MILES PARKS, HOST:
So as we just heard, the debate over extending the Affordable Care Act subsidies is intensifying this week. Millions of people's premiums are set to jump at the end of the year. But economist Craig Garthwaite wants the U.S. to think bigger when it comes to health care. He's a coauthor of a new study called "Coverage Isn't Care." It argues for fairly simple solutions that don't just paper over problems with the current system.
CRAIG GARTHWAITE: It's a frustrating thing, I think, for economists, as we watch this debate where, you know, they're saying if the subsidies expire or they don't, it'll change the cost of health care. That's not true. All that's going to change is who pays for it. Does the federal government pay for it or do individuals pay for it? And while that's an important question, it doesn't get at what I think we do care about, which is how much are we spending on health care overall, and how much care are people actually getting for the money that we're spending?
PARKS: His research comes from the Aspen Economic Strategy Group, and he's also the director of the Program on Healthcare at Northwestern University's Kellogg School of Management. Professor Garthwaite joins me now. Welcome.
GARTHWAITE: Hi. Thanks for having me.
PARKS: Yeah, thanks for being here. So your paper says it offers a roadmap for structural reforms to America's health care system that would make health care more affordable. The first of these recommendations is to ease restrictions on doctors who have been trained in other countries. Can you explain how that would work?
GARTHWAITE: Yeah, I mean, the idea would be that we want to increase the supply of people who can provide medical services, with - if we have more people who are intentionally coming here with the goal of treating low-income Americans, it'll provide more access and ideally lower costs. There is a readily available set of people who have graduated from reputable, credentialed medical schools abroad who could come here, and we could develop programs that say, we will - in exchange for you coming to the United States and being allowed to work here as a physician, you have to primarily concentrate on targeting low-income patients and in particularly, patients who are on Medicaid, which is our nation's insurance program for the low-income and the disabled.
PARKS: Is there any risk, I guess, in terms of people who receive this coverage, you know, having the care being different for people who are lower-income versus higher-income?
GARTHWAITE: The first thing to recognize is we already have different levels of care or different sites of care for people who are lower-income or higher-income in the United States. Lower-income individuals are often going to clinics that concentrate on them. The vast majority of individuals on Medicaid are treated in facilities that primarily concentrate on low-income individuals. And so what we want to do is recognize that reality and provide the most efficient way to get people access to care, with the idea being that perhaps the biggest problem that low-income Americans face is not that they get a different level of care. It's that they're unable to find care at all.
PARKS: So this study also mentions the idea of expanding the pool of providers by allowing nurse practitioners and physician assistants to practice independently. Can you explain that bit of it a little bit more?
GARTHWAITE: Yeah. So we have a ready-made set of providers, these mid-level providers who have advanced training. They are not doctors in the sense that they have an MD or a DO degree, but they've gone through a lot of advanced training. And for a lot of primary care, research has shown that they provide exceptional care for individuals. In addition, they are a lower-cost input that can be more readily deployed across the health care ecosystem. You can often spend more time with a mid-level provider than you can with a doctor. And for primary care, I think that's often what people want. They want to be able to sit down and talk to a doctor about the things that are concerning them. And so this can, again, augment the health care workforce.
We see a lot of use of mid-level providers among practices that are already engaged in what we refer to as value-based care - right? - the practices that are trying to, you know, make more money by making people healthier. And we think that there's a real place for that in the Medicaid and low-income population.
PARKS: Can I ask broadly about these changes? I mean, how radical are some of these changes, or are there ways or levers in place already to allow for some of these changes to more easily be applied?
GARTHWAITE: In many ways, certainly on the idea of foreign-trained doctors and mid-level providers, we already have experience with various kinds of programs that have different residency requirements or different what are referred to as scope-of-practice laws for the mid-level provider - kind of dictating, you know, how much prescribing behavior might they have independently. So we're really talking about expanding sort of an existing set of tools but really targeting it on a population where we know there is an identifiable need for more access to care.
And I think that's where Tim and I - Tim Layton is my coauthor on this - where we started with this, which is the title of the paper, which is "Coverage Isn't Care." There's so much discussion and so much of the debate we're going to have in Congress over the next two weeks is going to be about insurance coverage, which is good, but it's a necessary but not sufficient condition for getting access to health care. And I think we'd like to see the debate focus more on what actually gets people care, and that has to be a supply side conversation where we think about who's providing the care and not just what economists refer to as the demand side of conversation, which is who's paying for the care.
PARKS: I don't want to be cynical. I hate being the cynical voice here. But I guess, when you look at the current landscape in Congress, how realistic is it that they would take on some of these things as opposed to the sort of tweaks that they're negotiating to the current system right now?
GARTHWAITE: Well, you're talking to an economist, so you can't be more cynical than I am. I think I've lost almost all faith in the idea that Congress will do good government and pass laws anymore. The nice thing about this, though, is that a number of the things that we're talking about here can actually be accomplished at the state level. We have seen state governments be more active. But Medicaid, it's important to recognize, is a program that while it's jointly funded by the state and the federal government, it is administered at the state level. And through waivers and other processes, state Medicaid agencies actually can obtain a lot of flexibility to implement these.
And I actually - I think that's a wonderful thing about America. It's what we thought about - you know, the founders thought about for the country is, let's let all these states experiment, right? They become as we often refer to as the laboratories of democracy. Here, they can be the laboratories of low-income coverage and figure out what's the best way to provide true access to health care for low-income Americans.
PARKS: And your paper basically is arguing, like, if we fix some of the broader issues here, then the actual cost of health care could go down.
GARTHWAITE: Yes. And if the actual cost of health care goes down, we can provide care to far more people more efficiently. And that's ultimately what we want. We, as a society, want people to get access to the health care they need, and we should focus on providing that in the most cost-efficient manner.
PARKS: That's Craig Garthwaite of Northwestern University's Kellogg School of Management. Thanks so much for talking with us.
GARTHWAITE: Thank you for having me.
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