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Podcast: Jonathan Wiik, In U.S. Healthcare System, ‘The Patient is the New Payer’

The U.S. healthcare system can be confusing – never mind the actual medical care. It also is costly. And from changing coverage to high deductibles to co-pays and more, the question remains: Who pays? Even the doctors themselves have to hire a physician contract lawyer to make sure they are being paid enough. Physicians are in high amounts of debt as it is with student loans, and this can be worrisome. This is why to many medical professionals, physician disability insurance is important to them so that they can be covered if a day ever came where they couldn’t work. However, the current issue is all the confusion with payments. So what’s the answer to this muddle?

Jonathan Wiik has an answer. Jonathan is a Principal in Healthcare Strategy at TransUnion. He’s also the author of “Healthcare Revolution: The Patient Is the New Payer.”

Wiik has spent much of his career examining the health care payments transformation. From his experience and research, Wiik outlines a system where, as he has written, “On average, healthcare consumers are now responsible for 30% to 35% of their healthcare bill1. Patient payment and collection practices are highly complex, and with high deductibles, patients have evolved into a primary payer source.” Further, Wiik acknowledges, the system means too many patients ultimately can face debilitating medical debt.

Wiik outlines a go-forward approach that reimagines the patient as a consumer – and offers ways in which payers, providers, and patients must come together in new ways to address our health care crisis.

Transcript: Jonathan Wiik, Healthcare Revolution: The Patient Is the New Payer

We know that the health care system can be confusing – never mind the actual medical care itself. It also is costly. And from changing coverage to high deductibles to co-pays and more, the question remains: Who pays?Chris Riback: Jonathan, thanks for joining me. I appreciate your time.

Jonathan Wiik:Thank you so much Chris. Happy to be here.

Chris Riback:This is such an important topic, but it’s also often a confusing topic. Let’s start with some context. What is the broad history of health insurance and more specifically, how has healthcare financing evolved over the years?

Jonathan Wiik: Yeah, it’s interesting. In the book we talk about the birth of health insurance. It’s the first chapter. It starts with barber poles, believe it or not. Doctors worked in barber shops, they gave you a haircut and a physical that the strips on the barber pole actually relate to bloodletting in that that was something that they had, the red, white and blue had meaning believe it or not. I’ll let you look that part up in the book.

As far as insurance companies go, doctors practiced way back when, they were in horse-drawn carriages and did house calls to people who were sick and delivered babies. You remember the old Westerns where they boiled water. After the doc would come over and make sure everything was okay.

As industry started to come up, both with railroads and manufacturing and things, the railroads really were probably the first to start contracting for insurance on a group level just because they had so many workers that were getting injured, and docs were trying to get paid. They felt that there should be some … and it wasn’t for any benefit to the employee, it was that they wanted their employee to get better faster so they wanted to almost make a reservation like in a restaurant to have those docs “available” to fix their workers. I use that term, fix-

Chris Riback: It was like the precursor to

Jonathan Wiik: Exactly. From that, we’ve got a first fee schedule, it’s in the book. It’s kind of fun to look at. It talks about docs in Virginia that had the cost to amputate an arm was like $10, to deliver a baby it was $20, a dozen pills was 25 cents. Wouldn’t that be nice?

We really started to see Blue Cross as the first, that was the first hospital ward, if you will, that contracted with some of these workers and employers, like I said, to help get them back to work and help their families get back to work. And then the docs were like, “Hey, I want to create insurance too,” so they created Blue Shield. And then from that, here we are. We’ve got Medicare, Medicaid, just a proliferation of insurance.

I think what’s happened is, is technology and utilization, and I would argue just how some of our taxes are structured, and some of those things have really accelerated the healthcare costs. Population, some of our behaviors, we talk through that. And now we’ve got this divide, this giant chasm if you will between what should be paid under insurance, what is debatable to be paid under insurance, what’s affordable, what’s not. One of the quotes in the book that I love the absolute best is, “You can’t have affordable insurance for an unaffordable product.”

