces of neoliberalism that took over and re-engineered what was possible. And so that's why you know a lot of really smart and younger economists who've been looking at saying, okay, why does health care cost so much in the United States? What the heck is going on here? This has been going on for too long. It's been too long of a process. And a lot of these people are saying if you really want to understand what's behind medical care inflation and exploding costs, it is corporate consolidation number one, not the only thing, and probably number one.

SPEAKER_01 42:43

Yeah. Well, and you know, you don't spend the entire book talking about all the things that America has has kind of all the ways that America has gone off the tracks. You do kind of have some recommendations of some of the ways American can get back on track as it relates to healthcare. So what are some ways the the US can make a right turn on healthcare?

SPEAKER_00 43:05

I I've got about 12 of them. Um, you know, there's there's a simple way to do it, which I am fearful of because of just the political difficulty. That would be a Medicare for all type system where you just federalize the system under the traditional Medicare form. And uh it's it's a concern in terms of it. Every attempt at doing comprehensive reform of that nature, whether through Harry Truman, through Bill Clinton, uh, through others, has just collapsed and nothing got done and it set back reform for a good number of years. But but it is, if you're looking for a way to do it that makes policy sense, then uh that's that's one way. But but there are other things that you can do shortly. Of that. So, for example, we need a revolution to reestablish patients as the center of our healthcare system. We need a new, updated, more aggressive patient bill of rights that redefines for this era what it means to protect patients and to be patients first. We need to deal with the explosion of cost sharing that is imposed on patients through deductibles and co-pays and co-insurance, which, by the way, is straight out of the neoliberal playbook. The notion that consumers, aka patients need skin in the game. That's neoliberalism 101. Nothing can come for free. Everybody's got to feel some pain if it if the if the support comes from government. So and I would propose, I propose, I think that we need to put a cap on premiums, premium payments, and cost sharing together. Because the way it goes right now is you buy insurance and you have to decide, okay, will I take high premiums for low cost sharing, or will I take lower premiums and risk high cost sharing? And it's a it's a it's a roll of the dice with the devil. You lose either way, and it's it's that's gotta, that has to be addressed. We need to reinvigorate antitrust in a very big way. And the truth is, most people don't quite know this or have forgotten already, but President Joe Biden was the first president since Reagan to reinvent antitrust. He appointed people to the Department of Justice Antitrust Division, a guy named Joel Cantor, and importantly to the Federal Trade Commission, a a Wonder Woman by the name of Lena Khan, who just took after, just went after every neoliberal idea that had harmed consumers. They went after non-disclosure agreements, they went after non-compete clauses, they they were going after people who had to, everybody, sign your rights away to sue a company to submit to their arbitration. It was it was an extraordinary about three and a half years that I watched. And for me, it was one of the great regrets of moving to the Trump administration because the second Trump administration, when they came in, they they they hummed a few good tunes about yes, we believe that stuff. Lena Khan, there's never been, to my awareness, a leader of the Federal Trade Commission who developed a public image. In the fall of 2024, 60 Minutes did a 20-minute profile of Lena Khan. And the capitalist folks, the the corporate merger folks, they just they they were apoplectic about her. If I could just mention one guy, the guy who invented LinkedIn, you know, that that professional web for uh source, his name is Reed Hoffman, and he's become a billionaire from LinkedIn. Bully for you, Reid Hoffman. He's also a Democrat. And so in the fall of 2024, he was out campaigning like crazy for uh for Kamala Harris for president, and uh was going up and down the West Coast raising money from tech people. And somebody asked him, a reporter asked him, said, Why are you doing this? What are you hoping to get out of this? And he said, I don't want anything out of President Harris at all, with one exception. I want to make sure that if she gets in there, one of the first things she does is fire Lena Khan. So that's what's at stake. That's what's at stake. And so we need to reinvigorate antitrust. I think that we should ban private equity from being involved in any medical care organization that is patient-facing. If they want to invest in medical devices, if they want to invest in drugs, you know, those kinds of, yeah, okay, all right. But if if you want to take over a hospital where people's lives are at stake, um, or a home health organization that needs people showing up, I just I think I think we have to we have to exclude them. I think we need to go much more aggressive on prescription pricing regulation. So that's it. A lot more, but you know, the you I think you probably get the idea.

SPEAKER_01 49:22

Yeah. Well, and so as uh as we prepare to wrap up here, where should people go when they finish your book and they want to learn more about you and the work that you do?

SPEAKER_00 49:31

So I want people to understand that all the things that drive people crazy about our healthcare system right now, cost sharing, prior approval, inability to see providers, corporate concentration, private equity, the lack of attention to diversity and equity in the healthcare system, particularly in the last several years. All of these pieces, all of these elements, um, people look at them and think they are discrete, and they are not. They are joined together. And there's a source for most of them, and the source comes from the neoliberal revolution of the 1970s and 1980s that continued and impacted in many, many negative ways our system, our health care and medical care system. So I want people to understand that, to do some sense making, to understand, because if you don't understand where we came from, it's much harder then to figure out how do we act. I mean, you need to know that there was a period of time when the consumer welfare theory of antitrust was just some angry guy's hypothesis and theory. It wasn't reality. These things seem like they're set in stone and they're there forever, and it's not true. But if you don't go back and learn about where they came from, it's a lot harder. Harry Truman has a saying I like. He says, the only thing you don't know is the history you haven't read. And what I'm trying to provide for people is a different kind of a history of the US healthcare system over the past four decades to better prepare people for the battles that lie ahead.

SPEAKER_01 51:26

And where can folks find you to continue this discussion?

SPEAKER_00 51:32

I'm I'm easy to find. I'm, you know, I'm at the Harvard Chance School and my email is my email is there. Um I uh I write weekly on Substack um under uh under a column called Health Stew, S-T-E-W. And uh, and I um I do blogging, I do a uh a podcast myself monthly on Massachusetts health policy. But uh so but I'm I'm I'm there to be helpful to people, to make sense of where we are and how we got here, and then to help think creatively about where do we go forward from here.

SPEAKER_01 52:14

Wonderful. Well, and so for the listeners out there, definitely consider picking up a copy of America's wrong turn to get a better understanding of the history behind some of the political and economic decisions fueling the fractured landscape that is the American healthcare system.

SPEAKER_00 52:33

If I can add one thing. Sure. So, you know, you can obviously you can go on Amazon and and order it that way if you want to. But if you go to the publisher, Johns Hopkins Press, Johns Hopkins University Press, and you use the code HTWN, you can get 30% off the price.

SPEAKER_01 52:54

Well, there you go. Way to save some money. Thank you again, Mr. McDonough.

SPEAKER_00 52:59

Thank you. Pleasure to be here with you.

SPEAKER_01 53:02

My thanks again to John for sitting down with me. If you have any interest in the various moving parts that influence U.S. health policy, grab your copy of America's Wrong Turn today. Thanks, peeps. I'll see you next time. Thanks for sitting down with me as I explore this chapter of American history. If you liked what you heard, be sure to subscribe and share with your friends. I look forward to our next cup of coffee together.