We’ve got a really interesting model right now to where’s it’s pulling at the threads and unraveling very quickly. I think there’s solutions in there that work, but that’s a brief history of where we ended up. The HMOs, the PPOs, and all that stuff coming along to try and figure out how to incentivize some of that behavior to keep those costs in check and premiums down. But we haven’t seen much success there.

Chris Riback: No, we haven’t. And it is an incredible history. I want to ask you, the strings that you were talking about and the pulling on and that split between how expensive the care is and how do we create an insurance system and a payment system so that docs can get paid what they need, hospitals can get what they need, patients can get the care they need at the cost that they can afford and that healthcare is available.

Just one follow-up, though on the fascinating history component. I always was under the impression … Healthcare in the U.S. is tied obviously significantly to the employer. And I always was under the impression that that was a post-World War II phenomenon where employers were looking to insert additional benefits when there was so much employment opportunity, to insert that as a benefit to help differentiate. And what you’re describing is, did the idea then actually originally come from the railroads? Was that what inspired the post-World War II insertion of insurance as a benefit for employers? Or were those disconnected and it just so happened the railroads had done it whatever, 50 years previous?

We know that the health care system can be confusing – never mind the actual medical care itself. It also is costly. And from changing coverage to high deductibles to co-pays and more, the question remains: Who pays?

Jonathan Wiik

Jonathan Wiik: Like I said, the railroads had a model, yeah, I skipped over that part. The birth of insurance really was from a post-World War II tax benefit, which actually still exists today interestingly enough. In the effort to not have inflationary damage that was caused by World War I we saw in Germany, the government, I can’t remember the President at the time, but that President had said, “You cannot give raises, we’re going to give you an inflationary cap.” And so the employers were like, “Well, how do I attract employees here? I’m done with all the other things. I can’t pay them more, so I’m going to offer health benefits as a benefit.” We are, in a unique way, one of the few countries in the industrialized world that offers insurance as part of an employee’s salary package. And that also has caused some consternation. If employers had their way, most of them would probably tell you they would not want to be in that position today.

Chris Riback: For sure.

Jonathan Wiik: It’s one of their largest expenses. But they are nonetheless, and it’s very hard to get rid of it. We saw some things in legislation start to remove some of the ACA provisions in that, but I haven’t seen anything at a commercial market or a tax benefit in any way go away. It’s not an entitlement now, but it’s an expectation that when you take a job of some sort, that health benefits are part of that job. The law doesn’t require an employer to offer insurance. A lot of people don’t know that. It actually is just something that they do from a competitive standpoint. There isn’t anything that says … Now if you offer insurance, there’s a whole litany of laws that you have to follow. If you’re offering it, but you don’t have to. You’re not required, at least not anymore, to offer issuance as an employer. But you do ’cause you have to attract those folks and get them there. When you do, you got to follow those rules that our government have.

Chris Riback: Our government has just a couple of rules. I think there’s one or two. Another aspect of what you’re saying that’s so fascinating of the connection between insurance and employment is we’re in an age where the nature of work is evolving really quickly. That historical tie, even let’s just say going back to the post-World War II model, as the nature of work evolves, it will be interesting from my point of view to see what type of competitive market pressures start to get created around what is insurance, how does one have insurance as one switches from job to job to job, or maybe is in more of an individual employment market, what does insurance look like as the nature of work changes?

Jonathan Wiik: I think you’re going to see … It’d be a great topic for the next book … but I think you’re going to see an evolution if you will of direct-to-provider contracting to where insurance isn’t necessarily there. So employers may entice the hospitals directly if they’re going to be and compete with each other. You’re starting to see that now with the Amazon, JP Morgan, Berkshire Hathaway [effort] happening now.

They’re testing it on their own employees. They’re hiring healthcare folks in there. They’re being very quiet about it but they are basically packaging an integrated delivery network without an insurance company. There isn’t an insurance company in that deal at all. There may be a clearinghouse helping process the claims and things, but the utilization review and the actuarial stuff is frankly not happening. So there’s something to that.

I think with that they’re going to try to educate their employees. I think health literacy’s a big problem right now in our country. The emergency room seems to be the care du jour for most things. People try to self treat themselves or delay things because they’re fearful about the cost. Or they’ll go to their primary care doc, but the majority of folks are, “Oh, the emergency room is there, and they’ll help me if something really bad happens,” which is what they’re there for, but they’re going in for lots of things that aren’t for an emergency room. And that’s a very expensive, inefficient I would argue too, way to get healthcare. They’re designed to save lives, and they do it very, very well. They got lots of resources there and lots of things happening in that process, and it’s like throwing a wrench into a giant engine. It spins back off.

Chris Riback: It’s not meant to be a primary care facility. It’s an emergent care facility and an emergency care facility and that’s what it’s meant to be. We’ve covered a little bit the history, and you’ve started to touch on the future of healthcare. Let’s talk about right now. The patient is the new payer. What do you mean?

Jonathan Wiik: Right now, patients have about a third of a healthcare bill if they have insurance. What I mean by that is about 15, 20 years ago with insurance, we had plans like that if we’re old enough. We remember when we paid about $10 or $100 for most things, and it was 90% on stuff that was kind of expensive, like going to the hospital or having a major surgery. We remember those plans. You just kind of expected it. Billing was a lot simpler back then too. You knew roughly that when a bill went over that had a really big number on it, it would come down to a smaller number and you’d be on the hook for 10% of that or something. That number’s tripled. And I don’t see it not stopping or idling back at all from a growth standpoint.

So now it’s $300 or 30%, and that adds expenses across the board. Patients are horrible payers. We rank healthcare bills as number seven behind mortgage, rent, cell phones, groceries, and other things. We don’t want to pay them. When we get them, they’re confusing. We hope that they’ll go down when the next one comes ’cause we know another one’s coming. And we hope that someone will call us and explain it to us so that we understand it and then want to actually want to understand the value and then feel like we should pay. It’s a very reverse retail type scenario when you get a healthcare bill. I didn’t realize it was that much. I don’t think they did all that good of a job but it’s too late. They already did it. Very mechanic. Like with a car that kind of got fixed with a bad estimate.

Chris Riback: But like that analogy, maybe you’re a little bit more handy with cars than I am, but I go in and I don’t what they’re talking about. Under the hood is a complete mystery to me, very similar, and I think that’s the point of your analogy, very similar to underneath the hood of my own body. When you get a medical bill, I understand it … I agree with you … I understand it about as little as I understand the bill that I get from a car mechanic.

Jonathan Wiik: It is precisely. That health literacy, and you’re starting to see this word transparency, which I call the “T” word in the book ’cause it’s being used too I think broadly and the definition needs a little bit of refinement. I think that transparency in delivery and in cost and things like that make sense. Hey we’re going to do this test because the reason I have to do this one that’s more expensive versus that one is because. We don’t slow down for a minute and really discuss those things. When we buy a good that we really want, like an iPhone or a car or a television set, that experience is at a much, much slower pace than healthcare and it’s more consumer directed.

But I would argue a lot of the things that happen in healthcare don’t need to be accelerated at the level that they are, but for some reason they just are. Emergency room completely falls out of this and sudden onset illnesses. But that’s 20% of all the care that’s probably delivered is that part to your normal average American. The other 80% of the stuff, it’s like you go to the doc, the doc’s like, yeah, I need to “pop the hood” and find out what’s going on, we’re going to run some tests and we’ll see what it is. I think it’s this, and I think it’s that. Again, not very familiar with it. But there is ever if rarely a discussion on the cost, this is what I think that stuff’s going to run, and I think that’s just out of not having the costs there.

I think it’s out of a philosophical almost ethical type discussion about whether or not a physician should know what things cost as they’re ordering or should they just practice medicine. Which is tough. We’ve got to overcome that someday with patients as payer. But that’s where we’ve ended up is that we’re pushing towards this retail type experience, but we’ve got a few things we’ve got to figure out in terms of pricing and the actual conversation that’s going to have to start happening. Imagine it like a vacuum. Your doc’s telling you, “Well, I’ve got good, better, and best here.” We all want best, but maybe we can’t afford best. Maybe we can’t afford the MRI. Maybe we can only afford the X-ray or maybe we can’t afford the surgery. We can only afford the medications and the therapy.

I don’t know, it gets really weird when you start traveling that path. Insurance companies can’t and the country frankly can’t, the government spending trillions of dollars, can’t afford to pay for the best all the time without some fundamental changes in our tax base and some other things, which would be interesting to talk through as well.

Chris Riback: No doubt. It would be. Let me ask you one more question. Another question about the patient as the payer. In the book you cite the TransUnion Healthcare analysis that revealed the patients experience an 11% increase in average out-of-pocket costs during 2017. I don’t know if you have 2018 data and what’s happened with 2018, but that obviously will present a huge potential problem for nearly everyone in the ecosystem. What advice do you have for healthcare executives around navigating this new era of patient payments, particular when assuming the 2018 data show the same thing? Patients are experiencing double-digit increases in average out-of-pocket costs.

Jonathan Wiik: I think that trend is going to continue. I don’t have the data in front of me, but yeah, it is accelerating and I’ll try and share it with you Chris when I get back to the office next week. We know why that is. Most of us that have health insurance, it hasn’t gone down. Our premiums, we hope they stay flat from year-to-year, sometimes they do and sometimes the benefits may even stay flat.

A few things are happening. One, the deductibles and coinsurance tend to go up, so if you’ve been on a plan for a while and you’re with a pretty large employer, those things may stay pretty static. But that’s the exception, not the rule. Most other types of insurance plans that have the mid to small employer have accelerators on them that increase the coinsurance ’cause they’re frankly trying to keep premium in check. ‘Cause you’ve got this cost happening on the other side. New technology, aging populations, a sicker population, higher utilization. As we see facilities going up like Starbucks … I don’t know what your neighborhood’s like, but mine, there’s facilities going up everywhere and they’re all half full. It’s really interesting to understand where all that money is going and what’s happening.

Patients have to pay into that system to help fund some of those things. I love having the access. I think it’s great, but there’s an infrastructure there and there’s a cost to everything that we add to the system. I think hospitals and health systems are trying to meet the need of the patient consumer the best way they can. I gave that example through access.

In terms of payment, as patient is payer, I’m seeing more momentum now than when the book came out. I’ll be honest with you. I think about one in 10 people shopped for healthcare when I wrote the book a couple of years ago. It’s about three in 10 now. So that’s a pretty big jump, and I think that’s because our legislation and our media and just our general awareness of the population has finally came to passed that healthcare is really expensive. There aren’t too many people in our country that think healthcare is cheap now, I think. So that’s one, I don’t know if I would call it an accomplishment, but that’s an awareness cone that we’ve gone by now. That people know healthcare’s expensive and that you’re obligated to pay it when you come in and insurance is important and it’s important to understand what those costs are.

Where we’re at now is okay, now that I understand that’s it expensive, how am I going to afford it and how am I going to pay for it? So you’re seeing hospitals create these “patient engagement” digital front doors if you will to where they’re mobile-ly sending out messages saying, “Hey would you like to make your appointment? Would you like to leave a credit card on file and create an account?” Think Amazon there if you want or Amazon Prime. Anything you have will hit that card, you’ll get a notice about it, you could look at it, you could decline the charge or accept the charge.

You’re seeing very sophisticated things starting to happen. Do you need a payment plan? Do you need loans? They’re tailed to your financial position. Do you need discounting? Do you qualify for charity? It’s becoming much more of a push to where instead of just sending a bill in the mail and hoping that on the third one that goes out, the patient will pay you, is important. There’s still barriers there Chris from an affordability standpoint. $10,000 is still not something a lot of people can just pull out of their pocket and afford. They have to pay it over time. So we’re seeing an extension of debt. We’re seeing loans getting set up at hospitals in the three to five-year range. Those are automobile loans. If you think about just the term of that. For a healthcare bill.

Patients are going to become a payer, but it’s not going to be for the things that you just buy every day. These are going to be like when you go buy a car. We love when we get a car. We don’t like that coupon book or those payments that we have to make later. You’re going to see healthcare start to structure itself to that, because that’s what healthcare bills cost for the most part, and you’ll see those bills start to grow and the payment mechanisms around them evolve as well.

Chris Riback: You started to touch on this a little bit, and I just want to go ahead into it. Medical debt. How concerned are you about medical debt in this country?

Jonathan Wiik: I’m very concerned. Medicare beneficiary bad debt surpassed $8 billion last year. So that’s just on the Medicare side. I know that because we’ve got some tools at TransUnion that help hospitals recover some of that. Medicare’s actually got an interesting program where they refund unpaid copayments, coinsurance deductibles. That $8 billion, there’s a way to get back at it.

I think medical debt’s a large issue. I think a lot of people go into medical debt. One of these times, Chris, when I’m doing one of these interviews, I hope I won’t have to say this, but bankruptcy, the number one cause is still medical bills. ‘Cause they’re unexpected and they’re large.

I’m concerned about how the industry’s going to do with financially clearing its patients ’cause one of my mantras when I was at the hospital, and my CFO’s as well, was patients should always pay within their ability. If they can’t, your charity program should pick up that slack and figure it out. If you’ve got things structured right, you should be able to get patients into some sort of tailored funding mechanism that matches what their financial position is. I don’t think we’re doing a good job of that across 100% of the patients.

If you ask hospitals, they’re saying they’re getting at what they can with what they have. But that’s a way to prevent medical debt is to really stratify that bad debt portfolio, get patients appropriately classified into the charity program, set them up on those payment plans, get them to the right level of care. We’re seeing a lot of traction in that now. Rules like EMTALA hinder a hospital’s ability … ties their hands a little ’cause they have to treat that patient when they’re there instead of offering other options as silly as that sounds. When you come into the emergency room, they’ve got to stabilize and treat you, the costs drop. There isn’t a U-turn there.

But imagine, you just have a fever, this really isn’t appropriate for the emergency room. Here’s an urgent care, here’s Dr. Wilson’s number, call him in the morning. The liability and the legislation barriers that are there are too prevalent to prevent it. So you see a lot of medical debt coming from emergency room visits. I’d say that’s probably the majority of them, especially ones that turn into an inpatient admission. And it’s growing. I’ve got numbers at my desk I can get you later if you want.

Chris Riback: Incredible. You’re starting to get to maybe not the root cause, but among the root causes. You said 15 minutes ago how one of the major problems with our healthcare system is because of the cost, we all put off care and so we try to self diagnose, et cetera, until it’s too late and then we go to the emergency room, and that becomes a primary care facility. As you just noted right now, that then has a pile-on effect of that’s really expensive care. And all of a sudden for a fever, in your example, where I could have seen Dr. Wilson at whatever cost, I’m now in the emergency room for, I don’t know 10X the cost of Dr. Wilson and you’ve now set up … It’s really a vicious circle that you’ve identified.

Jonathan Wiik: There’s lot of factors and costs but that’s certainly one of the big ones. There’s Pharma, the group everyone loves to hate. And there’s high technology too.

We’re a Burger King healthcare society. I want it right now, right away every day. And by that I mean it’s great that we have such great technological advances and everything with implantables and MRIs and CT scans and things, but those are two, four, five million dollar machines that the hospitals have to buy to compete with each other and that cost gets passed down to the patient too. There’s ownership at all levels I think in healthcare costs.

We’ve got population stuff. The book talks about the Silver Tsunami. We’ve got underpayments as well. As we expand Medicaid or coverage or through the ACA, that’s actually an indirect driver of high healthcare costs as well. Those plans are awesome to give someone coverage. I think that’s great. The problem is the funding mechanisms behind them actually put the hospital in a poorer financial position than if they had commercial insurance.

Self pay may have opened up some doors as well. I think having expansion and having the ACA plans and things in place is great, but the patients can’t afford a lot of the plans that are set up that way. They have extremely high deductibles. The six, seven, eight thousand dollar range and that turns into medical debt quickly. I think on the Medicaid side, as we’ve expanded these states, they’re paying 10 cents on the dollar where a commercial payer maybe pays 40 or 50 cents on a dollar. And you wonder which one of these things are helping or not as you go.

I think it’s great to get folks on coverage, but we’ve got to look at the next step, which is, Ok, now that they’ve got coverage, can they afford the plan that they’re on? If they can’t afford the plan they’re on, does that make it better or worse for them so on and so forth.

So this patient as payer concept really needs to be one of the first decisions as we look at just the overall healthcare cost package and how hospitals are being reimbursed, because nobody that I’m aware of is making money on Medicaid. And it actually becomes a loss leader in a lot of hospitals. Hospitals want it ’cause it allows them to treat and get some payment, but the payment structure that comes from the states and the government isn’t covering the costs that the hospital has to incur and so it creates a debt issue as well.

Chris Riback: And so to close out, let me pick up just a little bit on the Medicaid question and more broadly, a policy idea that … We’re at the beginning of a new political cycle, and I don’t need you or I’m not asking you to take political sides, but I am asking you as someone who thinks about the healthcare industry I guess 24/7, maybe you take an hour off once a week, what do you think … Obviously, there is a new, it’s not a new idea, there is an advancing idea, particularly among Democrats and some of the new Democrats who have taken office around Medicare for All. As we enter this new political cycle, that idea that was a little bit out there even four years ago or two years ago I guess, at this point three years ago, is really becoming more center of the plate. Without assessing the politics, what about the policy? Would this be helpful? Is it practical? What’s your take on the idea of Medicare for All?

Jonathan Wiik: I think having health insurance that can get as many Americans on it is good. And as I mentioned before, they need to be structured in a way to where those costs are very transparent and there’s funding and assistance mechanisms for things. An example of that just on an extreme is if a single payer plan came out that had a $15,000 deductible on it, I don’t know that, that would necessarily help a lot of people that are going to the emergency room and inpatient necessarily, because they couldn’t afford it anyway. But the copays and things for the primary care, some incentives there would help.

I think, and I firmly believe this, that you will absolutely see healthcare become the number one debated platform in the 2020 election. I firmly believe that. I think you’ll hear about where pre-existing conditions go. I think you’ll hear about the effectiveness of Medicaid expansion and the ACA. And then you’ll certainly hear from the Democratic side, and there’s about six or seven ideas right now all the way from Bernie down to some old things that Paul Ryan, who’s not in the seat anymore came up with … I’m sorry, not Paul, Lamar Alexander and Murray some other plans that are there. And Paul Ryan’s plan on the Republican side has some ideas, it’s a better way plan in terms of how to replace some of the things that are with the ACA. The difficulty is in our country is that we are very polarized on this subject. I think there’s an entitlement discussion on the Democratic side in terms of that healthcare is a universal right and that we should figure out how to offer that. And fund it in a way that there’s a lot of equality there.

On the Republican side, they want to look at entitlement reform, so is Medicare, Medicaid, doing things in an effective way. There’s a lot of spend happening. Is the ACA necessary is the question they’re asking. Is there things that could be done with Medicaid block grants and to where there’s more control at the state level in terms of managing healthcare in ways that we did decades ago. What I think’s going to happen is you’re going to see a few bills get presented early in February, March, 2020 after the election happens, and a lot of this is going to depend on whether things stay the same or change, whether President Trump gets reelected or not and whether the House and Senate stay in the Houses that they’re in now ’cause they’re split. If they’re split, I think it’s going to be really hard to get anything done no matter who the President is. If things become aligned one way or the other, you may see some changes happen either in healthcare reform or expansion.

There’s some bipartisan things in there. I always like to cheer people up when I talk about this. There’s a lot of attention even right now on drug pricing, which I think is great. I think they’re really trying to … They’re not beating up on the pharmaceutical companies, but they’re trying to have some rational discussions about why a drug can go from five dollars to $500 in four years and understand the legalities and the equality and the profitability of those types of things and trying to put caps on that. There’s a surprise out-of-network bill that’s even being debated now, which is great. That’s the hey, you’re under anesthesia or you went to the hospital and no one told you that Dr. Smith is in Nebraska or in another county in Nebraska and doesn’t participate with this plan, so he’s “out of network.” His bill comes in the mail and it’s $50,000, and you didn’t know and they’re trying to put up some rules about notifications and caps on out-of-network bill balance billing from the docs or the insurance companies or the providers themselves. Those things there’s agreement on.

Believe it or not, I believe there’s agreement on pre-existing conditions now. I think the Republicans took at a pretty good backlash with that over the last election. And so that’s a good thing I think. I think pre-existing conditions are something that’s just tough. When you’re off insurance and you’ve got to get back in and try to get some coverage, and you’re really in a bad way, that’s difficult for you to get affordable insurance if you’re got some things going on and moral hazards and adverse selection things happen with pre-existing conditions that the funding mechanisms have to look at, but that’s where we’re at.

I’ll end with single payer, what I would encourage everyone, including you Chris to look at, is the book talks about who pays the monkey. Who’s paying the monkey? And it’s an old organ grinder example that I heard when I was in an insurance company. We were building health plans. These health plans that have these coinsurance and copayments and reimbursement deductions, the cost is still there. One could argue there’s huge opportunity there. And the funding’s still there, but there’s still this gap between them. And who’s paying that monkey? So if we have a Medicare for All or a single payer plan, is that a tax fund? Is that an out-of-pocket spend from the consumer? Is that a fundamental reduction in the scope and amount of services that are provided at the provider level? Those are questions that as voters we all have to look at and evaluate.

I think we’re short-sighted as a country when it comes to some of these bills, and I mean that respectfully. Coverage for all, let’s do it. Well, what would that mean to you financially is a question you need to ask. And what does that mean to our country financially as well? ‘Cause we have a deficit. It’s trillions of dollars, not billions. I don’t know that people fathom some of the magnitude of some of these decisions as they go.

I’m honestly on the fence with some of it just personally. I think there’s benefits to both sides of these arguments. We’ve got to curb spend. I think everybody would agree on that. On the Republican side I agree with some of the things that are happening over there. And I think on the Democratic side we’ve got to figure out a way to get folks that need insurance that can’t afford it, on it. And that should balance out this risk pool problem. And we’ve tried different things and there’s some innovative things you’ve seen. Like the state of Massachusetts, when you go get your driver’s license, we’ve all done this. You have to present an insurance card for your car. Your motor insurance. They require you to present health insurance. Novel concept if you think about it. You can’t get a driver’s license in the state of Massachusetts if you don’t have health insurance.

And that doesn’t mean that they send you the state-run plan and things to get it if you can’t afford it so that you can do it, but there’s ways to get at some of this stuff versus just the red button, I’ll call it. The easy button, let’s make a single payer plan.

I’ll end on this. Half of our country’s on a single payer plan right now. Medicaid and Medicare covers about half the country. You can say we’re halfway there or halfway not. That always adds perspective ’cause a lot of people don’t know that we have a single payer plan right now with Medicare and Medicaid and TriCare and the VA. It’s there. It’s just a matter of how much that gets expanded.

I’ve seen some interesting models with buying into Medicaid and such, but make a little more sense than having just this universal plan that’s like Medicare. That was a long answer.

Chris Riback: It’s a long answer, but it’s a thorough answer, and it’s a really complicated question. And as you said at the beginning, this is very likely the central issue in our country, not just right now but over the coming years. And understanding all the complexities and what’s possible is incumbent upon all of us. I thank you. Thank you for helping explain a significant portion of it and for the ideas going forward.

Jonathan Wiik: Thank you.